Treatment of difficult TRAM flap hernias using intraperitoneal synthetic mesh application.

The authors report the successful repair of large lower abdominal hernia defects after transverse rectus abdominis muscle (TRAM) flap breast reconstruction in 11 patients using a technique of intraperitoneal application of synthetic polypropylene (Prolene) mesh anchored to the peritoneal surface of the abdominal wall tissues. Five of these patients had previously failed hernia repairs after a unipedicle TRAM flap breast reconstruction employing the onlay mesh technique, with two of the patients having undergone three previous hernia repairs. The other six patients had developed large hernias after bipedicle TRAM flap reconstruction without previous mesh supplementation of the abdominal wall repair. After their successful hernia repairs, all of the patients healed without difficulty and demonstrated no sign of recurrence in an 8 to 36-month follow-up. Each patient returned to her activity level before breast reconstruction.

Early experience with SPAIR mammaplasty: a useful alternative to vertical mammaplasty.

The short-scar periareolar inferior pedicle reduction (SPAIR) mammaplasty is a recently developed "limited-scar" technique that attempts to combine favorable elements of several well-established mammaplasty operations. Parenchymal resection and nipple transposition are achieved in a manner similar to the standard inferior pedicle reduction. Skin closure is achieved through a combination of periareolar and vertical techniques. Indications, operative technique, and pitfalls of the operation are discussed. Early experience with this technique in 102 breasts in 61 patients has been very favorable.

The "aesthetic subunit" principle in late TRAM flap breast reconstruction.

The "aesthetic subunit" principle is well established in facial reconstruction. This principle dictates that the margins of regional reconstructions correspond to existing visual boundaries. This will minimize the visual perception of "abnormal." The subunit principle also applies to secondary TRAM flap breast reconstructions in which the available chest wall skin is of poor quality. In these situations, it might be aesthetically advantageous to replace poor quality chest wall skin with a TRAM flap skin paddle that ends at the inframammary fold.

Endothelial cell growth factor enhances musculocutaneous flap survival through the process of neovascularization.

The effect of an angiogenic growth factor-endothelial cell growth factor (ECGF)-was tested in the rat transverse rectus abdominis musculocutaneous (TRAM) flap model based on a single inferior vascular pedicle. The animals were divided into three groups (N = 8 per group) after flap elevation. In group A (control), each animal received both local and local intra-arterial injections of 1 ml saline. In group B (local), each received a 2-mg ECGF local injection and 1-ml saline local intra-arterial injection. In group C (local intra-arterial), each received a 1-ml saline local injection and a 2-mg ECGF local intra-arterial injection. All animals were evaluated on postoperative day 7. There was a significant increase in the percentage of the skin paddle survival area of the TRAM flap in both ECGF-treated groups when compared with the control group (group B vs. group A, p < 0.001; group C vs. group A, p < 0.001). This correlated with a significant increase in vascularity in both ECGF-treated groups compared with the control group (group B vs. group A, p = 0.007; group C vs. group A, p = 0.021). The results between groups B and C were not significant. ECGF, when administered via either local or local intra-arterial route, enhances musculocutaneous flap survival through the process of neovascularization.

The preconditioned TRAM flap: preliminary clinical experience.

The single-pedicled transverse rectus abdominis musculocutaneous (TRAM) flap is prone to partial flap loss and fat necrosis, especially in high-risk groups such as patients who smoke, irradiated patients, and obese patients. Possible methods to increase the reliability of the TRAM flap include the free TRAM, the double-pedicled TRAM, and the surgically delayed TRAM. When we traveled overseas to an underserved area we were largely unable to implement these options due to limitations in equipment, supplies, and the length of our trip. We encountered a combined fat necrosis and partial flap failure rate of 27% (3 of 11 patients) in a group of heavily irradiated patients. On subsequent trips we employed a technique of acute ischemic preconditioning of the TRAM flap in 5 high-risk patients and 1 low-risk patient with good results. Although this preliminary experience is too small to draw conclusions about clinical efficacy, it does demonstrate the feasibility of performing ischemic preconditioning in a musculocutaneous flap in a clinical situation.

Ischemic preconditioning improves the survival of skin and myocutaneous flaps in a rat model.

Inadequate blood supply of pedicle flaps results in partial necrosis, and prolonged ischemia during free-tissue transfer can result in partial or complete flap necrosis. Recent research in the field of cardiovascular surgery has shown that ischemic preconditioning (repeated brief episodes of coronary artery occlusion followed by reperfusion) improves myocardial muscle survival when the heart is subsequently subjected to prolonged ischemia. Preconditioning of skin or myocutaneous flaps as either pedicle or free flap models has never been studied. The goal of this investigation was to measure the effect of ischemic preconditioning on myocutaneous and skin flap survival areas and total necrosis rates after variable periods of global ischemia. In 220 rats, 100 transverse rectus abdominis myocutaneous flaps and 120 dorsal cutaneous flaps were randomized into treatment and control groups. The treatment flaps underwent preconditioning by three cycles of 10 minutes of pedicle clamping followed by 10 minutes of reperfusion for a total preconditioning period of 1 hour. The control flaps were perfused without clamping for 1 hour. Both control and treatment flaps then underwent global ischemia for 0, 2, 4, 6, 10, or 14 hours by pedicle clamping. Flap survival area was measured on the fifth postoperative day. Statistical analysis was performed with analysis of variance, student's t tests, and probit analysis. Preconditioning improved survival areas of pedicle myocutaneous flaps (0-hour group) from 47 +/- 16 percent (mean percent area surviving +/- SD) to 63 +/- 5 percent. This difference was statistically significant (t test, p < 0.04). There was no statistically significant improvement in pedicle skin flap survival. For free flap models (flaps undergoing global ischemia), preconditioning increased the survival areas of skin and myocutaneous flaps (analysis of variance, p < 10(-5)). For the skin flap model, statistical significance of the survival area difference was reached at 6, 10, and 14 hours of ischemia (t test, p < 10(-4)). The magnitude of this effect was higher in the myocutaneous flap model and reached statistical significance at 2, 4, 6, and 10 hours of ischemia (p < 10(-3)). Preconditioned flap survival areas were increased by two to five times that of non-preconditioned flaps at these ischemia times. Preconditioning lowered total necrosis rates at all ischemia times for both flap models. The critical ischemia time when 50 percent of skin flaps became totally necrotic (CIT50) improved from 6.9 to 12.4 hours by preconditioning. Similarly, preconditioning improved the CIT50 of myocutaneous flaps from 3.6 to 9.2 hours. For the first time, statistically significant improvements of partial necrosis areas and total necrosis rates have been demonstrated through intraoperative ischemic preconditioning of skin and myocutaneous flaps. In clinical practice, application of this technique may lead to improved survival during pedicled or free transfer of myocutaneous flaps and free transfer of skin flaps.

TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure.

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.

Secondary use of the rectus muscle pedicle for TRAM flap volume deficiencies.

The residual subxiphoid rectus muscle pedicle was rotated secondarily to a position underneath the breast mound in 13 patients who had previously undergone transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. The indications for this maneuver were the presence of a subxiphoid muscle bulge and a deficiency of volume or projection of the TRAM flap breast mound. This revisional surgery was performed at least 8 weeks after the TRAM flap, typically at the time of nipple-areolar reconstruction. Minor to moderate volume deficiencies were corrected and aesthetic improvement was substantial. There were no major complications. The danger of vascular compromise to the breast mound itself or to the remobilized muscle appears to be minimal, although the need for caution in the previously irradiated chest wall should be emphasized.

Breast reconstruction in previously irradiated patients using tissue expanders and implants: a potentially unfavorable result.

There exists a paucity of definitive information on the suitability of implant reconstructions in previously irradiated breast cancer patients. This controversial topic prompted a review of our prosthetic reconstructions in this select group of patients. A retrospective study of patients treated between 1976 and 1993 with lumpectomy and radiation therapy for early breast cancer revealed 67 patients with local recurrences. Nine of these patients (10 breasts) underwent a two-stage prosthetic reconstruction following a salvage mastectomy. The average age was 47.9 years. The mean dose of irradiation was 6,070 cGy. The average interval from radiation therapy to placement of a tissue expander was 4.6 years. In one patient (10%) the tissue expander extruded. The average follow-up for 8 patients (9 breasts) who underwent exchange to a permanent prosthesis was 5.1 years. In four reconstructions (40%) there was an uneventful postoperative course. Two cases (20%) were difficult to expand and the final result lacked projection. One patient (10%) developed an infection requiring removal of the permanent prosthesis. Two patients (20%) developed Baker class III or IV capsular contractures. Overall, in our group of 10 implant reconstructions, 60% of the patients resulted in either a complication or an unfavorable result.

Comparison of the effects of ischemic preconditioning and surgical delay on pedicled musculocutaneous flap survival in a rat model.

Both surgical delay (SD) and ischemic preconditioning (IP) have been shown to be effective in improving the survival of pedicled musculocutaneous flaps. The goal of our study was to determine the effects of IP and SD, separately and together, on the survival of pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps in a rat model. Thirty-two male Sprague-Dawley rats were divided into four groups of 8 rats each: (1) control, (2) 2-week SD, (3) IP, and (4) SD plus IP. A TRAM flap was elevated in each rat. Flap viability was assessed on the fifth postoperative day by computerized video planimetry. Mean area of flap survival was compared between the control, IP, SD, and SD plus IP groups using analysis of variance and Student's t-test. Improvement in surface area survival was seen in musculocutaneous flaps subjected to IP, SD, and SD plus IP compared with the control. IP and SD improved survival 1.3 and 1.4 times the control area respectively. Differences between treatment and control flaps were statistically significant (p < 0.04). In addition, the combination of SD plus IP improved survival by 1.8 times, which is statistically different from controls and from either technique individually (p < 0.002). IP and SD have similar efficacy in improving survival in this musculocutaneous flap model. The effects of IP and SD appear to be additive. The advantage of IP over SD is that IP can be performed during the same operative session as the flap elevation and only adds 1 hour to the surgical procedure.

Ischemic preconditioning of musculocutaneous flaps: effects of ischemia cycle length and number of cycles.

Previous work in our laboratory has indicated that ischemic preconditioning improves musculocutaneous flap survival 2.5 times that of the control flap area when the flaps are subsequently subjected to 4 hours of global ischemia. The preconditioning protocol used in this study was arbitrarily designed to be 10 minutes of pedicle clamping followed by 10 minutes of reperfusion. This sequence was repeated for three cycles with a total preconditioning time of 1 hour. There are no published works comparing different preconditioning protocols in musculocutaneous flaps. The goal of this study was to determine if the ischemic cycle time and the number of cycles influenced the effectiveness of ischemic preconditioning. Fifty-one male Sprague-Dawley rats were divided into one control and six treatment groups of 6 to 10 animals in each group. A transverse rectus abdominis musculocutaneous flap based on the inferior epigastric vessels was elevated in each animal. Flaps were preconditioned by pedicle clamping and reperfusion for either 5 or 10 minutes per cycle. This was repeated for one, two, or three cycles. Controls were simply perfused for 30 minutes. Each flap was then subjected to 4 hours of global ischemia. Flap surface survival area was calculated on the fifth postoperative day by computerized video planimetry. Differences in survival areas between control and preconditioned flaps were compared using analysis of variance and t-tests. There was an overall statistical significance in the comparison of flap survival of preconditioned flaps with that of controls. A single 5-minute cycle improved flap survival 2.5 times the mean control area. Two and three 5-minute cycles resulted in a reduction of the preconditioning effect, with flap survival no different than controls. Ten-minute preconditioning cycles increased flap survival 1.5 to 3 times the mean control area. Flap survival was improved by increasing the number of 10-minute cycles. Cycle time and number of cycles have definite effects on the survival areas of preconditioned musculocutaneous flaps. Ischemic preconditioning with 10-minute cycles is superior to 5-minute cycles. Three cycles of 10-minute preconditioning is statistically superior to one or two cycles. Future studies are planned to study four or more cycles and longer cycle times.

The effect of prolonged clamping and vascular stasis on the patency of arterial and venous microanastomoses.

During free tissue transfer, an artery and one or two veins must be sutured. Either the artery or the vein can be repaired first, but the optimal order of vascular repair has not been established. Maintaining a clamp on a vessel is associated with vessel injury, and releasing the clamp may cause bleeding and vascular stasis. The purpose of this study was to determine if the order of vessel repair and the length of vascular clamping affects surgical outcome. Free flaps were created on Sprague-Dawley rats (400-450 g) as follows: Bilateral abdominal skin flaps (3 x 3 cm) based on the superficial inferior epigastric vessels were elevated. The femoral artery and vein were tied and divided distal to the branching of the inferior epigastric vessels. Proximal to the branching, the artery and vein were divided. The animals were then randomized into four groups as follows: In group I (N=16), the artery was repaired and then the clamps were released to revascularize the flap. Venous stasis occurred as the vein was being repaired because of the venous clamp. In group II (N=15), the artery was repaired, but the clamp was maintained to prevent blood from coming in contact with the fresh arterial anastomosis and to prevent venous stasis. The vein was then repaired. In group III (N=15), the vein was repaired first but the venous clamp was not released until the artery was repaired. In group IV (N=15), the vein was repaired first and the clamps were released, allowing venous blood to contact the fresh anastomosis while the artery was being repaired. After final clamp removal, all anastomoses were assessed immediately for evidence of thrombosis. Five days postoperatively the skin flap was evaluated for evidence of necrosis and the anastomosis was inspected for evidence of late thrombosis. The anastomoses were resected for histopathological evaluation. Flap success was compared between groups using chi-squared analysis. Eleven of 16 flaps failed (69%) in group I, and 3 of 15 flaps failed (20%) in each of groups II, III, and IV. Statistical significance was reached in comparing group I with the other three groups (p < 0.01). All failures in group I were caused by immediate venous thrombosis. The other failures were secondary to arterial thrombosis. Histopathological analysis failed to demonstrate any differences between the groups. According to these results, arterial repair followed by clamp release prior to the completion of the venous repair results in a low success rate, probably secondary to venous stasis within the draining vein while the venous anastomosis is being completed. If the arterial repair is performed first, then it is recommended that the arterial clamp be maintained until the venous repair is completed. If the vein is repaired first, then it can be clamped or unclamped with similar results.

Aesthetic management of the breast following explantation: evaluation and mastopexy options.

This retrospective study reviews 720 patients referred for evaluation of their silicone gel-filled breast implants from December of 1992 to January of 1996. Of the 720 patients evaluated, 282 (39.2 percent) subsequently underwent explantation, and 59 of these patients (20.9 percent) had a breast contouring procedure performed at the time of explantation. Our definition of explantation is the operative removal of the implant as well as the implant capsule. The overall complication rate for explantation was 5 out of 282 patients (1.8 percent), whereas the rate of complication among the patients who underwent simultaneous breast contouring was 2 out of 59 patients (3.4 percent). This article presents the management of the breast following explantation, implant removal, and capsulectomy. We review both the preoperative assessment of patients seeking explantation and our technique of explantation. Additionally, we address the importance of preoperative breast ptosis in technique selection and have developed a practical clinical algorithm for guiding simultaneous explantation and breast contouring. We also identify those patients who should undergo delayed breast contouring due to associated risk factors (smoking, need for > 4 cm of nipple movement, and paucity of breast parenchyma).

Vertical mammaplasty: technique and complications.

Vertical mammaplasty is among a group of mammaplasty procedures designed to minimize the extent of skin excision, and thus the potential for aesthetically unpleasing scars. However, these less traditional techniques have not enjoyed the same usage as classic inverted-mammaplasties, and thus the accumulated experience in these techniques is less. Vertical mammaplasty can yield excellent results when applied appropriately, but the learning curve can be significant. Details of operative technique are presented along with potential compfications, with the objective of maximizing the safety and outcome of vertical mammaplasty.

A new experimental model: the vascular pedicled cutaneous flap over the mid-dorsum of the rat.

The cutaneous vascular anatomy of the mid-dorsum in the rat and its role in flap design was studied in the rat. The investigation consisted of anatomic dissection, methylene blue injection into the axial artery, and flap harvesting in live animals. Dissection and injection revealed that the mid-dorsum of the rat derives its blood supply largely from the 10th intercostal artery, here referred to as the middle dorsal artery, which originates from the lateral aspect of the thoracic aorta. The cutaneous vascular territory of the middle dorsal artery was defined as follows: the medial border, midline of the dorsum; the lateral border, midaxillary line; the cephalic border, a line joining the medial and lateral borders midway between the level of the axilla proximally and 1 cm above the base of the rib cage distally; and the caudal border, a line drawn midway between the latter point proximally and the anterior superior iliac spine distally. Both unilateral and bilateral vascular pedicled island cutaneous flaps were harvested in living rats based on and exceeding the vascular territory delimited by methylene blue injection. Flaps limited to this territory with intact middle dorsal arteries showed total survival, while oversized flaps underwent partial necrosis peripherally. Because of its simplicity, reliability, and consistent vascularity, this flap has potential applications in the study of flap hemodynamics.

Timing, magnitude, and utility of surgical delay in the TRAM flap: I. Animal studies.

Surgical delay is an effective technique, but the precise timing of the delay effect and the required extent of the delay procedure are uncertain. We endeavored to study flap survival as a function of the duration of the delay period in a rat transverse rectus abdominis myocutaneous (TRAM) flap model. Two specific delay procedures (limited and extensive) were utilized, and flap survival was assessed after delay periods of 3, 7, 10, 14, 21, and 30 days (n > or = 7, all groups). A delay of 7 days or greater resulted in statistically significant improvement in flap survival in all groups. The delay effect appeared to be maximal at 14 days, and in the extensive delay group, a 14-day delay resulted in statistically greater flap survival than a 7-day delay. Improvement in flap survival was greater when an extensive delay procedure was used. Although the model system has limitations, the rat TRAM flap appears to be a suitable model for the study of the delay phenomenon. Possible clinical correlations are addressed in part II.

Timing, magnitude, and utility of surgical delay in the TRAM flap: II. Clinical studies.

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction was performed in 15 patients 1 week after a preliminary delay procedure. The indications for surgical delay were obesity, smoking, prior radiation therapy, a requirement for large volumes of transmidline tissue, or combinations of these risk factors. The delay procedure consisted of outpatient ligation of the deep and superficial inferior epigastric vessels. Prior to and 1 week following the delay procedure, noninvasive Doppler examinations of the superior epigastric vessels were performed. Following the delay procedure, the diameter of the superior epigastric artery increased from 1.3 +/- 0.2 to 1.8 +/- 0.3 mm (p < 0.001) and the calculated superior epigastric artery flow increased from 7.25 +/- 0.8 to 18.2 +/- 2.7 ml/min (p < 0.001). Breast reconstruction in these high-risk patients was successful without major ischemic complications, but a tendency toward unreliability of zone IV was noted. This clinical observation is consistent with the findings in our animal studies (part I). The preliminary delay procedure was well tolerated with minimal morbidity. We feel that a preliminary delay procedure is a very useful option for breast reconstruction patients at high risk for TRAM flap vascular compromise.

Surgical delay in TRAM flap breast reconstruction: a comparison of 7- and 14-day delay periods.

Thirty-one transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstructions were performed after a delay period either of 1 week (group I, N = 15) or 2 weeks (group II, N = 16). The preliminary delay procedure consisted of bilateral deep inferior epigastric and superficial inferior epigastric artery and vein ligation. In group I the diameter and flow in the superior epigastric artery increased from baseline values of 1.3 +/- 0.3 mm and 7.25 +/- 0.8 ml per minute to 1.8 +/- 0.3 mm and 18.2 +/- 2.7 ml per minute at 1 week. In group II the diameter and flow in the superior epigastric artery increased from baseline values of 1.2 +/- 0.3 mm and 5.85 +/- 1.5 ml per minute to 1.7 +/- 0.4 mm and 23.4 +/- 6.2 ml per minute at 2 weeks. The differences between 1 and 2 weeks were not statistically significant. The complication rate in either group was similar. We conclude that a preliminary delay procedure is highly effective at augmenting TRAM flap vascularity and may be implemented between 1 and 2 weeks prior to TRAM flap breast reconstruction in high-risk patients.

Distal dorsal forearm flap.

The goal of this study was to investigate the vascular supply of the distal dorsal forearm and the feasibility of using a local skin flap based on perforating vessels of the anterior interosseous artery (AIA) to reconstruct the dorsal aspect of the hand. The results of anatomic studies on 71 adult, fresh-frozen cadaveric upper extremities indicate that a new flap can be designed based on a cutaneous branch of the AIA. The AIA runs along the volar surface of the anterior interosseous membrane. At the proximal border of the pronator quadratus muscle it gives off a dorsal septocutaneous branch (DSCB) that pierces the interosseous membrane and supplies the extensor muscles of the thumb and the skin of the distal two-thirds of the dorsal forearm. The average artery diameter at the origin of the DSCB was 1.1 +/- 0.2 mm (mean +/- standard error of mean). The mean pedicle length was 3.1 +/- 0.6 cm. The pedicle could be extended to 12.4 +/- 0.9 cm if the entire AIA was included. Based on dye injection studies, the smallest skin paddle that could be supported by this vessel ranged from 5 x 9 cm to 8 x 15 cm. The flap can be configured as an island vascular flap based on the DSCB or AIA, a distally based flap, a free flap, a fascial flap, or a composite flap including muscle, bone, nerve, and skin.