Carbon dioxide laser treatment for lentigo maligna: a retrospective review comparing 3 different treatment modalities.

OBJECTIVE: To assess outcomes in managing primary lentigo maligna through surgical excision, radiation therapy, and carbon dioxide laser ablation. METHODS: Retrospective case series review of all patients with primary lentigo maligna diagnosed and treated in London, Ontario, Canada, between July 2, 1991, and June 29, 2010. RESULTS: Seventy-five patients aged 39 to 93 years (mean age, 64.8 years) were included in the study; 73 patients chose treatment. Twenty-seven patients were treated with surgical excision, 31 patients with radiation therapy, and 15 patients with carbon dioxide laser ablation. The median follow-up times were 16.6 months for surgical excision, 46.3 months for radiation therapy, and 77.8 months for carbon dioxide laser ablation (P < .001). Recurrence rates by treatment modality were 4.2% (1 of 27) for surgical excision, 29.0% (9 of 31) for radiation therapy, and 6.7% (1 of 15) for carbon dioxide laser ablation. CONCLUSIONS: A trend toward lower recurrence rates with surgical excision and carbon dioxide laser ablation was identified, but the results were not statistically significant. Carbon dioxide laser ablation may have a role as an alternative treatment for lentigo maligna among patients in whom standard treatments, such as surgical excision and radiation therapy, are declined or carry significant morbidity.

Intra-lesional interleukin-2 for the treatment of in-transit melanoma.

PURPOSE: To investigate the role of intra-lesional interleukin-2 (IL-2) injection for treatment of in-transit melanoma metastases. METHODS: Consecutive patients with in-transit metastases were treated with intra-lesional IL-2 injections. Two independent observers evaluated response to treatment using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria. A blinded pathologist confirmed clinical response with post-treatment biopsies. RESULTS: Thirty-nine patients were included. Patients received biweekly IL-2 injections. At each treatment session, a mean of 2.08 ml (5 µ/ml) of IL-2 were distributed amongst a mean of 12 (range 1-57) in-transit lesions. Patients were followed for an average of 30.4 months (range 2.2-66.6 months). The overall patient response rate was 82%. A complete response was obtained in 20 patients (51%), a partial response in 12 (31%), and no response in seven (18%). Of the 629 in-transit metastases, 479 (76%) completely resolved. Complete responders had a significant in transit-free (P = 0.0005) and an overall (P = 0.012) survival advantage compared with partial responders. CONCLUSIONS: The treatment of in-transit metastatic melanoma with intra-lesional IL-2 resulted in a 76% percent clearance of lesions. Complete response is associated with superior in transit-free and overall survival when compared with partial response.

Acquisition of evidence-based surgery skills in plastic surgery residency training.

INTRODUCTION: The teaching and learning of critical appraisal skills and evidence-based practices by surgical residents has been identified as an unmet need in many surgical training programs. METHODS: Monthly journal clubs over a calendar year were the setting for a critical appraisal curriculum. Preassigned homework assignments and carefully selected articles with specific methodologies were posted electronically and formed the course material. Pretests and posttests on medical statistics and methodology were administered. Presurveys and postsurveys on attitudes toward evidence-based surgery (EBS) were administered. RESULTS: Precourse surveys revealed a lack of confidence in residents' knowledge of epidemiology and biostatistics, with an increase in confidence postcourse (2.6 vs 2.9; p = 0.4). Precourse and postcourse, there was strong support for more critical appraisal training in residency (5.1 vs. 4.8; p = 0.1) and an agreement that understanding evidence-based practices is important for the clinical practice (4.6 vs. 4.6; p = 0.4) as well as the research endeavors of a plastic surgeon (5.4 vs. 5.5; p = 0.8). Pretest scores, when compared with PGY level, showed an increase in knowledge with increasing PGY level (p = 0.6). Average pretest scores were 6.5 of a total of 15 points, or 43%. Posttest scores were improved, at 7.8 of 15, or 52% (p = 0.6). Sixty-four percent of learners felt that journal club was a good venue for teaching critical appraisal skills precurriculum. Fifty percent of learners were still of that impression at course completion (p = 0.3). The modest improvement in test scores indicates an impact on critical appraisal skills, but reliance on journal clubs to teach these skills is insufficient. CONCLUSIONS: Through monthly journal clubs and self-directed assignments, critical appraisal skills were improved across PGY levels in an academic surgical training program; however, other settings and methods of teaching are required to augment a curriculum in evidence-based surgery.

A new, validated instrument to evaluate competency in microsurgery: the University of Western Ontario Microsurgical Skills Acquisition/Assessment instrument [outcomes article].

BACKGROUND: The authors present a model for microsurgery learning as well as a validated instrument to evaluate microsurgical competency. METHODS: Novice microsurgeons participated in three 3-hour sessions wherein they completed a number of increasingly complex, standardized microsurgical tasks. Performance was recorded and graded using a newly developed University of Western Ontario Microsurgery Skills Acquisition/Assessment (UWOMSA) instrument. The knot-tying and anastomosis modules contained three categories with five-point Likert scales. Each learner's performance was assessed by two blinded surgeons. Reznick's validated global rating scale for operative performance was utilized to establish criterion validity. Within-scale scores were compared via intraclass correlation and between-scale scores with Pearson correlation coefficient. Linear regression was used to evaluate the effect of various predictors on UWOMSA scores. RESULTS: Thirty-seven videos (9.6 hours) were reviewed, including 20 knot-tying sessions and 17 anastomoses. Interrater reliability of UWOMSA was high, with an intraclass correlation coefficient of 0.75 (0.57, 0.87). The intraclass correlation of the global rating scale was 0.79 (0.62, 0.89). Intrarater reliability of the UWOMSA was also high, with an intraclass correlation of 0.69 (0.48, 0.83). The intraclass correlation of the global rating scale was 0.69 (0.47, 0.84). Measures of criterion validity demonstrated strong agreement between UWOMSA and the global rating scale (Pearson correlation coefficient, 0.96; p < 0.001). Measures of construct validity demonstrated that higher scores on the UWOMSA were associated with faster knot tying (p < 0.0001) and higher postgraduate year level (p = 0.05). CONCLUSIONS: The UWOMSA instrument performed well in terms of reliability and validity. Further study is planned to assess the instrument's ability to predict microsurgical skills translation to the clinical setting.

Obtaining high cure rates for challenging facial malignancies: A new method for producing rapid, accurate, high-quality frozen sections.

PURPOSE: The authors developed a new system to provide rapid, accurate, full-face frozen sections. OBJECTIVE: To evaluate the efficacy of the system when applied to the treatment of nonmelanoma cutaneous malignancies using Mohs micrographic surgery (MMS). METHODS: Patients undergoing MMS procedures between 2003 and 2007 for nonmelanoma head and neck cutaneous malignancies were prospectively collected. Specimens were prepared either in a traditional cryostat-based manner or using the new system. RESULTS: A total of 196 patients with 234 head and neck nonmelanoma cutaneous malignancies were included. The majority of tumours were basal cell carcinomas (89.5%). Of these, 38% demonstrated aggressive histologies (sclerosing or micronodular), and 30% were recurrent. On average, two levels (range one to six) and four blocks (range two to 23) were required to obtain clear margins. The mean defect size was 3.68 cm(2) (range 0.13 cm(2) to 37.68 cm(2)). Over the five-year study period, there were two recurrences in 234 cases (less than 1%), which compares favourably with other MMS series. The new system was associated with a shorter operative time than traditional specimen preparation (102 min versus 131 min; P=0.004). The new and traditional specimen preparation groups were similar in terms of the number of previous recurrences (29% versus 30%; P=1.00), defect size (3.7 cm(2) versus 4.0 cm(2); P=0.81) and the number of levels required (1.9 versus 1.5; P=0.05). CONCLUSIONS: The new system enables fast, accurate, full-face frozen section specimens that are ideal for MMS. The speed of specimen preparation is demonstrated by faster operative times, and a low recurrence rate attests the accuracy and quality of the sections.

A primer in meta-analysis for the plastic surgeon.

Meta-analyses are useful tools for clinicians to remain current in their field of study. Meta-analyses are used to gain statistical power through the pooling of results from multiple smaller studies. As the highest level of evidence is considered meta-analysis of high-quality randomized-controlled trials, it is important that the plastic surgeons understand the methodology behind a meta-analysis-herein lies the goal of this article.

Refining perforator selection for DIEP breast reconstruction using transit time flow volume measurements.

Transit time flow volume has been used in cardiac surgery to assess small vessel flow characteristics. This study examines the usefulness of transit time flow volume (TTFV) in assessing perforator vessels in deep inferior epigastric artery perforator (DIEP) flap harvesting. The purpose of this study was to evaluate the correlation among computed tomographic angiography (CTA), intraoperative TTFV measurements, and hand-held Doppler signals in identifying perforators. Ten consecutive free DIEP breast reconstructions were prospectively evaluated using CTA to identify abdominal wall perforators. Intraoperatively, perforating vessels >1 mm in diameter were evaluated with a conventional hand-held 8-MHz Doppler and a TTFV measurement device. Vessel location was correlated with preoperative CTA . Waveform patterns and TTFV measurements were recorded for each vessel and correlated with both CTA and hand-held Doppler signals. Of the 54 perforators identified, TTFV showed arterial flow waveforms in 15 of 16 perforators identified by CTA and in 2 of the remaining 38 vessels. The sensitivity and specificity of TTFV in identifying arterial perforators were 94 and 95%, respectively. In contradistinction, hand-held Doppler was misleading in 70% of vessels. TTFV distinguishes arterial from venous waveforms in vessels that appear arterial by hand-held Doppler signals. CTA and TTFV are highly correlated, and the use of TTFV may prevent poor perfusion seen in some DIEP flaps.

Development of a breast reconstruction satisfaction questionnaire (BRECON): dimensionality and clinical importance of breast symptoms, donor site issues, patient expectations, and relationships.

OBJECTIVES: To develop a valid, reliable and responsive, self-administered questionnaire to assess women's satisfaction with breast reconstruction. METHODS: Item generation: Three sources for item inventory were utilized: focus groups, expert panel, and literature review.Item reduction: Item impact scores were derived from patients and experts each ranking the importance and frequency of each item. Correlation between patient and expert scores was calculated. The highest impact questions were maintained. RESULTS: Four focus groups comprising 20 women generated 515 items, 10 experts developed 171 items, and literature review produced 227 items. These 913 potential items were reduced to 183 by combining redundancy. The 183 items underwent formal reduction by assessing importance and frequency of each item. Thirty-two of 40 reconstructed women and 19 of 19 experts responded to the mail-out. Seventy-seven items of the women's top 100 also made the experts' top 100 list. Intraclass correlation between patients and experts was 0.71 [0.62 0.77], indicating "good" but not "excellent" agreement, reinforcing the importance of patient involvement in questionnaire development. Women rated abdominal donor site issues higher than experts, and experts rated breast softness and symmetry higher than women. CONCLUSIONS: A 100-item pilot questionnaire for breast reconstruction satisfaction was developed for psychometric testing.

Factors affecting surgical wait times for breast reconstruction.

OBJECTIVE: To examine factors that affect wait times for women seeking breast reconstruction at a Canadian academic centre. METHODS: A retrospective audit of 57 women seeking breast reconstruction over a three-year period was completed. Comparisons of wait times were made considering the surgical pathology, timing of reconstruction (immediate versus delayed), urgency of pathology, method of reconstruction (implant versus autologous) and the number of surgeons involved. Specifically, the wait times from referral to specialist consultation, consultation to surgery, and referral to surgery were examined. RESULTS: WOMEN WITH ACTIVE CANCER (DUCTAL CARCINOMA IN SITU: 43 days, invasive cancer: 40 days) had shorter wait times compared with those who had no active cancer (benign/high risk: 242 days, previously treated cancer: 343 days) (P<0.05). Women seeking delayed reconstruction had longer wait times (359 days) from referral to surgery than women seeking immediate reconstruction (98 days) (P<0.0001). Women seeking reconstruction at the time of mastectomy, with benign/high-risk disease, waited longer (242 days) than those with ductal carcinoma in situ (43 days) or invasive cancer (40 days) (P<0.001). Wait times for autologous free tissue transfer (213 days) were not significantly longer compared with implant reconstruction (116 days) (P=0.27). Women with acute cancer experienced similar wait times for implant reconstruction (44 days) as for a free tissue transfer (56 days) (P=0.46). Women with no acute cancer had similar wait times for implant (239 days) as free tissue transfer (369 days) (P=0.25). Patients requiring only plastic surgeons involved in the reconstructive effort waited longer (one surgeon: 299 days, two surgeons: 550 days) than patients requiring either two plastic surgeons and one general surgeon (130 days) or one plastic surgeon and one general surgeon (82 days) (P<0.05). Although more coordination is required with three surgeons, this is frequently associated with a diagnosis of acute cancer and, therefore, wait times are shorter.

Sensibility following innervated free TRAM flap for breast reconstruction: Part II. Innervation improves patient-rated quality of life.

BACKGROUND: Restoring sensory innervation may be a useful adjunct in free flap head and neck reconstruction but, as yet, has not been shown to improve outcomes of breast reconstruction. The authors' previous study demonstrated objectively improved sensation in a group of innervated transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction patients relative to noninnervated flaps. This study compared patient-rated outcomes of free TRAM breast reconstruction in innervated versus noninnervated flaps. METHODS: Twenty-seven women were randomized prospectively to undergo either innervated or noninnervated free TRAM flap breast reconstruction. For innervated flaps, the T10 intercostal nerve was harvested with the TRAM flap and neurotized to the T4 sensory nerve at the recipient site. Three validated outcome tools were administered after surgery: the Medical Outcomes Study 36-Item Short Form Health Survey, the Body Image after Breast Cancer Questionnaire, and the Functional Assessment of Cancer Therapy-Breast. Results were correlated with previously reported objective sensibility outcomes. RESULTS: Eighteen of 27 women returned their questionnaires a mean 48 months after free TRAM flap reconstruction. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola complex reconstruction between randomized patient groups. There was a statistically significant improvement in all three measures in patients who were randomized to receive innervated free TRAM flaps compared with those receiving noninnervated flaps. CONCLUSION: This study demonstrates that innervation of free TRAM flaps used for breast reconstruction not only improves sensibility but also has a positive effect on patient-rated quality of life.

Immediate postmastectomy reconstruction is associated with improved breast cancer-specific survival: evidence and new challenges from the Surveillance, Epidemiology, and End Results database.

BACKGROUND: Although immediate breast reconstruction is increasingly offered as part of postmastectomy psychosocial rehabilitation, concerns remain that it may delay adjuvant therapy or impair detection of local recurrence. No single population-based study has examined the relationship between immediate breast reconstruction and breast cancer-specific survival. METHODS: By using data from the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registries, breast cancer-specific survival was compared for female unilateral mastectomy patients who did or did not undergo immediate breast reconstruction. Cox proportional hazards models were fitted, adjusting for known demographic and disease severity variables and stratifying on reconstruction type (implant or autologous) and age. RESULTS: Improved breast cancer-specific survival was observed among all immediate breast reconstruction patients compared with patients who underwent mastectomy alone (hazard ratio [HR]=0.74; 95% confidence interval [CI], 0.68 to 0.80). Implant reconstruction patients below 50 years of age demonstrated the greatest apparent survival benefit (HR=0.47; 95% CI 0.28 to 0.80). Similarly, autologous reconstruction was associated with improved cancer-specific survival among patients below the age of 50 (HR=0.58; 95% CI, 0.42 to 0.80) and between ages 50 to 69 (HR=0.61; 95% CI, 0.43 to 0.85). CONCLUSIONS: Immediate breast reconstruction is associated with decreased breast cancer-specific mortality, particularly among younger women. We believe this association is more likely attributable to imbalances in socioeconomic factors and access to care than to inadequate adjustment for tumor characteristics and disease severity. Further research is needed to identify additional prognostic factors responsible for the improved cancer survival among women undergoing immediate postmastectomy reconstruction.

Topical imiquimod therapy for lentigo maligna.

Lentigo maligna (LM) presents a challenge for complete surgical excision. Imiquimod is a topical immune-response modifier that acts on the immune system. We report our experience using imiquimod 5% cream as a surgical alternative for treatment of LM. Consecutive patients between December 2004 and February 2006 with LM were treated with topical imiquimod. Data on patient and lesion characteristics, side effects of therapy, posttreatment biopsy results, and follow-up was collected. Seven patients were treated with imiquimod 5 nights/wk for 12.4 weeks. Complete histologic and clinical resolution was seen in 86% (6 of 7 patients), at 19.1 months follow-up. Side effects included erythema (86%) and crusting (71%), resulting in dose alteration in 71% of patients. Topical imiquimod therapy demonstrates a high response rate for treatment of LM, with tolerable side effects. Further investigation into its efficacy in the treatment of LM in controlled clinical trials is warranted.

The role of the randomized controlled trial in plastic surgery.

This article discusses the role of the randomized controlled trial (RCT) in plastic surgery. There are unique challenges in the execution of an RCT in plastic surgery, including: (1) surgical equipoise, (2) the surgical learning curve, (3) differential care, (4) randomization, (5) concealment, (6) expertise-based design, (7) blinding, (8) intention-to-treat analysis, (9) loss to follow-up, and (10) treatment effect and implications for sample size calculations. The RCTs conducted in plastic surgery to date are generally of poor quality in design and reporting, are fraught with bias, and have small sample sizes, thus this article attempts to help future investigators perform better quality RCTs.

Minimizing morbidity in the treatment of penile melanoma: Mohs micrographic surgery and sentinel lymph node biopsy.

The combination of Mohs micrographic surgery and sentinel lymph node biopsy in the treatment of penile melanoma is novel. Mohs surgery allows the removal of penile malignancies with microscopically controlled tumor-free borders, while maintaining cosmetic and functional demands through the maximal preservation of normal tissue. Sentinel lymph node biopsy minimizes the morbidity associated with inguinal node dissection. At 30 months follow-up, these two modalities together have achieved local control and regional nodal staging while minimizing functional morbidity.

Long-term limb allograft survival using a short course of anti-CD45RB monoclonal antibody, LF 15-0195, and rapamycin in a mouse model.

BACKGROUND: The purpose of this study was to determine if a short course of monoclonal antibody (mAb) against CD45RB, LF 15-0195, and rapamycin would achieve long-term survival by inducing tolerance in a mouse limb transplant model. METHODS: Group 1 (n=9) consisted of nine isogenic (C57BL/6) transplants. Group 2 (n=3) included C57BL/6-to-BALB/c transplants receiving no drug therapy. Group 3 mice (n=4) were treated with mAb (3 mg/kg) and LF (2 mg/kg), and Group 4 (n=13) was treated with mAb, LF, and rapamycin (2 mg/kg). Both treatment groups received drug treatment for only 14 days posttransplantation. Animals were sacrificed if they displayed evidence of rejection or when deemed to be tolerant (defined as >day 100). RESULTS: All isografts had normal histology and graft function on day 100. Untreated C57BL/6-to-BALB/c allografts developed acute rejection within 10 days. The combination of mAb and LF prolonged allograft survival to a mean of 39+/-7 days. In Group 4, two animals had to be sacrificed at days 28 and 76 due to acute urinary retention. Transplant tolerance was achieved in 8 of the remaining 11 animals with a mean survival time of 100+/-12 days. Donor specific tolerance was demonstrated through permanent acceptance of skin grafts from the donor strain and rejection of skin grafts from C3H mice. Three Group 4 animals showed clinical and histological signs of mild, chronic rejection. Dendritic cells isolated from tolerant recipients exerted a suppressive effect in mixed lymphocyte reaction. CONCLUSION: A short course of anti-CD45RB mAb and LF 15-0195 prolonged limb allograft survival. The addition of rapamycin induced limb allograft tolerance which is associated with the generation of tolerogenic dendritic cells that suppressed T-cell proliferation.

Mohs micrographic surgery in the treatment of lentigo maligna and melanoma.

BACKGROUND AND OBJECTIVES: The treatment of lentigo maligna (LM) and lentigo maligna melanoma (LMM) is challenging due to lesion location, size, patient age, and potential for recurrence and spread. The largest studies to date confirm that for melanocytic tumours, MMS provides high local control rates while minimizing tissue loss. Herein we report our local control rate for melanoma treated by MMS over a decade. METHODS: Charts were reviewed on all patients with melanocytic tumors treated by a single physician (JPA) using MMS over the time period of 1993-2002. Demographic, surgical and pathological details were recorded. Patients were followed for local, regional and distant recurrences. RESULTS: The patient population was comprised of 199 patients with 202 melanomas. There were 69 invasive lesions, with a mean Breslow depth of 0.92 mm (0.2-3.6 mm). The mean number of levels required to clear the lesions was 2.7 (1-7), resulting in a mean defect size of 11.8 cm2 (0.9-70.7 cm2). Patients with LMM were significantly older (73.2 vs. 66.5 yrs, p = 0.012) and had larger defects after MMS (16.74 cm2 vs. 10.27 cm2) than patients with LM. At a mean follow-up of 29.8 months, there were no local recurrences, four regional recurrences, and two distant recurrences. CONCLUSION: MMS is an effective modality for the clearance of melanocytic tumors.

Role of the metal oxidation state in the SNS-Cr catalyst for ethylene trimerization: isolation of di- and trivalent cationic intermediates.

The reaction of the highly selective [CySCH2CH2N(H)CH2CH2SCy]CrCl3 catalyst precursor with alkyl aluminum activators was examined with the aim of isolating reactive intermediates. Reaction with Me3Al afforded a cationic trivalent chromium alkyl species {[CySCH2CH2N(H)CH2CH2SCy]CrMe(mu-Cl)}2{(AlMe3)2(m-Cl}2.(C7H8)2 (1a). Although it was not possible to obtain crystalline samples of sufficient quality from the reaction with MAO (the most preferred activator), the near-to-identical EPR spectra indicated a very close structural similarity with 1a. Ethylene oligomerization tests clearly revealed that 1 and other cationic trivalent dimeric complexes {[CySCH2CH2N(H)CH2CH2SCy] CrCl(mu-Cl)}2{AlCl4}2.(C7H8)1.5 (2), monomeric [(CySCH2CH2N(H)CH2CH2SCy)CrCl2 (THF)][AlCl4] (3), and {[CySCH2CH2N(H)CH2CH2SCy]Cr(eta2-AlCl4)}{Al2Cl7} (4) adducts display the same catalyst selectivity as the [CySCH2CH2N(H)CH2CH2SCy]CrCl3 complex and, therefore, are probably all precursors to the same catalytically active species. 2, 3, and 4 were obtained upon treatment of [CySCH2CH2N(H)CH2CH2SCy] CrCl3 with different stoichiometric ratios of AlCl3.. When i-BAO activator was used, reduction of the metal center occurred readily, affording {([CySCH2CH2N(H)CH2CH2S Cy]Cr)(mu-Cl)]2}{(i-Bu)2AlCl2}2 (5). 5 is also a selective catalyst, thus indicating that trivalent species are most probably precursors to a divalent catalytically active complex. Reaction of CrCl2(THF)2 with the ligand afforded the labile divalent adduct [CySCH2CH2N(H)CH2CH2SCy]CrCl2(THF) (6), also catalytically active and selective. Instead, deprotonation of the ligand with n-BuLi followed by reaction with CrCl2(THF)2 gave the dinuclear complex [(mu-CySCH2CH2NCH2CH2SCy)CrCl]2 (7), which did not produce oligomers.

Sensibility following innervated free TRAM flap for breast reconstruction.

BACKGROUND: The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast. METHODS: Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern. RESULTS: Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout. CONCLUSIONS: Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.