Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.

The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.

Synchronous elective contralateral mastectomy and immediate bilateral breast reconstruction in women with early-stage breast cancer.

BACKGROUND: The role of elective contralateral mastectomy (ECM) in women with early-stage breast cancer who elect or require an ipsilateral mastectomy and desire immediate bilateral breast reconstruction (IBR) is an intellectual and emotional dilemma for both patient and physician. In an attempt to clarify the rationale for this approach, we reviewed our experience with ECM and IBR and evaluated operative morbidity, the incidence of occult contralateral breast cancer, and patterns of recurrence. PATIENTS AND METHODS: We retrospectively reviewed the records of 155 patients with primary unilateral breast cancer (stage 0, I, or II) and negative findings on physical and mammographic examinations of the contralateral breast who underwent ipsilateral mastectomy and simultaneous ECM with IBR between 1987 and 1995. RESULTS: The median age of the patients was 46 years (range, 25 to 69 years). Clinical stage at diagnosis was stage 0, I, and II in 19.4%, 54.2%, and 26.4% of patients, respectively. Factors likely to influence the use of ECM were family history of breast cancer in first-degree relatives (30%), any family history of breast cancer (56%), difficulty anticipated in contralateral breast surveillance (48%), associated lobular carcinoma in situ (23%), multicentric primary tumor (28%), significant reconstructive issues (14%), and failure of mammographic identification of the primary tumor (16%). Skin-sparing mastectomies were performed in 81% of patients. Overall, 70% of patients underwent reconstruction using autogenous tissue transfer. Reoperations for suspected anastomotic thrombosis were performed in seven patients. Two patients experienced significant partial or complete flap loss. Histopathologic findings in the ECM specimen were as follows: benign, 80% of patients; atypical ductal hyperplasia, 12% of patients; lobular carcinoma in situ, 6.5% of patients; ductal carcinoma in situ, 2.7% of patients; and invasive carcinoma, 1.3% of patients. Eighteen patients (12%) had evidence of locoregional or distant recurrences, with a median follow-up of 3 years. In one patient (0.6%), invasive ductal carcinoma developed on the side of the elective mastectomy. CONCLUSIONS: The use of ECM and IBR cannot be justified if the only oncologic criterion considered is the incidence of occult synchronous contralateral disease. However, in a highly selected population of young patients with a difficult clinical or mammographic examination and an increased lifetime risk of developing a second primary tumor, ECM and IBR is a safe approach.

Second free flaps in head and neck reconstruction.

Over the past decade, free-tissue transfer has greatly improved the quality of oncology-related head and neck reconstruction. As this technique has developed, second free flaps have been performed for aesthetic improvement of the reconstructed site. This study evaluated the indications for and the success of second free flaps. Medical files for patients who underwent second free flaps for head and neck reconstruction at the University of Texas M.D. Anderson Cancer Center, from May 1, 1988 to November 30, 1996, were reviewed. The flaps were classified as being either immediate (done within 72 hr) or delayed (done within 2 years) reconstructions. Indications, risk factors, recipient vessels, outcome, and complications were analyzed. Of the 28 patients included in this study, 12 had immediate (nine as salvage after primary free flap failure, and three for reconstruction of a soft-tissue defect), and 16 had delayed second free flaps (two for reconstruction of a defect resulting from excision of recurrent tumors, and 14 for aesthetic improvement). Reconstruction sites included the oral cavity in 18 patients; the midface in six; the skull base in two; and the scalp in two. The success rate for the second free flaps was 96 percent. Five patients had significant wound complications. In a substantial number of cases, identical recipient vessels were used for both the first and second free flaps. The authors conclude that second free flaps can play an important role in salvaging or improving head and neck reconstruction in selected patients. In many cases, the same recipient vessels can be used for both the first and second flaps.

Reconstruction of complex radiation-induced injuries using free-tissue transfer.

The purpose of this study was to evaluate the use of free-tissue transfers for the reconstruction of radiation-induced complex injuries. The case files for patients who underwent reconstruction for radiation-induced injuries between May 1988 and November 1995 at The University of Texas M.D. Anderson Cancer Center were retrospectively reviewed. Thirty patients in whom 33 free flaps were done were included. Radiation-induced defects were located in the head and neck (n=23), extremities (n=4), chest wall (n=2), and inguinal area (n=1) The mean period between irradiation and injury was 78 months (range: 4 months to 38 years). Free-tissue transfer was successful in 97 percent (32/33) of patients. The overall complication rate was 40 percent (12/30). Flap donor sites included the fibula (n=12), latissimus dorsi (n=6), rectus abdominis (n=6), iliac crest (n=4), scapula (n=3), and radial forearm (n=2). Large-caliber vessels in the cervical, axillary, or inguinal regions were most commonly used to revascularize flaps. Vein grafts were used in five cases for the artery (2/5) or vein (3/5). Pedicle thrombosis occurred in three cases in recipient vessels located within the irradiated field. Two flaps were salvaged; one was lost, and the patient required a second free-flap reconstruction The mean follow-up was 40 months (range: 2.5 to 83 months). The disease-free survival rate was 67 percent (20/30), local failures occurred in 10 percent (3/30) of patients, and 23.3 percent (7/30) of patients either died or were lost to follow-up. Healing of radiation-induced wounds may be achieved using free-tissue transfers, but complications are frequent. Large-caliber irradiated vessels may be used to revascularize flaps, but there may be an increased risk of pedicle thrombosis.

Does prior irradiation increase the risk of total or partial free-flap loss?

Answers to the question, "Does previous irradiation of a recipient site interfere with reconstruction by free-tissue transfer?" have been elusive. In an attempt to address that question, all free-flap procedures performed for reconstruction of the breast or of head and neck defects at the University of Texas M. D. Anderson Cancer Center between May 1, 1988 and February 15, 1996 were reviewed. The effects of prior irradiation of the recipient site on the incidence of total flap loss, partial flap loss, and thrombosis were assessed. During the study period, 1384 eligible free-flap reconstructions were performed. Total flap loss and partial flap loss were more common in the 428 flaps transferred to previously irradiated sites than in the patients without previous irradiation, but multiple logistic regression analysis showed that these differences were due to confounding factors. The authors conclude that previous irradiation of flap recipient sites does not statistically significantly affect the rate of partial or total free-flap loss.

A comparison of resource costs of immediate and delayed breast reconstruction.

The resource cost (cost to our hospital) of providing mastectomy plus breast reconstruction was calculated for 276 patients who had received both mastectomy and breast reconstruction at our institution. All patients had completed the entire reconstructive process, including reconstruction of the nipple. The resource costs of providing mastectomy with immediate breast reconstruction were compared with those of mastectomy with subsequent delayed reconstruction. We found that the mean resource cost for the 57 patients who had separate mastectomy followed by delayed breast reconstruction ($28,843) was 62 percent higher than that of mastectomy with immediate reconstruction ($17,801; n = 219, p < 0.001). Similar differences were found when patients were subgrouped by type of reconstruction (TRAM versus tissue expansion and implants), by laterality (unilateral versus bilateral), and by history of preoperative irradiation. We conclude that mastectomy with immediate breast reconstruction is significantly less expensive than mastectomy followed by delayed reconstruction and can potentially conserve resources.

From cadavers to implants: silicon tissue assays of medical devices.

A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels in patients with saline implants or tissue expanders. We have compared these levels with tissue samples from a variety of patients with and without medicinal silicone devices from both the northeast and southwest United States over a 4-year period. All specimens were harvested by a "no touch" technique, non-formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was used to obtain the tissue silicon measurements. Silicon tissue values in cadaveric tissue (n = 20 cadavers; n = 120 specimens) averaged 2.2 mcg/gm of tissue with undetectable silicon levels in over 50 percent of the specimens (range 0 to 45 mcg/gm; median = 0). Silicon levels surrounding port-a-catheter devices (n = 15 patients; n = 15 specimens) averaged 8.04 mcg/gm of tissue (range 0 to 41 mcg/gm; median = 0). Tissue levels in the capsules surrounding saline (n = 10 patients; n = 22 specimens) and silicone implants (n = 31 patients; n = 58 specimens) averaged 292 mcg/gm (range 0 to 1380 mcg/gm; median = 110) and 1439 mcg/gm (range 0 to 9800 mcg/gm, median = 490), respectively. Tissue levels, however, from distant sites (n = 22 specimens) in these same patients were equivalent to the cadaveric nonaugmented values (average = 3.2 mcg/gm; range 0 to 5.8 mcg/gm; median = 2.7). The results imply that there is a continuum of exposure to silicone medical devices based on the mechanical properties of silicone. The data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicone exposure a person has over his or her lifetime. It is our hope that these levels will serve as a baseline for our continuing knowledge of implantable medical devices.

Cosmetic saline breast implants: a survey of satisfaction, breast-feeding experience, cancer screening, and health.

Saline breast implants have been used for the past 30 years for cosmetic and reconstructive purposes. Data based on a large number of patients are needed to evaluate patient satisfaction, cancer screening practices, problems associated with breast-feeding, and health effects. We conducted a follow-up study of 292 cosmetic saline breast implant patients from Texas and Louisiana who consented to a telephone interview. Using a Likert scale, we measured the patients' degree of satisfaction with the implants. The results indicated that 80.5 percent were satisfied, 73.3 percent would recommend saline breast implants to others, and 65.1 percent felt that implants improved their quality of life. The extent of satisfaction was independent of the number of additional surgeries, age at implant, and follow-up time. Mammography use and breast self-examination were reported with high frequency in this survey. Ninety-one percent of study participants who were between 40 and 49 years of age at time of interview and 94 percent of those 50 or older reported having had at least one mammogram. Breast self-examination was practiced by 75 percent of the women, and 61 percent reported checking their breasts at least once a month. Of the 46 women who had children after augmentation, 28 reported breast-feeding and 8 (28.6 percent) reported having implant-related problems. The patients were asked to provide information regarding a series of conditions for which they sought medical attention. They reported: atypical rheumatoid syndrome (n = 1), Sjögren syndrome (n = 1), atypical autoimmune disorder (n = 1), and chronic fatigue syndrome (n = 2). Overall, women who elected to have saline breast implants were satisfied with their augmentations, had mammograms and performed breast self-examinations more often than nonaugmented women. A few had problems when breast-feeding that could be related to their implants. There were no reports of breast cancer, but five women reported autoimmune conditions.

Local rotational flaps for breast conservation therapy as an alternative to mastectomy.

BACKGROUND: An anticipated poor cosmetic result has traditionally been deemed a relative contraindication for breast conservation therapy (BCT). We sought to determine whether a local rotational flap could achieve satisfactory cosmesis in patients who were anticipated to have a poor cosmetic result following standard segmental mastectomy but who nevertheless desired BCT. METHODS: Within the past 3 years, nine patients were treated with BCT using local rotational flap techniques. Their records were reviewed for patient characteristics, pre- and postoperative treatment, disease-free status, and patient satisfaction with cosmesis. RESULTS: The cosmetic outcome following a segmental mastectomy was anticipated to be unacceptable due to the following features: a large previous biopsy cavity with unknown or positive margins (three patients); initial large primary tumors with unknown extent of residual disease following induction chemotherapy (five patients); and pre-existing poor cosmesis (one patient). One patient had refused modified radical mastectomy and had satellitosis from inadequately treated primary tumor (excisional biopsy with positive margins and no further therapy). The median initial tumor size was 2.7 cm (range, 1.5 cm to 5.0 cm). Final resection margins were negative in all patients. Postoperative radiotherapy was given in seven patients; one patient did not receive radiotherapy because of a pre-lupus condition and one did not require radiotherapy because her pathologic diagnosis was Paget's disease without an invasive component. Cosmesis was judged to be good to excellent by eight of nine patients. The patient who refused mastectomy was dissatisfied with cosmesis because of mild asymmetry. With a median follow-up of 24 months, only one patient has developed a local recurrence. CONCLUSION: Local rotational flaps composed of adjacent breast tissue are an acceptable method of achieving satisfactory cosmesis in selected patients who desire BCT.

Adjuvant therapy: the effects on microvascular lower extremity reconstruction.

Adjuvant therapy and microsurgery have allowed advances in surgical extirpation of lower extremity neoplasms. This retrospective study was designed to evaluate the microvascular transfer for lower extremity reconstruction in patients receiving pre- or post-operative irradiation and chemotherapy alone and in combination. Over a 5-year period, 24 free tissue transfers were performed in 22 patients undergoing surgical resection with adjuvant therapy for lower extremity neoplasms. There were 13 male and 9 female patients with an average age of 51 years. The latissimus dorsi muscle was most commonly transferred (N = 15). Eighteen tumors received pre- and three received postoperative radiotherapy. Two tumors received a combination of radiotherapy and brachytherapy. Pre- and/or postoperative chemotherapy was used in 14 patients. Twelve of these patients had both chemo- and radiation therapy. A total of six complications occurred, with no flap loss. Complications were evenly distributed among adjuvant regimens. All patients who underwent attempted limb salvage were able to ambulate postoperatively, except for 1 patients who had local recurrence. In conclusion, adjuvant therapy did not increase the complication rate for free tissue transfer in the lower extremity. Adjuvant therapy did not require alterations in the free tissue transfer and, similarly, free tissue transfer did not alter adjuvant therapy. We believe that free tissue transfer in complicated wounds allows for better wound healing with adjuvant therapy rather than local or primary wound closure alone.

Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction.

BACKGROUND: Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT. METHODS: The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result. RESULTS: PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence. CONCLUSIONS: These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.

Comparison of nipple projection with the modified double-opposing tab and star flaps.

This study compared nipple projection after nipple reconstruction (following breast mound reconstruction) with either the modified double-opposing tab flap or the star flap. Areolar reconstruction and pigmentation of the nipple were achieved with tattooing. Nipple projection for 153 nipples was measured at least 6 months after the reconstruction, when projection was believed to have become stable. Mean follow-up was 2.27 years. In the 106 nipples reconstructed with modified double-opposing tab flaps, the mean projection was 2.4292 mm, while in the 47 nipples reconstructed with star flaps, the mean projection was 1.9681 mm (p = 0.021). We conclude that although both methods are effective, the modified double-opposing tab flap has slightly more projection after approximately 2 years. It is not known, however, whether this is because of reduced flap atrophy or longer initial projection by the modified double-opposing tab flap; further studies are ongoing.

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps.

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.

Silicon tissue assay: a measurement of capsular levels from chemotherapeutic port-a-catheter devices.

A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels (n = 15) in capsules that form around chemotherapeutic port-a-catheter devices, which consist of a metal dome encapsuled by silicone. We have compared these levels with previously established silicon levels in augmented breast capsules, distant tissue sites in these same augmented women, and nonaugmented cadaveric tissues from various geographic locations in the United States. All specimens were harvested by a "no touch" technique, not formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was employed to obtain the tissue silicon measurements. Results demonstrated silicon values ranging from nondetectable in 9 patients to as high as 41 micrograms/gm. These values fell in between our cadaveric (0.5 to 6.8 micrograms/gm) and augmented tissue silicon levels (18 to 8700 micrograms/gm). Although the sample size is small and the power of statistical analysis is low, there was no correlation between the patient's silicon level and age, type of cancer, type of chemotherapeutic agent, radiation therapy, or length of time the port-a-catheters were in place. Although detectable levels of silicon identified around port-a-catheter devices were higher than expected, it is impossible to make any conclusions about these levels and the role of a potential collagen-vascular disease. What we have shown, however, is that silicone breast implants may not be the only medical device that can elevate tissue silicon levels. Our data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicon exposure a person has had at a particular time in his or her life. It is our belief that as we identify these tissue silicon levels, they will serve as a baseline and reference for further scientific studies.

Timing of pedicle thrombosis and flap loss after free-tissue transfer.

A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred, when it occurred, and if the timing of thrombosis detection had any relationship to the probability of flap salvage. The overall thrombosis rate was 5.1 percent, and the flap loss rate was 3.2 percent. The majority (80 percent) of thrombi occurred within the first 2 postoperative days. Only 5 thrombi (10 percent) were known to have occurred after the third postoperative day. No flaps that developed thrombosis after the third postoperative day were salvaged successfully. Had flap monitoring been discontinued after the first 3 postoperative days, our results in this series would have been unchanged. Thrombosis of the vein (54 percent) was more common than arterial thrombosis (20 percent) or thrombosis of both artery and vein (12 percent). Almost all purely arterial thrombi (90 percent) occurred before the end of the first postoperative day, whereas 41 percent of all venous thrombi occurred later. We conclude that arterial monitoring is most critical immediately after surgery. Beginning on the second postoperative day, venous monitoring becomes progressively more important to flap success. The cost-effectiveness of postoperative monitoring of free flaps is greatest during the first 2 days, after which it decreases significantly.

Silicon tissue assay: are there intracapsular variations?

In previous studies, we were able to demonstrate baseline non-augmented cadaveric silicon tissue values as well as silicone-augmented breast capsular tissue silicon levels from various geographic locations in the United States. One of the limitations of these previous studies was the potential for intracapsular variations in the silicon level and whether a single measurement would be a valid comparison for the entire breast capsule. This study was then undertaken to measure the variations in tissue silicon levels from multiple sites within each breast capsule sampled. Four patients that underwent silicone breast and three tissue expander explantations were evaluated. All the women had silicone implants for breast augmentation and the placement of tissue expanders for reconstruction following mastectomy. A variety of reasons for explantation were noted. Each of the patient's breast capsules were divided into four quadrants (upper inner, upper outer, lower inner, and lower outer). All samples were harvested in a no-touch technique and were sent for silicon tissue assays. Silicon values ranged from 44 to 9,000 micrograms per gram of tissue and were consistent with our previously measured values. We conclude that random samples of breast capsules reflect the variations within the specimen samples, but can be used to measure elevated silicon values accurately. It is our belief that multiple samples do not need to be taken for each capsule measurement and that a previous potential limitation to the measurements has been eliminated.

Choice of flap and incidence of free flap success.

A review of 854 consecutive free flaps was performed to determine whether the choice of flap used for the reconstruction influenced the probability of a successful outcome. Flaps were grouped into nine categories: rectus abdominis, free transverse rectus abdominis myocutaneous, radial forearm, jejunum, latissimus dorsi, fibula, scapula, iliac crest, and other. There were significant differences among the success rates of different flaps (p < 0.0001). Rectus abdominis-based flaps used for breast or head and neck reconstruction had lower failure rates (0.9 percent) than did non-rectus abdominis flaps (6.6 percent; p < 0.0001). Flaps requiring vein grafts had a higher rate of flap loss (18.4 percent) than did flaps that did not require vein grafts (2.9 percent; p < 0.0001). There was a strong trend favoring survival of flaps without a bone component (compared with osteocutaneous flaps), and a weaker trend favoring survival of flaps in nonobese patients (compared with flaps in obese patients). Smoking, age, and previous irradiation had no significant effect on flap failure rates. Surgeons should consider the flap success rate as one (but not necessarily the most important) factor in choosing the best reconstruction for any individual patient.

Comparison of resource costs of free and conventional TRAM flap breast reconstruction.

Resource costs, which are the costs to the hospital of providing a service, were measured for 154 patients who underwent mastectomy and immediate breast reconstruction with TRAM flaps. Unilateral and bilateral reconstructions were evaluated separately. The resource costs required to perform mastectomy and reconstruction with free TRAM flaps were then compared with those required when conventional TRAM flaps were used. The mean total resource cost in the free TRAM group was slightly higher than in the conventional TRAM group, but the difference was small (4.1 percent) and not statistically significant (p = 0.290). The mean resource cost of performing bilateral mastectomy and reconstruction was higher than that of unilateral mastectomy and reconstruction, but the difference was only 5.0 percent (p = 0.046). This study shows that the cost to an institution of providing breast reconstruction with free TRAM flaps is not significantly higher than that of performing reconstruction with conventional TRAM flaps. Also, our findings show that the resource costs of performing bilateral mastectomy and reconstruction are not much higher than those of treating only one breast.

Unexpected vascular compromise in transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction: a report of two patients.

Although the vascular anatomy of the transverse rectus abdominis musculocutaneous flap has been well described, poor flap perfusion can lead to partial or total flap ischemia. To minimize the potential for flap loss, criteria have been developed to identify those patients who are deemed to be high risk. Some of these high-risk patients include smokers and those with previous abdominal surgery, obesity, and/or poor medical health. Despite our diligence in patient and operative selection, 2 patients with no preexisting risk factors have recently had venous congestion of their transverse rectus abdominis musculocutaneous flap, necessitating a delayed procedure. The cases are presented here and the potential etiology for this venous congestion explored.

Comparison of resource costs between implant-based and TRAM flap breast reconstruction.

Resource costs, as measured by hours of time in the operating room, days of stay in the hospital, and other costs of care, were evaluated for 240 patients who underwent mastectomy with immediate breast reconstruction using either TRAM flaps or breast implants at The University of Texas M. D. Anderson Cancer Center. To make costs comparable, only patients who completed reconstruction of the nipple were included. As expected, the initial resource costs of implant-based reconstruction were much lower than those of TRAM flap reconstruction. After correcting for patients whose reconstructions were unsuccessful and including the costs of surgery subsequent to the initial reconstruction, however, the cost advantage of implant-based reconstruction disappeared. If current trends continue, it is likely that with increased follow-up, the long-term resource costs of implant-based reconstructions will continue to increase, while those of autogenous tissue reconstructions will not. Autogenous breast reconstruction with the TRAM flap therefore appears to be more cost-effective, in terms of time as well as dollars, in the long run than reconstruction based on prosthetic implants.