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Background: The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes., Methods: A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases., Results: Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04)., Conclusions: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States., Methods: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling., Results: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242)., Conclusions: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Abdominoperineal resection is used to treat a variety of colorectal pathologies. Traditionally, the vertical rectus abdominis myocutaneous flap has been most commonly used for reconstruction. Here, we explore the role of the profunda artery perforator (PAP) flap for perineal reconstruction., Methods: A prospectively maintained database was retrospectively analyzed to identify patients who had undergone perineal reconstruction with a pedicled PAP flap. Parameters of interest included age, sex, body mass index, primary diagnosis, comorbidities, and history of radiation, and postoperative complications., Results: Fifteen patients (5 men and 10 women) with a median age of 52 years (interquartile range, 48.5-61.5 years) were included in the study. Median body mass index was 26.3 kg/m2 (interquartile range, 24.0-29.3 kg/m2). Patients underwent abdominoperineal resection for treatment of rectal cancer (n = 9, 60.0%), recurrent anal squamous cell carcinoma (n = 3, 20.0%), and Crohn's disease (n = 3, 20.0%). Twelve patients (80.0%) underwent neoadjuvant radiotherapy. Eight patients (53.3%) experienced a total of 10 complications (2 major and 8 minor). The most common complication was donor (n = 3, 20.0%)/recipient (n = 3, 20.0%) site wound dehiscence. Stable soft tissue coverage was achieved in all patients., Conclusions: The PAP flap provides stable soft tissue coverage of perineal defects with a low donor-site morbidity. This flap should be strongly considered in the reconstructive algorithm when approaching perineal defects., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Reinforcement of the abdominal wall with synthetic mesh in autologous breast reconstruction using abdominal free tissue transfer decreases the risk of bulging and herniation. However, the impact of the plane of mesh placement on donor site complications has not yet been investigated., Methods: We performed a retrospective analysis of 312 patients who had undergone autologous breast reconstruction with muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps or deep inferior epigastric perforator (DIEP) flaps as well as polypropylene mesh implantation at the donor site. Donor site complications were compared among patients with different flap types and different mesh positions including overlay (n = 90), inlay and overlay (I-O; n = 134), and sublay (n = 88)., Results: Abdominal hernias occurred in 2.86% of patients who had undergone MS-TRAM reconstructions and in 2.63% of patients who had undergone DIEP reconstructions. When comparing patients with different mesh positions, donor site complications occurred in 14.4% of patients with overlay mesh, 13.4% of patients with I-O mesh, and 10.2% of patients with sublay mesh (P = 0.68). Abdominal hernias occurred in 4.44% of patients with overlay mesh, 2.24% of patients with I-O mesh, and 2.27% of patients with sublay mesh (P = 0.69). Multivariable logistic regression analysis did not identify a significant association between mesh position and hernia rates as well as wound complications., Conclusions: Our data indicate that the plane of synthetic mesh placement in relation to the rectus abdominis muscle does not impact the rate of postoperative donor site complications in patients undergoing breast reconstruction with MS-TRAM or DIEP flaps., Competing Interests: Conflicts of interest and sources of funding: The authors have no financial disclosures or conflict of interest. The funding of this study was solely institutional., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Sacropelvic resection is the treatment of choice for pelvic bone tumors and can be associated with intraoperative electron radiotherapy (IOERT) to optimize local control of the disease. Reconstruction with flaps also is essential to avoid pelvic complications. There is scarcity of publications evaluating outcomes of reconstructive procedures associated with IOERT., Methods: A prospective study in 53 patients between 2005 and 2018 was performed. Thirty-four patients received IOERT (group I [GI]) and 19 did not (GII). We examined demographic characteristics, tumor pathology, type of resection and volume of surgical specimen, timing of surgery, IOERT doses, postoperative stay, and complications. We used it for reconstruction rectus abdominis, gluteal, omental and gracilis, superior gluteal artery perforator flap, and free flaps., Results: Colonic adenocarcinoma and chordoma were the most frequent tumors. The median (interquartile range) IOERT dose was 1250 (1000-1250) cGy; operating time was 10.15 (8.6-14.0) hours versus 6.0 (5.0-13.0) hours, hospital stay was 37 (21.2-63.0) days versus 26.0 (12.0-60.0) days, and volume of surgical specimen was 480.5 (88.7-1488.0) mL versus 400 (220.0-6700.0) mL in GI and GII, respectively. Operating time was significantly longer in GI (P < 0.03). There were significant positive correlations between operating time, hospital stay, and volume of surgical specimen. Main complications were exudative wounds (50% vs 31.5%), wound dehiscence (41.1% vs 31.5%), and seroma (29.4% vs 26.3%) in GI and GII, respectively. Complications were similar to previous studies with or without radiotherapy., Conclusions: Under a reconstructive approach, IOERT did not harm flap survival nor increased pelvic complications when compared with similar cases without IOERT., Competing Interests: Conflicts of interest and sources of funding: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined., Methods: A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons., Results: There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022)., Conclusions: The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Bulge and hernia may occur after abdominally based breast reconstruction. The purpose of this study is to provide an estimate of the effects that the type of flap used for breast reconstruction (ie, transverse rectus abdominis muscle [TRAM] vs muscle-sparing [MS]-2 TRAM vs DIEP) has on the postoperative development of both abdominal bulge and abdominal hernia, taking into consideration the method of donor site closure (ie, with mesh vs without mesh), based on the available literature. Twenty-eight studies met the inclusion criteria and were included in the systematic review. From these, 9 studies were comparative and suitable for meta-analysis. The results showed that, for unilateral breast reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flap without mesh, MS-2 TRAM flap with mesh, and DIEP flap without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flap without mesh, and TRAM flap with mesh, whereas for bilateral reconstructions, there was no statistically significant difference in hernia/bulge rates in the following techniques: MS-2 TRAM flaps with mesh and DIEP flaps without mesh, and they showed significantly lower hernia/bulge rates compared with TRAM flaps without mesh, TRAM flaps with mesh, and MS-2 TRAM flaps without mesh., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: As the detection of breast cancer in Ghana improves, the incidence of mastectomy has increased and the outcomes have improved. As a secondary result, the need for breast reconstruction is increasing. The cultural hesitation to undergo a mastectomy and live without a breast can be decreased by making breast reconstruction available, cost-effective, and acceptable. Cultural, economic, and technical factors were considered in choosing the best method of breast reconstruction. Discussions, lectures, and cadaver dissections investigated the various reconstructive options. Operative cases were performed using a latissimus musculocutaneous flap, a lower abdominal transverse rectus abdominis myocutaneous (TRAM) flap, and a midabdominal TRAM flap. The midabdominal TRAM was found to be the best choice at Komfo Anokye Teaching Hospital. It is a reliable, robust, well-perfused, single-stage flap that produced excellent patient satisfaction., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction., Methods: The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables., Results: Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate., Conclusions: Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

Purpose: The aim of the study was to provide an applied and digital anatomical basis of acquiring extended deep inferior epigastric perforator (DIEP) flaps for clinical use., Methods: Five formalin-soaked specimens were received red latex injection and dissected by layers. The arteriography using the modified mixture of lead oxide-gelatin was performed on 10 adult cadavers that were serially scanned by a spiral computed tomography. The DIEPs were 3 dimensionally reconstructed by Mimics., Results: The medial row perforators of DIEP arteries are located in the medial 1/third of rectus abdominis muscle, and lateral row perforators in the lateral 1/third of the muscle. The perforators distribute mainly from the upper tendinous intersection of umbilicus to below umbilicus within 8.0 cm, especially 4.0 cm. There are constant diameter 0.8-mm perforators or greater accompanied with nerveswithin this region. The main perforators are shown by fast direct volume rendering (VR) reconstruction method, and 3-dimensional images of DIEPs are acquired by dynamic reconstruction (DR) method. Consecutively, the adjacent perforators can be combined freely and the position and anastomosis of extended branches can be easily observed. The extended DIEP flaps were designed by VR and DR methods., Conclusions: The DIEPs can obtain large extended perforator flaps accompanied with nerves. The perforator close to the umbilicus should be selected while designing the DIEP flap. The 3-dimensional model of extended DIEP flaps can be established conveniently and intuitively by VR and DR methods of Mimics.

Background: This study evaluated health related quality of life and morbidity in patients who had a superiorly based partial rectus abdominis and external oblique (SPREO) flap for lower pole coverage as a component of 2-stage prosthetic breast reconstruction., Methods: A prospective cohort study of patients undergoing immediate and delayed 2-stage breast reconstruction including a SPREO flap for lower pole coverage was conducted. The BREAST-Q and a study-specific questionnaire were used to determine outcomes after this procedure. BREAST-Q questionnaires were completed preoperatively and postoperatively and compared with normative values., Results: BREAST-Q questionnaires were completed by 27 women. The mean patient age was 54.3 ± 9.6 years. Mean BREAST-Q scores improved significantly between preoperative and postoperative time points in Satisfaction with Breasts (preoperative 43.2 ± 26.9, postoperative 66.2 ± 19.5, P = 0.001) and Psychosocial Wellbeing (preoperative 59.4 ± 16.4 postoperative 75.5 ± 19.4, P = 0.002). Mean scores were not significantly different in the domains Physical Wellbeing Chest, Physical Wellbeing Abdomen and Sexual Wellbeing. Postoperative BREAST-Q scores were significantly higher (P < 0.05) than previously published normative scores in Satisfaction with Breasts., Conclusions: This study reports the use of the SPREO flap for lower pole coverage in 2-stage prosthetic breast reconstruction and demonstrates that it may be a useful addition to the existing repertoire of flaps used in breast reconstruction.

Background: The reconstruction of a large postmastectomy chest wall defect for patients with stage III/IV breast cancer is a challenge for plastic surgeons. In this study, we present the application of an extended transverse rectus abdominis myocutaneous (TRAM) flap to easily and safely reconstruct these defects., Patients and Methods: A retrospective review from November 1997 to November 2016 revealed that 65 patients with stage III/IV breast cancer immediately underwent postmastectomy TRAM flap reconstruction. In total, 16 patients were enrolled in this study based on the inclusion criteria of a postmastectomy chest skin defect size of greater than or equal to 100 cm and a TRAM flap size of greater than or equal to 80% of the lower abdominal area for reconstruction., Results: Eleven (68.9%) and 5 patients (31.3%) were diagnosed with stage III and stage IV breast cancer, respectively. The chest wall skin defects ranged from 135 to 440 cm. All flap areas exceeded 80% of the lower abdominal area. Overall, 100% of the harvested flaps were used in 3 patients, and only 1 patient had marginal necrosis in zone IV. No total flap loss was observed. The average length of hospital stay was 5.8 days, and the mean follow-up duration was 46.6 months (range, 4.5-117.7 months). On a Likert scale, the mean follow-up satisfaction score of 10 patients was 4.7., Conclusions: Even when the flap area exceeded 80% of the lower abdominal area, the extended TRAM flap proved an effective and viable method for the immediate reconstruction of extensive postmastectomy chest wall skin defects, resulting in few minor complications and high follow-up satisfaction scores.

Background: We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap., Methods: Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them., Results: The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially., Conclusions: Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.

Introduction: Pyoderma gangrenosum following free tissue transfer for breast reconstruction is rare. This unusual ulcerative condition is frequently misdiagnosed, leading to inappropriate debridement and escalation of the subsequent wound through pathergy. Once diagnosed, treatment with immunosuppressive agents, including corticosteroids, results in an initial rapid response, but prolonged treatment is required. There is a paucity of literature regarding how to approach future surgery., Methods: This was a retrospective case review from a single center over a 17-year period. All patients diagnosed with postsurgical pyoderma gangrenosum after free tissue transfer from the abdomen for breast reconstruction were included., Results: Of 456 free tissue transfers from the abdomen for breast reconstruction, 8 women who underwent 13 free flaps were diagnosed with postsurgical pyoderma gangrenosum in 10 flaps. The surgeries performed included transverse rectus abdominis muscle (n = 5), deep inferior epigastric perforator (n = 4) and superficial inferior epigastric artery (n = 4) flaps. Mean age at diagnosis was 52.8 years, and 3 patients had preexisting autoimmune conditions: type 2 diabetes mellitus, dermatomyositis, and Graves disease. The mean time of presentation of wound symptoms was 3.9 days after surgery, and mean time diagnosis was made was 9.4 days., Conclusions: Pyoderma gangrenosum after autologous breast reconstruction is a rare, but serious, complication that is worsened by misdiagnosis and inappropriate debridement. We present a case series of 8 patients and emphasize the importance of early recognition and treatment with immune suppression. We include a treatment algorithm to manage these patients, once the diagnosis is suspected. Future surgery can be considered with a fully informed patient and careful collaboration with dermatology colleagues.

Introduction: In extensive radionecrosis following radiotherapy for breast cancer (BC) treatment, the defect after excision can be reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap. In this study, we report outcome of free TRAM flap using contralateral internal mammary artery (IMA) as a recipient in comparison with pedicled TRAM., Methods: We reviewed cases of chest wall radionecrosis following BC treatment during the past 8 years. Radionecrosis involving full-thickness soft tissue with defect sizes greater than 10 × 10 cm were included. We compared the outcomes of patients who underwent reconstruction with either pedicled TRAM flaps or free TRAM flaps. We used IMA as a recipient for free TRAM flap, whereas we used contralateral superior epigastric artery-based flap for pedicled TRAM., Results: A total of 14 BC patients underwent chest wall reconstruction due to radionecrosis: 7 received pedicled TRAM flaps, 5 received free TRAM flaps, and 2 were excluded because of the small defect size. The pedicled and free TRAM groups were similar in patient demographics and defect size. However, distal flap loss rate was significantly higher in the pedicled TRAM group compared with the free TRAM group (P = 0.028). There was no difference in abdominal hernia incidence between the 2 groups (P = 0.100)., Conclusions: Wide chest wall defects caused by radionecrosis following BC treatment can be successfully reconstructed with a free TRAM flap that uses a contralateral IMA as a recipient. The free TRAM flap demonstrates a lower rate of distal flap loss than the pedicled TRAM flap, hence reduces the risk of severe morbidity.

Background: Several techniques for vaginal reconstruction after pelvic exenteration such as myocutaneous and myoperitoneal flaps are available. However, the use of a myofascial flap has not been previously described. Thus, the objective of this article is to present our experience of vaginal reconstruction with rectus abdominis myofascial (RAMF) flap., Methods: Between May 2008 and March 2017, 16 patients underwent anterior, posterior, or total pelvic exenteration with RAMF flap vaginal reconstruction. Patient records were systematically reviewed; demographic, clinic and pathologic, operative details, flap-related and non-flap-related complications, and risk factors for wound healing are reported. Quality of life and sexual function were also investigated., Results: Eleven (68.8%) of 16 patients died during the follow-up (29.1 ± 25 months), whereas 5 (31.3%) are still alive. Early complications were reported in 7 patients (43.8%), with 2 (12.5%) flap-related and 5 (31.3%) non-flap-related complications. Similarly, late complications were reported in 5 patients (31.3%), with 2 (12.5%) flap-related and 3 (18.8%) non-flap-related complications. Quality of life measured by SF-36 (Survey Short Form 36) significantly improved at 12-month follow-up in comparison with baseline (physical component summary 31.5 ± 4.8 vs 26.8 ± 2.9; P = 0.027; mental component summary 29.5 ± 6.0 vs 25.9 ± 2.0; P = 0.042)., Conclusions: This study demonstrates for the first time that RAMF flap vaginal reconstruction after pelvic exenteration is an efficacious and safe technique. Furthermore, it is associated with a significant improvement of quality of life and sexual function in those women who had sexual intercourse before surgery.

Background: The pedicled transverse rectus abdominis myocutaneous (TRAM) flap is a reliable reconstructive option in breast cancer patients; however, it carries known risk of donor site hernia formation. Some hormonal therapy drugs have been associated with hernia formation in animal models. Minimal data exist concerning impact of hormonal therapy for breast cancer on abdominal donor site complications after breast reconstruction., Methods: Patients who underwent TRAM flap for breast cancer or high-risk status at a single institution by the senior author from 2003 to 2015 were identified. Charts were reviewed. Patient demographics, comorbidities, treatments, and abdominal complications were recorded. Patients were divided into groups based on use of hormonal therapy as well as exposure to specific drugs. Statistical analyses were performed., Results: A total of 358 patients were included. Overall hernia rate was 5.9%. About 231 (64.5%) patients had hormonal therapy, whereas 127 (35.5%) did not. Difference in hernia formation was not statistically significant between the hormonal therapy group (6.9%) and the no hormonal therapy group (3.9%; P = 0.359). Patients exposed to tamoxifen and those exposed to anastrozole had no significant difference in complication rates compared with the no hormonal therapy group, whereas patients exposed to letrozole had increased rate of hernia (13.5%; P = 0.037) and infection (21.6%; P = 0.013) compared with the no hormonal therapy group (3.9% and 7.1%, respectively)., Conclusions: Hormonal therapy is a useful adjunct for chemoprevention in breast cancer; however, use of letrozole in patients undergoing reconstruction with pedicled TRAM can lead to increase in certain complication rates.

Aims: Plastic surgical reconstruction of the perineum is often required after abdominoperineal excision of the rectum. Options for this reconstruction include a vertical rectus abdominis myocutaneous (VRAM) flap, gluteal fasciocutaneous flap, and gracilis myocutaneous flap. Although the VRAM flap is well established at most centers, less experience exists with the gluteal and gracilis flaps. In the era of laparoscopic colorectal resection, plastic surgeons are being forced to use gluteal and gracilis flaps because the VRAM flap must be tunnelled intra-abdominally requiring laparotomy. We therefore aimed to systematically review the evidence comparing VRAM, gluteal, and gracilis flaps., Methods: A comprehensive, structured literature search was conducted using Medline, Google Scholar, and Science Direct. Studies included were randomized control trials and observational studies documenting complication rates associated with the VRAM, gluteal, or gracilis flap., Results: Eleven studies meeting all inclusion and exclusion criteria were identified. When meta-analyzed, the overall rate of any perineal wound or flap complication among VRAM patients (35.8%) was significantly lower than gluteal flap (43.7%) and gracilis flap patients (52.9%) (P = 0.041)., Conclusions: The VRAM flap is well established for perineal reconstruction, and this study suggests that it may be superior to the gluteal and gracilis flaps in terms perineal wound and flap complication rates. This should be taken into account when weighing up the risks and benefits of a laparoscopic approach to abdominoperineal excision of the rectum. Large studies making direct comparisons between the flap options should be conducted.

Objective: Over the recent years, there has been an increase in prophylactic mastectomies with an associated increase in bilateral breast reconstruction. We aimed to compare outcomes in terms of patient satisfaction with unilateral versus bilateral breast reconstruction after deep inferior epigastric perforator (DIEP) flap and implant-based reconstruction., Methods: Patients who underwent breast reconstruction by a single surgeon between July 2011 and July 2015 were surveyed using the independently validated BREAST-Q questionnaire. Mean satisfaction scores between patients undergoing unilateral versus bilateral breast reconstruction were compared and stratified based on the type of reconstruction [eg, DIEP flap, tissue expander to implant (TE/I)]. Groups were further categorized by age (patients <55 years and ≥55 years of age) and body mass index (<24.9 and >24.9). Complications were recorded., Results: Of the 308 patients included, 118 (38%) had unilateral reconstruction (42 TE/I and 76 DIEP) and 190 (62%) had bilateral reconstruction (124 TE/I and 66 DIEP). A total of 95 patient surveys were included (31% response rate). Overall, patients receiving unilateral reconstruction demonstrated increased satisfaction with outcome (P = 0.028), psychosocial well-being (P = 0.043), and sexual well-being (P = 0.002). Complication rates were similar between unilateral and bilateral reconstruction. No significant differences for satisfaction were found in the TE/I group (N = 58; unilateral, 10; bilateral, 48).In the DIEP group (N = 37; unilateral, 20; bilateral, 17), those receiving unilateral reconstruction had higher satisfaction with outcome (P = 0.013) and sexual well-being (P = 0.014).Additionally, younger patients (<55 years) were more likely to undergo bilateral reconstruction (P = 0.018). Body mass index did not have a significant association with unilateral or bilateral reconstruction., Conclusions: Patients undergoing DIEP flap reconstruction showed higher satisfaction with unilateral reconstruction, whereas patients receiving TE/I reconstruction, either unilateral or bilateral, were equally satisified. Additionally, younger women were more likely to undergo bilateral reconstruction, which is consistent with current data trends. When considering surgical options, unilateral DIEP flap reconstruction may provide improved outcomes in terms of patient satisfaction when compared with bilateral reconstruction in select patients.

Purpose: There is an ongoing debate on the optimal sequence of radiation and breast reconstruction. The purpose of this article was to (a) assess the impact of radiation on autologous breast reconstruction and (b) analyze the best timing for autologous breast reconstruction in the setting of radiation in a Chinese population., Methods: A retrospective review of patients undergoing breast reconstruction with autologous lower abdominal flaps between 2001 and 2014 in the Tianjin Medical University and Cancer Hospital was performed. Patients were grouped by their irradiation status (irradiated vs nonirradiated). The irradiated group was further stratified into 2 groups by the timing of irradiation (immediate breast reconstruction followed by radiation vs prior radiation and delayed breast reconstruction). The primary outcomes were early and late breast complications, secondary and revision surgeries to the reconstructed breast, whereas the secondary outcomes were aesthetic and psychological evaluations of the patients. Logistic regression was used to assess the potential association between irradiation, patient and treatment variables, and surgical outcomes., Results: Three hundred sixty patients with 370 reconstructed breasts were included in the study. Two hundred seventy-eight cases were nonirradiated, of which 158 were immediate and 120 were delayed. Ninety-two cases were irradiated, of which 61 were immediate, and 31 were delayed. Three hundred thirty-two cases underwent pedicled transverse rectus abdominis myocutaneous flap, 38 had deep inferior epigastric perforator flap. The irradiated group had a significant increase in secondary surgery due to fat necrosis (P < 0.001) and in late complications (P = 0.011). A significant increase in flap contracture (P = 0.043) and an increasing trend in the severity of fat necrosis were observed when radiation was performed after breast reconstruction. However, radiation and its timing did not have an adverse impact on patients' aesthetic and psychological evaluations by the Breast-Q survey., Conclusions: Radiation administered to the reconstructed breast mound increased the rate of late complications and the need for secondary surgery with increased abdominal flap shrinkage and contracture and the severity of flap fat necrosis. Irradiation on the reconstructed breast did not lead to worse aesthetic outcomes due to the generally different expectation in the Chinese female patients in that they were more focused on the breast shape when clothed. Immediate breast reconstruction followed by irradiated was a generally successful treatment sequence in the Chinese module.

Introduction: Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep inferior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of complete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM)., Methods: We reviewed the Nationwide Inpatient Sample database (2010-2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs., Results: Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an academic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for increased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications., Conclusions: The fTRAM cohort was more likely to develop surgical site complications and have an increased length of stay, but TCs were higher for the DIEP group.

Background: Tamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The purpose of this study is to determine whether tamoxifen taken at the time of free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap breast reconstruction affects thrombotic complication rates., Methods: A retrospective review of microvascular breast reconstruction with TRAM/DIEP flaps over the last 20 years was carried out at a single institution. Patients were divided into 2 cohorts: those receiving tamoxifen at the time of reconstruction (tamoxifen cohort) and those not taking tamoxifen (control). Demographic information, procedural characteristics, and rates of microvascular flap complications were compared., Results: Forty-three patients (56 flaps) received tamoxifen at the time of microvascular breast reconstruction, and 185 patients (267 flaps) did not. Patients in the tamoxifen cohort had a lower mean age of 48.9 years (P = 0.013). A greater percentage of patients in the tamoxifen cohort had preoperative radiation (P < 0.0001) and chemotherapy (P = 0.018) and underwent delayed reconstruction (P < 0.0001). There were no significant differences between the 2 cohorts with regard to flap complications including both arterial and venous thrombosis, flap failure, and other local flap complications., Conclusions: Patients receiving tamoxifen during TRAM/DIEP flap breast reconstruction did not have increased rates of flap thrombosis or failure; therefore, stopping tamoxifen prior to these procedures may not be necessary.

To date, there have been several experimental studies to assess tissue viability of transverse rectus abdominis myocutaneous (TRAM) flaps. Botulinum toxin A (BoTA) has gained popularity in many clinical fields, for a variety of therapeutic and aesthetic purposes. In addition, there have been reports regarding the positive effect of BoTA on flap survival by various mechanisms. In this study, we hypothesized that pretreatment with BoTA could augment the survival of TRAM flaps via increased hypoxia-inducible factor (HIF)1α/vascular endothelial growth factor (VEGF)-dependent angiogenesis.Twenty-four Sprague-Dawley rats were randomly divided into 2 groups: a control group and a BoTA group. Five days before superiorly based TRAM flap elevation, the BoTA group was pretreated with BoTA, whereas the control group was pretreated with normal saline. Gross flap survival rates were assessed, and quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) and Western blotting were performed for the evaluation of angiogenesis-related factors (CD34, HIF-1α, and VEGF).In the BoTA group, the gross flap survival rate was significantly higher than that in the control group on both ipsilateral (92.78.3 ± 5.05% vs 86.8 ± 3.88%, P = 0.009) and contralateral (91.57 ± 5.79% vs 74.28 ± 11.83%, P < 0.001) sides.The relative mRNA expression of CD34 and VEGF was significantly higher in the BoTA group than that in the control group in every zone, whereas the relative mRNA expression of HIF-1α was significantly higher in the BoTA group than that in the control group on contralateral sides. The relative protein expression of CD34, VEGF, and HIF-1α was significantly higher in the BoTA group than that in the control group in every zone.In conclusion, we demonstrate that presurgical BoTA treatment might increase angiogenesis by HIF-1α/VEGF, subsequently increase superiorly based TRAM flap survival in a rat model.

Background: Although several studies have found obesity to increase the risk of postoperative morbidity in autologous breast reconstruction, there remains some controversy over the influence of obesity for muscle-conserving abdominal flaps, including muscle-sparing transverse rectus abdominis myocutaneous (msTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. This review evaluates the effects of obesity on complications in breast reconstruction using muscle-conserving abdominal flaps and compares them to those for conventional free transverse rectus abdominis myocutaneous (TRAM) flaps., Methods: A literature search was conducted using MEDLINE, Ovid, and Cochrane databases for studies reporting complication rates for obese and nonobese patients undergoing breast reconstruction using msTRAM, DIEP, and SIEA flaps and conventional free TRAM flaps. The pooled relative risks (RRs) of the obesity for flap-related and donor complications were estimated in the muscle-conserving flaps by meta-analytic methodology and the pooled complication rates in obese patients were compared between muscle-conserving flaps and conventional TRAM flaps. Here, only those studies following the World Health Organization definition of obesity (body mass index ≥ 30 kg/m) were included., Results: A total of 17 articles were analyzed. Eight studies were used to compute the obesity-related risks of flap-related and donor complications for msTRAM, DIEP, and SIEA flaps. Obesity increased the risk of total flap loss [RR, 1.68; 95% confidence interval (CI), 0.85-3.33], partial flap loss (RR, 2.26; 95% CI, 1.01-5.02), abdominal bulge or hernia (RR, 1.72; 95% CI, 1.00-2.95), and overall abdominal complications (RR, 1.53; 95% CI, 1.10-2.14). The results of a pooled analysis with 15 studies are consistent with those of the meta-analysis. In comparison to free TRAM flaps, muscle-conserving abdominal flaps showed a lower pooled incidence of flap loss, fat necrosis, and abdominal bulge or hernia in obese patients., Conclusions: This review suggests that obesity increases the risk of both flap-related and donor-site complications in breast reconstruction using msTRAM, DIEP, and SIEA flaps. In comparison to conventional TRAM flaps, however, muscle-conserving abdominal flaps may have an advantage in reducing the morbidity in obese patients.

Background: Obesity is widely recognized as a major health concern and a leading cause of preventable death. The correlation between obesity and breast cancer has been thoroughly described by several authors. Bariatric surgery is often associated with redundant abdominal tissue, often leading patients to consider body-contouring procedures. Autologous tissue breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has advantages because it is tissue that is normally discarded during postbariatric body contouring., Methods: We conducted a retrospective chart review of 18 DIEP flaps performed by the senior author in 9 patients for breast reconstruction between February 2008 and May 2013. All patients underwent mastectomies. All patients underwent bariatric surgery preceding breast reconstruction. Breast reconstruction was performed immediately in 13 cases and delayed in 5 cases., Results: Mean age of the study population was 44.6 years (range, 41-57 years). The mean maximum body mass index of the patients was 44 (range, 37.6-52.1), and the mean current body mass index at the time of the reconstruction was 30.7 (range, 24.3-38.1). No intraoperative complications were reported. No fascia or muscle was taken during flap dissection. Mean operative time was 632 minutes (range, from 480 to 750 minutes). Average hospital stay was 4 days. No partial or total flap loss was reported. There were no postoperative hernias or bulges at the abdominal donor site., Conclusions: This series represents the largest group of patients undergoing DIEP flap breast reconstruction after bariatric surgery. In the hands of experienced microsurgeons, breast reconstruction with the DIEP flap in postbariatric patients represents a low-risk option with high satisfaction.

Ever since its introduction, the transverse rectus abdominis myocutaneous flap has become the mainstay of autologous breast reconstruction. However, concerns regarding donor site morbidity due to the breach of abdominal wall musculature integrity soon followed. Muscle-sparing techniques, eventually eliminating the muscle from the flap all-together with the deep inferior epigastric artery perforator flap, did not eliminate the problem of abdominal wall weakness. This led to the conclusion that motor innervation might be at fault. Studies have shown that even in the presence of an intact rectus abdominis muscle, and an intact anterior rectus sheath, denervation of the rectus abdominis muscle results in significant abdominal wall weakness leading to superior and inferior abdominal bulges, and abdominal herniation. Our aim was to establish a mathematical model to predict the location of the motor innervation to the rectus abdominis muscle, and thus provide surgeons with a tool that will allow them to reduce abdominal morbidity during deep inferior epigastric artery perforator and free muscle-sparing transverse rectus abdominis myocutaneous surgery. We dissected 42 cadaveric hemiabdomens and mapped the course of the thoracolumbar nerves. We then standardized and analyzed our findings and presented them as a relative map which can be adjusted to body type and dimensions. Our dissections show that the motor innervation is closely related to the lateral vascular supply. Thus, when possible, we support the preferred utilization of the medial vascular supply, and the preservation of the lateral supply and motor innervation.

Pelvic floor reconstruction with pedicled vertical rectus abdominis myocutaneous flap has been popularized in patients undergoing pelvic exenteration due to locally advanced rectal carcinoma. Abdominal wall fascial dehiscence and incisional hernia may occur as a result of large skin and fascia islands as well as muscle required to close these large defects. The purpose of this paper was to describe a novel technique, consisting of VRAM flap donor-site closure with component separation technique, performed on the contralateral side as the flap harvest, allowing for a lower tension closure between ipsilateral external oblique/internal oblique/transverse abdominis muscles complex and contralateral rectus abdominis muscle. In 10 patients undergoing this technique, no abdominal fascial dehiscence, incisional hernia, or parastomal hernia occurred during a mean follow-up of 15 months. Overall 3-year patient survival rate was 80% with abdominal hernia free-survival rate of 100%. The addition of this technique represents an advance in overall patient care to provide a more successful outcomes in this complex scenario.

In concert with advances in surgical reconstruction techniques and improved survival after breast cancer, both the aesthetic and functional outcomes, especially sensory recovery, of breast reconstruction have been addressed. Most studies on sensory recovery in reconstructed breasts have utilized patients' subjective responses to touch, pain, temperature, and pressure. In contrast, this report describes a case of herpes zoster that developed in a free transverse rectus abdominis myocutaneous flap, which provides objective evidence of spontaneous reinnervation after breast reconstruction.

Introduction: Osteomyelitis of the elbow may be a complex clinical problem. Treatment goals include the eradication of infection and preservation of maximal joint function. Bony debridement may be necessary in addition to elbow joint arthroplasty. The use of synthetic material or allograft as the arthroplasty material may be contraindicated in the setting of infection. The use of free muscle transfer as an arthroplasty medium has not been well described., Methods: A 22-year-old paraplegic man developed recurrent osteomyelitis of the right elbow, necessitating extensive bony debridement by the orthopedic surgery team. Reconstruction arthroplasty was performed using a free rectus abdominis muscle flap as the arthroplasty material to serve as a source of biologically active, well-vascularized arthroplasty medium in the presence of ongoing infection., Results: A successful free muscle flap arthroplasty was performed. External fixation and physical therapy were implemented postoperatively. The patient had resolution of osteomyelitis and excellent functional use of the elbow for activities of daily living and wheelchair motion., Conclusions: Elbow arthroplasty in the setting of active infection may be accomplished by means of free tissue muscle transfer. Elimination of infection and acceptable joint function may be possible with this form of reconstruction.

Background: This study of stage III (locally advanced) breast cancer patients evaluated the survival improvement conferred by immediate breast reconstruction by transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction after modified radical mastectomy (MRM) in comparison with MRM alone., Methods: This retrospective study analyzed data for all women who had received TRAM immediately after unilateral modified radical mastectomy for locally advanced breast cancer at a single institution from January 2002 to December 2009. The analysis included 192 patients divided into 2 groups: patients who had received MRM immediately followed by TRAM flap reconstruction (MRM-TRAM group, n=52) and patients who had received MRM alone (MRM group, n=140). Data collection included demographic characteristics, underlying comorbidities, and cancer characteristics. Postoperative adjuvant therapies, oncologic outcomes, and survival were compared between the 2 groups. Kaplan-Meier plots, univariate log-rank test, multivariate Cox proportional hazards regression models, and t-test were used to evaluate potential predictors of cancer recurrence and patient survival., Results: In comparison with the MRM group, significant differences in the MRM-TRAM group included a younger mean age, a better overall health status, and a higher education level (all P<0.001). Severity of breast cancer disease did not significantly differ in terms of cancer characteristics. Additionally, there were no significant differences in local recurrence (P=0.326) and distant metastasis (P=0.338). Immediate breast reconstruction was not associated with delays in detection of local recurrence and initiation of adjuvant therapiesThe 5-year breast cancer-specific survival rate was significantly higher in the MRM-TRAM group (84.6%) compared with the MRM group (61.2%) (P=0.003). Multivariate analysis showed that TRAM flap reconstruction is an independent predictor of survival in breast cancer patients. The MRM-TRAM group had a significantly lower hazard of death (HR, 0.235; 95% CI, 0.070-0.788; P=0.019) compared with the MRM group., Conclusions: Immediate TRAM flap reconstruction is oncologically safe and is unassociated with delayed adjuvant therapies or delayed detection of local recurrence. Patients with locally advanced breast cancer can be considered appropriate candidates for TRAM flap reconstruction because the procedure is an independent predictor of breast cancer survival and is associated with a 76.5% decrease (HR, 0.235) in the risk of cancer death.

Background: The use of internal mammary perforators (IMPs) as recipient vessels in autologous free flap breast reconstruction has many additional benefits compared with the internal mammary or thoracodorsal vessels. Our goals were to analyze the characteristics of these vessels and to evaluate the reliability of using them in an Asian population., Methods: Thirty-five consecutive patients were prospectively studied between November 2000 and December 2010. Twelve patients underwent muscle-sparing-2 transverse rectus abdominis musculocutaneous flap, and 23 had deep inferior epigastric perforator flap reconstructions., Results: Internal mammary perforator vessels were used in 29 patients (83%). Most (75%) of the vessels were located in the subcutaneous plane, and 85% were in the second and third intercostal spaces. There were significantly more usable IMP vessels in the immediate than in the delayed reconstructions (P = 0.049). All the flaps in the study were successful despite 1 requiring emergency re-exploration because of venous congestion., Conclusions: Most of the IMP vessels are small; however, they are still reliable and safe for use as recipient vessels in selected Asian patients. Most are located in the subcutaneous plane, which further facilitates dissection and also reduces recipient-site morbidity.

The purpose of this study is to compare the effects of spinal and epidural anesthesia on a rat transverse rectus abdominus myocutaneous flap ischemia-reperfusion injury model.Forty Sprague-Dawley rats were divided into 4 experimental groups: group I (n = 10), sham group; group II (n = 10), control group; group III (n = 10), epidural group; and group IV (n = 10), spinal group. After the elevation of the transverse rectus abdominus myocutaneous flaps, all groups except for the sham group were subjected to normothermic no-flow ischemia for 4 hours, followed by a reperfusion period of 2 hours. At the end of the reperfusion period, biochemical and histopathological evaluations were performed on tissue samples.Although there was no significant difference concerning the malonyldialdehyde, nitric oxide, and paraoxonase levels in the spinal and epidural groups, the total antioxidant state levels were significantly increased, and the total oxidative stress levels were significantly decreased in the epidural group in comparison to the spinal group. The pathological evaluation showed that findings related to inflammation, nuclear change rates and hyalinization were significantly higher in the spinal group compared with the epidural group.Epidural anesthesia can be considered as a more suitable method that enables a decrease in ischemia-reperfusion injuries in the muscle flaps.

Many different approaches have been used to minimize the risk of bulge or hernia formation when using autologous abdominal tissue for breast reconstruction. Studies have shown that further reinforcement of the abdominal wall using a mesh may decrease the complication rate.The current study included 40 consecutive patients having unilateral breast reconstruction with the pedicled transverse rectus abdominus musculocutaneous flap. The defect in the abdominal fascia was closed primarily and further reinforced using a Prolene mesh (Ethicon), n = 20, or using a self-fixating Parietex ProGrip mesh (Covidien), n = 20. The patients were examined at an outpatient consultation, with a minimum follow-up of 1 year and questioned about donor-site symptoms using a standardized questionnaire.Of the 20 patients in the Prolene group, 2 (10%) developed abdominal wall bulging, and of the 20 patients in the ProGrip group, 11 (55%) developed abdominal wall bulging (P = 0.006). In both the Prolene and the ProGrip group, most patients reported having continued donor-site symptoms at the time of the follow-up (70% and 80%, respectively); 15% and 30%, respectively, reported having symptoms that influenced their daily or physical activities (not a significant difference). All but 1 patient in our study reported being very happy with the reconstruction and would have done it again, had they known what they did at the time of the follow-up.We conclude that the self-gripping properties of the Parietex ProGrip mesh are not sufficient in withstanding the abdominal wall tension at the donor site after transverse rectus abdominus musculocutaneous-flap harvest and do not recommend using the Parietex ProGrip mesh without fixating sutures for this procedure.

Background: After unilateral breast reconstruction, a procedure on the contralateral breast is often needed to achieve symmetry. However, there is no consensus regarding when to perform the contralateral balancing procedure. Here, we present a single surgeon's experience with performing contralateral symmetry procedures simultaneously with free flap autologous breast reconstruction., Methods: We evaluated 77 consecutive patients (mean age, 50.5 years) who underwent abdominal-based free flap unilateral breast reconstruction and a simultaneous contralateral breast procedure performed by a single surgeon., Results: Thirty-eight patients (49%) underwent immediate breast reconstruction, and 39 patients (51%) underwent delayed reconstruction. Forty patients (52%) received preoperative chemotherapy, and 31 (40%) received preoperative radiation therapy. Patients' mean body mass index was 28.3 kg/m. The most common free flaps were the muscle-sparing transverse rectus abdominis myocutaneous flap (n = 53) and deep inferior epigastric perforator flap (n = 22). Contralateral procedures included reduction mammoplasty (n = 48, 62%) and mastopexy (n = 29, 38%). In 43 patients (56%), breast reconstruction was completed after a single stage, and in 34 patients (44%), revisions were performed (flap: n = 16, 21%; contralateral breast: n = 8, 10%; both breasts: n = 10, 13%). Mean follow-up for patients was 53.2 months. At last follow-up, most patients had no evidence of disease (n = 68, 88%), six patients (8%) had died of disease, 1 patient (1%) was alive with disease, and 2 patients (3%) had died of other causes., Conclusions: For patients who need contralateral reduction mammoplasty or mastopexy for symmetry, performing these procedures and breast reconstruction simultaneously facilitates single-stage breast reconstruction in most patients.

Background: Head and neck cancer extirpation frequently creates complex 3-dimensional defects involving both intraoral and external tissues. Reconstruction can be accomplished either with 2 free flaps, a simultaneous free and pedicle flap, or a single double-island folded free flap. Herein, the outcomes and rationale for reconstruction of multilaminar head and neck defects using the multi-island vertical rectus abdominis myocutaneous (MI-VRAM) flap are reported., Methods: A retrospective review was performed of a prospectively collected database of all head and neck reconstructions completed by a single surgeon between 1992 and 2011. Forty-six patients were identified who underwent reconstruction of composite defects using MI-VRAM flaps. Oncologic defects were classified into 3 categories based on anatomic location, namely, the midface, lower face, and neck. Indications and outcomes were reviewed., Results: Patients' ages ranged from 7 to 84 years with two thirds being male; 45% received preoperative radiation. Average MI-VRAM skin paddle size was 9×25.5 cm. Of the 46 reconstructions, 27 (59%) were performed in the midface, 14 (30%) in the lower face, and 5 (11%) in the neck region. There were no complete flap loses; however, 1 patient lost the external skin island, requiring pectoralis flap coverage. Of these cases, 15% had surgically related complications. Ten patients required secondary contouring procedures to revise bulky flaps., Conclusions: The MI-VRAM flap is a safe and reliable technique for reconstruction of complex defects throughout the head and neck region. Compared to 2 simultaneous free flaps or a free flap combined with a regional flap, it saves time and eliminates a second donor site., Level of Evidence: Level IV. Clinical question addressed in this paper is whether a multi-island VRAM flap is a safe technique in head and neck reconstruction.

The purpose of this study was to evaluate complications and patient satisfaction after pedicled transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap reconstruction at a single institution. There were 346 patients identified from 1999 to 2006 who underwent 197 pedicled TRAM and 217 DIEP flap reconstructions. Flap complication rates were similar between groups, whereas pedicled TRAM reconstructions had higher rates of abdominal bulge (9.5% vs. 2.3%, P = 0.0071) and hernias (3.9% vs. 0%, P = 0.0052). DIEP flap patients had significantly higher general satisfaction (81.7% vs. 70.2%, P = 0.0395), whereas aesthetic satisfaction was similar between groups. Furthermore, DIEP flap patients, particularly those undergoing bilateral reconstructions, were more likely to choose the same type of reconstruction compared with pedicled TRAM patients (92.5% vs. 80.7%, P = 0.0113). Understanding the differences in complications and satisfaction will help physicians and patients make informed decisions about abdominal-based autologous breast reconstruction.

The combination of radiation and mastectomy reduces the 3-dimensional topography of the breast into a relatively inelastic, 2-dimensional plane. This environment presents specific challenges to aesthetic breast reconstruction with autologous tissue transfer, and a relative sparsity of information exists in the surgical literature on how to address these challenges. Accordingly, this article details a formalized and reproducible approach for flap inset in postradiation breast reconstruction. We outline a novel technique for optimizing the recipient bed and present a sequential flow for contouring the autologous abdominal flap, so that it recreates the individual subunits of an aesthetic breast.

Purpose: This study evaluates how the transition from pedicled transverse rectus abdominis myocutaneous (pTRAM) to perforator flaps at an academic center has affected outcome and reimbursement., Methods: In 2006, our practice transitioned to almost exclusively perforator flaps for breast reconstruction. This study retrospectively compares pTRAM flaps performed from 2002 to 2006 (group 1) with perforator flaps from 2006 to 2010 (group 2). Operative time, complications, and reimbursement were compared between the 2 groups., Results: We performed 93 pTRAM flaps in 69 patients in group 1 and 102 perforator flaps in 69 patients in group 2. Operative time was shorter in group 1 for unilateral breast reconstruction (399 vs. 543 minutes, P = 0.0001), but no significant difference was noted for bilateral cases (547 vs. 658 minutes, P = 0.1). Fat necrosis requiring reoperation (23.7% vs. 5.9%, P = 0.0004) and partial flap necrosis (20.6% vs. 7.2%, P = 0.045) were more frequent in group 1. There was a higher frequency of abdominal hernia (8.8% vs. 1.6%, P = 0.2) but fewer hematomas (1.5% vs. 10%, P = 0.06) in group 1, although statistical significance was not reached between the 2 groups. Mean adjusted payment per case was $3658.67 for group 1 versus $5256.48 for group 2 (P = 0.004), whereas payment per minute was $9.25 for group 1 versus $9.13 for group 2 (P = 0.9). Perforator flaps appear to be as profitable as pTRAM flaps with lower morbidity., Conclusions: The transition from pTRAM to perforator flap can be done successfully with appropriate resources and support. The development of a perforator flap practice represents an opportunity cost in optimizing patient care and should be an option to patients seeking breast reconstruction.

There have been many methods to use the superficial inferior epigastric vein (SIEV) for improvement of flap circulation during breast reconstruction with free abdominal flap. If the SIEV is used for the purpose of adding another draining route, selection of ideal recipient vein is a crucial step. We reviewed our experiences of using the SIEV as additional vein in free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator breast reconstruction to find out the ideal recipient vein for SIEV. Between April 2006 and July 2010, 153 cases of breast reconstruction were performed using free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps. Additional SIEV anastomosis was performed in 45 cases with risk factors. First choice of the recipient vein was the lateral thoracic vein if the SIEV was placed laterally after the inset of the flap. If the lateral thoracic vein was ablated with lymph node dissection, the branch of the thoracoacromial vein was selected. If the SIEV was placed medially, the perforator of the internal mammary vein was used. No vascular compromise was observed in cases with additional SIEV anastomosis with those recipient veins, whereas 9 cases of flap-related complications were observed in the remaining 108 cases without additional SIEV anastomosis. The incidences of the venous congestion were significantly different between the 2 groups. Combination of the lateral thoracic vein, branch of the thoracoacromial vein, and the perforator of the internal mammary vein provided an excellent choice of the recipient vein for the SIEV with reliability and availability.

Recurrent poststernotomy mediastinitis has significant morbidity and mortality. Reconstructive treatment begins with pectoral muscle or omental flaps. When these options are unavailable or inadequate, surgeons resort to internal mammary artery-based vertical rectus abdominis muscle flap. If the internal mammary artery is harvested for coronary artery bypass grafting, surgeons are reluctant to use the muscle for pedicled flap because of the elevated risks. However, recent reports suggest that if enough time passes for intercostal artery collaterals to develop, they would support the viability of the flap. Moreover, recent improvements in defining flap microvasculature and proposed surgical techniques have enabled us to further refine the procedure. Although it appears that the intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle is safe and effective for chest wall reconstruction, potential for failure remains elevated until sample size accumulates.

Superficial inferior epigastric artery (SIEA) flap breast reconstruction has advantages over deep inferior epigastric perforator flap (DIEP) and muscle sparing transverse rectus abdominus myocutaneous flap (TRAM) reconstructions with less donor site morbidity and less complicated flap dissection. Not all patients have an adequate SIEA and superficial inferior epigastric vein (SIEV) to support free tissue breast reconstruction, and dissection of the SIEA in all patients can be time consuming. Preoperative computed tomography (CT) angiograms can be used to identify the SIEA and SIEV in patients planning to undergo free abdominal tissue breast reconstruction and direct more efficient dissection in patients with a large SIEA. Retrospective analysis of free abdominal tissue flap breast reconstruction from a single plastic surgeon was performed. All patients undergoing free abdominal tissue breast reconstruction had a preoperative CT angiogram using a protocol for the evaluation of the abdominal wall perforating arteries. CT scans were reviewed by the surgeon preoperatively and evaluated for the presence, caliber, and image quality of the SIEA and SIEV. All patients, regardless of CT angiogram findings, had operative dissection and evaluation of the SIEA and SIEV. A total of 177 free flaps were performed on 113 patients who underwent preoperative CT angiogram and free abdominal tissue breast reconstruction. Of them, 64 patients had bilateral breast reconstruction. Twelve SIEA flaps (10.6%) were performed on 12 patients. During preoperative CT angiographic evaluation, 49 patients (43%) were noted to have at least one visible SIEA, whereas only 24 of those patients (21%) were felt to have an SIEA of adequate caliber. No flaps were lost during the postoperative period. All 12 SIEA flaps performed had an adequate SIEA when observed on preoperative CT angiogram. Overall, 50% of patients found to have at least one adequate SIEA on CT angiogram had a single breast reconstructed with an SIEA flap. If the SIEA was not visualized on CT angiogram, no usable SIEA was found during surgery. Preoperative CT angiogram of the abdominal wall perforating arteries can help predict which patients may have adequate anatomy for an SIEA-based free flap. This information may help direct more efficient dissection of the abdominal flaps by selecting out patients who do not have an adequate SIEA.

Background: A subset of patients with hypopharyngeal cancer has tumors involving the neck skin and soft tissues in addition to vital structures such as the larynx and alimentary tract. Surgical extirpation creates a complex composite deformity for the reconstructive surgeon. The objective of this article is to describe the rationale for closure of these defects with the double-island vertical rectus abdominis musculocutaneous (VRAM) flap., Methods: Retrospective chart review of all head and neck reconstructions performed over the past 20 years identified 4 patients who underwent reconstruction of combined defects involving less than 50% of the pharyngoesophageal circumference and anterior neck soft tissues. All wounds were closed in a single-stage with a double-island VRAM. Outcomes and complications were reviewed., Results: Indication for resection was locally advanced disease or recurrence with pharyngocutaneous fistula. Mean age was 54 years with a follow-up time of 2 years. The average external skin defect measured 10 × 15 cm. There was no complete or partial flap loss. No major and 2 minor complications were identified. All patients tolerated an oral diet postoperatively. No revisions have been performed., Conclusion: In contrast to perforator flaps where creation of separate skin paddles may not always be possible, the VRAM's robust axial blood supply facilitates formation of 2 independent skin islands in all cases. The external island serves as a flap monitor and obviates the need for a second flap. In conclusion, the double-island VRAM flap is safe, has minimal donor-site morbidity, and reliably accomplishes reconstruction of composite head and neck defects in a single-stage.

Purpose: Healthy, viable mastectomy skin is a critical factor in the outcome of immediate breast reconstruction. Unfortunately, mastectomy skin viability can be problematic and intraoperative assessment is unreliable. For this reason, we have modified our approach to immediate transverse rectus abdominus myocutaneous flap (TRAM) reconstruction. Instead of completing the reconstruction with a definitive inset at the time of the mastectomy, the TRAM flap is left intact and buried beneath the mastectomy skin for 3 to 5 days. This falls within the normal period of postoperative hospitalization, and at this point, the viability of the mastectomy skin is clear. Ischemic skin is debrided and replaced with healthy TRAM skin, and nipple reconstruction can be performed at the time of this interval inset. The purpose of this study was to review a large case series of patients who underwent an interval inset of their TRAM flap in the setting of immediate skin-sparing mastectomy., Methods: Retrospective chart data were obtained for all TRAM patients who underwent immediate postmastectomy breast reconstruction by a single surgeon during a 5-year period. Data were collected on procedures, complications, margin status, and number of immediate versus delayed nipple reconstructions., Results: There were 63 patients who underwent immediate TRAM reconstruction with interval inset of the flap. This included 25 bilateral cases, for a total of 89 flaps. Interval insets were performed an average of 3.9 days after the TRAM. Twenty-seven percent (17/63) required replacement of nonviable mastectomy skin with TRAM skin and had no nipple reconstruction; 4.8% (3/63) had additional skin taken because of residual tumor close to or at the mastectomy margins. Seventy-three percent of patients (46/63) had a nipple reconstruction with minimal or no mastectomy skin loss., Conclusion: We present the interval inset of TRAM flaps during the normal period of postoperative hospitalization as a technical refinement to optimize cosmetic outcomes. Mastectomy skin viability can be more easily assessed and necrotic or ischemic skin replaced with TRAM skin as needed. This avoids the need for prolonged dressing changes or a compromised aesthetic result from skin loss. When there is no major skin loss, the nipple reconstruction can be performed concurrently with the inset. These refinements optimize the appearance of the reconstructed breast and reduce the need for future surgeries. In addition, the surgical oncologist has the opportunity to excise close or positive margins as indicated by pathologic findings. Thus, the benefits of the interval inset of TRAM flaps are shared by the reconstructive surgeon, the surgical oncologist, and most importantly, the patient.

To obtain pleasing symmetry in breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) free flap, a large amount of abdominal flap is elevated and remnant tissue is trimmed in most cases. However, elevation of abundant abdominal flap can cause excessive tension in donor site closure and increase the possibility of hypertrophic scarring especially in lean patients. The TRAM flap was divided into 4 zones in routine manner; the depth and dimension of the 4 zones were obtained using ultrasound and AutoCAD (Autodesk Inc., San Rafael, CA), respectively. The acquired numbers were then multiplied to obtain an estimate of volume of each zone and the each zone volume was added. To confirm the relation between the estimated volume and the actual volume, authors compared intraoperative actual TRAM flap volumes with preoperative estimated volumes in 30 consecutive TRAM free flap breast reconstructions. The estimated volumes and the actual elevated volumes of flap were found to be correlated by regression analysis (r = 0.9258, P < 0.01). According to this result, we could confirm the reliability of the preoperative volume estimation using our method. Afterward, the authors applied this method to 7 lean patients by estimation and revision of the design and obtained symmetric results with minimal donor site morbidity. Preoperative estimation of TRAM flap volume with ultrasound and AutoCAD (Autodesk Inc.) allow the authors to attain the precise volume desired for elevation. This method provides advantages in terms of minimal flap trimming, easier closure of donor sites, reduced scar widening and symmetry, especially in lean patients.

Although free flap has largely replaced pedicled transverse rectus abdominis musculocutaneous (TRAM) flap, the latter has also evolved by increased understanding of anatomy and physiology. We report the outcomes in 500 consecutive pedicled TRAM in Asian patients performed by a single surgeon, providing incidences of complications and ideas of prevention. Fascia was minimally harvested with full width of muscle. The eighth intercostals nerve was severed and back-cut was made at the lateral belly. Anterior rectus sheath was directly repaired. Breast complication occurred in 24.6% with the most common being skin envelope necrosis. Major flap loss occurred in 1 (0.2%), and the incidence of fat necrosis was 14.2%. Abdominal complication rate was 16.4%, and bulging occurred in 3%. Exercise performance was almost completely restored after 1 year. Pedicled TRAM is still a competitive procedure with overall flap survival rate of 99.8%, yielding consistent results with acceptable complication rates for most patients under experienced hands.

Although experimental evidence suggests that the preliminary surgical delay procedure physiologically improves the circulation of the TRAM flap, there are no published controlled studies evaluating the clinical outcomes associated with this procedure. The purpose of this study was to evaluate the efficacy of the surgical flap delay versus no delay in consecutive patients having pedicle TRAM breast reconstruction. This was a retrospective cohort study of breast cancer patients at the University of Michigan who had pedicle TRAM reconstruction between January 2004 and March 2008. Prior to September 2005, all patients had pedicle TRAM reconstruction without the delay procedure. Starting in September 2005, all patients had the delay procedure prior to TRAM flap reconstruction. Descriptive statistics were used to compare demographic data, comorbidities, and complication rates between the 2 cohorts. Regression analysis was used to determine the effects of the surgical delay procedure on the incidence of flap ischemia and major and minor complications while controlling for patient and treatment level factors. Eighty-seven postmastectomy breast cancer patients had unipedicle TRAM flap reconstruction, in which 112 flaps were used to reconstruct breasts. The nondelay cohort consisted of 42 consecutive patients (51 flaps) and the delay cohort consisted of 45 consecutive patients (61 flaps). Of the patients without the surgical delay procedure 17.6% experienced at least one ischemic complication of the flap compared with 6.6% of those who were surgically delayed (P = 0.082). When controlling for patient and treatment level factors, the delay procedure was found to significantly decrease the incidence of flap ischemia (OR = 0.21, P = 0.018). In addition, there were no significant differences in the incidence of major or minor complication rates in the surgically delayed versus nondelayed groups (P = 0.247, P = 0.486, respectively). When patient and treatment level factors were taken into consideration, undergoing the delay procedure also did not increase the incidence of having a major or minor complication. These data support the use of the preliminary surgical delay procedure to decrease ischemic complications of the flap in pedicle TRAM postmastectomy breast reconstruction.

Background: The purpose of this study was to evaluate the effects of quilting suture (placement of stitches between the superficial fascia in the supraumbilical remaining flap and the musculoaponeurotic layer of the anterior abdominal wall) at the donor site of the transverse rectus abdominis musculocutaneous flap in breast reconstruction., Methods: There is a theory that the use of quilting suture, during the closure of the donor site with the abdominal flap, causes collapse of the dead space and enables the flap to rest, thus diminishing factors that may interfere in its adherence and help to reduce complications. Between January 2004 and March 2005, we performed 30 breast reconstructions using a unipedicled transverse rectus abdominis musculocutaneous flap. The sample was randomly distributed in 2 groups: 15 patients with quilting suture (group A) and 15 patients without quilting suture (group B). The study focused on daily drain output (mL), time to drain removal (days), and possible donor site complications (%)., Results: Group A presented an average of 4.2 days for removal of the drain and group B, 6.93 days, with a statistically significant difference (P < 0.001). Concerning the total volume upon removal of the drain, group A presented an average of 434.7 mL and group B, 620.7 mL, with a statistically significant difference (P = 0.002). Group A presented 13.3% complications at the donor site and group B, 53.3%, with a statistically significant difference (P = 0.05)., Conclusions: The quilting suture in this study reduces the permanence of drains, total volume of tissue fluids upon drain removal, and complication rates.

Lymphedema is common after inguinal lymphadenectomy or resection of groin tumors. Animal studies have shown success using the rectus abdominis musculocutaneous (RAM) flap as a treatment for lymphedema. Four patients with acquired lower extremity lymphedema were treated with a contralateral RAM flap with an inferior cutaneous pedicle left intact to facilitate lymphatic drainage into the unaffected groin. One patient also had lymphaticovenous anastomoses performed during flap transfer. All flaps survived with no postoperative complications. With a mean follow-up of 31 months, the mean reduction in limb circumference from the preoperative excess was 81% at the thigh, 70% at the calf, and 71% at the ankle. None of the patients with recurrent cellulitis had further incidences of groin cellulitis. Two patients required future flap debulking. Lymphoscintigraphy was performed in 1 patient and demonstrated reconstitution of lymphatic flow from the affected leg through the flap. According to this preliminary study, transfer of a contralateral RAM flap to the groin of a lymphedematous leg improves lymphedema and decreases the incidence of cellulitis.

A muscle perforator flap is a unique form of fasciocutaneous flap whose circulation is derived from musculocutaneous perforators, but without including any muscle. This anatomic relationship intuitively should readily allow the formation of branch-based chimeric or polyflaps consisting of a cutaneous perforator flap and its corresponding muscle as a combined flap, both ultimately supplied by a common source vessel. Many versions of the rectus abdominis musculocutaneous flap based on the deep inferior epigastric vessels are well known, but formation of a chimeric flap consisting of its component parts has heretofore not been reported. This treatise is intended primarily to provide an anatomic description that introduces the deep inferior epigastric artery perforator (DIEAP)-rectus abdominis muscle chimeric flap, with a clinical example that mainly demonstrated its usefulness to be the aesthetic advantage of a concomitant abdominoplasty.

Radiotherapy is being increasingly used in the treatment of breast cancer after breast conservation as well as after total mastectomy. The effect of radiation on pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstruction is examined. A retrospective review of 199 patients undergoing 232 pedicled TRAM flap reconstructions was performed to identify patients who received radiotherapy. Patients were stratified into 5 groups by the use and timing of radiation as well as the timing of the reconstruction. The overall esthetic appearances were assessed by blinded reviewers. The incidence of flap complications was 34.2% in the immediate nonirradiated group, 10.7% in the delayed nonirradiated group, 44% in the post-TRAM radiation group, 60% in the immediate pre-TRAM radiation group, and 33% in the delayed pre-TRAM radiation group (P = 0.010). Patients who had immediate TRAM flap reconstruction and did not receive radiation had a better global esthetic outcome (P < 0.001) than the other 4 groups. The esthetic outcome was similar whether radiation was administered pre- or post-TRAM flap reconstruction. Radiation therapy has a deleterious effect on the esthetic outcome of pedicled TRAM flap reconstruction whether administered before or after reconstruction. There was no difference in TRAM flap complications in any of the groups that received radiation therapy.