The effect of hypotonic pharmacologic lipodissolution on abdominal free flap perfusion: a case report.

Background: Hypotonic pharmacologic lipodissolution (HPL) has gained popularity as a treatment for abdominal fat reduction, especially among Asian individuals. However, research on the effect of HPL on abdominal vascularity and abdominal autologous tissue flap are limited. Case Description: This case report describes a patient who underwent HPL treatment in November 2022 and subsequently underwent nipple-sparing mastectomy with free transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction on April 4, 2023. The preoperative evaluation included computed tomography (CT) angiography to assess the viability of abdominal perforators and vasculature for TRAM flap reconstruction. Intraoperatively, indocyanine green (ICG) fluoroscopy was performed after TRAM flap elevation to evaluate flap perfusion. The findings revealed compromised skin-side perfusion but satisfactory deep layer perfusion, with subdermal plexus perfusion observed during de-epithelialization. Conclusions: These findings suggest that in nipple sparing mastectomy cases with minimal skin flap preservation requirements, a history of HPL may have less negative impact on TRAM flap reconstruction. However, in skin sparing mastectomy cases with extensive skin flap preservation needs, careful assessment, including preoperative CT angiography and intraoperative ICG imaging, is essential to minimize the risk of partial flap necrosis.

Trunk Muscle Function and Core Stability in Women Who Had Muscle-Sparing Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction.

OBJECTIVE: The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer. METHODS: Forty women (mean age = 42.6 years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6 months earlier (mean = 10.3 [standard deviation, SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2 years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test), and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit. RESULTS: Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups. CONCLUSIONS: Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10 months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis. IMPACT: Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation.

A systematic review of the scientific evidence of venous supercharging in autologous breast reconstruction with abdominally based flaps.

BACKGROUND: Abdominally based free flaps are commonly used in breast reconstruction. A frequent complication is venous congestion, which might contribute to around 40% of flap failures. One way to deal with it is venous supercharging. The primary aim of this study was to investigate the scientific evidence for the effects of venous supercharging. METHODS: A systematic literature search was conducted in PubMed, CINAHL, Embase, and Cochrane library. The included articles were critically appraised, and certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. RESULTS: Thirty-six studies were included. Most studies had serious study limitations and problems with directness. Three studies report 'routine' use of venous supercharging and performed it prophylactically in patients who did not have clinical signs of venous congestion. Seventeen studies report on flap complications, of which one is a randomised controlled trial demonstrating statistically significant lower complication rates in the intervention group. The overall certainty of evidence for the effect of a venous supercharging on flap complications, length of hospital stay and operative time, in patients without clinical signs of venous congestion, is very low (GRADE ⊕ ⊕ ⊝ ⊝), and low on and surgical takebacks (GRADE ⊕ ⊕ ⊝ ⊝). Twenty-one studies presented data on strategies and overall certainty of evidence for using radiological findings, preoperative measurements, and clinical risk factors to make decisions on venous supercharging is very low (GRADE ⊕ ⊝ ⊝ ⊝). CONCLUSION: There is little scientific evidence for how to predict in which cases, without clinical signs of venous congestion, venous supercharging should be performed. The complication rate might be lower in patients in which a prophylactic venous anastomosis has been performed. TRIAL REGISTRATION: PROSPERO (CRD42022353591).

Reconstruction of a lateral thigh defect with a transverse rectus abdominis myocutaneous (TRAM) free flap: A case report.

INTRODUCTION: Despite advancements in reconstructive surgery, the repair of large thigh deformities remains challenging. When other options are not feasible, distant flaps become necessary. Successful repairs have been achieved using a transverse rectus abdominis myocutaneous (TRAM) flap for the chest wall, groin, abdominal wall, sternum, and breast. CASE PRESENTATION: This study presents the case of a 40-year-old man who experienced a large deformity, measuring 20 cm ∗ 10 cm in his left lateral thigh resulting from a road accident that occurred a decade ago. Additionally, he developed osteomyelitis due to exposed bone based on MRI and clinical signs. To address this large defect, a free TRAM flap was utilized, effectively covering the area with a well-vascularized skin graft. This approach eliminated the need for a latissimus flap with a skin graft. DISCUSSION: In cases of covering large thigh defects, a variety of flaps can also be considered. The latissimus dorsi muscle is mainly used as a free flap, but surgeons should be cautious regarding the use of the latissimus dorsi flap while this flap is an attractive option in many other parts of the body, it's functional loss must be carefully weighed in lower extremity patients who are often crutch- and/or wheelchair-dependent. CONCLUSION: Based on this experience, the free-TRAM flap has proven to be a highly resilient option for similar defects and ranks among our top choices. It is important to note that in cases of infected and traumatic wounds where fatty tissue is undesirable, the flap may not be the best solution.

Deep Inferior Epigastric Perforators Topography for "Island Transverse Rectus Abdominis Musculocutaneous Flap" in Breast Reconstruction.

Background The Island transverse rectus abdominis musculocutaneous (TRAM) flap is well vascularized with very reliable blood flow, because all perforators of the zone I are included when it is harvested. The number of perforators, topographic mapping, and their relationship with reconstructed outcomes were investigated. Methods Fifty patients with Island TRAM breast reconstruction from September 2021 to August 2022 were investigated. The zone I was divided into a total of eight sections. Under the loupe magnification, all perforators larger than 0.5 mm in zone I were counted with fine dissection, and photographs were taken in background of vessel loops. Complications like flap necrosis, seroma, and hematoma were also investigated. Result There are 12 ideal perforators on average in zone I such as one perforator in section I, II, IV, V, VI, VIII, and three perforators in section III and VII. However, two perforators (M6 and L6) below arcuate line were sacrificed in the time of flap harvest to prevent hernia. Island TRAM included 10 perforators on average (5 perforators in each side) above arcuate line to be transferred to the recipient site. Only minor complications were identified. Conclusion The Island TRAM flap includes 10 perforators to get the vigorous blood flow. The periumbilical to upper medial perforators become more dominant in the perfusion of the flap after deep inferior epigastric artery division. Well preserved perforators will guarantee the satisfactory breast reconstruction with the least complication.

Outcomes of leaflet-shaped acellular dermal matrix with a thickness-gradient for abdominal fascial defect repair in muscle-sparing TRAM flap-based breast reconstruction.

BACKGROUND: Numerous fascial closure techniques have been used to reduce donor site morbidities after transverse rectus abdominis myocutaneous (TRAM) flap harvest. A leaflet-shaped acellular dermal matrix (ADM) with a thickness gradient was designed to cover the defect effectively and to withstand the pressure applied to the lower portion of the defect. The complication and functional recovery rates of the donor site of the custom ADM were compared with those of previous methods of fascial closure (primary closure and polypropylene mesh assisted closure). MATERIALS AND METHODS: A retrospective review of patients undergoing immediate or delayed breast reconstruction using muscle-sparing TRAM flaps was performed. Abdominal bulging, hernia, wound dehiscence, infection, seroma, and hematoma rates were compared. The Back Performance Scale measured four months postoperatively was compared to evaluate the donor site's recovery rate. RESULTS: A total of 173 patients were analyzed. The three groups did not differ in hernia, wound dehiscence, infection, and hematoma rates. However, the abdominal bulging rate was lower in the primary closure group, while the seroma rate was higher in the mesh group. Functional recovery was the fastest in the custom ADM group. CONCLUSION: A thickness-gradient, leaflet-shaped ADM can be effectively used as an onlay graft to cover the abdominal fascial defect, with similar complication rates, while providing a faster recovery of abdominal function.

A review of different breast reconstruction methods.

Breast reconstruction is necessary for the comprehensive treatment of breast cancer. For successful breast reconstruction, the timing of surgery and the surgical methods used are vital. The methods of breast reconstruction can be divided into implant-based breast reconstruction (IBBR) and autologous breast reconstruction (ABR). With the development of acellular dermal matrix (ADM), IBBR has become more common in clinical practice. However, the choice for the position in which the implant should be placed (prepectoral or subpectoral) and the use of ADM is currently controversial. We summarized the differences in indications, complications, advantages, disadvantages, and prognosis between IBBR and ABR. We also compared the indications and complications of different flaps in ABR and found that the LD (latissimus dorsi) flap is suitable for Asian women who have a low body mass index (BMI) and a low incidence of obesity, while the DIEP (deep inferior epigastric perforator) flap can be used in patients with severe breast ptosis. In conclusion, immediate breast reconstruction with an implant or expander is the primary method, as it causes lesser scarring and requires a shorter time compared to ABR. However, for patients with severe breast ptosis or reluctant to receive an implant, ABR can be performed for a satisfying cosmetic result. Indications and complications of different flaps in ABR are also inconsistent. Surgeons should make surgical plans based on the preferences and conditions of each patient. In the future, breast reconstruction methods need to be further refined, and minimally invasive and personalized approaches need to be implemented to provide more benefits to patients.

Preoperative planning of unilateral breast reconstruction with pedicled transverse rectus abdominis myocutaneous (TRAM) flaps: a pilot study of perforator mapping.

Background: Pedicled transverse rectus abdominis myocutaneous (TRAM) flaps are well-established autologous reconstructive options for breast reconstruction. Preoperative computed tomographic angiography (CTA) has since become part of the routine workup in breast reconstruction with deep inferior epigastric artery perforator (DIEP) flaps. CTA provides an improved understanding of perforator anatomy which can facilitate optimal choice of hemiabdominal wall, and guide sheath harvest. Despite this knowledge, the role of preoperative CTA for breast reconstruction with the pedicled TRAM flap has not yet been established. Methods: A consecutive cohort of patients undergoing breast reconstruction with pedicled TRAM flaps without preoperative imaging were compared to a similar cohort of consecutive patients undergoing the same procedure with the use of preoperative CTA. Both flap and donor outcomes were assessed. Results: Thirty-four consecutive patients undergoing ipsilateral breast reconstruction with pedicled TRAM flaps were included. There was no statistical difference in the operative times or outcomes between the two groups. There were no complete flap losses in either group. Conclusions: The use of preoperative CTA may help to guide surgical technique and provide the surgeon with greater confidence intraoperatively, however, this study did not show significant change in operative outcomes. Further study and risk/benefit analysis may better highlight the role of CTA in pedicled TRAM flap planning.

The Partial Removal of Rectus Abdominis Muscle Inserting into Ribs in Ipsilateral Pedicled TRAM Flap for Breast Reconstruction.

BACKGROUND: The purpose of this study was to introduce a new surgical technique for pedicled TRAM flap that removes a part of the rectus abdominis muscle inserting into ribs, and to analyze this technique in comparison with classical pedicled TRAM flap. METHODS: A retrospective review of patient charts from May 2006 to February 2016 was performed. The patient group that underwent the removal of the part of the rectus abdominis that inserts into the thorax (partial muscle resection; PMR group) was compared with the group that did not undergo this muscle resection (Classical group). The complications and aesthetic effects of surgery between the two groups were analyzed. RESULTS: There were 34 patients in the classical group and 28 in the PMR group. There were no significant differences in postoperative complications between these two groups. The rates of fat necrosis were 32.1% in the PMR group and 36.1% in the classical group. The postoperative aesthetic outcome of the inframammary fold showed no significant differences in outcome between the classical and PMR groups. However, all items received higher scores in the PMR group. CONCLUSIONS: The authors' new surgical method was associated with a positive cosmetic effect of improving inframammary fold aesthetics and could thus represent a new option for pTRAM breast reconstruction.

Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA.

Background: Deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle flaps are commonly used flaps for autologous breast reconstruction. CT-angiography allows to analyse the perforator course preoperatively. Our aim was to compare the different aspects of perforator anatomy in the most detailed study. Methods: CT-angiographies of 300 female patients with autologous breast reconstruction of 10 years were analysed regarding the anatomy of the deep inferior epigastric artery and every perforator. Results: Overall, 2260 perforators were included. We identified correlations regarding the DIEA branching point and number of perforators and their intramuscular course. The largest perforator emerged more often from the medial branch of the DIEA than the smaller perforators (70% (416/595) vs. 54% (878/1634), p < 0.001) and more often had a direct connection to the SIEV (large 67% (401/595) vs. small 39% (634/1634), p < 0.01). Medial row perforators were larger than the laterals (lateral 1.44 mm ± 0.43 (n = 941) vs. medial 1.58 mm ± 0.52 (n = 1304) (p < 0.001)). The larger and more medial the perforator, the more likely it was connected to the SIEV: perforators with direct connection to the SIEV had a diameter of 1.65 mm ± 0.53 (n = 1050), perforators with indirect connection had a diameter of 1.43 ± 0.43 (n = 1028), perforators without connection had a diameter of 1.31 mm ± 0.37 (n = 169) (p < 0.001). Medial perforators were more often directly connected to the SIEV than lateral perforators (medial 56% (723/1302) vs. lateral 35% (327/941), p < 0.001). A lateral perforator more often had a short intramuscular course than medial perforators (69% (554/800) vs. 45% (474/1055), p < 0.001), which was also more often observed in the case of a small perforator and a caudal exit of the rectus sheath. Conclusion: The largest perforator emerges more often from the medial branch of the DIEA and frequently has a direct connection to the SIEV, making medial row perforators ideal for DIEP flap transplantation.

Laparoscopic intraperitoneal mesh repair of an incisional hernia after transverse rectus abdominis myocutaneous flap reconstruction for breast cancer.

Breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap is performed for the treatment of large defects of the breast. However, this may result in an abdominal wall hernia or bulging. A 53-year-old Japanese woman with left breast cancer underwent left skin-sparing mastectomy, sentinel node lymph node dissection, and immediate reconstruction with a contralateral pedicled TRAM flap. Thirty-two months following surgery, right lower abdominal wall hernia (15.5 × 12 cm) and bulging were observed at the suprapubic region. The patient was diagnosed with an incisional hernia and was scheduled for laparoscopic intraperitoneal mesh repair. The mesh was coated with an absorbable hydrogel barrier and was trimmed to 26 × 22 cm, with a 5 cm overlap around the defect. The patient demonstrated a good postoperative course. In conclusion, intraperitoneal onlay mesh with hernia repair closure (IPOM-Plus) is a simple and useful method for hernia repair following TRAM flap reconstruction.

Muscle-sparing transverse rectus abdominis musculocutaneous free flap breast reconstruction following cryolipolysis.

Cryolipolysis refers to the sub-physiological cooling of regional body parts (typically the abdomen) in order to reduce the volume of adipose tissue. It provides a non-invasive alternative to procedures such as liposuction, which have traditionally been considered as relative contraindications for future abdominal free flap-based reconstructions. We describe the first case of a patient undergoing skin-sparing mastectomy and a muscle-sparing transverse rectus abdominis musculocutaneous (msTRAM) free flap breast reconstruction, following cryolipolysis therapy. Pre- and intraoperative radiological investigations and clinical examination showed no obvious adverse effect of cryolipolysis on the flap. The patient recovered well, with no vascular complications noted on follow up.

Relapsing phyllodes cystosarcoma and chest wall invasion with long-term survival: is aggressive surgery worthwhile?

A case of a 46-year-old woman with disease relapse and surgical intervention with a transverse rectus abdominalis muscle flap (TRAM) of the chest wall is reported. Long-term survival (64 months) following aggressive surgery was succeeded.

Reinforcement of the abdominal wall with acellular dermal matrix or synthetic mesh after breast reconstruction with the pedicled transverse rectus abdominis musculocutaneous flap. A prospective double-blind randomized study.

INTRODUCTION: The pedicled transverse rectus abdominis musculocutaneous flap (p-TRAM) is a well-established option for autologous breast reconstruction (BR) but donor-site morbidity is still reported. The aim of the present study was to compare donor-site morbidity after reinforcement of the abdominal wall regarding development of bulging or hernia, abdominal muscle strength, complications, and abdominal pain hypothesizing, that reinforcement with acellular dermal matrix (Strattice™) is superior to reinforcement with synthetic mesh (Prolene®). MATERIALS AND METHODS: A randomized, prospective, double-blind study was conducted with 29 patients admitted for BR with the p-TRAM flap at Department of Plastic Surgery, AUH, Denmark, 2014-2016. Allocation rate 1:1. Follow-up at 4, 12, and 24 months. RESULTS: 24 months postoperatively the computerized tomography verified bulging frequency was 35.7% in the ADM group and 6.7% in the synthetic mesh group (p = 0.11). Two patients (14.3%) in the ADM group and no patients in the synthetic mesh group developed hernia. No significant difference between baseline and 2-year measurement of abdominal muscle strength was observed. CONCLUSION: The present study did not demonstrate any statistically significant differences between treatment groups regarding risk of bulging or hernia, abdominal muscle strength, complications, pain or pain related QoL within two years of follow-up. Although the small sample size sets limitations for drawing wide conclusions the hypothesis that reinforcement with ADM is superior to synthetic mesh cannot be confirmed. Further research into methods for decreasing donor-side morbidity related to the TRAM flap or other rectus abdominis muscle-based flaps is needed.

Shaping of the abdominal flap in breast reconstruction: The coning technique in muscle sparing TRAM.

In the setting of autologous breast reconstruction, achieving an aesthetic outcome through shaping of the flap is of the upmost importance. We describe the abdominal flap folding technique of 'coning' and the indications. We define 'coning' as the technique of folding the abdominal flap in a circular fashion to create a conical breast mound, with the line of fusion forming a pillar of tissue for structural integrity. A retrospective study of 34 patients undergoing unilateral muscle-sparing TRAM flap was performed. Of these patients, the majority (79.4%) underwent immediate reconstruction, with the thoracodorsal vessels largely acting as the recipients (94.1%). Three (8.8%) patients were noted to have a contour defect secondary to incomplete folding of the flap. Two (5.9%) patients had partial skin envelope necrosis. One patient had 50% flap loss, requiring return to theatre for excision. In conclusion, coning was used exclusively in the muscle-sparing TRAM flap. This cuff of muscle protected the pedicle during folding through cushioning the perforators at their most vulnerable points. This technique allowed for muscle cuff harvest whilst minimising anterior sheath sacrifice. Coning achieved long-term maintenance of shape, volume and projection.

Supercharged Free Transverse Rectus Abdominis Myocutaneous Flap: An Autologous Reconstructive Option for the Thin Breast Reconstruction Patient.

The free transverse rectus abdominis myocutaneous (fTRAM) flap is a frequently used option for autologous breast reconstruction, typically based on deep inferior epigastric vessels anastomosed to either the axillary or internal mammary systems. The distal portion of the fTRAM flap is routinely discarded prior to anastomosis, due to tenuous blood supply in the vascular territory most distal to the pedicle. This becomes problematic in cases that require use of the entire flap, such as in thin patients with large soft-tissue defects. We report a case where an additional "supercharged" venous microsurgical anastomosis was successfully performed to minimize adverse events while utilizing the entire fTRAM flap.

Can pedicled TRAM flap be a satisfying alternative to free TRAM in developing countries? - a systematic review and meta-analysis.

BACKGROUND: Breast reconstruction can ease the psychological burden in breast cancer patients that have undergone mastectomy. The aim of our study is to collect the latest evidences to summarize whether pedicled TRAM (pTRAM) is non-inferior in terms of patient satisfaction and complications to free TRAM (fTRAM) so that it may be used in region with limited resources. METHODS: We performed a comprehensive search on studies that compared pTRAM and fTRAM flap from several databases. RESULTS: There are six studies included. Despite the diversity among the correspondents, all studies demonstrated no difference between the two groups regarding patient overall satisfaction. However, two studies found that pTRAM had lower abdominal well-being score, three found higher abdominal related morbidity, while fTRAM had a higher overall cost. Pooled mean difference was not significant on all BREAST-Q subscales, meaning that pTRAM and fTRAM has a similar outcome. CONCLUSION: Although pTRAM is non-inferior in terms of satisfaction to fTRAM, it is associated with a more frequent complication. It may be used in developing countries that lack facilities and limited by cost. However, pTRAM should be done by experienced surgeons to minimize the risk of complications.

Total laparoscopic surgery for treatment of leiomyoma of the transverse colon in a patient with an abdominal mesh: A case report.

INTRODUCTION: Gastrointestinal stromal tumors are the most common mesenchymal tumors of the gastrointestinal tract; however, gastrointestinal leiomyomas are relatively rare. Surgical resection is recommended for leiomyomas and gastrointestinal stromal tumors of the colon. We present a case in which we performed laparoscopic right hemicolectomy with intraabdominal anastomosis for treating leiomyoma of the transverse colon in a patient with an abdominal mesh. PRESENTATION OF CASE: A 64-year-old woman with a history of right subtotal adrenalectomy and right mastectomy was incidentally found to have an abdominal mass on a follow-up computed tomography (CT) scan, which was confirmed as a gastrointestinal stromal tumor of the mesentery following abdominal contrast-enhanced CT. We planned surgical resection for preoperative diagnosis because the tumor was >5 cm in diameter. However, she had undergone transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after right mastectomy, in which the TRAM flap was replaced with an abdominal mesh; hence, total laparoscopic surgery was performed to avoid damaging the mesh owing to the risk of mesh infection. Laparotomy revealed that the tumor originated from the transverse colon; thus, transverse colectomy with intraabdominal anastomosis was performed. The total operative time and blood loss were 3 h 32 min and 5 mL, respectively. No postoperative leakage or mesh infection was observed. The resected specimen revealed a leiomyoma without malignancy. DISCUSSION: We successfully performed colectomy that minimized the resection range and intraabdominal anastomosis. CONCLUSION: Total laparoscopic surgery was effective for colonic leiomyoma with an abdominal mesh to avoid mesh-related complications.

Should free deep inferior epigastric artery perforator flaps be considered a quality indicator in breast reconstruction?

Over the past several decades, technical advances in breast reconstruction have resulted in the development of flaps that are aimed at progressively decreasing abdominal wall morbidity. There is, however, ongoing controversy related to the superiority of deep inferior epigastric perforator (DIEP) flaps over muscle-sparing TRAM (MS-TRAM) flaps. Hence, the question remains unanswered as to which approach should be considered the standard of care, and more importantly, whether the rate of DIEP flap utilization should be considered a quality metric in breast reconstruction. In this review article, we examine the literature pertaining to abdominal free tissue transfer in breast reconstruction from both donor site and flap characteristics as well as the resultant complications and morbidity. The impact on the donor site remains a prevailing principle for autologous breast reconstruction; thus, must be adequately respected when classifying what is left behind following flap harvest. The most commonly used nomenclature is too simplistic. This, in turn, leads to inadequate incorporation of critical variables, such as degree of muscular preservation, fascial involvement, mesh implantation, and segmental nerve anatomy. Currently, there is insufficient evidence to support DIEP flap harvest as a quality indicator in breast reconstruction, as DIEP flap outcomes are not clearly superior when compared with MS-TRAM flaps.