Pyrotinib plus capecitabine for patients with human epidermal growth factor receptor 2-positive breast cancer and brain metastases (PERMEATE): a multicentre, single-arm, two-cohort, phase 2 trial.

BACKGROUND: Patients with HER2-positive metastatic breast cancer have a high risk of developing brain metastases. Efficacious treatment options are scarce. We investigated the activity and safety of pyrotinib plus capecitabine in patients with HER2-positive metastatic breast cancer and brain metastases. METHODS: We did a multicentre, single-arm, two-cohort, phase 2 trial in eight tertiary hospitals in China. Patients aged 18 years or older who had radiotherapy-naive HER2-positive brain metastases (cohort A) or progressive disease after radiotherapy (cohort B), with an Eastern Cooperative Oncology Group performance status of 0-2, received pyrotinib 400 mg orally once daily, and capecitabine 1000 mg/m2 orally twice daily for 14 days, followed by 7 days off every 3 weeks until disease progression or unacceptable toxicity. The primary endpoint was confirmed intracranial objective response rate by investigator assessment according to the Response Evaluation Criteria In Solid Tumours (version 1.1). Activity and safety were analysed in patients with at least one dose of study drug. The study is ongoing, but recruitment is complete. The study is registered with ClinicalTrials.gov, NCT03691051. FINDINGS: Between Jan 29, 2019, and July 10, 2020, we enrolled 78 women: 51 (86%) of 59 patients in cohort A and 18 (95%) of 19 patients in cohort B had previous exposure to trastuzumab. Median follow-up duration was 15·7 months (IQR 9·7-19·0). The intracranial objective response rate was 74·6% (95% CI 61·6-85·0; 44 of 59 patients) in cohort A and 42·1% (20·3-66·5; eight of 19 patients) in cohort B. The most common grade 3 or worse treatment-emergent adverse event was diarrhoea (14 [24%] in cohort A and four [21%] in cohort B). Two (3%) patients in cohort A and three (16%) in cohort B had treatment-related serious adverse events. No treatment-related deaths occurred. INTERPRETATION: To our knowledge, this is the first prospective study showing the activity and safety of pyrotinib plus capecitabine in patients with HER2-positive breast cancer and brain metastases, especially in radiotherapy-naive population. This combination deserves further validation in a randomised, controlled trial. FUNDING: National Cancer Centre Climbing Foundation Key Project of China, Jiangsu Hengrui Pharmaceuticals. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

In vitro Demonstration of Melanoma Metastasis in Lymph Nodes of Prepared Specimens Using a Light-emitting Diode-based Multispectral Photoacoustic Ultrasound Imaging System.

Although an excellent photoacoustic (PA) ultrasound method has been reported for the evaluation of lymph node melanoma metastasis in animal experiments, it remains to be evaluated in clinical trials. Recently, we performed PA ultrasound assessment using light-emitting diodes to detect metastatic melanoma in the lymph nodes of specimens prepared for microscopic examination. The PA effect was not obvious in amelanotic melanoma, but was seen in melanotic melanoma by PA imaging (PAI) and histopathological correlation in cases of primary melanotic melanoma accompanied by metastatic lymph nodes, including the coexistence of amelanotic melanoma and melanotic melanoma. Clinical workup should be performed with not only PAI but also conventional ultrasonography in cases with metastasis related to amelanotic transformation, which would likely be missed by PAI alone.

Influence of Flap Thickness on Nipple Projection After Nipple Reconstruction Using a Modified Star Flap.

BACKGROUND: In nipple reconstruction, the width, length, and thickness of modified star flaps are concerns for long-term reconstructed nipple projection. However, the flap's projection has not been analyzed, based on its thickness. The aim of the present study was to investigate how flap thickness in a modified star flap influences the resulting reconstructed nipple and achieves an appropriate flap width in design. METHODS: Sixty-three patients who underwent nipple reconstruction using a modified star flap following implant-based breast reconstruction between August 2014 and July 2016 were included in this case-controlled study. The length of laterally diverging flaps was 1.5 times their width. The thickness of each flap was measured using ultrasonography, and the average thickness was defined as the flap thickness. We investigated the correlation between the resulting reconstructed nipple and flap thickness, and the difference of the change in the reconstructed nipple projection after using a thin or thick flap. RESULTS: The average flap thickness was 3.8 ± 1.7 (range 2.5-6.0) mm. There was a significant, linear correlation between the flap thickness and resulting reconstructed nipple projection (ß = 0.853, p < 0.01). Furthermore, the difference between the thin and thick flaps in the resulting reconstructed nipple projection was significant (p < 0.01). CONCLUSION: Measuring the flap thickness preoperatively may allow surgeons to achieve an appropriate flap width; otherwise, alternative methods for higher projection might be used. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[A case of vesicovaginal fistula repair with rectus abdominus myofascial interposition flap after radical hysterectomy and radiation therapy].

Vesicovaginal fistulas (VVFs) caused after radiation are difficult to repair and require interposition of non-irradiated, well-vascularized tissue between urinary bladder and vagina. A 48-year-old female suffered cervical cancer and underwent radical hysterectomy followed by radiation therapy which caused VVF. The initial surgical repair performed 3 months after development of VVF, was unsuccessful because of the absence of peritoneum or omentum to interpose between urinary bladder and vagina probably due to history of cesarean section and radical hysterectomy. The second surgical repair was performed 15 months after the first surgery utilizing a rectus abdominus myofascial (RAM) interposition flap. Fifteen months after the second operation, she remains free from incontinence. This case suggests that RAM is useful even for postradiation VVF.

Postoperative electron beam irradiation to prevent recurrence of refractory subungual exostosis: a case report.

Background: Subungual exostosis is a type of heterotopic ossification, which often has unclear margins. Therefore, marginal resection may cause recurrence and wide resection is sometimes required to achieve a complete cure. However, wide resection may cause postoperative nail deformity and revision of this deformity is generally difficult. The primary treatment of subungual exostosis is surgical treatment, and there have been no comprehensive reports on the efficacy of adjunctive treatments. Although postoperative electron beam irradiation has been successfully used after heterotopic ossification excision to prevent recurrence, there are no reports on the use of this procedure following subungual exostosis resection. Case Description: Herein, we report a case of refractory subungual exostosis that developed as a result of chronic irritation and inflammation caused by an ingrown nail and recurred after initial resection. We performed marginal resection of the lesion to preserve the nail matrix and nail bed as possible, a two-stage skin grafting procedure, and electron-beam irradiation to prevent recurrence. Conclusions: Excellent results were achieved both in terms of complete cure and cosmetic appearance, suggesting that electron-beam irradiation following refractory subungual exostosis excision may help prevent its recurrence. We expect a further study including many cases of subungual exostosis treated with postoperative electron-beam irradiation to be conducted.

Flap Monitoring Using Interstitial Fluid Glucose Measurements.

Background: Various flap monitoring techniques have been used in the early detection of anastomotic thrombus; however, the use of automatic and continuous monitoring methods is presently uncommon. The purpose of this study was to investigate trends in interstitial fluid glucose concentration (IFG) in flap monitoring by measuring IFG automatically and continuously. Methods: Nine patients underwent unilateral breast reconstruction using a transverse rectus abdominis myocutaneous flap with vascular anastomosis. Two IFG measuring devices were attached to each patient. One device was attached to the flap (flap IFG) and the other to the healthy breast (control IFG). In each case, flap IFG, control IFG, and IFG ratio (flap IFG/control IFG) were recorded in the initial 72 h post-surgery (first half) and also in the subsequent 72 h (second half). In all of the cases, the mean values recorded in the first half and those in the second half were compared. Results: All flaps survived. The flap IFG didn't fall below 40 mg/dL in the first half. The minimum flap IFG and IFG ratio were 42 mg/dL and 0.55 in the first half. The flap IFG was significantly higher in the first half than in the second half in all cases, and the IFG ratio was similar in 8 cases. Furthermore, mean flap IFG and mean IFG ratio in all cases in the first half were significantly higher than in the second half. Conclusions: IFG measurements may complement conventional flap monitoring, particularly in the early postoperative period.

Historique: Diverses techniques de surveillance du lambeau sont utilisées pour favoriser le dépistage précoce du thrombus anastomotique, mais peu de méthodes de surveillance automatique et continue sont utilisées en ce moment. La présente étude visait à examiner les tendances du glucose interstitiel (GI) lors de la surveillance du lambeau par une mesure automatique et continue. Méthodologie: Neuf patientes ont subi une reconstruction mammaire unilatérale au moyen d'un lambeau myocutané du grand droit transverse avec anastomose vasculaire. Chaque patiente était dotée de deux dispositifs de mesure du GI. L'un d'eux était fixé au lambeau (GI du lambeau) et l'autre au sein en bonne santé (GI témoin). Dans chaque cas, les chercheurs ont enregistré le GI du lambeau, le GI témoin et le ratio du GI (GI du lambeau/GI témoin) pendant les 72 premières heures suivant l'opération (première moitié), puis pendant les 72 heures suivantes (deuxième moitié). Dans tous les cas, les chercheurs ont comparé les valeurs moyennes enregistrées pendant la première moitié à celles enregistrées pendant la deuxième moitié. Résultats: Tous les lambeaux ont survécu. Le GI du lambeau n'a pas chuté sous 40 mg/dl pendant la première moitié. Le ratio minimal du GI était de 42 mg/dl et 0,55 pendant la première moitié. Dans tous les cas, le GI du lambeau était beaucoup plus élevé pendant la première moitié que pendant la deuxième moitié, et le ratio du GI était semblable dans huit cas. De plus, dans tous les cas, le GI moyen du lambeau et le ratio moyen du GI était beaucoup plus élevé pendant la première moitié que la deuxième. Conclusions: Les mesures de GI peuvent compléter la surveillance habituelle du lambeau, notamment au début de la période postopératoire.

Current status of pre- or subpectoral breast reconstruction in Japan.

Breast reconstruction using silicone breast implants (SBIs) has been performed for many patients in Japan under the initiative of the Japan Oncoplastic Breast Surgery Society (JOBSS) since SBIs were first covered by insurance in 2013. A change in the lineup of available SBIs owing to the Allergan crisis caused a decrease in the availability of SBIs appropriate to Japanese breast contours. Recently, the number of immediate implant-based breast reconstructions (IBRs) was approximately 4,000 in one year and was slightly decreasing. The SBI is generally placed under the pectoralis major muscle. Because the number of patients with one-stage, implant-based operative indications is small, an acellular dermal matrix is not available in Japan, and the complication rate in one-stage, IBR is high, most immediate, IBRs are performed in two stages. The prevalence of immediate, one-stage, IBRs is approximately 10%. Fat grafting by injection using Coleman's technique is performed in many hospitals under the JOBSS initiative as a surgery combined with SBI insertion. Complications after SBI placement may be less common in Japan than those in other countries. Japanese breast reconstructive surgeons undertake preventive measures to lessen these complications according to guidelines and experts' opinions, which may contribute to the low complication rate after SBI placement. The total reported number of patients with breast implant-associated anaplastic large cell lymphoma is four, and no patients have died because of this disease. In Japan, procuring informed consent and diagnosing and treating this disease are performed according to the JOBSS guidelines.

Reconstructive surgery for severe breast asymmetry post-paediatric cardiovascular operation by anterolateral thoracotomy.

Breast maldevelopment is a troublesome long-term complication of anterolateral thoracotomies, and several cases of this event have been reported. However, breast reconstruction in such cases has not yet been reported in detail, and solutions for managing this event remain unexplained. Herein, we present a case of breast maldevelopment after anterolateral thoracotomy, in which symmetrical breasts were successfully obtained by breast reconstruction based on autologous tissue transfer. The surgical approach prior to pleurotomy in anterolateral thoracotomy, particularly when performed on female infant patients, must be modified to prevent postoperative breast malformation.

Pediatric-acquired Idiopathic Blepharoptosis with the Eyelids Being Habitually Opened Using the Frontalis Muscle.

Pediatric-acquired idiopathic blepharoptosis is rare, and no studies on surgery for the disease have been reported. We present a case of the disease with an atypical postoperative course. The patient initially underwent levator aponeurosis advancement. However, she cannot sufficiently open the affected eyelid without conscious effort and has developed a habit of opening the eyelids using the frontalis muscle. She underwent secondary frontalis suspension with the fascia latae, and then she was able to open her eyelids well all the time. When the disease duration in pediatric-acquired blepharoptosis is long, the habit of opening the eyelids using the frontalis muscle may be difficult to break. In such cases, we believe that frontalis suspension is the best operation.

False-positive diagnoses of damaged breast implants on imaging: a report of two cases.

Background: Silicone breast implants (SBIs), used in breast reconstruction, are durable and resistant to breakage and internal gel leakage. However, regular imaging examinations are crucial, as symptoms may not be apparent even if the implant ruptures. There are several known imaging findings that suggest SBI failure. Although artifacts such as moisture and air bubbles or substances similar to the gel extending outside the shell may appear on imaging, no reports have demonstrated false-positive diagnoses of damaged SBIs in detail. Hence, we present two cases in which failure was suspected based on the imaging results but not confirmed. Case Description: In case 1, at the 4-year follow-up after implant-based breast reconstruction, ultrasonography revealed a stepladder sign, and magnetic resonance imaging (MRI) revealed the salad oil sign. Although SBI failure was suggested, intraoperative examination revealed only a small amount of fluid retention within the capsule and no SBI fractures. Consequently, the imaging results were proved to be artifacts. In case 2, at the 7-year follow-up after implant-based breast reconstruction, ultrasonography revealed a subcapsular line sign, and MRI confirmed a keyhole sign. Although SBI failure was suggested, intraoperative examination revealed no implant fractures. Hematogenous serous effusion was found within the capsule, and blood clots and a large amount of fibrinous mass were found deposited at the bottom of the capsule. These findings caused false-positive diagnoses on imaging. Conclusions: In cases of suspected fractures, patients may opt for either observation or surgical removal, or replacement of the implant. When choosing the latter, it is important to inform patients of the possibility of an unbroken implant.

A Case of Refractory Heel Ulcer Complicated by Moderate Osteomyelitis and Cellulitis Successfully Treated with Rheocarna.

Revascularization surgery was first considered for the treatment of ulcers in patients with critical limb ischemia (CLI). However, it may not be indicated for patients with severe infections or peripheral vascular occlusions. Although blood purification therapy is adjuvant therapy for such patients, it is not yet widely used due to insurance coverage. We report a case of a refractory heel ulcer with moderate osteomyelitis and cellulitis that was not amenable to revascularization. Treatment with the adsorptive blood purifier rheocarna® (Kaneka Corporation; Osaka, Japan) resulted in complete epithelialization of the ulcer and control of inflammation. Although this case required careful follow-up, we believe rheocarna might be a promising treatment option for patients with CLI who do not respond to revascularization. Rheocarna could improve peripheral blood flow and control inflammation by improving antibiotic drug delivery.

A Novel Dissection Method of the Internal Mammary (Thoracic) Artery: Anastomotic Vessel of the DIEP Flap.

Deep inferior epigastric perforator flaps are commonly used for breast reconstruction using autologous tissue. For such free flaps, the internal mammary artery provides stable blood flow as the recipient for anastomosis. We report a novel dissection method of the internal mammary artery. First, the perichondrium and costal cartilage of the sternocostal joint are dissected with electrocautery. Then, the incision on the perichondrium is extended along the cephalic and caudal ends. Next, this C-shaped superficial layer of perichondrium is elevated from the cartilage. The cartilage is incompletely fractured with electrocautery, with the deep layer of perichondrium intact. Then, the cartilage is completely fractured by leverage and removed. The remaining deep layer of perichondrium is incised at the costochondral junction and shifted aside, revealing the internal mammary artery. The preserved perichondrium creates a rabbet joint to protect the anastomosed artery. This method not only enables a more reliable, safer dissection of the internal mammary artery, but also allows reusage of the perichondrium as underlayment in the setting of anastomosis, and coverage for the incised rib edge, protecting the anastomosed vessels.

Potential prognostic value of the lymph node ratio and its correlation with circulating sex hormone concentration in pathological T1/2 breast cancer patients: a retrospective study.

Background: The lymph node ratio (LNR) is an additional informative factor complementing anatomic TNM staging in breast cancer patients. The aim of this study was to evaluate the role of LNR in the cancer-specific and overall survival (OS) in a cohort of pT1/2 breast cancer patients and examine its correlation with circulating sex hormone concentrations in postmenopausal cases of the cohort from eastern China islands. Methods: Clinical and pathological characteristics, preoperational sex hormone and tumor markers concentrations, and breast cancer-specific survival (BCSS) and OS were analyzed retrospectively in 732 pathological T1/2 breast cancer patients. Results: The LNR was calculated, and the cut-off value was defined as 0.042 by receiver operative characteristic (ROC) curve according to the patient's mortalities. Patients with LNR ≥0.042 exhibited worse BCSS and OS than others (P<0.001) in pT1/2 breast cancer. Among patients with non-triple negative breast cancer (TNBC) and TNBC subtypes, the LNR ≥0.042 group also exhibited worse BCSS and OS than the LNR <0.042 group (P=0.003, 0.001, and P=0.032, 0.001, respectively). In univariate analysis, unfavorable BCSS and OS were both related with LNR ≥0.042 (P=0.001, <0.001). However multivariate analysis demonstrated TNBC subtypes were independent predictor for BCSS and OS [hazard ratio (HR) =1.449, 95% CI: 1.097-1.914, P=0.009; HR =1.365, 95% CI: 1.093-1.705, P=0.006, respectively]. Notably, Pearson or spearman correlation analysis revealed follicle-stimulating hormone (FSH) and, luteinizing hormone (LH) levels were significantly negatively associated with the LNR (P=0.007, 0.011, respectively) in postmenopausal cases, whereas CA153, CA125 and CEA were positively correlated with it (P<0.001, <0.001, 0.001, respectively) in all cases. Conclusions: Among pT1/2 breast cancer patients from eastern China islands, the LNR is a predictive prognosis factor; a higher LNR seems to correlate with a worse survival outcome both overall and in the subgroups. Strikingly, the current results reveal that serum FSH and LH level inversely associated with axillary node invasion in postmenopausal cases, whereas tumor markers directly related with it. The LNR is an informative factor complementing TNM staging.

A 10-miRNA risk score-based prediction model for pathological complete response to neoadjuvant chemotherapy in hormone receptor-positive breast cancer.

Patients with hormone receptor (HR)-positive tumors breast cancer usually experience a relatively low pathological complete response (pCR) to neoadjuvant chemotherapy (NAC). Here, we derived a 10-microRNA risk score (10-miRNA RS)-based model with better performance in the prediction of pCR and validated its relation with the disease-free survival (DFS) in 755 HR-positive breast cancer patients (273, 265, and 217 in the training, internal, and external validation sets, respectively). This model, presented as a nomogram, included four parameters: the 10-miRNA RS found in our previous study, progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2) status, and volume transfer constant (Ktrans). Favorable calibration and discrimination of 10-miRNA RS-based model with areas under the curve (AUC) of 0.865, 0.811, and 0.804 were shown in the training, internal, and external validation sets, respectively. Patients who have higher nomogram score (>92.2) with NAC treatment would have longer DFS (hazard ratio=0.57; 95%CI: 0.39-0.83; P=0.004). In summary, our data showed the 10-miRNA RS-based model could precisely identify more patients who can attain pCR to NAC, which may help clinicians formulate the personalized initial treatment strategy and consequently achieves better clinical prognosis for patients with HR-positive breast cancer.

[A case of Fournier's gangrene reconstructed using a rectus abdominis muscle flap].

We encountered a case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled rectus abdominis muscle flap (pedicled RA m-c flap). A 75-year-old man was admitted with consciousness disorder and swelling of the scrotum. The patient had noticed swelling of the scrotum 4 days before admission, but he had ignored this condition. The scrotum and the penis appeared necrotic. On the basis of clinical and radiological findings, we diagnosed this condition as Fournier's gangrene. Surgical debridement was performed in conjunction with the use of broad-spectrum antibiotics. After the patient's general condition was improved, the broad defect in the perineal tissue was covered with a pedicled rectus abdominis muscle flap. The flap was successful. In Japan, this is the first case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled RA m-c flap. In order to determine whether plastic surgery after debridement shortens the duration of hospitalization, we reviewed the cases of 120 patients with Fournier's gangrene in Japan. We conclude that plastic surgery after debridement does not shorten the duration of hospitalization, however, this procedures is very useful to deep and broad defects by Fournier's gangrene.

Generation of Chow Parameters and Reduced Variables Through Nearest Neighbor Relations in Threshold Networks.

Generation of useful variables and features is an important issue throughout the machine learning, artificial intelligence, and applied fields for their efficient computations. In this paper, the nearest neighbor relations are proposed for the minimal generation and the reduced variables of the functions in the threshold networks. First, the nearest neighbor relations are shown to be minimal and inherited for threshold functions and they play an important role in the iterative generation of the Chow parameters. Further, they give a solution for the Chow parameters problem. Second, convex cones are made of the nearest neighbor relations for the generation of the reduced variables. Then the edges of convex cones are compared for the discrimination of variables. Finally, the reduced variables based on the nearest neighbor relations are shown to be useful for documents classification.

Comparison of Two Types of Tapes for Taping After Breast Reconstruction Using Silicone Materials.

BACKGROUND: Several kinds of tapes are used for postoperative wounds, which occasionally cause contact dermatitis and result in noticeable pigmentation. A comparison of the postoperative course between different tapes has not been reported. This study aimed at investigating the differences between two postoperative tapes used after breast reconstruction with silicone materials for simple mastectomy. MATERIALS AND METHODS: Eighty-eight nonconsecutive patients undergoing tissue expander operation and 75 nonconsecutive patients undergoing tissue expander and silicone breast implant operations were included in this prospective study. Two postoperative tapes were used: a nonwoven surgical tape (Yu-ki ban®) or a hypoallergenic polyester-woven fabric tape (Atofine TM), which have different base materials, a removed keratinocyte area, and moisture permeability. We determined the differences in the incidence of skin complications, scar width, and aesthetic results with respect to scarring between the patients using Yu-ki ban and those using Atofine. RESULTS: Statistically similar results were achieved for the patients who underwent reconstruction using either the tissue expander or silicone breast implant. Scar width was similar between the groups; however, the incidence of skin complications was significantly lower in patients using Atofine than in those using Yu-ki ban. Aesthetic results with respect to scarring were better in patients using Atofine than in those using Yu-ki ban, with a significant difference in the incidence of pigmentation between the groups. CONCLUSION: The tape with higher moisture permeability and a lower removed keratinocyte area should be used to reduce the incidence of contact dermatitis and achieve better aesthetic results with respect to scarring.

Complications and Surgical Treatment of Breast Augmentation Using Autologous Fat Transfer and Fillers.

BACKGROUND: Breast augmentation with autologous fat grafting or hyaluronic acid injection requires minimal loss of healthy tissue. With an increasing trend of breast augmentation with these fillers, accompanying complications have also increased. Patients with complications often complain of induration, cyst formation, calcification, and infection, which require surgical treatment. We will discuss these complications and their surgical treatment through our experience of cases. METHODS: This retrospective study included 20 patients who all required surgical treatment due to breast augmentation complications such as induration, cyst formation, calcification, and infection, and who visited us between May 2007 and June 2018. The patients' ages ranged from 25 to 63, and the mean age was 39.9. The material used for breast augmentation was fat for 17 cases, and hyaluronic acid, paraffin, and silicon for one case each. The results were analyzed through plastic surgeons at our hospital. RESULTS: We performed a zigzag incision in the peri-areola margin to 17 of 18 patients for complications of autologous fat grafting and hyaluronic acid injection. The one excluded patient required an adipo-fascial flap from an inframammary fold incision. For one patient with silicon injection complication and one patient with paraffin injection complication, each required mammary gland resection. CONCLUSIONS: A zigzag incision in the peri-areolar margin was useful for treating complications of breast augmentation with autologous fat grafting and hyaluronic acid injection. All cases resulted in inconspicuous fine scars, with high patient satisfaction. However, this incision was insufficient to remove injected silicon and paraffin.

Breast reconstruction using delayed pedicled transverse rectus abdominis muscle flap with supercharging: reports of three cases.

Breast reconstruction using a pedicled transverse rectus abdominis muscle (TRAM) flap is a well-established surgical procedure. Although studies suggest that transplanting this flap using a delayed method reduces the risk of partial flap necrosis, challenges persist. Hence, we present three cases of breast reconstruction using a pedicled TRAM flap with both delaying and supercharging. Patient age, excised tissue volume for mastectomy, and follow-up period were as follows: Case 1, 58 years, 429 cm3, 5 months; Case 2, 35 years, 910 cm3, 6 months; and Case 3, 56 years, 489 cm3, 4 months. One patient (Case 2) required a large flap tissue volume to achieve breast symmetry, whereas the other two (Cases 1 and 3) had long, longitudinal scars from previous cesareans sections. In a delayed surgery, the flap was partially elevated with partial dissection and no ligation of the deep inferior epigastric artery and vein (DIEAV). An artificial dermis with a silicone membrane (Teldermis®) was used to prevent adhesion of the rectus abdominal muscles and DIEAV to the surrounding tissue. Supercharging was performed by anastomosis between the ipsilateral DIEAV and internal thoracic AV. Flaps in zones I-III and in half of zone IV for Case 2, and zones I-III for Cases 1 and 3, were transferred; all survived without infection. This method allowed the transferring of a larger tissue volume compared with the conventional pedicled TRAM flap-transfer method. Thus, it may be useful for patients who require larger tissue volume or high-risk patients.