Search

Study Objective: To analyze outcomes and postoperative complications in patients undergoing robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction., Design: Case series., Setting: Academic setting., Patients: Pelvic reconstruction surgery patients., Interventions: The rectus abdominis muscle flap can be used as a flap for pelvic reconstruction, providing a large volume of soft tissue that can be used in the treatment of many comorbid conditions, including genital fistulas, postradiation pelvic exenteration, and abdominoperineal resection defects. Intraperitoneal harvest of the rectus muscle using a robotic approach allows avoidance of laparotomy and subsequent disruption of the anterior rectus sheath, thus preserving the integrity of the abdominal wall., Measurements and Main Results: A retrospective analysis of patient demographic and clinical characteristics was performed for all patients who underwent robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction at our institution from October 1, 2016, to October 31, 2018. The postoperative complications analyzed included bowel obstructions, surgical site infections, emergency room visits, and need for readmission. Six patients (4 women and 2 men), with a mean age of 69.2 years (range = 57-79 years) and median follow-up time of 9.2 months (range = 5-12 months), were included. Muscle flap harvest was performed on the right side in 4 patients and on the left in 2 patients. The indications for reconstructive surgery included vesicovaginal fistula, complex pelvic organ prolapse, anterior and posterior exenteration, partial and total vaginectomy, partial vulvectomy, and abdominoperineal resection. Two patients received neoadjuvant chemoradiation. One of the 6 cases was converted to laparotomy; however, this was not owing to the rectus harvest. Three patients experienced no complications after reconstruction; 1 patient reported occasional abdominal pain; 1 patient had intermittent bowel obstruction; and 1 patient developed a pelvic abscess, requiring readmission. All 6 patients achieved satisfactory healing of the pelvic wound after robot-assisted rectus abdominis flap inset., Conclusion: Robot-assisted rectus abdominis flap harvest for pelvic floor reconstruction is a reliable means of defect closure, despite the presence of substantial comorbidities and risk factors in this patient cohort. Patient selection and counseling are crucial to optimize surgical outcomes in this complex population., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Background: Postpregnancy full-length diastasis of the recti abdominis muscles is a common condition occasionally associated with atrophy of the subcutaneous fat located at the midline above and below the umbilicus., Objectives: The authors report a preliminary clinical experience with the suprapubic flap to prevent the late postoperative contour deformities of the postpregnancy abdomen., Methods: Between January 2005 and January 2015, all female patients undergoing abdominoplasty with the suprapubic flap were included in the present study. Electronic clinical records were reviewed to analyze the patients' ages, body mass index (BMI) scores, pregnancies, risk factors, and operative times, followed by a telephone-based survey to measure patient satisfaction., Results: Twenty-two patients were included. Their ages ranged from 19 to 36 years (mean, 27 years) and their BMI ranged from 17.5 to 22.5 kg/m2 (mean, 20.5 kg/m2). Postoperative follow up ranged from 12 months to 10 years (mean, 89 months). All patients had experienced at least one pregnancy and many of them multiple or twin pregnancies. Umbilical hernias were present in 18 patients. There were 5 unusual cases: one hematoma, one seroma, and three cases of hypertrophic scarring. Thirteen additional minutes were required, on average, to associate the flap. All patients were satisfied or very satisfied with the results., Conclusions: The suprapubic dermoadipose flap is an effective option to prevent the midline depression that would otherwise remain on the hypogastric region of postpregnant slim women with midline fat tissue atrophy.

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.

Purpose: To investigate the blood vessels' concentration in TRAM flap's rat model, in the presence of pentoxifylline., Methods: 32 male, Wistar-EPM rats were divided into two groups. Control group (C): 0.5 ml of saline, intraperitoneally, once a day, for seven days before flap elevation; PTX group (P): pentoxifylline (20mg/kg/day), intraperitoneally, for seven days before flap elevation. After that, they were submitted to a caudal unipedicle TRAM flap. On the fifth postoperative day, percentages of flap necrosis were determined via the "paper template" method and Tram flap's zone IV skin biopsies were taken for histological analysis., Results: the mean percentage of flap necrosis in group C was 58.7 % and in group P, 31.1 (Wilcoxon test; p = 0.003). Mean capillary vessels number in zone IV's skin in C group was 33.4 and in P group was 71.9 (p=0.008)., Conclusions: Pentoxifylline was effective reducing the necrosis in the caudal unipedicle TRAM flap in the rat as well as increasing the number of capillaries in an ischemic zone (zone IV).

Purpose: To investigate the microscopic changes in the rectus abdominis muscle in rats subjected to five delay procedure., Methods: 30 male Holtzmann rats, weighting between 250 and 350 grams, were used. The animals were divided into five groups (n=6): A - cranial section of the right muscle; B - caudal section of the right muscle; C - craniocaudal section of the right muscle; D - cranial section reflecting the right muscle in the craniocaudal direction; E - caudal section reflecting the right muscle in the caudocranial direction. On the seventh day after surgery, a resection of the cranial and caudal fragments of the right and left muscles, respectively, was performed for microscopic analysis. Histological alterations were quantified and the right and left (control) muscle fragments compared. Fisher's exact test was used for statistical purposes with a significance level of 5%., Results: The comparison between right and left muscles showed statistically significant differences in group A - inflammatory infiltrate in the cranial fragment (p=0.015); in group C - inflammatory infiltrate (p=0.000) and necrosis (p=0.015) in the caudal fragment; and in group E - edema in the caudal fragment (p=0.000). No significant alterations were noted in groups B and D., Conclusions: Irrigation exclusively through the perforating muscle vessels is inappropriate; irrigation exclusively through the cranial pedicle causes milder, insignificant histological alterations, when compared with irrigation exclusively through the caudal pedicle; irrigation exclusively through the caudal pedicle causes more pronounced, but still insignificant, histological alterations when compared with other forms of devascularization.

Objectives: Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion., Methods: A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction., Results: The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months., Conclusions: Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.

Necrosis in TRAM (transverse rectus abdominis myocutaneous) still occurs in flap breast reconstruction. Blood flow may be improved by vascular endothelial growth factor (VEGF), an endogenous protein that stimulates neovascularization. Experimental studies of gene therapy with plasmid vector expressing human VEGF (hVEGF) presented inadequate results. Low level of gene expression could be the cause. To prove that high level of VEGF gene expression can minimize necrosis of TRAM flap, electroporation of VEGF plasmid was tested.Forty-two adult, male, Wistar-EPM rats were randomly distributed in 6 groups of 7 animals and 50 microg of vectors were injected in the intradermal layer of TRAM flap donor region, by electroporation: LacZ (beta-galactosidase gene); CG (no substance injected and flap elevated); P2G (empty gT plasmid in area 2); PV2G (gT-VEGF165 in area 2); P4G (empty gT plasmid in area 4); PV4G (gT-VEGF165 in area 4). Five days after flap elevation, the animals were euthanized and the degree of necrosis was analyzed by histology and paper template method.Dermal X-gal staining after electroporation with pSV2lacZ proved high rate of gene transfer. Mean values of necrosis by the paper template method were: CG (74.5%), P2G (62.2%), PV2G (41.1%), P4G (76.6%), and PV4G (59%). Degree of necrosis, preservation of muscle layer, and degree of infiltrates seen by histology were in accordance with mean values of necrosis.Intradermal injection of gT-VEGF165 in area 2, by electroporation, was effective in reducing unipedicle TRAM flap necrosis, in rats.

The operative management of midline full-thickness abdominal wall gaps is difficult, often requires several surgical procedures and is associated with significant short- and long-term complications. A rectus abdominis-posterior sheath (RAPS) flap with skin grafting provides a tension-free one-step repair which was used in three patients successfully with midline abdominal wall (including the skin) gaps who had multiple previous operations related to intra-abdominal malignancy. No complications occurred in these patients in relation to this procedure.

Perineal wound failure associated with infection is one of the intractable complications after abdominoperineal resection including pelvic exenteration. It is supposed that there is a strong possibility of this complication occurring in patients with infected perineal lesions after radiation therapy. We describe herein a case of a 56-year-old female who received pelvic exenteration for recurrent rectal cancer, the perineal wound of whom was successfully managed by a two-step operation using muscle flaps. The patient had a recurrent tumor in her pelvis after abdominoperineal resection for locally advanced rectal cancer. She had been treated with chemoradiotherapy for the recurrent tumor. The tumor was exposed to the perineum and was associated with bacterial infection. The tumor was curatively resected by total pelvic exenteration. The perineal wound infection was controlled by a lay-open method after reconstruction of the pelvic floor using a rectus abdominis muscle. The perineal wound was secondarily closed using gracilis mycocutaneous flaps 14 days after pelvic exenteration. She was discharged uneventfully 14 days after perineal closure. The strategy in the present report may be a useful option for perineal wound management in patients with a high risk of perineal wound failure due to infection after abdominoperineal resection.

Background: Deep sedation is often necessary after major reconstructive plastic surgery in the face and neck regions to prevent sudden spontaneous movements capable of inflicting mechanical injury to the transplanted musculocutaneous flap(s). An adequate positioning may help to optimize oxygenation and perfusion of the transplanted tissues. We hypothesized that dexmedetomidine, a central alpha2-agonist and otherwise potentially ideal postoperative sedative drug, may induce vasoconstriction in denervated flaps, and thus increase the risk of tissue deterioration., Methods: Two symmetrical myocutaneous flaps were raised on each side of the upper abdomen in 12 anesthetized pigs. The sympathetic nerve fibers were stripped from the arteries in one of the flaps (denervated flap), while nerve fibers were kept untouched in the other (innervated flap). After simulation of ischemia and reperfusion periods, the animals were randomized to deep postoperative sedation with either propofol (n = 6) or dexmedetomidine (n = 6). Flap tissue metabolism was monitored by microdialysis and tissue-oxygen partial pressure. Glucose, lactate, and pyruvate concentrations were analyzed from the dialysate every 30 min for 4 h., Results: Mean arterial blood pressure was higher in the dexmedetomidine group (P = 0.036). Flap tissue metabolism remained stable throughout the experiment as measured by lactate-pyruvate and lactate-glucose ratios (median ranges 14.3-24.5 for lactate-pyruvate and 0.3-0.6 for lactate-glucose) and by tissue-oxygen partial pressure, and no differences were found between groups., Conclusions: Our data suggest that dexmedetomidine, even if used for deep sedation, does not have deleterious effects on local perfusion or tissue metabolism in denervated musculocutaneous flaps.

Methods: The authors retrospectively reviewed 500 free TRAM flaps performed between 1992 and 2003. This cohort was subdivided based on smoking history, obesity, preoperative chemotherapy, preoperative radiation therapy, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and hypertension, and compared surgical complication rates. Measured complications included fat necrosis, mastectomy flap necrosis, abdominal flap necrosis, partial TRAM flap loss, wound infection, hematoma, seroma, vessel thrombosis, and abdominal hernia. Chi2 analysis and Fisher exact test were performed to determine differences between groups, and linear regression models were used to predict the risk factors of surgical complications., Results: Smokers were more likely to have a higher incidence of wound infection (P = 0.01), mastectomy flap necrosis (P = 0.015), abdominal flap necrosis (P = 0.033), and fat necrosis (P = 0.01). Obese patients were more likely to have higher rates of mastectomy flap necrosis (P = 0.01) and hematoma (P = 0.01). Patients with peripheral vascular disease were more likely to have a higher incidence of wound infection (P = 0.031), and patients with preoperative radiation therapy were more likely to have a higher incidence of seroma (P = 0.043). Logistic regression showed that smoking was found to be a risk factor for fat necrosis (P = 0.006), wound infection (P = 0.002), mastectomy flap necrosis (P = 0.039), and abdominal flap necrosis (P = 0.042). Obesity was a risk factor for mastectomy flap necrosis (P = 0.002). Peripheral vascular disease was a risk factor for wound infection (P = 0.032)., Conclusion: Awareness of risk factors and associated complications will lead to modification and individualization of surgical techniques in an attempt to limit these complications and continually improve outcomes.

Objective: Ischemia-related complications may occur during postmastectomy transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. The aim of our study was to investigate whether necrosis of susceptible flap regions could be reduced by dichloroacetate (DCA)-induced stimulation of oxidative metabolism in hypoxic tissue., Methods: The study was a randomized control trial using male Sprague-Dawley rats. A pedicled TRAM flap based upon the right inferior epigastric artery was elevated and reapproximated. Animals were randomly assigned to 1 of 5 treatment groups (n = 6). Group I received no DCA; groups II through V were administered 75 mg/kg DCA orally 24 hours preoperative; in addition, groups II through IV received 75 mg/kg/d DCA orally postoperative for 4 days; group III also received 75 mg/kg DCA (IP) intraoperatively; groups IV and V were given 15 mg/kg/d DCA orally for 6 days before the 24-hour preoperative treatment. Four days postsurgery, skin paddles were photographed and assessed for viability. Underlying TRAM muscle was biopsied for histologic analysis. Blood lactate levels were measured at pre- and postoperative time points. The mean percentages of viable skin paddle were as follows: 32.0%+/- 4.0% (group I), 68.1% +/- 6.2% (group II), 84.3% +/- 5.9% (group III), 92.8% +/- 2.0% (group IV), 82.6% +/- 5.8% (group V)., Results: Statistically significant differences were found in all experimental (DCA) groups relative to the controls (P < 0.01). Group IV (6-day DCA preconditioning, plus 24-hour preoperative and 4-day postoperative treatment) displayed the greatest improvement in flap viability, significantly better than other DCA groups (P < 0.01). Group IV also had significantly lower serum lactate levels than controls (P < 0.05). Histologic examination of muscle biopsies revealed reductions in inflammation and necrosis correlating with DCA treatment and skin paddle survival., Conclusions: This study indicates that DCA may provide a useful pharmacologic tool for reducing ischemia-related necrosis in TRAM flaps.

The aim of this study was to evaluate whether the dissection of the vascular pedicle of the deep inferior epigastric perforator (DIEP) flap could induce secondary muscle atrophy. Evaluation of the rectus abdominis muscle was performed using ultrasonography, and the muscle thickness was measured as an expression of muscle substance. This was performed at 4 levels: below the xiphoid process, at the umbilicus level, above the symphysis, and between the 2 last mentioned (central zone). The results were expressed as the ratio of the muscle thickness on the operated side where dissection of the vascular pedicle was performed to the thickness of the contralateral not operated muscle. Thirteen patients were included with a mean follow up of 20 months (range, 7-42 months). The combined measurements showed that the thickness of the muscle as a whole was significantly reduced on the operated side compared with the opposite side. Broken down to the specific levels, the greatest reduction in thickness, approximately 10%, was found at the xiphoid process and above the symphysis. We conclude that performing the dissection of the vascular pedicle of the DIEP flap gives a small but significant degree of muscular atrophy.

Reconstruction after mastectomy for breast carcinoma with implants or myocutaneous flaps is a widely used surgical technique. Recurrence of breast carcinoma after these procedures is uncommon. Most recurrences occur in the skin or scar site of the mastectomy and are readily detectable by physical examination. There are rare reported cases of recurrent carcinoma occurring within the flaps that are usually diagnosed with the aid of imaging and subsequent pathologic examination. In most cases, these recurrences represent invasive or in situ ductal carcinoma. We report an additional 2 cases of breast carcinoma recurring within the myocutaneous flap, both of which exhibited uncommon histologic features not previously reported.

This study was undertaken to assess the changes in the local morphology of the rectus abdominis muscle following intramuscular dissection of the deep inferior epigastric artery perforators after harvesting of the deep inferior epigastric perforator (DIEP) flap. While the DIEP provides the well-known advantage of use of the lower abdominal tissue with preservation of the integrity of the abdominal wall musculature, postoperative problems such as abdominal asymmetry, bulges and reduced flexion capacity have been found. These changes may be due to rectus abdominis muscle damage from ischemia or denervation. We used ultrasonography to assess the changes in rectus abdominis muscle thickness and contractility, preoperatively, 1-month and 1-year postoperatively. The study group consisted of 17 rectus abdominis muscles in 14 patients subjected to intramuscular dissection of perforators. The control group consisted of 11 intact rectus abdominis muscles in 11 patients who had undergone unilateral DIEP flap elevation, the dissected muscles being part of the study group. We found that the resting muscle thickness in the study group was, significantly increased at 1-month postoperatively, resolving by 1-year follow-up. As these changes were not seen in the control group, the increased muscle thickness is attributed to postoperative oedema that resolves with time. All muscles in the study and control groups retained contractility showing no evidence of muscle denervation. Our date demonstrates that intramuscular dissection of perforator vessels in the DIEP flap leads to minimal changes in the local morphology and contractility of the rectus abdominis muscle.

Hypothesis: Tissue flaps are commonly used for surgical reconstruction, especially to cover difficult wounds and in breast reconstruction following mastectomy. Complications due to inadequate flap perfusion are a source of morbidity and, in the lower extremity, can result in amputation., Setting: Laboratory., Interventions: We evaluated the ability of platelet-derived growth factor (PDGF) B and fibroblast growth factor 2 plasmid DNA, formulated in a type I collagen matrix, to promote tissue survival in a rat transverse rectus abdominis muscle flap model based on the inferior deep epigastric vascular supply. In the absence of any therapeutic agent, only about 24% of flap tissue survives in this model. The DNA/matrix formulations were delivered subcutaneously into the skin paddles 7 days before flap elevation, and tissues were harvested 7 days later., Results: Our studies reveal dramatic increases in overall vascularity after treatment with PDGF-B and fibroblast growth factor 2 plasmid DNA; however, only PDGF-B increased flap survival (130% increase at 228 micro g/cm(2) of plasmid DNA vs controls; P<.01). Transdermal spectral imaging demonstrated an increase in patent vessels supporting blood flow in flaps treated with PDGF-B plasmid DNA vs the fibroblast growth factor 2 transgene., Conclusion: Matrix-enabled gene therapy may provide an effective nonsurgical approach for promoting flap survival and is well suited for surgical applications in which transient therapeutic transgene expression is desired.

The strength of porcine small intestinal submucosa in abdominal wall repair after transverse rectus abdominis myocutaneous flap harvesting was examined in a rat model. Changes in the levels of selected molecular markers of inflammation after small intestinal submucosa implantation were also studied. Eighty-three rats were divided into three groups. In experimental group I, an abdominal wall defect created by removal of the rectus abdominis muscle was repaired with placement of a 1.5 x 5-cm2 patch of small intestinal submucosa. In experimental group II, the muscle defect was repaired with a combination of small intestinal submucosa patch placement and fascial closure. In the control group, the defect was repaired with direct fascial closure. At postoperative times of 3 days, 2 weeks, 1 month, and 2 months, the muscle tissues adjacent to the abdominal wall repair site were subjected to biopsies for assessment of inflammation markers. Full-thickness sections of the abdominal wall from the repair site in each animal were removed for tensile strength testing and histological examinations. The results demonstrated that interleukin-6 and interferon-gamma levels were increased in the two experimental, small intestinal submucosa-treated groups at 3 days and 2 weeks postoperatively. The results of mechanical testing demonstrated that the average tensile strength of the repaired abdominal wall in the repair model with combined small intestinal submucosa placement and fascial repair was significantly greater than the values for repairs with fascial closure or small intestinal submucosa placement alone. The use of small intestinal submucosa placement in combination with fascial repair can significantly improve the strength of the repaired abdominal wall after transverse rectus abdominis myocutaneous flap harvesting.

The anterior rectus sheath, efficacious in reconstructive surgery, is used in oromandibular reconstruction with the free rectus abdominis musculocutaneous flap. This study describes reconstruction with this sheath in 20 patients: to preserve only the swallowing function in 10 patients (formation of the bulge of the reconstructed oral floor and prevention of its sinking); to preserve both swallowing and articulation in 5 patients (formation of the bulge of the reconstructed tongue and prevention of its sinking, concurrent with a money-pouch-like reconstruction of the tongue, laryngeal suspension, and neuroanastomosis); and to prevent exposure of the reconstruction plate, replacing the resected mandibular continuity in 5 patients. The purpose of reconstruction was achieved in all patients. The vascularized free rectus abdominis musculocutaneous flap with a firm anterior rectus sheath may be the first choice for these types of reconstruction., (Copyright 2003 Wiley-Liss, Inc.)

Aims: To evaluate the acute and chronic urodynamic effects of electrically stimulated detrusor myoplasty in dogs., Methods: Eight female mongrel dogs were studied acutely and six dogs chronically (0 to 12 weeks postoperatively). Bladders were wrapped with the rectus abdominis muscle, keeping an intact blood supply and at least two intercostal nerves of the flap preserved. Bladders were electrically stimulated with bipolar electrodes inserted into the muscle. Urodynamics and post void residual were measured post operatively in the acute studies and every 2 weeks for 3 months in chronic studies., Results: Acutely, the increase in intravesical pressure was 45+/-7 cm H(2)O, which resulted in a postvoid residual of 26+/-3%. In the chronic study, increases of intravesical pressure sufficient to empty the bladder during myoplasty electrical stimulation were not sustained, although detrusor compliance and flap viability were preserved., Conclusions: The electrically stimulated detrusor myoplasty worked well acutely to increase vesical pressure sufficient to empty the bladder, but the chronically stimulated myoplasty did not maintain efficient bladder emptying primarily due to electrode problems. Further studies with improved electrode material and placement are required before clinical application of the electrically stimulated detrusor myoplasty can be assessed., (Neurourol. Urodynam. 21:516-521, 2002. Copyright Wiley-Liss, Inc.)

In the transverse rectus abdominis musculocutaneous (TRAM) flap procedure, a portion of the abdominal wall is transposed to the chest as a pedicle or free flap. Patients who have undergone this procedure often subsequently undergo computed tomography (CT) for assessment of metastatic disease or unrelated pathologic conditions. CT scans obtained in patients who had undergone the TRAM flap procedure were reviewed to facilitate recognition of both the normal and abnormal postoperative CT appearances of the TRAM flap. In 28 reconstructed breasts in 21 patients, three general appearances were identified: type 1 (homogeneous fat attenuation) (n = 4), type 2 (fat attenuation with a thin, curvilinear soft-tissue band parallel to the skin surface) (n = 19), and type 3 (thick soft-tissue band parallel to the skin surface) (n = 5). A mass that arose in a type 2 breast 21 months after surgery represented recurrent cancer. A markedly thickened soft-tissue band in another patient represented a dry eschar with inflammation and fat necrosis. The rectus abdominis muscle was partially absent in eight cases and completely absent in 20 cases. Recognition of the normal postoperative appearance of the body wall helps avoid confusion with disease states and allows identification of abnormal conditions such as inflammation, infection, and recurrent breast cancer.

Vascular supply to the contralateral portion of the conventional transverse rectus abdominis musculocutaneous (TRAM) flap (zone IV) may become compromised, resulting in partial flap loss and requiring segmental excision. The etiology of this necrosis is not clear. This study determines skin necrosis patterns on a superiorly pedicled caudal TRAM flap during conditions of venous and arterial insufficiency, and determines whether cutaneous venous outflow can sustain a flap with venous insufficiency. Twenty-eight adult male Sprague-Dawley rats underwent superior pedicled TRAM flap elevation, and the zones were marked on the skin paddle. The animals were divided into four groups: control (group A, N = 6), arterial ligation (group B, N = 6), venous ligation (group C, N = 8), and venous ligation with cutaneous venous outflow (group D, N = 8). After 10 days, the skin paddle was photographed and the areas of necrotic skin were measured. Results showed that group B (selective arterial ligation) had 51.7 +/- 2.8% and 40.0 +/- 2.0% skin necrosis in zones I and II respectively. Zone I necrosis was significantly greater in group B compared with the control (p < 0.05). Group C (selective venous ligation) resulted in 73.8 +/- 16.4% and 93.8 +/- 33.4% skin necrosis in zones III and IV respectively. This necrosis was significantly greater compared with the control (p < 0.001). Group D rats' lateral skin necrosis compared significantly less with group C (p < 0.001). These results demonstrate that the patterns of flap necrosis in rat TRAM flaps with poor arterial inflow differ from those with venous stasis. Necrosis of the contralateral portion (zone IV) of human TRAM flaps may be related to problems with venous stasis; thus, a cutaneous venous outflow may prevent this problem.

Inadequate blood supply of pedicle flaps results in partial necrosis, and prolonged ischemia during free-tissue transfer can result in partial or complete flap necrosis. Recent research in the field of cardiovascular surgery has shown that ischemic preconditioning (repeated brief episodes of coronary artery occlusion followed by reperfusion) improves myocardial muscle survival when the heart is subsequently subjected to prolonged ischemia. Preconditioning of skin or myocutaneous flaps as either pedicle or free flap models has never been studied. The goal of this investigation was to measure the effect of ischemic preconditioning on myocutaneous and skin flap survival areas and total necrosis rates after variable periods of global ischemia. In 220 rats, 100 transverse rectus abdominis myocutaneous flaps and 120 dorsal cutaneous flaps were randomized into treatment and control groups. The treatment flaps underwent preconditioning by three cycles of 10 minutes of pedicle clamping followed by 10 minutes of reperfusion for a total preconditioning period of 1 hour. The control flaps were perfused without clamping for 1 hour. Both control and treatment flaps then underwent global ischemia for 0, 2, 4, 6, 10, or 14 hours by pedicle clamping. Flap survival area was measured on the fifth postoperative day. Statistical analysis was performed with analysis of variance, student's t tests, and probit analysis. Preconditioning improved survival areas of pedicle myocutaneous flaps (0-hour group) from 47 +/- 16 percent (mean percent area surviving +/- SD) to 63 +/- 5 percent. This difference was statistically significant (t test, p < 0.04). There was no statistically significant improvement in pedicle skin flap survival. For free flap models (flaps undergoing global ischemia), preconditioning increased the survival areas of skin and myocutaneous flaps (analysis of variance, p < 10(-5)). For the skin flap model, statistical significance of the survival area difference was reached at 6, 10, and 14 hours of ischemia (t test, p < 10(-4)). The magnitude of this effect was higher in the myocutaneous flap model and reached statistical significance at 2, 4, 6, and 10 hours of ischemia (p < 10(-3)). Preconditioned flap survival areas were increased by two to five times that of non-preconditioned flaps at these ischemia times. Preconditioning lowered total necrosis rates at all ischemia times for both flap models. The critical ischemia time when 50 percent of skin flaps became totally necrotic (CIT50) improved from 6.9 to 12.4 hours by preconditioning. Similarly, preconditioning improved the CIT50 of myocutaneous flaps from 3.6 to 9.2 hours. For the first time, statistically significant improvements of partial necrosis areas and total necrosis rates have been demonstrated through intraoperative ischemic preconditioning of skin and myocutaneous flaps. In clinical practice, application of this technique may lead to improved survival during pedicled or free transfer of myocutaneous flaps and free transfer of skin flaps.

Abdominal wall competence is a major concern of all plastic surgeons using the TRAM flap for breast reconstruction. Low hernia rates and adequate abdominal stability are standard expectations in abdominal wall closure. Described here is this institution's experience with the use of a large piece of synthetic mesh as a supplementary reinforcement for the entire abdominal wall in an attempt to stabilize it and achieve a superior abdominal aesthetic result. Twenty-five consecutive patients had routine reinforcement with the extended mesh technique. Mean patient follow-up was 24 months with a minimum of 1 year. No hernia or mesh-related infection were encountered and only one patient had a lower abdominal bulge. We recommend the use of a large synthetic mesh for improved strength and aesthetic quality of the abdominal wall after TRAM flap breast reconstruction.

Surgical delay is an effective technique, but the precise timing of the delay effect and the required extent of the delay procedure are uncertain. We endeavored to study flap survival as a function of the duration of the delay period in a rat transverse rectus abdominis myocutaneous (TRAM) flap model. Two specific delay procedures (limited and extensive) were utilized, and flap survival was assessed after delay periods of 3, 7, 10, 14, 21, and 30 days (n > or = 7, all groups). A delay of 7 days or greater resulted in statistically significant improvement in flap survival in all groups. The delay effect appeared to be maximal at 14 days, and in the extensive delay group, a 14-day delay resulted in statistically greater flap survival than a 7-day delay. Improvement in flap survival was greater when an extensive delay procedure was used. Although the model system has limitations, the rat TRAM flap appears to be a suitable model for the study of the delay phenomenon. Possible clinical correlations are addressed in part II.

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction was performed in 15 patients 1 week after a preliminary delay procedure. The indications for surgical delay were obesity, smoking, prior radiation therapy, a requirement for large volumes of transmidline tissue, or combinations of these risk factors. The delay procedure consisted of outpatient ligation of the deep and superficial inferior epigastric vessels. Prior to and 1 week following the delay procedure, noninvasive Doppler examinations of the superior epigastric vessels were performed. Following the delay procedure, the diameter of the superior epigastric artery increased from 1.3 +/- 0.2 to 1.8 +/- 0.3 mm (p < 0.001) and the calculated superior epigastric artery flow increased from 7.25 +/- 0.8 to 18.2 +/- 2.7 ml/min (p < 0.001). Breast reconstruction in these high-risk patients was successful without major ischemic complications, but a tendency toward unreliability of zone IV was noted. This clinical observation is consistent with the findings in our animal studies (part I). The preliminary delay procedure was well tolerated with minimal morbidity. We feel that a preliminary delay procedure is a very useful option for breast reconstruction patients at high risk for TRAM flap vascular compromise.

High-field magnetic resonance imaging (Magnetom 42 SP, 1.0 Tesla) was performed a mean of 22 months (range, 8-42 months) postoperatively on 29 women who had undergone unilateral breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap (19 free and 10 pedicled TRAM flaps). Fifteen T1-weighed, cross-sectional spin-echo images of the abdominal wall were obtained using a surface coil. The free TRAM flap was elevated sparing the lateral third of the rectus muscle. In the pedicled TRAM flap the whole rectus muscle was used. The patient groups were demographically similar, with no statistical differences in age or body mass index. In the free TRAM group the mean (+/-standard deviation) area of the rectus muscle in the upper third of the muscle (first five slices) was smaller on the operated side (376 +/- 135 mm2) than on the contralateral side (462 +/- 78 mm2), p = 0.02. The mean signal intensity (reflecting intramuscular fat content) of the upper third of the muscle was significantly higher on the operated side than on the nonoperated side, p = 0.04. Intramuscular fat content was also estimated and graded using an arbitrary scale from 1 to 4. The fat content of the upper third of the muscle was graded higher on the donor side (median, 3) than on the contralateral side (median, 2), p < 0.01. In pedicled TRAM flap patients, the remaining rectus was responsible for a mean of 47 +/- 5% of the distance between the lateral muscles, leaving a mean of 63 +/- 10 mm of the abdominal wall covered by fascia only. No hernias were detected in either group. This study shows that harvesting of a free TRAM flap seems to affect the quality of the donor rectus muscle over its whole length.

Background: Breast reconstruction is performed with increasing frequency and has become important in the treatment of mastectomy patients., Methods: The development of recurrent carcinoma after a mastectomy and transverse rectus abdominus myocutaneous (TRAM) flap procedure is described., Results: The lesion was nonpalpable and was detected by mammography., Conclusion: This case raises questions about the practice of not performing postreconstruction mammography for detection of local recurrence after mastectomy.