Fuat YÜKSEL, Fikret EREN, Yalçın KÜLAHÇI, Hüseyin KARAGÖZ, Ceyhun CESUR, Cihan ŞAHİN, Celalettin SEVER

Three-layer primary closure of the bipedicled TRAM flap donor site for unilateral breast reconstruction: a 15-year experience with 124 consecutive patients

Background/aim: The pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains widely used as a breast reconstruction technique. The bipedicled TRAM flap is not as preferable as it was formerly, mainly because of its donor site complications. However, in a number of situations, a bipedicled TRAM flap may be the only alternative. Therefore, a three-layer primary closure technique used with bipedicled TRAM flap breast reconstructions that can avoid donor site complications without using a mesh is presented. Materials and methods: A retrospective study was performed that included patients who underwent bipedicled TRAM flap breast reconstruction with the three-layer primary closure technique. Between 2000 and 2015, 124 breast reconstruction patients were reviewed for donor site morbidity. Results: During the 15-year study period, 106 patients had conventional bipedicled TRAM flaps and 18 had bipedicled TRAM flaps with a surgical delay procedure. For all groups, none of the patients developed abdominal wall hernia, but three patients had bulging. Partial flap loss was the most common flap complication, present in 6 flaps (4.8%). Conclusion: The suturing technique studied provided abdominal wall closure without the use of a mesh even when utilizing a bilateral pedicle with very low complication rates.

PDF

___

1. Schusterman MA, Kroll SS, Weldon ME. Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap? Plast Reconstr Surg 1992; 90: 255-261.
2. Kroll SS, Coffey JA Jr, Winn RJ, Schusterman MA. A comparison of factors affecting aesthetic outcomes of TRAM flap breast reconstructions. Plast Reconstr Surg 1995; 96: 860- 864.
3. Watterson PA, Bostwick J, Hester TR, Bried JT, Taylor GI. TRAM flap anatomy correlated with a 10-year clinical experience with 556 patients. Plast Reconstr Surg 1995; 95: 1185.
4. Chun YS, Sinha I, Turko A, Lipsitz S, Pribaz JJ. Outcomes and patient satisfaction following breast reconstruction with bilateral pedicled TRAM flaps in 105 consecutive patients. Plast Reconstr Surg 2010; 125: 1-9.
5. Serletti JM. Pedicle TRAM, free TRAM and perforator flaps. In: Guyuron B, Eriksson E, Persing JA, editors. Plastic Surgery: Indications and Practice. Philadelphia, PA, USA: Elsevier; 2009. pp. 247-259.
6. Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006; 117: 737-746.
7. Yüksel F, Çeliköz B. Double-pedicle TRAM flap breast reconstruction: following Bostwicks principles. Aesthetic Plast Surg 2002; 26: 444-450.
8. Singletary SE. Skin-sparing mastectomy with immediate breast reconstruction: the M. D. Anderson Cancer Center experience. Ann Surg Oncol 1996; 3: 411-416.
9. Hogge JP, Robinson RE, Magnant CM, Zuurbier RA. The mammographic spectrum of fat necrosis of the breast. Radiographics 1995; 15: 1347-1356.
10. Schusterman MA, Kroll SS, Miller MJ, Reece GP, Baldwin BJ, Robb GL, Altmyer CS, Ames FC, Singletary SE, Ross MI et al. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one centers experience with 211 consecutive cases. Ann Plast Surg 1994; 32: 234-241.
11. Arnez ZM, Bajec J, Bardsley AF, Scamp T, Webster MH. Experience with 50 free TRAM flap breast reconstructions. Plast Reconstr Surg 1991; 87: 470-478.
12. Yüksel F, Şilit E, Çeliköz B. Reliance on double pedicle TRAM flap technique in breast reconstruction based on mammographic evidence. Indian J Plastic Surg 2004; 37: 44-50.
13. Carlson GW. Trends in autologous breast reconstruction. Semin Plast Surg 2004; 18: 79-87.
14. Bostwick J 3rd. Plastic and Reconstructive Breast Surgery. St. Louis, MO, USA: Quality Medical Publishing; 2000.
15. Sværdborg M, Damsgaard TE. Donor-site morbidity after pedicled TRAM breast reconstruction: a comparison of two different types of mesh. Ann Plast Surg 2013; 71: 476-480.
16. Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients. Ann Plast Surg 2009; 63: 378-382.
17. Kind GM, Rademaker AW, Mustoe TA. Abdominal-wall recovery following TRAM flap: a functional outcome study. Plast Reconstr Surg 1997; 99: 417-428.
18. Simon AM, Bouwense CL, McMillan S, Lamb S, Hammond DC. Comparison of unipedicled and bipedicled TRAM flap breast reconstructions: assessment of physical function and patient satisfaction. Plast Reconstr Surg 2004; 113: 136-140.
19. Schaverien MV, Perks AG, McCulley SJ. Comparison of outcomes and donor-site morbidity in unilateral free TRAM versus DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 2007; 60: 1219-1224.
20. Atisha D, Alderman AK. A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg 2009; 63: 222-230.
21. Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, Dalio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008; 121: 1519-1526.
22. Ascherman JA, Seruya M, Bartsich SA. Abdominal wall morbidity following unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 117 consecutive patients. Plast Reconstr Surg 2008; 121: 1-8.
23. Rossetto LA, Abla LE, Vidal R, Garcia EB, Gonzalez RJ, Gebrim LH, Neto MS, Ferreira LM. Factors associated with hernia and bulge formation at the donor site of the pedicled TRAM flap. Eur J Plast Surg 2010; 33: 203-208.
24. Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 2010; 126: 367-374.
25. Glasberg SB, DAmico RA. Use of regenerative human acellular tissue (AlloDerm) to reconstruct the abdominal wall following pedicle TRAM flap breast reconstruction surgery. Plast Reconstr Surg 2006; 118: 8-15.
26. Boehmler JH 4th, Butler CE, Ensor J, Kronowitz SJ. Outcomes of various techniques of abdominal fascia closure after TRAM flap breast reconstruction. Plast Reconstr Surg 2009; 123: 773- 781.
27. Paterson P, Sterne GD, Fatah F. Mesh assisted direct closure of bilateral TRAM flap donor sites. J Plast Reconstr Aesthet Surg 2006; 59: 347-351.
28. Bharti G, Groves L, Sanger C, Thompson J, David L, Marks M. Minimizing donor-site morbidity following bilateral pedicled TRAM breast reconstruction with the double mesh fold over technique. Ann Plast Surg 2013; 70: 484-487.