Modified Mid-Abdominal TRAM Flap for Breast Reconstruction after Mastectomy: Further Experience
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- Category: Vol. 81, September 2013
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Modified Mid-Abdominal TRAM Flap for Breast Reconstruction after Mastectomy: Further Experience, ALAA EL-ERIYAN, AMR ABDEL RAOUF, MORAD EL KHOLY and HOSAM HAMDY
Abstract
Background: The mid-abdominal transverse rectus abdo-menis myocutaneous (TRAM) flap is characterized by a more reliable vascularity and a lesser donor site abdominal wall morbidity than conventional lower TRAM flap, its importance as an alternative approach for breast reconstruction has been overlooked.
Aim: Is to describe and evaluate mid-abdominal TRAM flap (instead of conventional lower TRAM flap) breast recon-struction with its added novel modification of inclusion and eversion of the umbilicus to further assert its practical impor-tance especially in high risk conditions for TRAM flap pro-cedure.
Patients and Methods: 30 selected patients with operable breast cancer and wishing to undergo immediate breast recon-struction (IBR) after either skin sparing (SSM) or non-skin sparing mastectomy (NSSM) from 2008 through 2010 in breast & endocrine surgery unit in national institute of diabetes and endocrine diseases (NIDE) were included. Inclusion criteria were: Patients with early breast cancer preferring to undergo mastectomy (SSM or NSSM) & IBR, T1 & T2 tumors not eligible for breast conservation therapy, after prophylactic mastectomy, ductal carcinoma in situ (DCIS), Paget's disease of the nipple. Exclusion criteria were: Locally advanced tumors i.e. stage III, inframammary fold tumors, neoadjuvant therapy, thin patients with flat abdomen, previous mid-line or upper abdominal incision, severe morbid obesity. Details of the 30 patients of the study (operative, post-operative, morbidity and mortality data) were reported for proper assess-ment of the procedure.
Results: Operative time was 3 hours on average with one to 2 units blood transfusion needed and an average of 10 days hospital stay. During a follow-up period of 6 months to 1.5 year, there were no mortalities or life threatening morbidities. As regards flap morbidities; there were no total flap loss, only one case (3.3%) developed partial flap necrosis, 5 cases (16.6%) developed superficial flap necrosis (epidermolysis) and 5 (16.6%) developed partial skin necrosis of the native breast skin, 3 cases (10%) with superficial wound infections were noticed in the recipient site. There were no cases with wound dehiscence but 2 (6.6%) developed seroma and 3 (10%) developed hematoma in the recipient site. There were 2 (6.6%) cases with minimal fat necrosis in the reconstructed breast. In regard to donor site morbidities; 3 (10%) developed hematoma, 2 (6.6%) developed seroma and 5 (16.6%) devel-oped infection. There were no abdominal wall herniation but only 2 (6.6%) developed abdominal bulge, 2 complained of abdominal discomfort and 2 developed donor site hypertrophic scar. The cosmetic results were rated as good to excellent both by the patient and the surgeon regarding the shape, the natural aspect of the breast and durability of nipple protrusion (A longstanding protruding nipple is obtained in all of the cases) and in no case remedial surgery on the contralateral breast to achieve symmetry was required.
Conclusion: Mid-abdominal TRAM flap with the added modification of inclusion and eversion of the umbilicus is safe and outstandingly reliable procedure for IBR with excel-lent therapeutic and cosmetic outcomes and we believe it may be considered an alternative approach other than traditional lower TRAM flap especially in obese and diabetics who are considered as high risk or even relative contraindications to traditional lower TRAM flap procedure.