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The abdominal wall function of 57 patients who have undergone TRAM flap breast reconstructions using the whole rectus muscle, on one side (33 patients) or both (24 patients), was evaluated 6 months to 2 years after surgery. The defect was repaired with a Teflon mesh buried in the rectus sheath. There was a perfect tolerance to the mesh, and no hernia or bulging of the abdominal wall developed. Patients had less back pain after (10 patients) than before (18 patients) the operation and found their sit-up and sport possibilities about the same as before. Detailed assessment of the abdominal muscles by the physiotherapist showed, however, a decreased function, more evident in bilateral cases. CT scans demonstrated a medialization of the lateral muscles, leaving only a small medial portion of the abdominal wall devoid of muscles. On the whole, no problem of clinical significance was encountered, and patients showed a high degree of satisfaction with the operation.
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PMID:Abdominal wall function after rectus abdominis transfer. 182 22

The value of synthetic mesh use in the treatment of recurrent abdominal hernias is well recognized and has led to its advocacy by some authors as an adjunct in primary hernia repair. Mesh use in the donor-site closure associated with TRAM flap reconstruction is typically restricted to situations where undue tension or questionable tissue integrity may be predisposing factors to herniation. Although more liberal use of mesh has been advocated for these circumstances, fear of mesh complications may continue to restrict its use. We present a series of 65 consecutive patients who had routine mesh application to fascial closures following TRAM flap breast reconstruction. The use of mesh provides an added margin of strength to fascial reconstruction and was found to have additional benefit as a technical adjunct to the aesthetic aspects of the abdominoplasty. Mean patient follow-up was 56.4 months. The resulting rates of hernia (1.5 percent) and mesh-related infection (1.5 percent) demonstrate its considerable safety. We recommend consideration of polypropylene mesh use for improved strength and aesthetic quality of the donor-site closure following TRAM flap breast reconstruction.
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PMID:Hernia prevention and aesthetic contouring of the abdomen following TRAM flap breast reconstruction by the use of polypropylene mesh. 748 Feb 32

The incidence of postoperative abdominal bulge, hernia, and the ability to do sit-ups was reviewed in a series of 268 patients who had undergone free TRAM (FTRAM) or conventional TRAM (CTRAM) flap breast reconstruction. Minimum follow-up was 6 months. Patients were divided into four groups: unilateral FTRAM (FT1P; n = 123), double-pedicle bilateral FTRAM (FT2P; n = 45), single-pedicle CTRAM (CT1P; n = 40), and double-pedicle or bilateral CTRAM (CT2P; n = 60). The incidence of abdominal bulges (3.8 percent) and hernia (2.6 percent) was similar in the four groups. Synthetic mesh, however, was required for reinforcement of donor site closure twice as often in the CTRAM patients. The ability to perform sit-ups was greatest in the FT1P group (63.0 percent), slightly lower in the CT1P group (57.1 percent), still lower in the FT2P group (46.2 percent), and lowest in the CT2P group (27.1 percent; p = 0.0005). Patients reconstructed with an FTRAM flap were more likely to be able to do sit-ups (58.3 percent) than were those reconstructed with a CTRAM flap (38.2 percent; p = 0.0074). Patients who had only one muscle pedicle used were more likely to be able to do sit-ups (61.7 percent) than were those who had two muscle pedicles used (35.6 percent; p = 0.0003). We conclude that the incidence of abdominal bulge or hernia is relatively independent of the type of TRAM flap used and the number of muscle pedicles harvested. On the other hand, postoperative abdominal strength, as measured by the ability do sit-ups, is influenced significantly by both of these factors.
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PMID:Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction. 763 85

This study examines the vascular anatomy of the TRAM flap and evaluates risk factors associated with complications among 556 women who had TRAM flap breast reconstruction. Fifty-nine patients (10.6 percent) developed fat necrosis involving 10 percent or more of their breast. Risk factors associated with fat necrosis were a history of chest-wall irradiation (p = 0.001), significant abdominal scar (p < 0.01), and obesity (p < 0.02). Among unipedicle reconstructions, patients with multiple risk factors had three times the incidence of fat necrosis (24.7 versus 8.3 percent) compared with patients with one or no risk factors (p < 0.002). Patients with multiple risk factors who had bipedicled TRAM flap reconstruction had no associated increased incidence of fat necrosis (p > 0.18). Forty-nine patients (8.8 percent) developed abdominal hernias. Risk factors associated with hernia formation included smoking at the time of surgery (p = 0.00001) and abdominal-wall repair with interposed mesh (p < 0.00001). The overall complication rate for this series was 23.7 percent (132 of 556). Risk factors associated with any complication included smoking (p < 0.002), history of chest-wall irradiation (p < 0.002), significant abdominal scar (p < 0.005), and obesity (p < 0.02). Patient selection is a fundamental determinant of successful TRAM flap breast reconstruction. Among patients with multiple risk factors, the risk of tissue loss in the reconstructed breast may be diminished by use of a bipedicled TRAM flap.
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PMID:TRAM flap anatomy correlated with a 10-year clinical experience with 556 patients. 861 79

The myocutaneous rectus abdominis flap described by Hartrampf was used for 156 breast reconstructions between 1982 and 1992. 107 reconstructions were done with one pedicle. 142 were delayed reconstructions. Partial necrosis of the flap occurred in 10% of the cases in bipedicled flaps and 20% in unilateral flaps. No hernia occurred in this series. Cosmetic results are considered satisfactory or very satisfactory in 59% of the cases when evaluated by the medical team and 76.5% when evaluated by the patients. As a conclusion of this study, the TRAM flap is preferred in delayed reconstructions when local and general conditions are suitable, rather than latissimus dorsi flap reconstructions which require an implant.
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PMID:[Analysis of 156 breast reconstructions by transverse rectus abdominis muscle flap (TRAM)]. 786 73

To define the long-term abdominal consequences of the TRAM flap procedure, 150 consecutive patients were evaluated 5 to 7.5 years postoperatively. Of 137 surviving patients, 135 (98.5 percent) returned a questionnaire (68 single pedicle, 63 double rectus harvest, and 4 single pedicle with contralateral microvascular augmentation) and 132 (96.4 percent) were examined and tested. By questionnaire, 64 percent noted overall improvement of the abdomen, 72 percent noted improved abdominal appearance, and 20 percent noted improved posture. Decreased abdominal strength was noted by 46 percent, and decreased exercise ability was noted by 25 percent. These figures were higher after double rectus harvest (60 and 35 percent) than after single rectus harvest (35 and 16 percent) (p = 0.005 and p = 0.014, respectively). Activities of daily living were rarely (4.0 to 5.8 percent) affected. Three of the patients had uncomplicated pregnancies and deliveries (two vaginal, one cesarean section). Situp performance was worse comparing postoperative patients with unoperated controls (p < 0.0005) and comparing double rectus harvest with single rectus harvest patients (p < 0.0005). Comparing double rectus harvest patients with direct abdominal closure and those closed with mesh, there was a trend toward poorer situp performance in the mesh subgroup; however, this was not statistically significant. On examination, a classic post-TRAM hernia was not encountered in any patient, but three single-pedicle patients had asymptomatic diffuse bulges through the fascial harvest site, visible only on straining to do a situp. Eight patients (seven bilateral and one single pedicle) had varying degrees of abdominal laxity, but only one had operative correction of diffusely attenuated abdominal fascia following pregnancy and delivery. Examiners' ratings of aesthetic abdominal appearance were higher for postoperative patients than for unoperated controls (p = 0.05). The vast majority of patients considered the TRAM procedure worthwhile (93 percent) and continued to recommend it to others (96 percent).
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PMID:Assessment of the abdominal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients. 813 92

This technique has evolved over 13 years and has been associated with very few mesh-related complications. A recently reported study of 65 consecutive patients with a mean follow-up of 47.4 months reported a hernia rate of 1.5% (1 of 65) and an incidence of mesh-related infection of 1.5% (1 of 65). It appears that the use of polypropylene (Marlex mesh) offers the reconstructive surgeon several advantages, including elevation of the entire rectus flap, thereby preserving the entire blood supply to the rectus muscle. Second, the interrupted suture technique surrounding the mesh allows for greater distribution of force and diminishes the risk of fascial dehiscence. Therefore, one can obtain a tighter, narrower abdomen to achieve an improved aesthetic abdominal result. The TRAM flap breast reconstruction should not only yield a fine reconstructed breast but also deliver an aesthetic abdominal contour improvement that represents a significant benefit to the patient undergoing this procedure.
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PMID:Synthetic mesh. Its use in abdominal wall reconstruction after the TRAM. 818 20

Although breast reconstruction has been shown to provide psychological benefits in mastectomy patients, there is reluctance to perform immediate, bilateral TRAM flap reconstruction because of concerns regarding magnitude of the procedure, length of hospitalization, potential complications, and long-term recovery. Between June, 1990 and March 1992, 15 patients underwent immediate, bilateral TRAM flap reconstruction following bilateral mastectomy at the University of Michigan Hospitals. Diagnoses included lobular carcinoma in situ (nine patients), strong family history of breast cancer (five), or bilateral breast cancer (one). Invasive breast cancer was present in three patients. Three modified radical mastectomies and 27 simple mastectomies were performed. Bilateral pedicle TRAM flap reconstruction was carried out at the same time in all patients (30 flaps total). Marginal loss occurred in one flap (3%). Additional complications included marginal necrosis of the abdominal donor site wound (one), wound infection (two), and abdominal donor site hernia (one). Median hospital stay was 7 days. Median follow-up was 13 months (range 4-25 months). All patients have resumed their accustomed pre-operative activity patterns. These findings demonstrate that immediate, bilateral TRAM flap reconstruction is a safe and effective option for breast reconstruction after mastectomy.
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PMID:Immediate, bilateral transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction after mastectomy. 833 83

Proponents for the free TRAM flap have advocated enhanced tissue vascularity, easier inset, and limited abdominal dissection. Equal aesthetic results without increased morbidity and without the risks of microvascular surgery have been suggested by surgeons using the pedicled technique. The free TRAM flap has been criticized for its considerably higher costs. The purpose of this study was to provide a cost comparison and outcome analysis of the free versus the pedicled TRAM flap. All patients who had had a TRAM flap performed in the authors' teaching institutions between March of 1990 and April of 1995 were evaluated. Outpatient and hospital records, and hospital and surgeon billing records, were reviewed for patient demographics, TRAM technique, delayed versus immediate, operating room time, length of stay, hospital and surgeon reimbursement, and surgical complications and their costs. All patients were sent a questionnaire asking about time back to work, abdominal strength, fitness, symmetry, and satisfaction. During the 5-year period, 125 TRAM flaps were performed. Of these flaps, 72 were free flaps and 53 were pedicled. Seventy percent were immediate reconstructions regardless of the technique used. Four percent of the free and 17 percent of the pedicled TRAM flaps were bilateral. There were no significant differences between the two techniques with regard to patient age, weight, or percentage of smokers, diabetes, hypertension, or preoperative chemotherapy or radiotherapy. Average operating room time was 7 hours with both techniques either delayed or immediate. Average length of stay was 7 days with the free (immediate and delayed) and 8 days with the pedicled (immediate and delayed) technique, although the difference was not significant. Average hospital reimbursement was $5300 for both the free and pedicled TRAM patients. Average surgeon reimbursement was significantly different, with $5000 for the free and $3500 for the pedicled TRAM flap. There were no differences in the occurrence of hematoma, partial/total flap loss, wound infection, hernia/bulge, fat necrosis, deep vein thrombosis, and pulmonary embolus with regard to the technique used. The cost of the treatment of the complications was not significantly different between the two techniques. There was a significant difference in the complication rate for the free TRAM patients compared with those treated by a routine reconstructive microsurgeon versus a more occasional microsurgeon. Ninety percent of both the free and pedicled patients responded to the questionnaire. There were no statistical differences between the free flap and pedicled flap survey results. The free flap patients returned to work 9 weeks after surgery; the pedicled flap patients returned at 10 weeks. Abdominal strength and overall fitness ranged from 74 to 79 percent for both groups. Symmetry and overall satisfaction averaged 3.4 of 4 for all. Average follow-up for the survey respondents was 20 months. This study did not demonstrate any significant differences in outcome or complications between the free and pedicled TRAM flaps. A modest cost difference of $1500 occurred for the free TRAM patients. An experienced microsurgeon had significantly fewer complications with the free TRAM patients. The authors recommend that surgeons use the technique with which they are comfortable and obtain predictable results.
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PMID:Free versus the pedicled TRAM flap: a cost comparison and outcome analysis. 938 52

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.
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PMID:Use of synthetic mesh for the entire abdominal wall after TRAM flap transfer. 950 Mar 87


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