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The TRAM-flap has become a well-established method for breast reconstruction. Even though the aesthetic result is superior to implant reconstruction, a main disadvantage is the potential risk to create weakness of the abdominal wall. For evaluation of abdominal wall function, an imaging method has to be used which is able to prove functional properties of the remaining muscle. This study was undertaken in order to verify if ultrasound imaging is a reasonable method to examine muscle movements after TRAM-flap procedures in addition to clinical examination. In 8 patients, a DIEP-flap, in 11 patients, a free TRAM-flap, and in 3 patients, a pedicled TRAM-flap were used for breast reconstruction. Patients were examined 10-72 months (mean, 32 months) after surgery. Ultrasound imaging of the abdominal wall was performed in longitudinal as well as cross sections (multifrequent, 13 Mhz; Siemens Elegra, Erlangen, Germany). The diameter of the remaining muscle was measured 2 cm below the rib bow, at the level of the umbilicus, and at the level of the skin scar. The operated side was compared to the nonoperated contralateral side. In order to evaluate the contractility of the remaining rectus muscle, patients were invited to perform sit-ups during ultrasound monitoring of muscle movement. Clinically the functional testing was performed by the method of Janda (Muskelfunktionsdiagnostik, 2nd ed. Berlin: Volk- und Gesundheit; 1986). The abdominal wall was inspected for bulging or hernia formation. Additionally, patients answered a six-scale self-designed questionnaire concerning the impairment of daily living and pain. Muscle contractility as well as muscle diameter were graded into four degrees from 0-3. The highest degree of 3 with normal muscle contractility and muscle diameter was found in 1 of 5 patients after DIEP-flap. Degree 2, with reduced muscle contractility and reduced muscle diameter, was found in 10 of 22 patients, especially after unilateral TRAM-flap. Degree 1, with no muscle contractility and remaining muscle, and degree 0, with scar tissue, were found in 11 patients. Impairment in daily-life activity was found in 10 patients, while 8 patients complained of pain. Muscle strength scored by the method of Janda (Muskelfunktionsdiagnostik, 2nd ed. Berlin: Volk- und Gesundheit; 1986) reached 4 and 5 in 19 patients after all kinds of flap harvesting; 3 patients reached Janda 2 and 3 after unilateral free TRAM or unilateral DIEP-flap. In one patient, a hernia was detected after unilateral DIEP-flap; 10 patients showed bulging of the abdominal wall. Functional testing of the abdominal wall by the method of Janda as well as CT-scans or MRI for evaluation of the remaining muscle is reported in the literature. As there is a need for cost reduction in medical treatment, we were looking for a more cost-effective evaluation method compared to CT-scan or MRI. Ultrasound imaging of the donor site after TRAM-flap harvesting in order to evaluate the remaining function of the rectus muscle is not yet reported in the literature. We consider ultrasound imaging to be superior to CT-scan or MRI in terms of functional evaluation and cost effectiveness.
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PMID:Clinical and ultrasound evaluation of donor site morbidity after tram-flap for breast reconstruction. 1516 Mar 74

The objective of this article is to compare the flap-specific complications associated with vertical (VRAM) and transverse (TRAM) rectus abdominis myocutaneous flap vaginal reconstructions performed during radical pelvic procedures. A retrospective chart review was performed to identify all patients who underwent VRAM and TRAM neovaginal reconstructions performed on the Gynecologic Oncology Service at Duke University Medical Center. Flap-specific complications were compared between the two techniques. From 1988 to 2003, 14 VRAM and 18 TRAM flap neovaginal reconstructions were performed on 32 women during the course of 22 (68%) total pelvic exenterations, 8 (25%) partial exenterations, and 2 (6%) radical vulvovaginectomies. Twenty-eight (88%) patients had been previously treated with radiation therapy or concurrent chemoradiation. Associated procedures included continent urinary conduit in 21 (66%), rectosigmoid reanastomosis in 8 (25%), and intraoperative or postoperative sidewall radiation therapy in 7 (22%) of patients. Overall median survival was 14 months (range: 2-week postoperative death to 65 months), with two (6%) acute postoperative mortalities. Fifteen flap-specific complications occurred in 12 (38%) patients, with no significant differences in flap type. Abdominal wound complications included four (12%) superficial wound separations, while one (3%) patient had a fascial dehiscence associated with complex fistulas that contributed to her death, but no patient developed incisional hernia. One patient each developed > 50% flap loss after TRAM and < 50% flap loss after VRAM flap, respectively. Four (12%) patients developed vaginal stricture or stenosis, two (6%) required percutaneous drainage of pelvic abscess or hematoma, and two (6%) developed rectovaginal fistula. Univariate analysis revealed a trend for increasing flap loss with body mass index > 35 (P = 0.056, Fisher exact two-tailed test), but there were no significant associations with other patient characteristics or flap-specific complications. Thirteen (62%) of 21 patients who survived >12 months reported coitus. Both VRAM and TRAM are reliable techniques for neovaginal reconstructions after radical pelvic surgery and have a similar distribution of flap-specific complications involving the donor and recipient sites.
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PMID:Rectus abdominis myocutaneous flaps for neovaginal reconstruction after radical pelvic surgery. 1588 83

An accurate preoperative evaluation of the vascular anatomy of the abdominal wall is essential in deep inferior epigastric perforator (DIEP) flap reconstruction. We present our experience of using computed tomographic angiography (CTA) of the abdomen as part of our standard preoperative assessment of abdominal-based breast reconstruction. One hundred consecutive cases were examined retrospectively, divided equally into non-CTA and CTA periods. Following use of CTA, fewer superficial inferior epigastric artery (SIEA) flaps were performed (18% vs. 0%), although the number of DIEP and muscle-sparing transverse rectus abdominis myocutaneous (MS TRAM) flaps remained similar. There was an increased use of single perforators in the CTA group than in the non-CTA group (48% vs. 18%) as well as increased numbers of medial-row perforators (65% vs. 32%). Unilateral reconstructions were performed 1h faster in the CTA group (489min vs. 566min). Finally, hernia rates decreased from 6% in the non-CTA group to 0% in the CTA group. A clear knowledge of the dominant perforator(s) to the abdominal skin prior to surgery can greatly increase the success of this procedure and reduce surgical time. In addition, by choosing the largest well-placed perforator supplying the bulk of the flap, it may be possible to reduce the overall morbidity.
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PMID:One hundred cases of abdominal-based free flaps in breast reconstruction. The impact of preoperative computed tomographic angiography. 1992 53

Results of our analysis show as that breast reconstruction become a standard part of the care of female patients with breast cancer We will analyse the factors that are important for the primary or secondary breast reconstruction after mastectomy, and also take a closer look on the most recent scientific advances on breast reconstruction and on the protocols regarding them. The breast is the most common site of cancer in Croatia women. Breast cancer is the first leading cause of cancer death among women today. The incidence of female breast cancer in Croatia estimates that approximately 2.200 news cases of female breast will be diagnosed every year. We retrospectively analysed data of 101 female patients undergoing reconstructive surgery for breast reconstruction after mastectomy at Division of Plastic Surgery and Burns, University Hospital Center Split and University Clinic of Plastic and Reconstructive Surgery, Innsbruck, Austria, between 1998 and 2008. For the purpose of outcome assessment, we performed the tree different type of questionnaire: (1) Personal/medical profile (Table 1), (2) Aesthetic assessment (Table 2), and (3) Psychosocial assessment (Table 3). The occurrence of main complications during breast reconstruction (partial necrosis of flap, hernia of donor site, pulmonary embolism, deep venous thrombosis, infection rate, hemathoma and seroma formation, and extrusion of expander/implant) during hospitalisation and follow up period until 6 post operatively were analysed with respect to use different type of reconstructive methods for breast reconstruction. The difference in complication between patients groups was evaluated by chi2-test. The level of significance was set up at p = 0.05. Mann-Whitney test was used to compare the time from mastectomy to breast reconstruction, due to asymmetrical data distribution. The three main variables of this study were to identify significant risk factors, asses the aesthetic outcome, and patient satisfaction with performed different methods for breast reconstruction (LD flap with or without tissue expander and implant, pedicle and free TRAM flaps, and expander /implants only. These variables determined the current guidelines for early and late breast reconstruction after mastectomy such as patient data, age and own decision, relation ship between reconstruction and radiotherapy, and chemotherapy, and finally about breast preserving operation. The result should confirm that breast reconstruction after mastectomy is justified, especially in young women, as well as how essential is team work involved in breast cancer operation and breast reconstruction after mastectomy.
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PMID:Breast reconstruction after mastectomy. 2040 6

Autologous breast reconstruction with the deep inferior epigastric perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap is a common method in the majority of patients after mastectomy. Because of an increased perioperative risk profile the benefit in older patients is questionable. To assess the postoperative quality of life and peri- and post-operative complications of older compared to younger patients is the aim of this retrospective study. In a retrospective analysis 39 older (i.e. >60 years) and 140 younger patients (i.e. <60 years) with autologous breast reconstruction in the Department of Plastic Surgery at the University Hospital of Erlangen-Nuernberg were surveyed at least 6 month postoperative using the BREAST-Q questionnaire. Correlations were generated between comorbidities and complications. Significant differences were observed regarding hospitalization, pre-existing diseases and the choice of DIEP versus ms-TRAM flaps. Parameters such as major and minor complications, bulging or hernia and risk factors (e.g. smoking or obesity) showed no significant differences. The results of the questionnaire parameters showed no significant difference between both groups, revealing high satisfaction with the aesthetic result and an improvement in quality of life independent of age. Autologous breast reconstruction after mastectomy generates a gain in quality of life and shows a good to excellent overall satisfaction in older as well as younger patients. Despite a longer hospitalization and a different risk profile there were no significant differences regarding minor and major complications in the postoperative course. Hence autologous breast reconstruction for older patients is justified and should be taken into consideration.
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PMID:Is there a Rationale for Autologous Breast Reconstruction in Older Patients? A Retrospective Single Center Analysis of Quality of life, Complications and Comorbidities after DIEP or ms-TRAM Flap Using the BREAST-Q. 2640 37

The umbilicus is a unique physiologic scar of human life resulting from the healing process of the cut umbilical cord at birth. Its absence leads to an unnatural abdominal appearance, and an abnormally shaped or misplaced umbilicus may draw undue attention to the central abdomen. Loss of the umbilicus can be an embarrassing deformity; this occurs when older techniques of umbilical hernia or incisional hernia repair are employed and after abdominoplasty, urachal cyst repair, omphalocele repair, gastroschisis repair, some tumor excisions, and mobilization of bipedicled or bilateral TRAM/DIEP flaps for breast reconstruction. Umbilicoplasty, in which the umbilicus remains anchored to the deep abdominal fascia but is transposed through a newly-formed aperture in the upper abdominal skin flap, is performed in abdominoplasty either for abdominal flap harvest or purely for aesthetics. On the other hand, umbiliconeoplasty describes the de novo creation of an umbilicus that is absent for either congenital or acquired reasons. The optimal umbilical reconstruction should be reliable, reproducible, aesthetically appropriate, and associated with low morbidity. Ideally, it is also single-staged, except in the case of an infected wound, in which case a delayed primary approach may be prudent. (www.actabiomedica.it).
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PMID:Umbilical reconstruction: different techniques, a single aim. 3191 Jan 76

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5-3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.
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PMID:Interdisciplinary Treatment of Breast Cancer After Mastectomy With Autologous Breast Reconstruction Using Abdominal Free Flaps in a University Teaching Hospital-A Standardized and Safe Procedure. 3219 71


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