Source Breast Diseases: A Year Book Quarterly Volume: n/a Number: n/a March 2001

Abdominal Wall Competence After Free Transverse Rectus Abdominis Musculocutaneous Flap Harvest: A Prospective Study

Suominen S. Asko-Seljavaara S. Kinnunen
J. et al (Helsinki Univ; ORTON
Rehabilitation Centre, Helsinki)

Ann Plast Surg 39:229-234, 1997

Background

The free transverse rectus abdominis myocutaneous (TRAM) flap is frequently used in immediate and delayed breast reconstruction. The incidence of hernias and bulging is lower with the free TRAM flap than with the pedicled TRAM flap. However, a 20% incidence of abdominal wall complications has been reported. In this prospective study, changes in abdominal wall musculature after free TRAM flap harvest were examined.

Methods

Twenty-two consecutive patients had breast reconstruction with free TRAM flaps. The patients were examined 1 day before surgery and 3, 6, and 12 months after surgery. Trunk muscle strength was measured by a physiotherapist using an isokinetic dynamometer. Peak and average torque for flexion and extension at 60 degrees per sec angular velocity were recorded.

Results

Twenty-one patients completed the 6-month follow-up examination; 15 patients completed the 12 month follow-up examination. At 3 months, a significant reduction in trunk flexionstrength was seen, but this reduction was corrected by 6 months, and trunk flexion strength had improved to 98~o of baseline by 12 months. The patients' ability to do curled trunk sit-ups was graded on a scale of 1-6. In 9 of 19 patients, the surgery did not affect the ability to do sit-ups. In 10 of 19 patients, a reduction in the ability to do sit-ups of 1 or 2 grades was seen at 3 months, and this reduction did not improve by 12 months. Nine patients underwent MRI of the abdominal wall to measure the mean area of the upper third of both rectus muscles on axial images. At 3 months, the mean area of the upper third of the donor muscle was significantly larger than that of the contralateral muscle. At 6 months, there was no difference in size, and, at 12 months, the donor side was smaller.

Conclusions

In these patients, isokinetic dynamometry and physiotherapist assessment showed that harvesting a free TRAM flap results in a subclinical reduction in abdominal flexion strength. The better the patient's preoperative strength, the more evident was the strength reduction. Patients should be encouraged to begin abdominal exercises by 3 months after surgery. It is unclear whether these patients would benefit from active physiotherapy.

Editorial
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R.J. Allen, M.D.

The TRAM flap currently is the most popular flap for autologous breast reconstruction despite significant donor site problems. To isolate and study the rectus abdominis muscle has proven quite difficult. This prospective study does uncover loss of abdominal muscle function. Excluding the patients who could not perform sit-ups before surgery, the ability to perform a sit-up deteriorated.

In 1992, looking for a way to decrease donor site morbidity, I abandoned the TRAM flap in favor of the deep inferior epigastric perforator (DIEP) flap. This technique involves microsurgical transfer of skin and fat from the lower abdomen without sacrifice of any anterior rectus sheath or rectus abdominis muscle. Blondeel et al.2 have compared patients who have DIEP flaps with patients who have free TRAM flaps with regard to donor site morbidity. Their study demonstrates the superiority of the DIEP flap. My personal experience with more than 300 cases reveals less postoperative pain, shorter hospital stays, and return to preoperative level of function with the DlEP flap. The DlEP flap should replace the free TRAM flap as the procedure of choice for microsurgical breast reconstruction.

References

1. Allen RJ, Treece P: Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32:32-38, 1994.

2. Blondeel PN, Vanderstraeten GG, Monstrey SJ, et al: The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 5O:322-330, 1997.