The perfect method for breast reconstruction would
be safe, reliable, reproducible, applicable to all patients,
and have no donor site morbidity. The ideal reconstructed
breast would provide symmetric, permanent, and natural results.
The pursuit of these goals has fueled the development and
refinement of autogenous methods of breast reconstruction.
In 1976, Fugino et al [1] described the gluteus maximus
myocutaneous flap for breast reconstruction. This was followed
in 1979 by Holmstrom's [2] use of the rectus abdominus myocutaneous
free flap, and in the early 1980s, Hartrampf et al [3,4]
popularized the pedicled transverse rectus abdominus flap
(TRAM).
The TRAM flap remains the most popular method of autogenous
reconstruction. This popularity is due to the relative ease
with which the procedure is performed and the fact that
no microsurgical expertise is required. Proponents also
argue that the pedicled TRAM is quicker to perform, and,
thus, saves operative time and expense; this has not been
borne out in the literature [4]. The pedicled TRAM has proven
to be a basically reliable method of reconstruction but
the rate of partial flap necrosis may approach 25% [5].
This can be a problem when open wounds cause delays in chemotherapeutic
protocols, and, later, when the differentiation of fat necrosis
from a recurrent tumor is required. The high rate of partial
flap necrosis is the result of a basic anatomic problem
with the flap, which requires reversal of flow through intramuscular
choke vessels into the inferior vasculature. This, combined
with folding and tunneling of the pedicle at its pivot point,
can compromise vascular exchange within the flap. Tunneling
may also affect the medial breast contour [6]. The free
TRAM flap has been used in an effort to increase flap perfusion
but it suffers from the same limitation of rectus muscle
sacrifice. When patients with rectus sacrifice are compared
with those in which it is preserved, the importance of this
consideration is clear.
The deep inferior epigastric arttery perforator (DIEP) flap
for breast reconstruction was innovated to improve the donor
site morbidity that is associated with the TRAM flap [7).
Patients who are reconstructed with the DIEP flap experience
substantially less postoperative pain than those who are
subjected to muscle sacrifice (TRAM) [8]. Muscle sacrifice
in pedicle flaps is also responsible for abdominal asymmetries,
hernias, pain, and impaired ability to perform daily, occupational,
and sporting activities. Kroll et al [9] and Mizgala et
al [10] reported that abdominal wall morbidity was significant
and proportional to the amount of muscle that was removed
after TRAM flap breast reconstruction. The "muscle
sparing" free TRAM is considered less morbid to the
abdominal wall. Some studies indicated, however, that the
integrity of the remaining rectus muscle is lost if a small
portion is removed with the flap [11-13]. Weakness and atrophy
of the remaining muscle occur when the insertion is sacrificed
and the quality of the abdominal wall after the free TRAM
has been described as comparable to a pedicle TRAM donor
site [14].
W.B. SAUNDERS COMPANY A Division of Elsevier Inc.
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CLINICS IN PLASTIC SURGERY July 2003
Editor: Molly Jay
Volume 30, Number 3 ISSN 0094-1298
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