James E. Craigie, MDa, Robert J. Allen, MDb, Frank J. DellaCroce, MD, Scott K. Sullivan, MD
"East Cooper Plastic Surgery, 1300 Hospital Drive, Suite 120, Mt. Pleasant, SC 29464, USA Division of Plastic Surgery, LSU Health Sciences Center; 4429 Clara Street, Suite 440, New Orleans, LA 70115, USA
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  described the gluteus maximus myocutaneous flap for breast reconstruction. This was followed in 1979 by Holmstrom's  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 . The pedicled TRAM has proven to be a basically reliable method of reconstruction but the rate of partial flap necrosis may approach 25% . 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 . 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) . 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  and Mizgala et al  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 .
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CLINICS IN PLASTIC SURGERY July 2003 Editor: Molly Jay
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