Reconstructive Outcomes of Extensive Soft-Tissue Defects after Palliative Mastectomy for Advanced Breast Cancer

Background: In advanced breast cancer, reconstruction can be performed depending on the patient’s situation, and can improve the subsequent treatment and quality of life. We examined the effect of reconstruction after palliative mastectomy on survival and quality of life.Methods: Between April 2010 and April 2021, 40 patients underwent reconstruction after palliative mastectomy for stage-IV breast cancer. To evaluate postoperative satisfaction, changes in the global health and quality-of-life scores after reconstruction were evaluated using questionnaires by the European Organisation for Research and Treatment of Cancer. The survival rate according to reconstructive surgery was estimated by the Kaplan-Meier survival analysis.Results: Reconstruction methods included free transverse rectus abdominis musculocutaneous (TRAM) flap (n=3), pedicled latissimus dorsi (LD) flap (n=3), pedicled TRAM flap (n=2), pedicled LD with pedicled vertical rectus abdominis musculocutaneous flap (n=1), tissue expander insertion (n=3), and split-thickness skin graft (n=28). There were no major complications or decreased life expectancy due to reconstruction. All patients healed well and started conventional chemoradiotherapy at 31.3 days postoperatively. The quality-of-life scores increased from 37 to 83 after reconstruction. There was no difference in the survival rates between those who underwent reconstruction with split-thickness skin graft and flap operation (P>0.05). The mean survival time postoperatively was 43.9 months.Conclusion: Compared to primary closure, reconstruction of extensive soft-tissue defects after palliative mastectomy did not affect life expectancy or delay postoperative chemoradiotherapy; it led to an improved quality of life. Therefore, the extensive defects expected after palliative mastectomy should not influence indications for reconstruction surgery.

A Variation of the Components’ Separation Technique that Preserves the Semilunaris for Treatment of Abdominal Wall Deformities

The variation of the components’ separation technique, which uses the anterior rectus sheath and the release of the oblique muscles, proved to be effective in tension reduction. This paper aimed to present the initial experience using a variation that preserves semilunaris through the incision of the lateral aspect of the rectus sheath. All of the 12 patients presented an abdominal wall defect that included incisional hernia, peritoneostomy, lateral implantation of the rectus muscle, and defect secondary to TRAM flap. The separation was done in the following stages: stage 1—anterior rectus sheath and stage 2—external oblique muscles. From the 12 patients, three presented early complications: seroma (n = 2) and epitheliolysis (n = 1). There were no recurrences or other late complications (48 months follow-up period). The separation of the anterior rectus sheath, and incision in the lateral recess to undermine the oblique muscles, allowed the treatment of abdominal wall defects, without late complications.

Pedicled transverse rectus abdominis myocutaneous flap breast reconstruction: Hospital Kuala Lumpur’s early experience

Background: Breast reconstruction is traditionally performed by the plastic surgeons. In the last four years, we have embarked on autologous breast reconstruction. We conducted a retrospective study to evaluate the complications and cosmetic outcomes of a pedicled transverse rectus abdominis myo-cutaneous (TRAM) flap breast reconstruction.Methods: We enrolled forty-one patients who underwent a TRAM flap reconstructive surgery between January 2016 and January 2020 at the hospital Kuala Lumpur, Malaysia. Thorough retrospective reviews of medical records were performed. Patient’s satisfaction on the cosmetic outcome were assessed with the breast-Q questionnaire.Results: Forty-one patients with a mean age of forty-six years old, had ipsilateral pedicled TRAM breast reconstructions for various breast pathologies including invasive carcinoma (n=31, 75.6%), ductal carcinoma in situ (n=8, 19.5%) and phylloides tumor (n=2, 4.9%). Immediate reconstruction was performed in thirty-nine patients and delayed reconstruction in two patients. Based on The American joint committee on cancer (AJCC) TNM system, the pathologic stages among those patients with breast cancer were 0 (n=8, 20.5%), I (n=3, 7.69%), II (n=9, 23.1%), III (n=18, 46.1%), and IV (n=1, 2.56%). During the mean follow-up of seventeen months, flap and donor site complications were reported in twelve patients (29.3%) and five patients (12.1%) respectively. Nineteen were very satisfied and sixteen were satisfied.Conclusions: Breast reconstruction with a TRAM flap can be safely performed by the oncoplastic breast surgeons with good aesthetic outcomes.

Breast reconstruction with deep inferior epigastric artery perforator flap (DIEP-flap). History of development

The article is devoted to the actual topic of breast reconstruction with autologous tissues. The article discusses the key stages in the development of breast reconstructive surgery using free flaps using microsurgical techniques. A flap of the anterior abdominal wall, among other techniques, is the method of choice for breast reconstruction today, also because it allows you to achieve the most "natural" result. The authors compares different variants of autologous flaps, describes the advantages of the DIEP flap in comparison with the TRAM flap. Also, special attention is paid to the choice of breast reconstruction method depending on age, constitutional characteristics and the presence of risk factors such as smoking, diabetes mellitus and excess BMI. Analyzing the advantages of breast reconstruction with autograft flaps, the author concludes that there is a higher quality of life and improved outcomes in these patients than in patients who underwent implant-based reconstruction. Based on the literature review, it was found that breast reconstruction with the help of perforating flaps is still an area of innovation and constant progress: research in this area to date is mainly aimed at reducing the morbidity of the donor area and methods for isolating recipient vessels, shortening the rehabilitation period and developing reproducible reconstruction method.

Clinical Study about Latissimus Dorsi Based Breast Reconstruction at a Tertiary Health Centre in Mangalore, India

BACKGROUND The most common cancer among urban Indian women is breast cancer. Mastectomy causes loss of body image and negatively impacts the quality of life. Restoration of body image is an important step for breast cancer survivors. Recent reconstruction options are autologous or implant-based reconstruction or combined approach. This present clinical study was done to describe about latissimus dorsi based breast reconstruction (BR) at a tertiary health centre. METHODS This retrospective study was conducted at a tertiary health care centre from Jun 2018 to Dec 2020. Eligible desiring patients’ divided into the small, medium and large breasts and were willing to undergo BR were taken up for surgery. Patients considered as suitable candidates were further assessed for the option of reconstruction by latissimus dorsi (LD) flap, LD flap with an implant. All the patients were fully explained about the procedure. RESULTS The total number of mastectomies were 158 and breast reconstruction was done in 45 patients, with a percentage of 29 %. In our study, majority of the patients (91.1 %) underwent immediate breast reconstruction. Reconstructive methods used in our study were autologous LD flap (64.4 %), LD flap with silicone implant (24.2 %) and pedicled transverse rectus abdominis myocutaneous (TRAM) flap (11.2 %) based on the size of the contralateral breast. The most common type of reconstruction in our study was the LD flap (64.4 %). CONCLUSIONS Immediate reconstruction of mastectomy defects was offered to all interested patients. Autologous or implant-based can be done safely with minimum morbidity. Latissimus dorsi flap-based breast reconstruction is a cost-effective, safe, reliable method at a tertiary health centre. KEY WORDS Breast Reconstruction, Flap, LD Flap, Implant

TRAM flap breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) flap retains a prominent role in contemporary breast reconstruction surgery. This chapter reviews the origins and anatomy of the TRAM flap, both as a pedicled and free tissue transfer. Patient selection and flap planning are examined in the context of immediate and secondary breast reconstruction with attention to oncological considerations and patient risk factors. The elements influencing choice between a pedicled or free flap are discussed and some guidelines to decision-making for abdominal based breast reconstruction are offered. Detailed descriptions of surgical technique and perioperative care follow, illustrated by case examples.

Application of Botulinum Neurotoxin Injections in TRAM Flap for Breast Reconstruction: Intramuscular Neural Arborization of the Rectus Abdominis Muscle

Breast reconstruction after mastectomy is commonly performed using transverse rectus abdominis myocutaneous (TRAM) flap. Previous studies have demonstrated that botulinum neurotoxin injections in TRAM flap surgeries lower the risk of necrosis and allow further expansion of arterial cross-sectional diameters. The study was designed to determine the ideal injection points for botulinum neurotoxin injection by exploring the arborization patterns of the intramuscular nerves of the rectus abdominis muscle. A modified Sihler’s method was performed on 16 rectus abdominis muscle specimens. Arborization of the intramuscular nerves was determined based on the most prominent point of the xyphoid process to the pubic crest. All 16 rectus abdominis muscle specimens were divided into four muscle bellies by the tendinous portion. The arborized portions of the muscles were located on the 5–15%, 25–35%, 45–55%, and 70–80% sections of the 1st, 2nd, 3rd, and 4th muscle bellies, respectively. The tendinous portion was located at the 15–20%, 35–40%, 55–60%, and 90–100% sections. These results suggest that botulinum neurotoxin injections into the rectus abdominis muscles should be performed in specific sections.

Response to ‘Australia's contribution to the free abdominoplasty flap in breast reconstruction’

Perhaps few realise that the development of what became known as the free transverse rectus abdominis myocutaneous (TRAM) flap was a race involving not one but two surgical teams, one in Sydney and the other, with the aid of the Australian Richard Hamilton, in Sweden

Single-port 3-dimensional Videoscope assisted Endoscopic Nipple-sparing Mastectomy Followed by Immediate Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap Reconstruction: Report of Two Cases

Background: Minimal access surgery has become the mainstreams of breast surgery, and it is applied for benign lesion, partial mastectomy and total mastectomy. Dual axillary-areolar incision was the most frequent surgical approach in the early stage, but single axillary incision hybrid technique was proposed in recent years. Endoscopic nipple sparing mastectomy was usually applicable to patients with small to medium sized breast. Here, we reported two cases of breast cancer patients, who presented with large and ptosis breast, underwent single port 3-dimension (3D) endoscopic nipple sparing mastectomy (E-NSM) followed by pedicled transverse rectus myocutaneous (TRAM) flap breast reconstruction. Case presentation: The first patient was a 42-year-old woman had palpable right breast mass and enlarged axillary lymph nodes for 4 months. Core needle biopsy(CNB) revealed invasive ductal carcinoma of breast and lymph node metastasis. Breast Magnetic Resonance Imaging(MRI) revealed multi-centric masses in right upper breast, about 6.1 cm in size, without nipple and skin invasion, and right axillary lymphadenopathy. Neoadjuvant chemotherapy was suggested, but the patient refused and preferred surgery first. She underwent single-port 3D E-NSM with immediate pedicled TRAM flap reconstruction. The post-operative recovery was uneventful except partial nipple ischemia/necrosis, which recovered after 2 to 3 months of wound care. The second case was a 39-year-old woman had one palpable mass over right breast for one month. CNB showed ductal carcinoma in situ with focal infiltrating ductal carcinoma. MRI revealed multi-focal mass, 8.7 cm in size, without skin or nipple invasion and no lymph node metastasis. NSM was suggested, but she decided to undergo single-port 3D E-NSM with immediate pedicled TRAM flap reconstruction due to previous history of Cesarean section and obese abdomen. The post-operative recovery was uneventful. Conclusion: Single-port 3D E-NSM followed by pedicled TRAM flap reconstruction is a feasible, safe procedure with satisfactory cosmetic outcome. Time-consuming and technical demanding are two limiting factors of this procedure.