Importance of Right Subcostal Incisions in Patients Undergoing TRAM Flap Breast Reconstruction

Abstract

The presence of a preexisting subcostal incision alters the approach to breast reconstruction and is thought to predispose to donor site skin complications and flap loss. The purpose of this study was to determine whether the presence of a subcostal scar affects breast or donor site morbidity adversely after transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. Twenty-six patients with a right subcostal incision (group A) underwent TRAM flap breast reconstruction (13 immediate, 13 delayed). The average age was 51 years, and the patients had an average body mass index of 25.3. There were 15 right, 10 left, and 1 bilateral reconstruction (4 free flaps, 22 pedicled). Outcome measures were compared with 126 age- and risk-matched patients (group B) who underwent TRAM flap reconstruction without any preexisting abdominal scar. The average age in group B was 46.7 years, and the patients had an average body mass index of 24.8. The average length of stay in group A was 5.9 days, compared with 4.8 days in group B ( < 0.05). There were no significant differences in breast-related complications. Donor site complications were higher in group A, with abdominal wall skin necrosis being significantly higher in patients with a subcostal incision (25%) compared with those patients without abdominal wall scars (5%; = 0.02). Multivariate analysis revealed a 6.5-fold increase in donor site complications in patients with a subcostal incision and a smoking history ( < 0.05). When adjusted for radiation treatment, the increased incidence in donor site complication rate was only marginally significant ( = 0.08). TRAM flap breast reconstruction in patients with preexisting right subcostal scars is effective with certain technical modifications; however, there is a slight predisposition to increased abdominal wall complications. Smoking influenced outcome further in patients with a subcostal incision, stressing the importance of proper patient selection.

Trends in Autologous Breast Reconstruction

“…Losken and coworkers reviewed 26 patients with a right subcostal incisions and 126 age-and risk-matched patients who underwent TRAM flap reconstruction. 41 Abdominal wall skin necrosis in patients with a subcostal incision (25%) was significantly higher than those patients without abdominal scars (5%, P ¼ 0.02).…”

Internal Mammary Vessels’ Impact on Abdominal Skin Perfusion in Free Abdominal Flap Breast Reconstruction

“…Although closure of these wounds usually can be obtained with local wound care, wound healing problems are often associated with longer hospital stays, intensive wound care, and more outpatient visits. 1 , 2 Wound treatment not only causes psychological stress to a patient but is also an economic burden for health-care systems. 2 Wound breakdown in itself has been associated with an increased risk for hernia formation.…”

Algorithmic Approach to the Design and Harvest of Abdominal Flaps for Microvascular Breast Reconstruction in Patients With Abdominal Scars

“…Previously, the free TRAM has been reviewed for its complication rate in the presence of abdominal scars. [8][9][10][11][12][13][14][15] The reviews are mixed, but overall, the studies showed the free TRAM was felt to have minimal complications when harvested in the presence of abdominal scars. However, in some studies, there was an increased risk of partial flap loss and fat necrosis.…”