Is Unipedicled Transverse Rectus Abdominis Myocutaneous Flap Obsolete Owing to Superiority of DIEP Flap?

Background: The extensive nature of perforator-based breast reconstructions, combined with the need for postoperative flap monitoring, often leads to long hospitalizations. We present an early report demonstrating the feasibility and advantages of a modified operative technique and recovery protocol, allowing us to perform outpatient breast reconstructions with the DIEP flap. This follow-up comprises the experience gained, which is expanded to other perforator-based flaps and not limited to DIEP breast reconstructions. Methods: We have implemented a general protocol in patients undergoing breast reconstruction with autologous flaps, promoting early mobilization and discharge by improving postoperative pain and decreasing opioid requirements. This protocol includes intraoperative local anesthesia, a microfascial incision for DIEP harvest with rib preservation, along with prophylactic anticoagulation. Results: Ninety-two consecutive patients underwent autologous tissue-based breast reconstruction with DIEP, IGAP, and PAP flaps. No intraoperative complications were reported. All patients were discharged within 23 hours, without evidence of flap compromise. One patient required operative takeback for evacuation of a hematoma on postoperative day 4. No partial or total flap losses were documented. The aim of any procedure should be to get to the patient back to the preoperative status as quickly as possible, as prolonged hospitalizations are associated with higher incidences of infection, deep venous thrombosis, overall dissatisfaction, and higher overall costs of care. Conclusions: By using a modified operative technique, multimodal pain control, and postoperative anticoagulant therapy, outpatient perforator-flap–based breast reconstructions can be performed with high success and low complication rates.

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“…Rates of flap failure have decreased dramatically, as expertise in microvascular techniques has grown. 2 , 3 …”

Section: Discussionmentioning

confidence: 99%

Outpatient Microsurgical Breast Reconstruction

Martínez

Boutros

2020

Plastic and Reconstructive Surgery - Global Open

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“…Due to recent microsurgical advances, breast reconstruction techniques have developed from a flap safety-based approach using pedicled or free TRAM flaps to more perforator-based flaps and super-microsurgery due to co-factors like donor-site morbidity [50] and lymphedema [23]. Furthermore, novel imaging technologies such as intraoperative perfusion mapping have increased the safety profile of the procedure and have allowed for more predictable results to be achieved [51].…”

Section: Discussionmentioning

confidence: 99%

Autologous Breast Reconstruction with Transverse Rectus Abdominis Musculocutaneous (TRAM) or Deep Inferior Epigastric Perforator (DIEP) Flaps: An Analysis of the 100 Most Cited Articles

et al. 2019

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Post-mastectomy autologous reconstruction with abdominal tissue has evolved over the past 4 decades and is a common reconstructive modality today. To gain more insight into this evolution, we performed an analysis of the 100 most commonly cited articles focusing on autologous breast reconstruction with transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. A review of the ISI Web of Knowledge database was performed. Only peer-reviewed articles in English were included for analysis. Articles were ranked by their total citations as well as citation density (citations divided by years since publication). The 100 most cited articles were analyzed by their bibliographic parameters. The 100 most cited articles were published in 12 journals. The highest ranked plastic surgery journal published almost 2/3 of the articles. All articles were published within 23 years and marked the “rising age” of autologous breast reconstruction with TRAM and DIEP flaps. The focus of clinical research changed over this time period and ranged from innovations in surgical technique to analysis of clinical outcomes, comparative analyses with other reconstructive modalities, timing of reconstruction, and preoperative diagnostic workup, as well as cost-effectiveness analyses. This literature review illustrates the dramatic change that has occurred subsequent to introduction of abdominal flaps for breast reconstruction. While the use of abdominal flaps has become widely accepted for breast reconstruction, many questions remain unanswered, thus highlighting the need for ongoing clinical investigation.

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“…12 Breast reconstruction began to enter the modern era with the application of the TRAM flap procedure by Hartrampf in 1982. 12,13 The main advantage of the procedure is that the reconstructed breast is identical to the natural breast in its softness and in the way the tissue covers the chest. If the TRAM flap procedure is applied adequately and carefully in the suitably selected patient, the TRAM flap procedure can be a safe and viable option with satisfactory outcome as well as providing a superior breast reconstruction to the other techniques.…”

Section: Discussionmentioning

confidence: 99%

“…If the TRAM flap procedure is applied adequately and carefully in the suitably selected patient, the TRAM flap procedure can be a safe and viable option with satisfactory outcome as well as providing a superior breast reconstruction to the other techniques. 13 We decided to perform a conventional TRAM flap for the first case because the onset of the procedure was considerably delayed. The patient was psychologically motivated and had adequate tissues in the abdominal area (FIGURE 1).…”

Section: Discussionmentioning

confidence: 99%

“…The Latissimus dorsi muscle was dissected, and the superior edge of the muscle was elevated and freed of medial and inferior attachments before the muscle harvest was then completed while the pedicle remained attached. Postoperative state of the patient can be seen in FIGURE [13][14][15]. At the four months follow-up, there were neither infection, nor wound dehiscence and the patient was satisfied with the result (FIGURE 16).…”

Section: Casementioning

confidence: 91%

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Breast reconstruction with autologous tissue following mastectomy: two case reports of a delayed conventional transverse rectus abdominismyocutaneous (TRAM) and latissimus dorsi myocutaneous (LDM) flap surgery

et al. 2018

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Breast cancer is the most common malignant tumor and the leading cause of death among females. Most women with breast cancer will undergo breast-conserving surgery (BCS) or lumpectomy, simple or total mastectomy, modified radical mastectomy or bilateral mastectomy. Breast reconstruction solves many of the problems. The goal is to return the patient to a near-normal state so that she is not handicapped in her daily living. Breast reconstruction is also intended to offer psychological benefits to women treated by mastectomy following a diagnosis of possibly terminal cancer. In these case reports, we reported two successful cosmetic reconstruction cases. The first case was a 39-yearsold female with non-recurrent breast cancer consulted and was referred by the oncology surgeon to the Plastic Reconstructive, and Aesthetic Surgery Division, Department of Surgery, Dr. Sardjito General Hospital. She wanted to undergo breast reconstruction. We planned to operate three years following mastectomy. She was diagnosed with 3B-stage of right breast cancer before. After the surgery, the patient received six series of chemotherapy. She also underwent radiotherapy 25 times and hormonal therapy. We decided to perform a transverse rectus abdominis myocutaneous (TRAM) flap surgery on her with 22 months follow up. The procedure provided good results, and the patient was satisfied. The second case was a 32-year-old woman who after excision of a phyllodes tumor and wanted breast reconstruction. Reconstruction was performed four years after tumor removal using latissimus dorsi myocutaneous (LDM) flap. The surgery provided good results, and the patient was satisfied. We reported two successful cosmetic reconstruction cases of non-recurrent 3B-stage of right breast cancer post-mastectomy after pedicled TRAM flap surgery and left breast post excision of phyllodes tumor after LDM flap surgery. ABSTRAKKanker payudara adalah tumor ganas yang paling umum dan merupakan penyebab utama kematian pada wanita. Sebagian besar wanita dengan kanker payudara akan menjalani bebeapa jenis operasi yang melibatkan operasi pengangkatan tumor atau lumpektomi, mastektomi simpel atau total, mastektomi radikal yang dimofidikasi dan mastektomi bilateral. Rekonstruksi payudara dapat mengatasi masalah akibat mastektomi dan bertujuan mengemballikan kondisi pasien mendekati normal sehingga tidak mengalami disabilitas dalam kehidupan sehari-hari. Rekonstruksi payudara juga dimaksudkan untuk menawarkan manfaat psikologis bagi wanita yang diobati dengan mastektomi setelah diagnosis kemungkinan kanker stadium akhir. Pada laporan kasus ini, dilaporkan keberhasilan dua kasus rekonstruksi payudara. Kasus pertama adalah seorang wanita berusia 39 tahun dengan kanker payudara non-rekuren berkonsultasi untuk dilakukan rekonstruksi payudara ke Divisi Bedah Plastik, Rekonstruksi, dan Estetika, Departemen Bedah, RSUP Dr. Sardjito, Yogyakarta. Rekonstruksi payudara direncanakan tiga tahun setelah mastektomi. Pasien terdiagnosis dengan kanker payudara stadium 3B sebelum mastektomi. S...

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Is Unipedicled Transverse Rectus Abdominis Myocutaneous Flap Obsolete Owing to Superiority of DIEP Flap?

Cited by 16 publications

References 12 publications

Outpatient Microsurgical Breast Reconstruction

Outpatient Microsurgical Breast Reconstruction

Autologous Breast Reconstruction with Transverse Rectus Abdominis Musculocutaneous (TRAM) or Deep Inferior Epigastric Perforator (DIEP) Flaps: An Analysis of the 100 Most Cited Articles

Breast reconstruction with autologous tissue following mastectomy: two case reports of a delayed conventional transverse rectus abdominismyocutaneous (TRAM) and latissimus dorsi myocutaneous (LDM) flap surgery

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