2 research outputs found
Pedicled and free TRAM flaps in breast reconstructions : a comparative study
The transverse rectus abdominis musculocutaneous (TRAM) flap is
frequently used when autologous tissue is desired for breast
reconstruction, and it can be transferred pedicled or free. The pedicled
TRAM flap is elevated as a lower transverse abdominal flap with the
rectus abdominis muscle attached in the epigastric area, by which means
the deep superior epigastric vessels nourish the flap. The flap is
tunneled to its new position on the thoracic wall. The free TRAM flap
consists of the same skin-fat paddle but the vascular pedicle consists of
the deep inferior epigastric artery and vein. This artery is usually the
dominant supplier of the flap area. The flap is raised with a small
portion of the rectus muscle, disconnected and anastomosed to recipient
vessels in the axillae or to the internal mammary vessels. The free flap
procedure is more time- and resource-consuming, requiring microsurgery.
If the anastomoses do not function, the whole flap is lost. On the other
hand, the pedicled TRAM flap carries a greater risk of partial flap loss
and subsequent longer healing than the free flap. It is therefore
important to evaluate whether one technique is superior to the other.
The most serious complication in all flap surgery is insufficient blood
circulation, leading to changed metabolism in the tissue. The
microdialysis technique provides a new way to survey local metabolic
changes in flaps. A slower stabilization with remaining ischemic signs,
such as lower glucose and higher lactate and glycerol values, was found
in flap zones with inferior circulation. More pronounced ischemic signs,
but a faster recovery were seen in free TRAM flaps than in pedicled ones.
The fact that the metabolites returned to normal earlier in the free
flaps than in the pedicled flaps indicates better perfusion.
Trunk muscle strength after TRAM flap surgery was evaluated prospectively
as more of the rectus abdominis muscle is included in the pedicled than
in the free TRAM flaps. An isokinetic dynamometer (KIN-COM) was used to
objectively assess maximal voluntary muscle strength preoperatively and
up to one year postoperatively. A transient decrease in abdominal
strength in both groups occurred at 6 months but was essentially regained
at 12 months. The use of pedicled or free TRAM flap did not influence
postoperative abdominal strength per se. Large individual variations
indicated more important factors than the type of surgery.
As alteration of sensibility is unavoidable when transferring tissue, the
somatosensory status (tactile and thermal perception thresholds, i.e.,
warmth, cold, heat pain, cold pain, measured by von Frey's hair and
Termotest, respectively) was assessed quantitatively at least two years
postoperatively. No clinically relevant differences between pedicled and
free TRAM flaps were demonstrated. The somatosensory status was still
impaired compared to a control group, but the majority of patients in
both groups reported that the reconstructed breast felt like a real
breast.
A new thermoplastic cast system was introduced to evaluate breast volume.
The method is simple and can measure the contralateral breast volume
preoperatively in a delayed breast reconstruction, indicating the volume
of the planned TRAM flap. It is also sufficiently accurate to evaluate
breast symmetry after breast reconstruction.
Since a breast reconstruction is performed mainly to improve the quality
of life of the patient, the most important issue would be the patient's
satisfaction with the result. The esthetic result was evaluated
subjectively and objectively. The free TRAM flap breast reconstructions
gave a higher degree of breast symmetry as judged by both the patients
and a three-member panel. These findings were supported by objective
measurements, such as breast symmetry and breast volume. Satisfaction
with the breast reconstruction and health-related quality of life did not
differ statistically between the two groups.
In conclusion, better perfusion was indicated in the free TRAM flaps as
well as a better esthetic result in terms of breast symmetry. However, no
findings favoring either technique were seen in terms of patient
satisfaction, trunk muscle strength, or tactile and thermal sensibility
An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects
Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearsonâs r, Spearmanâs Ï, and Kendallâs Ï. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P < 0.0001). This was also true for upper pole shape (0.826, P < 0.0001) and breast height (0.821, P < 0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P < 0.0001), breast size (0.644, P < 0.0001), and breast width (0.632, P < 0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P < 0.0001), areolar diameter (0.484, P < 0.0001), and areolar shape (0.403, P < 0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027). Conclusions: Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors