Abdominal Sequelae after Pedicled TRAM Flap Breast Reconstruction

Abstract

A considerable interest in autologous tissue breast reconstructions has developed recently, especially since Food and Drug Administration (FDA) experts have raised the polemic on silicone implants. Although such enthusiasm for the transverse rectus abdominis musculocutaneous (TRAM) flap is justified in what concerns the final cosmetic result of the reconstructed breast, the risk of abdominal sequelae should be explained to the patient. Abdominal scarring, parietal weakness, strength loss, and back pain have been recorded in a series of pedicled TRAM flap reconstructions performed at the Institut Gustave-Roussy before 1991. Cosmetic results of the abdomen were tested by three independent judges on the photographs taken of 132 patients. The global appearance of the abdomen was rated as "natural" in 70 percent of the patients. The umbilical scar was unacceptable in 25 percent and very good or not visible in 21 percent. The lower abdominal scar was rated as "not acceptable" in 35 percent. Abdominal strength was tested among the 38 patients who underwent both preoperative and postoperative muscular testing, of whom 18 had single-pedicled and 20 had bipedicled TRAM flap reconstructions. In the first group, the physiotherapist observed an impairment of function of the upper portion of the rectus abdominis and of the oblique muscle in almost 50 percent. In the second group, the same muscles were more severely impaired (in 60 percent), as well as the function of the lower portion of the rectus (in 15 percent). The percentage of patients complaining of "light back pain" in the 6-month postoperative period was 55 percent in the single-pedicle group and 30 percent in the double-pedicle group. However, 20 percent of the bipedicled patients complained of "severe" back pain, while there was none in the single-pedicled group. In conclusion, abdominal sequelae after TRAM flap breast reconstruction should not be underestimated and constitute one of the drawbacks of the technique when it is compared with reconstruction with a prosthesis.

Electromyographic Assessment of Rectus Abdominis Muscle Function after Deep Inferior Epigastric Perforator Flap Surgery

“…[15][16][17][18][19][20] However, some difficulties may occur in daily living, sports, or professional activities, likely because of the rectus abdominis strength deficit. Kind et al 21 and Edsander-Nord et al 22 have demonstrated that the harvest of a TRAM flap while preserving one-third to two-thirds of the muscle does not significantly preserve abdominal strength.…”

Technical Variations of the Bipedicled TRAM Flap in Unilateral Breast Reconstruction: Effects of Conventional versus Microsurgical Techniques of Pedicle Transfer on Complications Rates

“…The loss of both rectus abdominis muscles, which is required for a conventional bipedicled TRAM flap or conventional unipedicled TRAM/ conventional unipedicled TRAM flap, produces measurably greater abdominal weakness 22,23 and reduction in the ability to perform sit-ups 6,24 than does loss of only one rectus abdominis muscle, which is required for a conventional unipedicled TRAM flap. Concern over loss of abdominal function has led some authors to recommend abandoning the bipedicled technique, 7,25 but this view is not universally accepted.…”

Autologous and Alloplastic Breast Reconstruction – Overview of Techniques, Indications and Results

“…The reason why some surgeons have moved from pedicled TRAM flaps to free perforator flaps is to try to reduce the morbidity of the donor site and preserve abdominal wall integrity and function [28][29][30] . The complications encountered with techniques using lower abdominal tissue for breast reconstruction are related to repair techniques of the abdominal wall and the flap vascularization.…”