Introduction Skin sparing mastectomy and TRAM flap reconstruction are accepted modalities in the treatment of breast cancer; however the management of local recurrence of breast cancer after TRAM flap breast reconstruction is not standardized. The purpose of this study was to examine the incidence of local recurrence of breast cancer after TRAM flap breast reconstruction and evaluate treatment modalities.

Methods A retrospective review was conducted of all breast reconstruction patients at a major tertiary cancer center. All patients who underwent free or pedicled TRAM reconstruction were identified. A subset of patients who experienced local breast cancer recurrence was further identified. The medical records and prospectively maintained reconstructive database was reviewed for demographic data, medical history, surgical procedures, and clinical outcome. Only patients with Ан one year of postoperative follow up were included in this series.

Results Between 1987 and 2002, 419 TRAM flap breast reconstructions were identified in 395 patients. The mean follow up for this group of patients was 4.9 years (range 1-14.7). There were 218 pedicled TRAMs, 142 free TRAMs, and 59 supercharged TRAM flaps. Thirty four of 395 patients (9%) underwent complete skin sparing mastectomy (CSSM) utilizing a periareolar mastectomy incision only. Mean follow up in the CSSM group was 2.7 years (range 1-7 years). Local recurrence occurred in 4% of the total population (16 of 395 patients). The site of recurrence was the mastectomy skin flap (8) and chest wall (8). Tumor stage at initial diagnosis in patients with local recurrence was as follows: DCIS (1), Stage I (3), IIA (6), IIB (3), IIIA (2), and unknown (1). Six patients had prior breast conservation surgery treated with lumpectomy and radiation therapy, while 14 patients had chemotherapy prior to the recurrence (either post-lumpectomy or post-mastectomy). Mean time to local recurrence was 1.6 years (range 0.2-7.0). There were no local recurrences seen in patients with CSSM. Treatment of local recurrence included excision of recurrence in 75% (12 of 16), chemotherapy in 63% (10 of 16), radiation therapy in 50% (8 of 16), and bone marrow transplant 13% (2 of 16). Only three patients (19%) required removal of the entire TRAM flap to manage local breast cancer recurrence. Fifty six percent (9 of 16) of patients with local recurrence died of disease, a mean of 1.2 years after the development of recurrence.

Conclusions In this series, long term follow up demonstrated a local recurrence rate after TRAM flap breast reconstruction similar to that reported in the literature. Local recurrence was effectively managed with surgical excision of the involved tissues, chemotherapy and/or radiation therapy. Removal of the entire TRAM flap was only necessary in the setting of multifocal recurrence or involvement of the flap pedicle with disease. The risk of local recurrence was not increased in the setting of CSSM.