PURPOSE: To report the outcomes of a fascia-sparing, laparoscopically-delayed, pedicled TRAM reconstruction in 100 consecutive patients.
BACKGROUND –There has been considerable controversy as to which type of abdominal flap provides the highest quality breast reconstruction with the least functional impairment. Upon their introduction, both free TRAM and then perforator flaps have been touted as the gold standard for breast reconstruction. However, both types of microsurgical reconstructions have limitations, including the potential for increased risk of total flap loss and the greater resource requirements to support a microsurgical practice. Further, there has been little evidence to support a long-term difference in functional outcomes or patient satisfaction compared to the standard pedicled TRAM. Additionally, further refinements on the pedicled TRAM, such as a laparoscopic surgical delay, have had an impact on the quality of those reconstructions. In this report, we will present our outcomes with laparoscopically-delayed, pedicled TRAM flaps which are harvested using a fascia-sparing approach.
METHODS– A prospective consecutive cohort undergoing laparoscopic ligation of the deep inferior epigastric vessels prior to pedicled TRAM reconstruction. From March 2001 to September 2006, 101 women with a mean age of 49 yrs underwent laparoscopic epigastric vessel ligation on an outpatient basis. They subsequently underwent a fascia-sparing, pedicled TRAM reconstruction. (Approximate width of the fascial strip harvested was typically 2 cm.) The fascial defect was closed primarily and the contralateral side plicated to optimize abdominal contour. Outcomes were evaluated using administrative and chart review data for operative times, associated procedures and complication rates. Pre- and postoperative physical function was assessed using the SF-8 in a subset of patients.
RESULTS: Laparoscopic Procedures: The mean operative time for the ligation was 36 min. 27% had associated procedures including sentinel node biopsy (20), oophorectomy (5), hernia repair (2), Nissen (1) and liver biopsy (1). (The patient undergoing a liver biopsy was found to have previously-unsuspected metastatic disease, and therefore did not undergo further surgeries.) There were no complications. TRAM Reconstruction: Pedicled TRAM was performed an average of 12 days after the ligation. 71% were immediate reconstructions, and 32% were bilateral reconstructions, for a total of 132 flaps. 34% of patients undergoing unilateral reconstruction had a contralateral procedure including: reduction (11), mastopexy (11), and augmentation (1). Mesh overlay was used in 9% of patients. Complications: total flap loss = 0.7%; significant partial loss = 3.0%; hernia rate = 1.0%. Physical Function: 24 patients completed the SF-8 prior to surgery and at least 1 year postop (range 371 - 924 days). Mean Physical Component Summary (PCS) scores were not significantly different comparing pre and post surgery. Using norm-based scoring (mean = 50, a standard dev. = 10), the preop PCS score was 53.8 and the postop score was 54.1.
CONCLUSIONS: This report describes outcomes of a cohort of women undergoing postmastectomy breast reconstruction with a laparoscopically-delayed, fascia-sparing, pedicled TRAM flap. This approach minimizes patient risk and morbidity, while optimizing outcomes as demonstrated by very low flap loss and hernia rates and preserved physical functioning.