T R A M Outcomes


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T R A M Outcomes

  1. 1. SPECIAL TOPIC The Pedicled Transverse Rectus Abdominis Myocutaneous Flap: Indications, Techniques, and Outcomes Donald W. Buck, II, M.D. Summary: Breast reconstruction has evolved significantly during its short, 40- Neil A. Fine, M.D. year history. What began as limited reconstruction through the use of local skin Chicago, Ill. flaps has now become an entire array of procedures including novel autologous flaps and new techniques in implant/expander use. Throughout this evolution, the primary goal of reconstruction has always remained the same: to recreate the most natural breast mound possible. In the early 1980s, autologous tissue was at the forefront of breast reconstruction, and the pedicled transverse rectus abdominis myocutaneous (TRAM) flap quickly became the reconstructive method of choice for tissuebased reconstruction. Despite the advent of micro- surgery, advances in perforator-based flap design, and increasing procedural com- plexity, the pedicled TRAM flap is still one of the most common methods of autologous reconstruction performed today. In properly selected patients, the pedicled TRAM flap can provide a natural appearing breast mound with limited morbidity and superior patient satisfaction. (Plast. Reconstr. Surg. 124: 1047, 2009.) I n 1982, Hartrampf and colleagues first described INDICATIONS the use of the rectus abdominis muscle as a pedi- Pedicled TRAM flap reconstruction can be cled flap for breast reconstruction.1 Since its in- performed successfully in patients who desire im- ception, the pedicled transverse rectus abdominis mediate or delayed breast reconstruction. Imme- myocutaneous (TRAM) flap has become the work- diate breast reconstruction offers the patient im- horse with respect to autologous reconstructive pro- proved cosmesis and reduces the psychological cedures. Its advantages are well documented and stress of losing a breast.7–10 However, in patients include superior symmetry, contour, and aesthetic requiring adjuvant radiation therapy after mastec- appearance of the breast mound; improved abdom- tomy, delayed reconstruction is often the pre- inal aesthetics with avoidance of microsurgical facil- ferred choice.11,12 ities; and favorable patient satisfaction.2–5 There are no absolute indications for the se- Despite its glowing track record, the pedicled lection of one form of breast reconstruction versus TRAM flap is not immune to postoperative com- another; however, a few relative indications exist plications. These complications have been heavily with respect to pedicled TRAM flap reconstruc- documented within the literature and generally tion. In general, patients requesting pedicled fall within one of two categories: flap complica- TRAM flap reconstruction must have enough ab- tions and donor-site complications. Flap compli- dominal soft tissue to allow for adequate flap har- cations can include complete or partial flap loss, vest and donor-site closure. Highly motivated pa- tients with limited comorbidities are ideally suited fat necrosis, wound infection, and delayed wound for this reconstructive procedure. Several risk fac- healing. Donor-site complications can include se- tors have been identified that place patients at roma and/or hematoma formation, abdominal higher risk for complications after pedicled TRAM bulging, hernia formation, weakened trunk func- flap reconstruction. These factors include ciga- tion, and wound-healing problems.6 rette smoking, obesity, postoperative radiation therapy, and extensive medical comorbidities.13,14 From the Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine. Received for publication January 7, 2008; accepted January 27, 2009. Disclosure: The authors have no conflict of interest Copyright ©2009 by the American Society of Plastic Surgeons to report with regard to this research. DOI: 10.1097/PRS.0b013e3181b457b2 www.PRSJournal.com 1047
  2. 2. Plastic and Reconstructive Surgery • October 2009 Despite an inherent increased risk, patients with recommendations regarding complication rates the above risk factors may still choose to have a cannot be made at this time.18 –21 pedicled TRAM flap reconstruction. In this in- stance, any effort to increase flap blood supply TECHNIQUES should be considered to improve overall flap re- The pedicled TRAM flap procedure can be liability. Commonly used techniques, which are initiated concurrently with the mastectomy pro- discussed below, include flap “supercharging” and cedure to reduce overall operative time. The pa- surgical delay. tient is generally marked, either preoperatively or The increased risk associated with smoking intraoperatively, with a tapering transverse ellipse and obesity can be greatly reduced by performing with superior extensions above the umbilicus. a free TRAM flap rather than a pedicled flap.15–17 These extensions capture the superior perfora- The choice between free and pedicled TRAM flaps tors, which emanate from the superior epigastric is most commonly made by experience and com- vessels. The position of the ellipse is an important fort with microsurgical techniques and the avail- aspect in overall flap design. If the superior skin ability of instrumentation and postoperative mon- incision is placed at or below the umbilicus, there itoring facilities. More specialized microsurgical is a risk of missing direct perforators from the flaps, such as perforator flaps and superficial in- superior epigastric vessels. Using a higher supe- ferior epigastric artery flaps require even greater rior incision results in a more reliable pedicled familiarity with microsurgical technique and close flap. A woman with a high costal margin may be postoperative observation, with the ability to offered a “midabdominal” TRAM flap, centering quickly return to the operating room for correc- the ellipse about the umbilicus. The result is a tion of acute microvascular complications. Using more robust vascularity but a higher midabdomi- the pedicled flap will limit the vascularity as com- nal scar. pared with a free TRAM flap but may have as much The operation begins by using the superior vascularity as a perforator flap or an inferior epi- incision to elevate the upper abdominal wall off of gastric artery flap if those vessels are not unusually the rectus fascia to the level of the xiphoid and costal margins laterally. The patient is then flexed large. Thus, the surgeon who chooses a pedicled and the upper flap pulled taught over the pro- TRAM flap is providing an autologous abdominal posed TRAM flap to check the location of the reconstruction with reduced technical and facility inferior incision. This ensures that the abdominal demands and a decreased risk of total flap loss as closure will not be too tight. After verification of compared with free flap techniques. Most would appropriate positioning, the inferior incision is agree that in return there is an increased risk of fat then made and the subcutaneous fat is elevated, necrosis and a longer or more difficult early (first from lateral to medial, until reaching the lateral few months) convalescence for the patient; the rectus perforators. In a unilateral reconstruction, long-term outcome is still being debated, with the perforators are then divided on the side that many believing that there is no long-term (1 year will not be used, the umbilicus is cut free, and the or more) difference in abdominal recovery. dissection proceeds to the medial row of rectus Not all women are candidates for pedicled perforators. It is usually possible to perform either TRAM flap reconstruction, and there are a few an ipsilateral or a contralateral flap. At our insti- absolute contraindications for this procedure: the tution, an ipsilateral flap is usually preferred for presence of an old upper abdominal incision with immediate reconstruction, whereas a contralat- previous division of the rectus abdominis muscles eral flap may be best for a delayed reconstruction precludes a flap based on the superior pedicle if a wide skin paddle is needed. This is an expe- from that side. A history of prior abdominoplasty riential bias. Surgeons who become familiar and likely indicates disruption of the perforating ves- adept at a contralateral flap most commonly will sels to the abdominal skin and soft tissue, and a use that technique, whereas those who are more pedicled TRAM flap should not be performed.18 familiar with an ipsilateral flap will use that tech- In addition, there are few studies investigating the nique predominantly. Also, based on pedicle po- effects of prior TRAM flap reconstruction on the sitioning, we often choose the contralateral muscle expected abdominal changes related to preg- when greater than 50 percent of the abdominal nancy. A few case reports and small case series skin paddle is to be used. Using the contralateral suggest that a successful pregnancy can occur after muscle in this situation will result in less twisting the TRAM flap procedure; however, because of of the pedicle during tunneling. If 50 percent or the limited number of overall cases, meaningful less of the abdominal skin is needed, we prefer an 1048
  3. 3. Volume 124, Number 4 • Pedicled TRAM Flap ipsilaterally based flap. The ipsilaterally based flap long-term effects.24 –26 With regard to surgical delay, will also place the deep inferior epigastric vessels it is important to remember that ligation of the deep in good position for supercharging to the thora- inferior epigastric perforators will preclude the po- codorsal vessels, when necessary. tential for free-tissue transfer, supercharging, At this point, various accepted techniques and/or microvascular salvage on that side in the emerge, depending on the degree of rectus mus- event that the pedicled procedure is unsuccessful. cle harvest and/or preservation. In our experi- This consideration should be contemplated in pa- ence, we believe that there is no advantage to tients who have prior upper abdominal incisions, or leaving a medial or lateral strip of muscle; thus, we if there is concern over the reliability of the super- generally raise the entire muscle with both the ficial epigastric vasculature.25 medial and lateral row of perforators intact. After the TRAM flap is elevated completely, it At the inferior, lateral edge of the rectus mus- may be deepithelialized partly to assess blood flow cle, the deep inferior epigastric vessels are iden- and speed up the inset process. Next, it is passed tified, dissected to their origin, ligated, and trans- through a subcutaneous tunnel and into the mas- ferred with the flap. The deep inferior epigastric tectomy defect. It is important during the tunnel- vessels provide a backup blood supply in the event ing process to pay particular attention to the ori- that the superior pedicle is inadequate in perfus- entation of the pedicle, as excessive twisting, ing the flap. This may only be evident after the flap kinking, and/or tension can result in flap isch- is tunneled, folded, and inset within the mastec- emia. In its final resting state within the mastec- tomy defect. If flap perfusion is in question, or the tomy defect, the abdominal skin island is typically flap appears threatened, the harvested deep infe- rotated 180 degrees, such that the inferior abdom- rior epigastric vessels can then be anastomosed to inal soft tissue provides the superior tissue within the thoracodorsal system through the use of mi- the new breast mound and vice versa. The flap is crosurgical techniques. This technique is referred trimmed and contoured to match the opposite to as supercharging the flap.22 breast mound (Fig. 1). During the inset, it is im- In addition to supercharging, a surgical delay perative to find and divide the most superior in- can also be used to increase flap reliability when tercostal nerve supplying the rectus muscle. Fail- perfusion is a concern. In the surgical delay tech- ure to do so will result in an epigastric bulge nique, the deep inferior epigastric artery and because of persistent rectus muscle volume. Di- veins, on the flap side, are exposed and ligated before the final reconstruction. A small transverse viding the upper nerve causes muscle atrophy, incision is typically made just superior and lateral thus avoiding the telltale epigastric bulge. to the symphysis pubis. Dissection is carried Once the flap is inset, attention is turned to the through the subcutaneous tissue and down to the abdominal wall. When closing the abdominal fas- level of the rectus fascia. The vessels are typically cia, particular attention should be paid to incor- encountered at the lateral margin of the rectus porating the internal and external oblique fascia sheath, where they are cauterized using conven- within the anterior rectus closure (Fig. 1, above, tional bipolar electrocautery. The major perium- right). Failure to visualize the internal oblique fas- bilical perforators on the side for which the pedi- cia may mean missing it in the closure and result cle is not planned should also be divided. These in lower abdominal bulge formation. In our in- perforators are exposed by means of a small pe- stitution, we often reinforce the closure with fas- riumbilical incision. The vessels are identified and cial staples (Autosuture DFS Fascial stapler; Covi- cauterized using bipolar electrocautery. Surgical dien, Mansfield, Mass.). If a tension-free fascial delay will allow the recruitment, or opening, of repair cannot be achieved or abdominal wall in- choke vessels within the superior epigastric sys- tegrity is in question, inlay and/or onlay soft Pro- tem, optimizing perfusion by means of the re- lene mesh (Ethicon, Inc., Somerville, N.J.) can be maining superior pedicle.23 Traditionally, the li- used. At our institution, we prefer the inlay tech- gation procedure occurs 1 to 2 weeks before the nique. The mesh is secured in the subfacial plane planned TRAM flap procedure. The timing of the by means of interrupted 0 Prolene sutures. If there delay is generally surgeon dependent, and no rec- is considerable laxity in the anterior rectus sheath, ommendation for an “optimal time” has been re- it can be closed over the mesh to act as an addi- ported. Regardless of whether the delay takes tional layer of closure. Successful abdominal clo- place 1 or more weeks before the TRAM flap re- sure has also been achieved using acellular dermal construction, animal studies have proven that this matrix; however, this technique is rarely used at technique improves flap survival, with beneficial, our institution. 1049
  4. 4. Plastic and Reconstructive Surgery • October 2009 Fig. 1. (Above, left) Intraoperative image of the abdomen immediately after TRAM flap harvest and tunneling. (Below, left ) TRAM flap within the mastectomy defect before contouring for symmetry. (Below, right) TRAM flap inset within mastectomy defect after trimming and contouring for symmetry, before skin closure. (Above, right) Intraoperative image of the fascial closure after TRAM flap harvest and tunneling. The running suture incorporates the oblique fascia within the rectus fascial closure. It is imperative to be meticulous with the ab- muscles are sacrificed during these procedures, dominal wall closure, as technical errors can result trunk function during activities such as perform- in contour abnormalities, such as bulging and/or ing sit-ups or rising from a low chair may be hernia. The fascia should be palpated for “soft” impaired. Although this risk may be worrisome, areas at the inferior aspect of the fascial closure. proponents of the bipedicled TRAM flap, or This represents a fascial dog-ear which, if not ad- bilateral pedicled TRAM flaps, argue that the dressed, will become a bulge when the patient majority of these patients will eventually regain stands upright. sufficient trunk function, and those who do not In patients requiring a large volume of ab- will adapt and are not affected in the majority of dominal soft tissue for unilateral reconstruction daily activities.27,28 The bipedicled TRAM flap or seeking bilateral reconstruction, bipedicled technique is similar to that of the unipedicled or bilateral TRAM flaps can be used. The bi- procedure. This technique often requires more pedicled TRAM flap uses both rectus muscles, complex inset techniques, such as a “stacked” providing increased blood flow at the expense of inset. When performing bilateral pedicled rectus muscle function. Because both rectus TRAM flaps or the bipedicled TRAM flap for 1050
  5. 5. Volume 124, Number 4 • Pedicled TRAM Flap unilateral reconstruction, abdominal wall clo- sure nearly always requires mesh. OUTCOMES As the standard for autologous breast recon- struction, the pedicled TRAM flap has been heavily scrutinized in the academic literature. There are multiple large-volume series detailing institutional outcomes, concerns, and technical considerations.2– 4,13,27–29 In addition, the pedicled TRAM flap has served as the standard method and historical control against which other novel re- constructive techniques are measured. This has resulted in a plethora of comparative studies, fur- ther documenting outcome measures.30 –33 Overall, autologous abdominal tissue flaps are unrivaled in their ability to create a natural appearing breast mound2 (Figs. 2 and 3). These flaps age naturally with time, maintain a soft and ptotic appearance, and rarely require surgical Fig. 3. Follow-up image of the same patient after pedicled TRAM revision.2,3,34 Aside from surgeon-judged aes- flap reconstruction detailing excellent symmetry and the cre- thetic and anatomical results, pedicled TRAM ation of a natural appearing breast mound. flap reconstruction also leads to excellent over- all long-term patient satisfaction, which one could argue is a more important marker of a for developing fat necrosis. These factors include successful reconstruction.5,35 active smoking, obesity, and a history of prior chest Pedicled TRAM flap reconstruction is gen- wall irradiation.29 The most feared flap complica- erally a well-tolerated procedure. Complications tion, total flap loss, is fortunately a rare occur- are typically related to either donor-site or flap- rence, with a reported incidence of less than 1 related problems, with flap complications being percent.2,15 Likewise, partial flap loss occurs rarely the most frequent.13 Nonspecific postsurgical and, when present, can generally be managed with complications, such as hematoma and infection, conservative measures.2 occur rarely.2,13 The effect of postoperative radiation on au- Fat necrosis is the most common flap-related tologous flaps is an additional concern. Currently, complication, with a reported incidence of 10 to there is no definitive consensus on whether flaps 18 percent.13,19,28 –29,36 Several risk factors have should be delayed until after irradiation. Some been identified that place patients at greater risk reports indicate that post–TRAM flap radiother- apy is tolerated with few complications and ac- ceptable cosmetic results.37 A recent study by Spear and colleagues reported that neither pre- operative nor postoperative radiotherapy in- creased the risk of most serious flap or donor-site complications but that there was an effect on over- all aesthetic results. Given this concern, they rec- ommend that pedicled TRAM flap procedures be delayed until after radiotherapy when possible.12 Presently, the decision to delay autologous re- construction until after adjuvant therapy is insti- tution dependent. At our institution, we generally elect to delay our TRAM flap procedure until after the patient has completed her course of radiation therapy. Immediately after mastectomy, tissue ex- panders are placed as a first step, providing the Fig. 2. Preoperative image of a patient before left mastectomy advantages of immediate reconstruction without and pedicled TRAM flap reconstruction. subjecting autologous tissue to possible radiation 1051
  6. 6. Plastic and Reconstructive Surgery • October 2009 effects. Several studies have reported successful TRAM flap reconstruction results in an initial in- staged breast reconstruction using tissue expand- sult to abdominal wall integrity and overall trunk ers during adjuvant radiotherapy treatments. function, several reports suggest that the long- These reports indicate that expanders can with- term clinical effect of rectus muscle harvest is min- stand radiation therapy and provide an effective imal and well tolerated.43,44 Secondary surgical in- bridge to definitive reconstruction using implants tervention for abdominal wall complications is or autologous tissue.38 – 40 Although some centers warranted only when severe aesthetic concerns may postpone expansion until after radiotherapy and/or pain are present. is completed, at our institution, the expander is There have been numerous studies devoted to generally left inflated during the course of radia- pedicled TRAM flap–related abdominal wall com- tion treatment. Careful attention is paid to pre- plications, and multiple attempts to minimize this vent overexpansion. In addition, we work closely morbidity have been described.22,30,43– 46 These with our radiation oncologists and will decrease measures include fascial reinforcement using expander volume as needed if it is believed to mesh, rectus muscle preservation, layered closure interfere with treatment efficacy. After comple- of the rectus sheath and oblique fascia, and pli- tion of irradiation, the expander is removed, the cation of the rectus fascia above and below the pectoralis muscle is separated from the mastec- muscle harvest site.45 In their extensive analysis of tomy skin flap, and the TRAM flap is placed into contour abnormalities after TRAM flap recon- the original mastectomy defect. This staging tech- struction, Nahabedian and Manson established nique gives the benefit of immediate reconstruc- several important principles related to the pres- tion without risking radiation changes in the ervation of abdominal wall integrity: first, muscle- TRAM flap. The possibility of expander discom- sparing techniques do not significantly reduce the fort or complication is balanced against the ad- probability of contour abnormality. Second, mesh vantages of immediate reconstruction; these issues reinforcement is not necessary unless tension-free should be discussed fully, and women should be closure cannot be obtained. Third, the use of fas- allowed to choose which they prefer. cial plication superior and inferior to the harvest Donor-site morbidity following pedicled site, and incorporation of the oblique fascia within TRAM flap reconstruction can be divided into the anterior rectus sheath closure, can reduce the early and late complications. Early complications risk of contour abnormalities.45,47 can include delayed wound healing, hematoma, It is important to note that postoperative con- and/or seroma formation. The incidence of se- tour abnormalities are not isolated to pedicled roma formation is reportedly between 2 and 7 TRAM flap procedures. Within the general sur- percent of cases.41,42 The risk of seroma formation gery literature, the incidence of incisional hernia can be limited through the use of closed-suction after primary fascial closure is nearly 10 to 20 drains. The drain output should be monitored percent, regardless of technique.42 Popular autol- closely, and removal of the drains should not oc- ogous alternatives to pedicled TRAM flaps, includ- cur until the output is minimal (typically 30 ml ing the deep inferior epigastric perforator (DIEP) per 24 hours). If a seroma develops, it can gen- flap and free TRAM flap, are also not immune to erally be treated with serial aspiration.2 Delayed the development of abdominal bulging, hernias, healing is often related to tension on the abdominal and flap-related complications.42– 45,48 In fact, ab- closure and can usually be treated with local wound dominal contour abnormalities do not appear to care. Large skin flap loss is exceedingly rare, al- correlate with degree of muscle preservation.47 though the risk is increased in active smokers. There are several reports in the literature suggest- Late donor-site complications following pedi- ing that there is no significant difference between cled TRAM flap reconstruction are related pri- pedicled TRAM, free TRAM, and/or DIEP flaps marily to abdominal wall integrity. These compli- with regard to abdominal wall morbidity.44 – 46,49 In cations can include contour abnormalities, such as 1997, Blondeel and colleagues published a case abdominal bulging and hernia formation, and re- series comparison of donor-site morbidity be- duced trunk function. Abdominal bulging is the tween DIEP flaps and free TRAM flaps. Although most common late complication following pedi- their data suggested that DIEP flap patients suf- cled TRAM flap reconstruction, with some series fered from less trunk dysfunction than their reporting an incidence of nearly 44 percent.43 For- TRAM flap counterparts, it is unclear whether this tunately, the incidence of true hernia is much difference persists long term.48 lower, approximately 1 to 3 percent of cases.13,43 It is also worth noting that almost all of the Although rectus muscle harvest for pedicled reports detailing significant complications and/or 1052
  7. 7. Volume 124, Number 4 • Pedicled TRAM Flap CONCLUSIONS CODING PERSPECTIVE As the incidence of breast cancer continues to This information prepared by Dr. Raymond rise, an increasing number of patients will be seek- Janevicius is intended to provide coding guid- ing plastic surgery consultation for breast recon- ance. struction. Given its long history of success and reputation as the workhorse in autologous breast 19367 TRAM flap, single pedicle reconstruction, the pedicled TRAM flap will con- 19368 TRAM flap, with microvascular tinue to be a viable option in most patients. In a “supercharging” nonobese, nonsmoking patient with sufficient ab- 19369 TRAM flap, double pedicle dominal tissue, the pedicled TRAM flap is a rea- 19367 and sonable and time-tested choice for the creation of 19367-50 TRAM flap, bilateral (two a natural and symmetric breast mound, with lim- unipedicle TRAM flaps) ited morbidity and excellent patient satisfaction. • Three separate Current Procedural Ter- Neil A. Fine, M.D. minology codes are available to report Division of Plastic and Reconstructive Surgery TRAM flaps: unipedicle, unipedicle with Northwestern University “supercharging,” and bipedicle. Feinberg School of Medicine 675 North St. Clair Street • A bilateral TRAM flap is reported as two Galter 19-250 unipedicle TRAM flaps: 19367 and Chicago, Ill. 60611 19367-50. nfine@nmh.org • The three TRAM flap breast reconstruc- tion codes are global and include the REFERENCES following: 1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction E Creation of breast pocket with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216–225. E Elevation of abdominal flap 2. Serletti JM. Breast reconstruction with the TRAM flap: Pedi- E Muscle dissection cled and free. J Surg Oncol. 2006;94:532–537. E Flap transfer 3. Clough KB, O’Donoghue JM, Fitoussi AD, Vlastos G, Falcou E Fascial closure MC. Prospective evaluation of late cosmetic results following E Abdominal closure including umbili- breast reconstruction: II. TRAM flap reconstruction. Plast Reconstr Surg. 2001;107:1710–1716. coplasty 4. Moscona RA, Holander L, Or D, Fodor L. Patient satisfaction E Breast contouring and aesthetic results after pedicled transverse rectus abdo- minis muscle flap for breast reconstruction. Ann Surg Oncol. • Use of mesh in fascial closure is included 2006;13:1739–1746. in code 19369. Use of mesh in fascial clo- 5. Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy sure for unipedicle TRAM flaps (19367 breast reconstruction. Plast Reconstr Surg. 2000;106:769–776. and 19368) is reported separately: 49568 6. Erdmann D, Sundin BM, Moquin KJ, Young H, Georgiade GS. Delay in unipedicled TRAM flap reconstruction of the breast: A review of 76 consecutive cases. Plast Reconstr Surg. 2002;110:762–767. 7. Kroll SS, Khoo A, Singletary SE, et al. Local recurrence risk after skin-sparing and conventional mastectomy: A 6-year follow-up. Plast Reconstr Surg. 199;104:421–425. 8. Toth BA, Forley BG, Calabria R. Retrospective study of the limitations of pedicled TRAM flaps occurred skin-sparing mastectomy in breast reconstruction. Plast after the introduction of the free TRAM flap. Reconstr Surg. 1999;104:77–84. Likewise, the concerns for complications of free 9. Al-Ghazal SK, Sully L, Fallowfield L, Blamey RW. The psy- TRAM flaps surfaced after the introduction of chological impact of immediate rather than delayed breast perforator-based flaps. Perhaps in the near fu- reconstruction. Eur J Surg Oncol. 2000;26:17–19. 10. Miller MJ. Immediate breast reconstruction. Clin Plast Surg. ture these three methods of abdominal tissue 1998;25:145–156. transfer will all be mature enough to allow for 11. Kronowitz SJ, Robb GL. Breast reconstruction with postmas- true comparison studies to be performed. Al- tectomy radiation therapy: Current issues. Plast Reconstr Surg. most all reports suggesting that new abdominal 2004;114:950–960. tissue techniques are superior to pedicled 12. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled TRAM flap breast reconstruction: Outcomes TRAM flaps have used historical controls. Com- and implications. Plast Reconstr Surg. 2005;115:84–95. paring new procedures to historical controls 13. Ducic I, Spear SL, Cuoco F, Hannan C. Safety and risk factors rarely provides an accurate comparison. for breast reconstruction with pedicled transverse rectus ab- 1053
  8. 8. Plastic and Reconstructive Surgery • October 2009 dominis musculocutaneous flaps: A 10-year analysis. Ann 33. Serletti JM, Moran SL. Free versus the pedicled TRAM flap: Plast Surg. 2005;55:559–564. A cost comparison and outcome analysis. Plast Reconstr Surg. 14. Namnoum JD. Breast reconstruction: TRAM flap techniques. 1997;100:1418–1424. In: Grabb and Smith’s Plastic Surgery. Philadelphia: Wolters 34. McCraw JB, Horton CE, Grossman JA, Kaplan I, McMellin A. Kluwer Health/Lippincott Williams & Wilkins; 2007:641– An early appraisal of the methods of tissue expansion and the 647. transverse rectus abdominis musculocutaneous flap in re- 15. Spear SL, Ducic I, Cuoco F, Hannan C. The effect of smoking construction of the breast following mastectomy. Ann Plast on flap and donor-site complications in pedicled TRAM breast Surg. 1987;18:93–113. reconstruction. Plast Reconstr Surg. 2005;116:1873–1880. 35. Alderman AK, Kuhn LE, Lowery JC, Wilkins EG. Does patient 16. 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