BREAST SURGERY

Breast Reconstruction With a Turbocharged Transverse Rectus Abdominis Myocutaneous Flap on the Contralateral Perforator Juliano Carlos Sbalchiero, MD, MSc,*Þ Paulo Roberto de Albuquerque Leal, MD,* and Ce´sar Cabello dos Santos, MD, PhDþ Abstract: Seventeen patients were submitted to delayed unilateral breast reconstruction using pedicled, muscle-sparing turbocharged transverse rectus abdominis myocutaneous flap based on the contralateral perforator vessels. The lateral portion of the rectus abdominis muscle on the pedicled side was preserved in 12 patients. Zones II and IV were included in the flap in all cases. Mean duration of surgery was 7 hours and 15 minutes. Four complications developed in the abdominal donor site: contralateral abdominal bulging (n = 1), minor suture dehiscence (n = 2), and epidermolysis at the border of the abdominal flap and umbilical scar (n = 1). Three partial losses (10%Y30%) occurred in the reconstructed breast (17.64% of cases), whereas 2 cases of fat necrosis were associated with partial losses. One patient developed deep vein thrombosis with pulmonary embolism; however, outcome was favorable. This proved a viable alternative for breast reconstruction, with satisfactory results in most patients and acceptable morbidity and surgical time. Key Words: turbocharging, pedicled transverse rectus abdominis myocutaneous flap, breast reconstruction (Ann Plast Surg 2014;73: 503Y508)

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reast cancer is the most common form of cancer in women and an issue of the utmost relevance in public health.1 In Brazil, a lack of information associated with an ineffective public health system has resulted in locally advanced carcinomas (stages III and IV) still being diagnosed in 45.3% of cases.2 In advanced cases in which surgical treatment is indicated, the procedure has to be more radical, involving the loss of a large extent of the skin in addition to removal of the mammary gland and possibly loss of the pectoral muscle. This extensive skin loss together with the harmful effects of the association of radiotherapy and implants3,4 makes autologous tissue the preferred option for breast reconstruction in such cases. The pedicled transverse rectus abdominis myocutaneous (TRAM) flap5 is the most commonly used technique for breast construction with autologous tissue.6 The technique has undergone many modifications and there are currently several variants in the use of abdominal tissue from the infraumbilical area for breast reconstruction. The flap may be pedicled, bipedicled, free, turbocharged, supercharged, or based on perforators. The amount of tissue that has to be included in the flap depends on the technique and the pedicle used.7 In pedicled TRAM based on the superior epigastric artery and veins, the ipsilateral tissue whose limit is the midline (zones I and III) may be safely used in the flap.8 Nevertheless, under certain Received February 16, 2012, and accepted for publication, after revision, September 28, 2012. From the *Department of Plastic Surgery and Microsurgery, National Cancer Institute (INCA); †Department of Plastic Surgery, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ; and ‡Department of Gynecology and Obstetrics, School of Medical Sciences, University of Campinas (UNICAMP), Campinas, SP, Brazil. Conflicts of interest and sources of funding: none declared. Reprints: Juliano Carlos Sbalchiero, MD, MSc, Rua do Humaita´ 104 Cob 02, Humaita´, 22261-001 Rio de Janeiro, RJ, Brazil. E-mail: [email protected] Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7305-0503 DOI: 10.1097/SAP.0b013e318276d9f1

Annals of Plastic Surgery

circumstances, a poorly vascularized segment (zones II and IV) has to be included in the flap used in breast reconstruction to increase the volume and projection of the breast. In these cases, an accessory vascular pedicle must be included to guarantee viability.9 This situation is usually the result of a disproportion between the volume of the breast to be reconstructed and the volume of abdominal tissue available for donation using the conventional technique. This may be due to the volume of the contralateral breast or to the amount of tissue lost because of the radical nature of the mastectomy. Another situation is when there is a midline infraumbilical scar, requiring an accessory vascular pedicle to be made to nourish the contralateral tissue.10 Historically, when the contralateral tissue has to be included in the pedicled TRAM, the option has been the bipedicled flap, which includes both rectus abdominis muscles; however, this technique is being used less and less because of excess morbidity in the abdominal wall.11,12 The development of new microsurgical techniques to mobilize the TRAM flap13 has introduced new options of pedicled flaps such as free flaps and those based on perforators [deep inferior epigastric artery perforator (DIEP) flaps],14 which offer various advantages of morbidity and outcome.15Y17 Nevertheless, use of free flaps demands a sophisticated infrastructure, principally for postoperative monitoring, which is crucial in guaranteeing acceptable success rates.18,19 Such infrastructure is not always available in this country. In the search for alternatives, hybrid techniques have been developed such as ‘‘supercharged’’ flaps20 and ‘‘turbocharged’’ flaps,21 which use microsurgical anastomoses as a form of increasing vascularization of the flap and increasing tissue volume. The turbocharged flap has the advantage of not requiring a receptor pedicle and allows zones II and IV to be included in the reconstructed breast.22,23 The objective of the present prospective study was to evaluate a breast reconstruction technique using a pedicled turbocharged TRAM flap with microsurgical anastomosis to the contralateral perforator.

PATIENTS AND METHODS This prospective, descriptive study included 22 candidates for delayed unilateral breast reconstruction who had been referred to the Plastic Surgery and Microsurgery Department of the National Cancer Institute (INCA), Rio de Janeiro, between March 2005 and April 2006. These patients were selected for breast reconstruction using a pedicled TRAM flap with microsurgical anastomosis to the contralateral perforator. The following inclusion criteria were applied: (1) severe sequelae from mastectomy with extensive skin loss associated with trophic alterations provoked by radiotherapy, such as extensive fibroplasia and pigmentation; and (2) need to use zones II and IV of the abdominal flap to achieve symmetry with the contralateral breast. Patients were discontinued from the study if it proved impossible to carry out the proposed technique due to technical limitations. This study was approved by the internal review board of the National Cancer Institute (INCA), Rio de Janeiro, Brazil. After an initial evaluation and after signing an informed consent form, standardized photographic documentation was obtained in all cases and the following data were recorded: age, body mass index, data concerning mastectomy, clinical morbidities, duration of surgery, and the

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technical details of each procedure. A prospective record was maintained during outpatient follow-up to register any complications and the patients’ progress. All the surgeries were carried out by the principal investigator and by a supervised team of postgraduate students in microsurgery.

Surgical Technique The upper limit of the flap was defined before surgery by bimanual pinching with the patient in a seated position to evaluate the excess infraumbilical skin that could be included in the flap. During the surgical procedure, an incision was made at the cranial limit of the flap and the abdominal flap was detached. The island of skin forming the TRAM flap was then dissected and the rectus abdominis muscle, ipsilateral to the breast to be reconstructed, was removed from its aponeurotic sheath. Next, the deep inferior epigastric vessels were dissected up to where they arise in the external iliac vessels, and the rectus abdominis muscle was sectioned close to the line of Douglas. After the pedicled side of the flap had been dissected, dissection of the contralateral portion began, taking care to identify the myocutaneous perforator with the best caliber and flow and initiating intramuscular dissection at this point from its trajectory up to the beginning of the artery and the deep inferior epigastric veins. On this side, the rectus abdominis muscle and the aponeurosis were maintained intact, with only incision and divulsion being performed, permitting dissection of the vascular pedicle, a technique known as a perforator flap (DIEP flap). When this step was complete, the flap was fixed bilaterally in its distal portion only by the deep inferior epigastric vessels, which were then ligated and sectioned close to where they arise (Figs. 1 and 2). In the cases in which it was impossible to create a flap based solely on a perforator because the caliber was insufficient (G2 mm), there was no visible pulse, or due to a technical impossibility (perforator chosen localized medially), a segment of the rectus abdominis muscle containing a varying number of perforators was dissected. The flap was then transposed under the abdominal flap through a subcutaneous tunnel communicating with the mastectomized area and placed in such a way as to permit microsurgical anastomosis to be performed in a loop to the deep inferior epigastric arteries and veins. This was performed with the aid of a surgical microscope or 4.5 magnification lenses and using 8-0, 9-0, or 10-0 interrupted nylon sutures (Ethicon; Sa˜o Jose´ dos Campos, SP, Brazil) in accordance with the caliber of the vessels. When anastomosis was complete, the flap was then placed into position and modeled in an attempt to obtain maximum symmetry with the remaining breast. Concomitantly, the abdominal wall in the donor site was repaired in the pedicled portion by placing a polypropylene mesh (Marlex, Ethicon) substituting the aponeurosis included in the flap, and in the contralateral portion, using primary suturing of the incised aponeurosis (Fig. 3). The procedure was completed by passing the umbilical scar through the abdominal flap, draining the surgical sites, and suturing the planes.

RESULTS Of the 22 patients selected, the technique was performed as proposed in 17 patients. In the remaining 5, reconstruction was performed using a contralateral free flap due to technical limitations. The mean time of postsurgical follow-up was 11 months (range, 9Y18 months). The mean age of the patients was 47.7 years (range, 35Y68 years). Mean body mass index was 27.31 kg/m2 (range, 18.75Y31.75 kg/m2). Only 1 patient was classified as obese (grade I), whereas another 8 patients were classified as overweight and the remainder were considered to be of normal weight. At the preoperative evaluation, all the patients were considered American Society of Anesthesiologists classification I or II. With respect to the type of mastectomy, in 8 cases Madden mastectomy was performed, whereas 504

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FIGURE 1. Intraoperative images showing dissection of the pedicled turbocharged TRAM on the contralateral perforator. A, Note that the lateral strip of the pedicled rectus abdominis muscle has been preserved, and note the incision in the anterior edge of the contralateral rectus abdominis muscle, allowing the perforator to be dissected. B, Flap transposed to the mastectomized area. C, Details of the inferior epigastric vessels ready for microanastomoses. D, Deep inferior epigastric vessels after anastomosis to the contralateral perforator.

Patey mastectomy was carried out in 6 cases and the Halsted mastectomy was used in 3 cases. The mean time between mastectomy and reconstruction was 3 years and 9 months (range, 1Y7 years). Only 1 patient had a midline infraumbilical scar, this being the reason for the indication of this technique. Only 1 patient smoked and only 1 patient had not been submitted to adjuvant radiotherapy following mastectomy. This latter patient was also the only patient not submitted to axillary lymphadenectomy. In all cases, zones II and IV were included in the flap. The mean duration of surgery was 7 hours and 15 minutes (ranging from 5 hours and 20 minutes to 9 hours). The mean duration of hospitalization was 8 days (range, 6Y10 days) (Figs. 4 and 5). A major complication in the form of contralateral bulging occurred at the donor site in 1 (5.8%) patient. The following minor complications occurred: 2 cases of suture dehiscence in the midline portion of the abdominal scar at around 8 days after surgery and epidermolysis of the edges of the abdominal flap and the umbilical * 2013 Lippincott Williams & Wilkins

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Turbocharged TRAM Flap in Breast Reconstruction

complications occurred on the opposite side to the muscle pedicle, in the lateral quadrants of the reconstructed breast (zones II and IV) and were resolved with early debridement and repositioning of the reconstructed breast. Clinical complications occurred in only 1 patient, who developed deep vein thrombosis in a lower limb and then pulmonary embolism on the 22nd day after surgery; however, her condition progressed favorably. There were no complications at all in 10 patients and the results were satisfactory in all patients except one in whom, even after debridement and resuturing, a new surgical intervention was required and a latissimus dorsi pedicled flap was performed. No blood transfusions were necessary. No recurrences of the tumors were registered throughout the entire follow-up period.

DISCUSSION FIGURE 2. Intraoperative detail of the dissection of the perforators and inferior epigastric vessels. In this case, 2 perforators were included in the pedicle and the inferior epigastric vessels had already been separated from the internal iliac artery. Note complete preservation of the aponeurotic plane and the rectus abdominis muscle.

scar. Complications in the reconstructed breast occurred in 3 (17.64%) patients, with partial loss of the flap, which ranged from a 10% loss in 2 cases to 30% in 1 case. Fat necrosis occurred in 2 patients in association with partial loss (Table 1). In all cases, the

The myocutaneous flap of pedicled rectus abdominis muscle (TRAM),5 based on the deep superior epigastric vessels, continues to be the most commonly used technique for breast reconstruction using autologous tissue and is able to provide sufficient tissue for satisfactory reconstruction in a large percentage of cases.6,24 Nevertheless, this technique is not free of complications. It may be associated with hernias and bulging of the abdominal wall in 0.4% to 8.3% of cases,25 necrosis and partial loss of the flap, and fat necrosis caused by areas of marginal ischemia with damage to the skin and subcutaneous tissue.26 Fat necrosis may occur in 26.9%27 to 58.5% of cases.15 These events may impair the outcome of breast reconstruction and in the case of fat necrosis may be mistaken postoperatively for tumor recurrence.

FIGURE 3. Intraoperative details of the dissection of the turbocharged TRAM flap on the contralateral perforator. A, Note that the lateral strip of the rectus abdominis muscle from the pedicled side has been preserved. B, Dissected flap ready to be transposed to the receptor area together with its innervation. Arrows show the deep inferior epigastric vessels from the pedicled side and the contralateral perforator. C, Tweezers indicating the preserved intercostal nerve close to its entry into the rectus abdominis muscle. D, Repair of the donor areas, showing simple suture of the abdominal wall on the side of the perforator and insertion of a Marlex mesh on the pedicled side. * 2013 Lippincott Williams & Wilkins

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TABLE 1. Complications of the Reconstructed Breast and the Abdominal Donor Site No. Patients (n = 17) Complications in the reconstructed breast Partial loss e10% and fat necrosis Partial loss 30% and fat necrosis Total Complications in the abdominal donor site Suture dehiscence Epidermolysis Bulging Total

FIGURE 4. A 35-year-old patient with severe sequelae after radical mastectomy on the right breast and radiotherapy (top). Appearance 1 year after reconstruction surgery on the right breast.

The application of microsurgical techniques to pedicled TRAM resulted in supercharged and turbocharged flaps. Supercharged flaps use microsurgical anastomoses between the deep inferior epigastric artery and veins of the pedicled TRAM and the thoracic receptor vessels such as the axillary and thoracodorsal vessels, providing additional circulatory support for the flap. In patients with an increased risk of complications, such as obese women, this may represent a safe option for breast reconstruction28; nevertheless,

FIGURE 5. A 44-year-old patient with severe sequelae after radical mastectomy on her right breast and radiotherapy (above). Appearance 8 months after reconstruction surgery on her right breast. 506

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receptor vessels must be available and zones II and IV cannot be included in the flap because of a greater risk of fat necrosis, which may reach rates as high as 29%.29 In the turbocharged flap, microsurgical anastomoses are performed between the deep inferior epigastric vessels on the pedicled side and the contralateral deep inferior epigastric vessels, permitting mobilization of zones I, II, III, and IV with only 1 muscle pedicle.21 In the series presented here, the incidence of complications is similar to the results obtained in 2 series described by Berrino et al.22,23 The slight increase in partial losses in the present sample may be explained by the inclusion of zone IV in all cases and by the variation in the technique, which consisted of the use of the contralateral perforator vessels and not a free flap as in the previous series. This variation could have compromised the perfusion of the most distal portions of the flap (zone IV), an occurrence that has already been reported in perforator free flaps (DIEP).30 Perforator flaps preserve the muscles of the abdominal wall; therefore, they are the techniques with the lowest morbidity rates. In addition, they produce the best results, because they use tissue with better vascularization, and a consequently lower incidence of fat necrosis.15,31 The freedom to model the tissue that is made possible by the absence of a muscle pedicle results in better reconstruction of the submammary fold, maintaining the natural ptosis of the breast and resulting in better symmetry with the remaining breast.32 Nevertheless, thoracic receptor vessels must be available and a sophisticated hospital infrastructure is required. Furthermore, there is a risk of complete loss if the microanastomoses fail.18,19 Patients who require a greater volume of abdominal tissue for satisfactory reconstruction (zones II and IV) and a lack of receptor vessels in the thorax or axillae may constitute a dilemma. In delayed reconstruction, the receptor vessels for microsurgical transference may not be available in 26% of cases concerning the thoracodorsal artery and in 20% of cases concerning the internal mammary vein due to the effects of radiotherapy associated with fibroplasia resulting from surgical manipulation.33 The turbocharged flap has the unique characteristic of offering accessory vascularization for zones II and IV, thus permitting their use without the need for a receptor flap. In addition, it generates similar damage to the abdominal wall as the pedicled TRAM flap. A similar concept has been described in a study that attempted to increase vascularization in the contralateral portion of the free TRAM flap, reducing the incidence of partial losses and fat necrosis.34 The physiology of the turbocharged flap is based on retrograde flow through the deep epigastric artery on the pedicled side that feeds the contralateral deep epigastric artery after microanastomosis.35,36 The increased blood flow from the contralateral side to the pedicle may help overcome valvular obstructions through the choke vessels and realign blood flow.37 Semple21 described a turbocharged flap (a * 2013 Lippincott Williams & Wilkins

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term used to describe a strategy applied to boost the power of a motor) using the contralateral free flap in 4 patients, one of whom had a midline infraumbilical scar. Results were good and no complications were reported. Another study conducted around the same time using turbocharged TRAM22 evaluated the systolic pressure of the deep inferior epigastric artery after sectioning in 4 patients and reported values of around 60% of the pressure recorded in the radial artery, with diastolic pressure at 90% of the systolic value. These findings were corroborated by other authors.38 Berrino and Santi22 divided the turbocharged flap into 2 categories: the ‘‘parasite’’ flap when a vertical midline infraumbilical scar is present and the ‘‘recharged’’ flap when no scar is present. The parasite flap was used in 6 patients, only one of whom went on to develop slight partial loss over a follow-up time of 10.2 months. The recharged flap was used in 22 patients who were considered to be at risk for partial loss due to obesity, smoking, or because the flap extended into zone II. In 20 patients, no losses occurred in the flaps. Complications consisted of 1 case of fat necrosis (6  4 cm), 1 partial loss, and 1 case of necrosis of the central portion of the flap in the abdominal donor site. One patient developed abdominal bulging in the 11th month after surgery. The authors argued that venous drainage from the side fed by the deep inferior epigastric system would reduce the incidence of fat necrosis superficial to Scarpa fascia in these areas, because it is more physiological compared to drainage through the subdermal plexus, as occurs with the simple pedicled flap or the supercharged flap. These authors conclude by recommending the technique for cases in which there is a high risk of partial losses with the conventional pedicled flap and for patients who need larger flaps that extend into the vascular territory of the contralateral deep epigastric vessels. Another argument in favor of the turbocharged flap is that it is not necessary to dissect an accessory pedicle, which may be particularly difficult when there is extensive fibroplasia as a consequence of radiotherapy or surgical manipulation.23,39 In another study, Berrino et al23 used a turbocharged ‘‘parasite’’ flap in 16 patients with a midline infraumbilical scar. An intra-arterial probe was used to measure arterial pressure in the deep inferior epigastric artery, confirming the data obtained in the previous study.22 The results were considered good or excellent in 13 patients and satisfactory in the remainder.23 To the best of our knowledge, no recent studies have been published in the literature on the use of turbocharged TRAM in breast reconstruction. We believe that the variation in this technique described here using turbocharged TRAM in the contralateral perforator is new. The case series presented here demonstrates the applicability of the technique, with satisfactory results and acceptable morbidity. The option of using the contralateral perforator, despite a possibly greater risk of ischemic complications in zone IV, is justified by the significant reduction in morbidity associated with donation of the contralateral deep inferior epigastric vessels in a technique that is similar to DIEP. The present sample shows the proposed technique to be a viable alternative, and indeed, in certain situations it may represent the only option for breast reconstruction. The severity of the sequelae in these patients, in most cases resulting from the aggressive treatment they required because of the advanced stage of their disease at initial diagnosis, is a common problem in this country. As shown in this sample population, some of these women are young and the outcome of their oncological treatment is satisfactory; therefore, the plastic surgeon then plays an important role in their rehabilitation process. In these circumstances, the technical problem encountered is not only limited to giving volume to the reconstructed breast, but, crucially, also to providing an adequate skin cover to substitute a considerable extent of the inelastic, damaged, and pigmented skin, making the use of autologous skin imperative. The option for free flaps is limited, because in most of these cases in which the cicatricial sequelae and * 2013 Lippincott Williams & Wilkins

Turbocharged TRAM Flap in Breast Reconstruction

actinic damage were visible clinically, an attempt at dissection invariably revealed a degree of fibroplasia severe enough to compromise the integrity of the vascular structures, making their dissection extremely difficult and compromising their use as a receptor pedicle.33 Another relevant point is the contraindication of this technique in patients with incipient lymphedema whose problem may be aggravated by an additional lesion to the remaining lymph vessels while attempting to identify a thoracodorsal or axillary receptor pedicle.40 In conclusion, adaptations of perforator flaps in pedicled TRAM that preserve muscles by anastomosing a loop to the contralateral perforator may add some of the benefits of perforator flaps to the safety of the single-pedicled TRAM. This technique avoids complete loss of the flap, allows zones I, II, III, and IV to be used, minimizes damage to the abdominal wall, and produces better results in breast reconstruction after mastectomy. ACKNOWLEDGMENT The authors thank the breast cancer patients receiving care at the National Cancer Institute (INCA), Rio de Janeiro, Brazil. REFERENCES 1. GLOBOCAN. Cancer incidence, mortality and prevalence worldwide, version 2.0. IARC CANCER BASE 2002. Available at: http://www.-dep.iarc.fr/globocan/ globocan.html. Accessed June 23, 2006. 2. Thuler LCS, Mendonc¸a GA. [Initial staging of breast and cervical cancer in Brazilian women]. Rev Bras Ginecol Obstet. 2005;27:656Y660. 3. Krueger EA, Wilkins EG, Strawderman M, et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys. 2001;49:713Y721. 4. Alderman AK, Wilkins EG, Kim HM, et al. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg. 2002;109:2265Y2274. 5. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216Y225. 6. Rezai M, Darsow M, Kummel S, et al. Autologous and alloplastic breast reconstructionVoverview of techniques, indications and results. Gynakol Geburtshilfliche Rundsch. 2008;48:68Y75. 7. Lipa JE. Breast reconstruction with free flaps from the abdominal donor site: TRAM, DIEP and SIEA flaps. Clin Plast Surg. 2007;34:105Y121. 8. Kim EK, Lee TJ, Eom JS. Comparison of fat necrosis between zone II and zone III in pedicled transverse rectus abdominis musculocutaneous flaps: a prospective study of 400 consecutive cases. Ann Plast Surg. 2007;59:256Y259. 9. Ng RL, Youssef A, Kronowitz SJ, et al. Technical variations of the bipedicled TRAM flap in unilateral breast reconstruction: effects of conventional versus microsurgical techniques of pedicle transfer on complications rates. Plast Reconstr Surg. 2004;114:374Y384. 10. Heller L, Feledy JA, Chang DW. Strategies and options for free TRAM flap breast reconstruction in patients with midline abdominal scars. Plast Reconstr Surg. 2005;116:753Y759. 11. Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. 1991;87:1054Y1068. 12. Mizgala CL, Hartrampf CR Jr, Bennett GK. Assessment of the abdominal wall after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecutive patients. Plast Reconstr Surg. 1994;93:988Y1002. 13. Holmstro¨m H. The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg. 1979;13:423Y427. 14. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989;42:645Y648. 15. Garvey PB, Buchel EW, Pockaj BA, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg. 2006;117:1711Y1719. 16. Blondeel PN, Van Landuyt KH, Monstrey SJ. Surgical-technical aspects of the free DIEP flap for breast reconstruction. Oper Tech Plast Reconstr Surg. 1999;6:27Y37. 17. Vandevoort M, Vranckx JJ, Fabre G. Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction. Plast Reconstr Surg. 2002;109:1912Y1918. 18. Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Surg. 1999;104:97Y101.

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19. Varkey P, Tan NC, Girotto R, et al. A picture speaks a thousand words: the use of digital photography and the Internet as a cost-effective tool in monitoring free flaps. Ann Plast Surg. 2008;60:45Y48. 20. Beegle PH. Microvascular augmentation of TRAM flap circulation (supercharged TRAM). In: Hartrampf CR, ed. Breast Reconstruction with Living Tissue. New York, NY: Raven Press; 1991:175Y182. 21. Semple JL. Retrograde microvascular augmentation (turbocharging) of a singlepedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg. 1994;93:109Y117. 22. Berrino P, Santi P. Hemodynamic analysis of the TRAM. Applications to the ‘‘recharged’’ TRAM flap. Clin Plast Surg. 1994;21:233Y245. 23. Berrino P, Casabona F, Adami M, et al. The ‘‘parasite’’ TRAM flap for autogenous tissue breast reconstruction in patients with vertical midabdominal scars. Ann Plast Surg. 1999;43:119Y126. 24. Jones G. The pedicled TRAM flap in breast reconstruction. Clin Plast Surg. 2007;34:83Y104. 25. Edsander-Nord A, Jurell G, Wickman M. Donor-site morbidity after pedicled or free TRAM flap surgery: a prospective and objective study. Plast Reconstr Surg. 1998;102:1508Y1516. 26. Morris SF, Taylor GI. Predicting the survival of experimental skin flaps with a knowledge of the vascular architecture. Plast Reconstr Surg. 1993;92: 1352Y1361. 27. Kroll SS. Bilateral breast reconstruction in very thin patients with extended free TRAM flaps. Br J Plast Surg. 1998;51:535Y537. 28. Wu LC, Iteld L, Song DH. Supercharging the transverse rectus abdominis musculocutaneous flap: breast reconstruction for the overweight and obese population. Ann Plast Surg. 2008;60:609Y613. 29. El-Mrakby HH, Milner RH, McLean NR. Supercharged pedicled TRAM flap in breast reconstruction: is it a worthwhile procedure. Ann Plast Surg. 2002; 49:252Y257.

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30. Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106: 576Y583. 31. Andrades P, Fix RJ, Danilla S, et al. Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction. Ann Plast Surg. 2008;60:562Y567. 32. Serletti JM, Moran SL. Microvascular reconstruction of the breast. Semin Surg Oncol. 2000;19:264Y271. 33. Temple CL, Strom EA, Youssef A, et al. Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy. Plast Reconstr Surg. 2005;115:105Y113. 34. Pennington DG, Nettle WJ, Lam P. Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg. 1993;31:126Y127. 35. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg. 1984;73: 1Y16. 36. Tuominen HP, Asko-Seljavaara S, Svartling NE, et al. Cutaneous blood flow in the TRAM flap. Br J Plast Surg. 1992;45:261Y269. 37. Hjortdal VE, Hansen ES, Kjølseth D, et al. Arteriovenous shunting and regional blood flow in myocutaneous island flaps: an experimental study in pigs. Plast Reconstr Surg. 1991;86:326Y334. 38. Harris NR 2nd, Webb MS, May JW Jr. Intraoperative physiologic blood flow studies in the TRAM flaps. Plast Reconstr Surg. 1992;90:553Y558. 39. Arnez ZM, Bajec J, Bardsley AF. Experience with 50 TRAM flaps breast reconstruction. Plast Reconstr Surg. 1991;87:470Y478; discussion 479Y482. 40. Kronowitz SJ, Kuerer HM, Hunt KK, et al. Impact of sentinel lymph node biopsy on the evolution of breast reconstruction. Plast Reconstr Surg. 2006; 118:1089Y1099.

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Breast reconstruction with a turbocharged transverse rectus abdominis myocutaneous flap on the contralateral perforator.

Seventeen patients were submitted to delayed unilateral breast reconstruction using pedicled, muscle-sparing turbocharged transverse rectus abdominis ...
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