RESEARCH

Pulmonary Function After Pedicled Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction Kevin J. Shultz, MD, Scott Don, MD, Raman C. Mahabir, MD, and Charles N. Verheyden, MD, PhD Abstract: Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous (TRAM) f lap breast reconstruction, have been shown to increase intra-abdominal pressure, thereby decreasing thoracopulmonary compliance and increasing the workload of breathing. The purpose of this article was to quantitate pulmonary function in patients who underwent pedicled TRAM f lap breast reconstruction. A prospective clinical trial was conducted involving 22 women undergoing unilateral or bilateral pedicled TRAM flap breast reconstruction. Pulmonary function testing was conducted 1 week before the operation, 24 hours postoperatively, and 2 months postoperatively. The patients were stratified by age (G50 years vs Q50 years), type of TRAM f lap (unilateral vs bilateral), tobacco use (smoker vs nonsmoker), and body mass index. Changes were analyzed using 1-way repeated-measures analysis of variance and paired t tests. All comparisons used a 2-tailed test at the 0.05 level of significance. Other than residual volume, the 24-hour postoperative values were significantly lower than the preoperative values. The smokers had less change in functional residual capacity, total lung capacity, and forced vital capacity values than the nonsmokers at 24 hours postoperatively; however, they were noted to have decreased pulmonary function at baseline. The patients 50 years or older had significantly greater decline in functional residual capacity and residual volume compared with the younger cohort. No significant difference in pulmonary function testing values existed between those undergoing bilateral versus unilateral pedicled TRAM flap reconstruction. Pulmonary function tests returned to baseline at 2-month follow-up. Pulmonary function test values were significantly decreased at 24 hours after pedicled TRAM flap breast reconstruction. Key Words: pulmonary function, TRAM, breast reconstruction, lung, intra-abdominal pressure (Ann Plast Surg 2016;77: 106Y109)

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ostoperative pulmonary complications remain a major cause of morbidity and mortality after abdominal procedures.1Y4 As health care costs increase and funding and reimbursements decline, attention has been directed toward curtailing this problem in hopes of improving patients’ health while decreasing hospital stay and health care costs.3,5 Pasteur’s papers in the early 1900s were the first to document the increased incidence of respiratory complications after upper abdominal surgery. He described paradoxical breathing movements of the abdomen in postoperative patients and used f luoroscopy to demonstrate a reduction in diaphragm motion.6 In 1933, Beecher7 studied lung volumes after laparotomy and showed a decline in pulmonary function values postoperatively, with gradual recovery during a week’s time.6 Received November 13, 2013, and accepted for publication, after revision, June 6, 2014. From the Division of Plastic Surgery, Scott & White Healthcare and Texas A&M Health Science Center, Temple, TX. Conflicts of interest and sources of funding: none declared. Reprints: Charles N. Verheyden, MD, PhD, Division of Plastic Surgery, Baylor Scott and White Health, 2401 South 31st St, Temple, TX 76508. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7701-0106 DOI: 10.1097/SAP.0000000000000310

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Since these initial publications, several articles have documented the changes in respiratory function after abdominal surgery. Research focusing on abdominal surgeries has provided insight into pulmonary function and mechanics as they relate to abdominal closures and increased intra-abdominal pressure (IAP).6,8Y13 As a result of tight abdominal closure, a multitude of pulmonary complications can result including atelectasis, bronchospasm, inadequate cough, respiratory tract infections, carbon dioxide retention, hypoxemia, and respiratory failure. In 1983, Ford and Thomas6 studied the respiratory muscle dysfunction after upper abdominal surgery and observed that patients postoperatively switched to an inspiratory pattern that was expected of patients with weak diaphragms. Abdominal excursions were noted to be markedly reduced with a comparable increase in ribcage movement.6,9 Similarly, it has been shown that increased IAP after large herniorraphies leads to a reduction in thoracopulmonary compliance and increased work of breathing.12 Breast reconstruction with pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps requires abdominal closure under tension, potentially increasing IAP and negatively affecting multiple organ systems. Because of the scarcity of literature on this topic, little is known about the specific pulmonary function changes associated with the TRAM flap donor site. The purpose of this study was to identify these f luctuations from the preoperative period to the immediate postoperative period (at 24 hours) and late postoperative period (2 months postoperatively) while determining those patients at increased risk for pulmonary complications.

METHODS This study was a prospective clinical trial at Scott & White Memorial Hospital. Institutional review board approval was acquired before study commencement. Written consent was obtained from all participants. Forty consecutive female patients scheduled for unilateral or bilateral pedicled TRAM f laps (with the senior surgeon) were eligible for the study. Abdominal closure was completed without mesh. Closure of the abdominal wall was accomplished by suturing the inferior end of the rectus abdominis up to the arcuate line and then closing the anterior rectus fascia with 2 layers of permanent sutures, as described by Hartrampf and Bennet14 in one of their original articles. Because the excision of anterior fascia was minimized, we did not have to use mesh. There was no components separation. All participants had to be 18 years or older and, if smoking, had to quit at least 1 month before surgery. All pulmonary function tests were performed using a SensorMedics G200 Autobox DL (automated body plethysmograph) at the Scott and White pulmonary laboratory 1 week before operation as well as 1 day and 2 months postoperatively. Testing parameters measured included functional residual capacity (FRC), total lung capacity (TLC), residual volume (RV), peak inspiratory f low rate (PIF), peak expiratory f low rate (PEF), forced vital capacity (FVC), and forced expiratory volume in 1 second (FEV1). Each patient received a patient-controlled analgesia pump. Immediately after surgery, each patient received a 2-mg bolus of morphine followed by 1 mg every 10 minutes. A 5-point Likert scale was used to assess each patient’s pain level before each testing period. All participants received instructions and encouragement regarding pulmonary hygiene. Each patient received a standard bedside incentive spirometer and instructions for use. Annals of Plastic Surgery

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The primary analysis consisted of evaluating the change in pulmonary function tests (PFT) from before surgery to the 24-hour postoperative period and the 2-month follow-up. These changes were assessed using 1-way repeated-measures analysis of variance and paired t tests. In addition, 95% confidence intervals for the changes in pulmonary function were also computed. The association between pain scores and pulmonary function results was assessed using Pearson product-moment correlation coefficients. All comparisons used a 2-tailed test at the 0.05 level of significance.

RESULTS Of the 40 patients enrolled, 22 women completed the preoperative and postoperative pulmonary function testing (PFT). Sixteen patients were either lost to follow-up or subsequently refused to participate. One patient was withdrawn from the study after epidural anesthesia had to be placed for pain control. Another patient who was brought back to the operating room 3 days after surgery for f lap debridement and placement of tissue expanders was excluded. Across all of the pulmonary function parameters, except RV, the 24-hour postoperative values were significantly lower than the preoperative values (Table 1). Values at 2-month follow-up were not significantly different from those preoperatively. There was no significant difference in pulmonary function when comparing unilateral and bilateral procedures. The smokers proved to have less change in pulmonary function compared with the nonsmokers. Decreases in FRC, TLC, and FVC were significantly less, relative to the nonsmokers (Tables 2, 3). Of the 22 patients who completed the study, half of the participants were 50 years or older. At 24 hours postoperatively, the older patients (Q50 years) had a significantly greater decline in FRC and RV, whereas the PIF was less affected. The other parameters were not significantly affected by age group (Table 4). Body mass index (G27 vs 927) proved to have little effect on postoperative values. Pain scores were higher at 24 hours postoperatively but returned to preoperative levels by the 2-month follow-up visit. Pain ratings increased from 1.16 (0.50) preoperatively to 2.94 (0.91) at 24 hours postoperatively, with a P value of less than 0.0001. The mean (SD) pain level at the 2-month follow-up was 1.21 (0.63).

Pulmonary Function After TRAM Flap Surgery

TABLE 1. PFT Results (N = 22)

FRC Preoperative 24-h postoperative 2-mo follow-up TLC Preoperative 24-h postoperative 2-mo follow-up RV Preoperative 24-h postoperative 2-mo follow-up PIF Preoperative 24-h postoperative 2-mo follow-up PEF Preoperative 24-h postoperative 2-mo follow-up FVC Preoperative 24-h postoperative 2-mo follow-up FEV1 Preoperative 24-h postoperative 2-mo follow-up

Actual Values, Mean (SD)

Percentage of Preoperative Values, Mean (SD)

P

2.48 (0.72) 2.22 (0.59) 2.47 (0.57)

91.16% (17.53%) 101.46% (10.24%)

0.03 0.51

5.18 (0.84) 4.22 (0.95) 5.06 (0.86)

80.70% (11.84%) 97.71% (6.44%)

G0.001 0.11

1.77 (0.44) 1.75 (0.48) 1.81 (0.50)

100.40% (24.91%) 102.60% (15.48%)

0.94 0.44

4.60 (1.15) 3.59 (0.97) 4.80 (1.23)

80.88% (22.76%) 106.56% (21.69%)

G0.01 0.17

6.51 (0.76) 4.08 (1.07) 6.33 (1.02)

62.57% (13.64%) 97.30% (11.75%)

G0.001 0.29

3.35 (0.62) 2.36 (0.62) 3.22 (0.52)

70.30% (12.83%) 96.78% (5.68%)

G0.001 0.01

2.53 (0.39) 1.81 (0.45) 2.47 (0.34)

71.35% (14.15%) 98.28% (6.81%)

G0.001 0.25

The table shows complete PFT results for the 22 TRAM f lap cases. The last column gives the P values for testing the hypothesis that the mean postoperative and follow-up values are no different from the mean preoperative values.

DISCUSSION Abdominally based breast reconstruction, in one form or another, is a common form of autologous breast reconstruction. Transverse rectus abdominis musculocutaneous flap donor sites may require tight fascial closure, which has been shown to increase IAP.15 Abdominal procedures necessitating tight abdominal closures can have a profound impact across multiple organ systems. In addition to negative pulmonary effects, increased IAP after surgical closure can result in decreased urine output, decreased cardiac output and stroke volume, venous stasis and increased risk for deep venous thrombosis formation, increased risk for abdominal wall necrosis and wound dehiscence, as well as gastroesophageal reflux and fluid retention.15Y18 Losken et al15 demonstrated the association between increased IAP and increased respiratory rate after pedicled TRAM f lap breast reconstruction. We believe that our study further elucidates the negative effect of tight abdominal closure on pulmonary function after pedicled TRAM f lap procedures. At 24 hours postoperatively, pulmonary function values were significantly decreased. Forced expiratory volume in 1 second and FVC declined and resembled more of a restrictive lung pattern, likely due to increased abdominal pressure, decreased diaphragmatic excursion, and decreased lung compliance. These alterations are transient, returning to baseline at 2-month follow-up. This correlates with the timing of IAP readings noted in the study of Losken et al.15 Using bladder pressure readings to estimate IAP, they observed that, 24 hours after pedicled TRAM flaps, pressure readings peaked with apparent decline by postoperative * 2014 Wolters Kluwer Health, Inc. All rights reserved.

day 2, at which time they observed volume diuresis and symptomatic improvement. Clinically, IAP measurements are rarely indicated, although the early recognition of intra-abdominal hypertension (IAH) may prevent serious pulmonary complications after abdominal procedures. Losken et al15 noted that patients with IAP of 20 mm Hg or greater had a higher incidence of complications after pedicled TRAM f lap breast reconstruction. Of those patients included in their study, 12.9% had IAP of 20 mm Hg or greater during their recovery. Additional studies have identified 20 mm Hg as the threshold for the development of abdominal compartment syndrome. Intra-abdominal pressure of greater than 12 mm Hg has been shown to exert adverse physiologic sequelae and may progress to IAH.19 Losken et al15 found that bipedicled TRAM procedures resulted in significantly higher IAPs relative to the unipedicle group on postoperative day 1. In the present study, although both unilateral and bilateral TRAM f lap procedures as well as subsequent closures resulted in objective changes in pulmonary function within the first 24 hours postoperatively, no significant difference was noted between the two. The small sample size in our study may explain these conf licting findings. Studies have attempted to determine the utility of preoperative PFT in an effort to identify high-risk patients, but controversy still exists.20Y22 A systematic review conducted in 2006, looking at www.annalsplasticsurgery.com

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TABLE 2. Preoperative PFT Values by Smoking Status

FRC TLC RV PIF PEF FVC FEV1

TABLE 4. Change in PFTs From Before Surgery to 24 Hours After Surgery by Age

Current Smoker Yes (n = 5)

Current Smoker No (n = 17)

P

2.37 (0.77) 4.97 (0.70) 1.66 (0.46) 4.42 (1.48) 6.00 (0.63) 3.18 (0.45) 2.41 (0.37)

2.51 (0.72) 5.24 (0.89) 1.80 (0.45) 4.66 (1.08) 6.66 (0.75) 3.40 (0.66) 2.56 (0.40)

0.70 0.54 0.53 0.70 0.09 0.50 0.44

The table shows preoperative PFT values by smoking status and respective P values. Values are expressed as mean (SD).

noncardiothoracic procedures, failed to identify any study supporting the routine use of spirometry for preoperative pulmonary risk stratification. It was concluded that patients identified as high risk by preoperative spirometry could be identified equally well by preoperative clinical evaluation.4 Further contributing to the postoperative respiratory concerns in patients who underwent TRAM f lap breast reconstruction is the known increased risk for thromboembolism.23Y25 The incidence of pulmonary thromboembolism in these patients has been reported as high as 6.3%.24 The increase is likely multifactorial. The risk for venous thromboembolism is known to be higher among patients with cancer.24,25 Procedures requiring tight abdominal closure, such as abdominoplasty, have been studied to better understand their effects on pulmonary function and risk for thromboembolus development.23,26Y28 Intra-abdominal hypertension is thought to contribute by decreasing venous return, thus increasing venous stasis and the risk for deep venous thrombosis.23 In addition to plication, f lexion of the bed and abdominal binder placement have been shown to increase IAP after abdominoplasty. Huang et al23 found that all of these factors significantly increased IAP values but not beyond 20 mm Hg, which has been considered the threshold for development of abdominal compartment syndrome. These postoperative maneuvers may play a role in increasing IAP after TRAM f lap breast reconstruction, thus contributing to the increased risk for pulmonary complications. The results of the present study, combined with the current literature on this topic, may help plastic surgeons better care for patients who underwent TRAM f lap breast reconstruction. Because of the observed decline in pulmonary function at 24 hours after pedicled TRAM f lap breast reconstruction, we recommend perioperative precautions against pulmonary morbidity, particularly in older patients with a history of smoking. Aggressive pulmonary hygiene, TABLE 3. Change in PFTs From Before Surgery to 24 Hours After Surgery by Smoking Status

FRC TLC RV PIF PEF FVC FEV1

Current Smoker Yes (n = 5)

Current Smoker No (n = 17)

P

105.81% (19.51%) 85.51% (15.87%) 111.65% (29.80%) 86.92% (24.26%) 63.58% (18.63%) 81.44% (15.51%) 78.64% (20.10%)

86.84% (14.87%) 77.95% (9.25%) 96.89% (23.13%) 79.10% (22.76%) 62.28% (12.53%) 67.32% (10.70%) 69.21% (11.84%)

0.03 0.05 0.26 0.51 0.86 0.04 0.20

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FRC TLC RV PIF PEF FVC FEV1

Age G 50 y (n = 11)

Age Q 50 y (n = 11)

P

102.15% (17.53%) 85.29% (13.58%) 112.03% (28.49%) 71.60% (14.85%) 61.82% (15.40%) 72.57% (14.54%) 73.63% (15.15%)

80.17% (8.49%) 75.66% (7.24%) 87.62% (11.42%) 90.15% (26.03%) 63.33% (12.35%) 68.03% (11.09%) 69.07% (13.40%)

G0.01 0.06 0.02 0.05 0.80 0.42 0.46

The table expresses change in PFT values from before surgery to 24 hours after surgery. Values 24 hours after surgery are expressed as mean (SD) percentage of preoperative values.

patient-controlled analgesia, and close monitoring for the first 48 hours postoperatively are recommended to reduce the potential for complications. Patients 50 years or older should be monitored more closely because they tend to have greater respiratory effects in the first 24 hours after surgery. The increase in pain scores at 24 hours postoperatively may have contributed to the decline in pulmonary function, emphasizing the potential role of adequate pain control in reducing postoperative respiratory complications. Infusion pain pumps with local infusion catheters have received much attention of late and have been touted to significantly improve pain control, reducing narcotic requirements after a variety of surgeries. A recent meta-analysis evaluating the efficacy of local wound pain pump use after microsurgical autologous breast reconstruction revealed a significant decrease in opioid use. Infusion pain pumps with local infusion catheters may serve as a means of reducing potential pulmonary derangement and morbidity after TRAM f lap breast reconstruction. Larger randomized prospective studies are needed to better delineate their efficacy and safety.29 The connection between increased IAP and postoperative pulmonary complications is well documented; therefore, in addition to perioperative/postoperative care to reduce respiratory problems, patients should be monitored closely for sequelae of IAH. As TRAM f lap breast reconstruction evolves, free TRAM and deep inferior epigastric perforator procedures have become more popular. In 2005, Losken et al30 studied the effects of free versus pedicled TRAM f lap procedures as it relates to changes in IAP. They found that IAP was significantly lower after free TRAM procedures than after pedicled TRAM f lap breast reconstruction. This may correlate with an improvement in pulmonary function, and future studies looking at pulmonary function values after free TRAM and deep inferior epigastric perforator f lap breast reconstruction may prove useful. Future studies directly comparing bladder pressure and pulmonary function values in the same patient sample would be helpful in assessing a more direct correlation between the 2 values.

CONCLUSIONS

The table illustrates the change in PFT values from before surgery to 24 hours after surgery by smoking status. Pulmonary function testing values 24 hours after surgery are expressed as mean (SD) percentage of preoperative values.

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Pedicled TRAM f lap procedures result in transient objective alterations in pulmonary function. Perioperative and postoperative precautions against pulmonary morbidity should be taken, particularly in older patients with a history of smoking. REFERENCES 1. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest. 1997;111:564Y571. 2. Lawrence VA, Dhanda R, Hilsenbeck SG, et al. Risk of pulmonary complications after elective abdominal surgery. Chest. 1996;110:744Y750. 3. Scholes RL, Browning L, Sztendur EM, et al. Duration of anaesthesia, type of surgery, respiratory co-morbidity, predicted VO2max and smoking predict postoperative pulmonary complications after upper abdominal surgery: an observational study. Aust J Physiother. 2009;55:191Y198.

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4. Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:581Y595. 5. Thompson DA, Makary MA, Dorman T, et al. Clinical and economic outcomes of hospital acquired pneumonia in intra-abdominal surgery patients. Ann Surg. 2006;243:547Y552. 6. Ford GT, Thomas RW. Respiratory physiology in upper abdominal surgery. Clin Chest Med. 1993;14:234Y252. 7. Beecher HK. The measured effect of laparotomy on the respiration. J Clin Invest. 1933;12:639Y650. 8. Bailey J, Shapiro MJ. Abdominal compartment syndrome. Crit Care. 2000; 4:23Y29. 9. Ford GT, Whitelow WA, Rosenal TW, et al. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis. 1983;127:431Y436. 10. Ivatury RR, Diebel L, Porter JM, et al. Intra-abdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am. 1997;77: 783Y800. 11. Kron IL, Harman PK, Nolan SP. The measurement of intra-abdominal pressure as a criterion for abdominal exploration. Ann Surg. 1984;199:28Y30. 12. Munegato G, Brandolese R. Respiratory physiopathology in surgical repair for large incisional hernia of the abdominal wall. J Am Coll Surg. 2001;192: 298Y304. 13. Ridings PC, Bloomfield GL, Blocher CR, et al. Cardiopulmonary effects of raised intra-abdominal pressure before and after intravascular volume expansion. J Trauma. 1995;39:1071Y1075. 14. Hartrampf CJ Jr, Bennet GK. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg. 1987;205:508Y519. 15. Losken A, Carlson GW, Jones GE, et al. Significance of intraabdominal compartment pressures following TRAM flap breast reconstruction and the correlation of results. Plast Reconstr Surg. 2002;109:2257Y2264. 16. Diebel L, Saxe J, Dulchavsky S. Effect of intra-abdominal pressure on abdominal wall blood flow. Am Surg. 1992;58:573Y576. 17. Kirsch AJ, Hensle TW, Chang DT, et al. Renal effects of CO2 insufflation: oliguria and acute renal dysfunction in a rat pneumoperitoneum model. Urology. 1994;43:453Y459.

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Pulmonary Function After TRAM Flap Surgery

18. Saggi BH, Sugerman HJ, Ivatury RR, et al. Abdominal compartment syndrome. J Trauma. 1998;45:597Y609. 19. Sugrue M. Abdominal compartment syndrome. Curr Opin Crit Care. 2005; 11:333Y338. 20. Chetta A, Tzani P, Marangio E, et al. Respiratory effects of surgery and pulmonary function testing in the preoperative evaluation. Acta Biomed. 2006; 77:69Y74. 21. Fuso L, Cisternino L, DiNapoli A, et al. Role of spirometric and arterial gas data in predicting pulmonary complications after abdominal surgery. Respir Med. 2000;94:1171Y1176. 22. Manzano RM, Carvalho CR, Saraiva-Romanholo BM, et al. Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial. Sao Paulo Med J. 2008; 126:269Y273. 23. Huang GJ, Bajaj AK, Gupta S, et al. Increased intraabdominal pressure in abdominoplasty: dilineation of risk factors. Plast Reconstr Surg. 2007;119: 1319Y1325. 24. Kim EK, Eom JS, Ahn SH, et al. The efficacy of prophylactic low-molecularweight heparin to prevent pulmonary thromboembolism in immediate breast reconstruction using the TRAM flap. Plast Reconstr Surg. 2009;123:9Y12. 25. Pannucci CJ, Chang EY, Wilkins EG. Venous thromboembolic disease in autogenous breast reconstruction. Ann Plast Surg. 2009;63:34Y38. 26. Perin LF, Saad R Jr, Stirbulov R, et al. Spirometric evaluation in individuals undergoing abdominoplasty. J Plast Reconstr Aesthet Surg. 2008;61:1392Y1394. 27. Talisman R, Kaplan B, Haik J, et al. Measuring alterations in intra-abdominal pressure during abdominoplasty as a predictive value for possible postoperative complications. Aesthetic Plast Surg. 2002;26:189Y192. 28. Tercan M, Bekerecioglu M, Dikensoy O, et al. Effects of abdominoplasty on respiratory functions: a prospective study. Ann Plast Surg. 2002;49:617Y620. 29. Giordano S, Verajankorva E, Koskivuo I, et al. Effectiveness of local anaesthetic pain catheters for abdominal donor site analgesia in patients undergoing free lower abdominal flap breast reconstruction: a meta-analysis of comparative studies. J Plast Surg Hand Surg. 2013;47:428Y433. 30. Losken A, Carlson GW, Tyrone JW, et al. The significance of intraabdominal compartment pressure after free versus pedicled TRAM flap breast reconstruction. Plast Reconstr Surg. 2005;115:261Y263.

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Pulmonary Function After Pedicled Transverse Rectus Abdominis Musculocutaneous Flap Breast Reconstruction.

Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, have been shown to inc...
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