SUPERCHARGING OF DELAYED PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAPS, IS IT A VIABLE OPTION? R. WESLEY VOSBURG, M.D.,* MICHAEL J. WHITE, M.D., and FREDERICK R. HECKLER, M.D.
Introduction: Arterial and venous insufficiency may become evident even in delayed pedicled TRAM flaps. This study assesses the possibility of using the previously ligated deep inferior epigastric vessels for microvascular supercharging during reconstruction. Methods: Twentytwo patients underwent delay by ligation of the inferior epigastric vessels prior to TRAM flap breast reconstruction. The deep inferior epigastric vessels were excised at the time of reconstruction 10–14 days after delay and microscopically examined for vascular compromise that might prevent use in microvascular anastomosis at the time of reconstruction. Results: 20/22 (91%) of the deep inferior epigastric vessels (20 arteries and accompanying veins) showed clot immediately adjacent to the ligature only and 2/22 (9%) showed clot extending only 5–10 mm. None of these vessels (0%) showed clot in the distal 2 cm of their length (adjacent to the flap). Evidence of intramural hematoma, delamination, and endothelial abnormalities were not found in any of the vessels. An additional patient who was a 48-year-old female underwent bilateral pedicled TRAM flap breast reconstruction and one of the flaps exhibited inadequate capillary refill intraoperatively after transfer to the mastectomy defect. Supercharging of the flap utilizing the previously ligated inferior epigastric artery improved capillary refill and the flap survived completely postoperatively. Conclusion: Our findings demonstrate patency of the inferior epigastric C 2014 Wiley Periodicals, Inc. vessels after ligation for TRAM delay during the time frame usually used for delay to take effect. V Microsurgery 35:204–206, 2015.
transverse rectus abdominis myocutaneous (TRAM) flap, first described in 1981, is a widely accepted technique for autogenous breast reconstruction.1–3 Complete TRAM flap tissue loss secondary to poor vascular supply is rare.2 However, traditional pedicled TRAM flaps are associated with segmental loss or fat necrosis in 5–33% of patients. Patients at high risk for TRAM flap compromise include those who smoke, are >25% over ideal body weight, have previous breast or chest wall radiation, and those who have prior abdominal incisions.4–7 In order to enhance blood supply to the flap, various techniques have been suggested including surgical flap delay and microvascular supercharging.4,8 Surgical delay of a TRAM flap by interruption of the inferior epigastric vessels has been shown to increase blood flow through the superior epigastric pedicle and enhance flap survival.4–7 Surgical delay does not appear to increase the risk for other complications.8 Delay may be especially useful in high risk patients and when a large volume of tissue may be needed for reconstruction.4–6,9 Even with delay, a pedicled TRAM flap may occasionally exhibit vascular insufficiency intraoperatively. Previously debridement, leech therapy, or abandonment of the flap may have been the only options to manage this complication.10 When faced with signs of inadequate perfusion of a pedicled TRAM flap that has not previously been Department of Plastics and Reconstructive Surgery, Allegheny General Hospital, Pittsburgh, PA. *Correspondence to: R. Wesley Vosburg, M.D., 320 East North Avenue, Pittsburgh, PA 15212. E-mail: [email protected]
Received 24 May 2014; Revision accepted 9 July 2014; Accepted 14 July 2014 Published online 28 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22301 Ó 2014 Wiley Periodicals, Inc.
delayed, microvascular anastomosis of the deep inferior epigastric vessels to recipient vessels in the axilla or thorax has been described.11,12 This technique has been termed “supercharging” and may specifically help with circulation to the periphery of the flap.11,12 It has been used with pedicled TRAM breast reconstruction since 1987.11 Supercharging has been proven to augment venous drainage of sural flaps as well as enhance survival of free jejunal flaps with arterial insufficiency.13,14 It has been widely assumed that supercharging a previously delayed TRAM flap would be extremely difficult if not impossible, since ligation of the inferior epigastric vessels 1 to 2 weeks prior to reconstruction would likely cause them to be unsuitable for microvascular anastomosis at the time of flap transfer.15,16 We wondered if this assumption was true and the purpose of this study was to evaluate the issue for proof of this concept.
PATIENTS AND METHODS
This study was designed as a case series with a retrospective review of prospectively gathered data. It was done in accordance with the standards of research for our institution. Twenty-two patients underwent unilateral pedicled TRAM flap breast reconstruction after surgical delay was performed 10–14 days prior. All cases were performed by a single plastic surgeon (FRH) at a single academic hospital. Surgical delay using the Restifo approach with ligation of the deep inferior epigastric vascular pedicle close to the external iliac junction and division of the superficial inferior epigastric vessels was performed in all cases.17,18 Hand held Doppler evaluation was used to assure complete occlusion of the vessels intraoperatively.
Supercharging of Delayed Pedicled TRAM Flaps
of patients). Put another way, none of the specimens showed microscopic evidence of clot, platelet aggregation or adhesion except in the segments of vessel at 1 cm adjacent to ligation. The remainder of vessel segments appeared normal. None of the vessels showed evidence of intramural hematoma, delamination, or endothelial abnormalities. Case Report
Figure 1. Deep inferior epigastric artery and venae comitantes segmentation. A: 1 cm segment adjacent to ligature site, B: 1 cm middle segment, C: 1 cm segment closest to the flap.
Efforts were made to use a “no touch” technique to avoid any trauma to the deep inferior epigastric artery and venae comitantes. Circumferential vessel dissection was therefore done only at the ligation point. No postoperative complications attributable to the delay procedure were encountered. Ten to fourteen days after the delay procedure pedicled TRAM flaps were created in the standard fashion. The deep inferior epigastric vessels were divided at this time and a 3 cm segment of the artery and venae comitantes was mounted and divided into 3 sections, each 1 cm in length (Fig. 1). Serial cross sections were obtained from each section and these arterial and venous segments were evaluated for microscopic platelet aggregation or thrombus within their lumens by pathologists not informed of the purpose of these examinations.
Twenty-two consecutive patients underwent surgical delay prior to TRAM flap reconstruction using the above described procedure. Microscopic examination was done by independent pathologists to evaluate the vascular specimens. Serial cross sections of the resected deep inferior epigastric arteries and veins showed clot present beginning at the site of ligation and extending toward the flap 5–10 mm in only 2 patients (9% of patients). The remaining specimens from the other 20 patients showed clot only immediately at the ligature site in both arteries and veins without extension (91%
A 48-year-old female who had previously undergone bilateral mastectomies elected to have bilateral pedicled TRAM flap reconstructions 2 years later. The patient underwent surgical delay 12 days prior to reconstruction with ligation of the superficial and deep inferior epigastric vessels. Care was taken to only minimally manipulate the vessels. At the time of reconstruction one TRAM flap was transferred without incident. The second exhibited inadequate capillary refill after transfer to the chest. This flap was returned to the abdomen and the capillary refill was noted to improve. The flap was again returned to the mastectomy site and the previously ligated deep inferior epigastric artery was used to supercharge to the ipsilateral thoracodorsal artery. Capillary refill of the flap immediately improved, and this flap remained completely viable postoperatively. A duplex Doppler ultrasound image was obtained of the supercharged deep inferior epigastric artery at the site of anastomosis to the thoracodorsal artery that showed patency of the supercharged vessel at 2 weeks postoperatively. The flap survived completely. DISCUSSION
To the best of our knowledge augmenting the vascular supply to a delayed pedicled TRAM flap by using the previously dissected and ligated deep inferior epigastric vessels for microvascular supercharging has not previously been reported. Our strategy involved ligation of the deep inferior epigastric vessels without transection to maintain length allowing for more accurate later histological evaluation. We also utilized a no-touch technique in order to minimize potential trauma to the vascular endothelium to decrease chances of stimulating platelet aggregation and thrombus formation. Microscopic evaluation of resected specimens of deep inferior epigastric vessels in 22 consecutive patients showed a length of vessel without evidence of thrombus formation at the time of reconstruction that should potentially encourage microvascular supercharging at the time of pedicled TRAM flap reconstruction if the need would arise, without automatically assuming that the previously ligated vessels are unusable. These findings may create a small safety net in case of poor arterial inflow or venous congestion in a delayed Microsurgery DOI 10.1002/micr
Vosburg et al.
TRAM flap. It has been shown to be a viable option when tissue compromise is noted after the flap is transposed into the mastectomy defect in patients who have not previously undergone delay.19 Vascular augmentation by supercharging may rarely be needed in delayed TRAM flap breast reconstruction, but careful dissection during surgical delay may protect the vessels’ future utility. It is unknown whether these same results would occur with a laparoscopic or angiographic approach to inferior epigastric vessel ligation for delay.4,20,21 We present one case that represents a successful arterial supercharging after a delayed pedicled TRAM flap for breast reconstruction shown to be patent by duplex ultrasound at 2 weeks postoperatively. We are still utilizing the no touch technique for vascular dissection during initial delay to preserve the vessels’ potential for microvascular supercharging. We would like to see a clinical case of successful venous supercharging in this setting. This theory has been proven in rat models but to our knowledge has not been used in humans.15
Our single case in addition to histological findings in 22 consecutive vascular specimens suggests that microvascular supercharging is still a viable option even in delayed pedicled TRAM flap breast reconstruction.
REFERENCES 1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;69:216– 224. 2. Shestak KC. Breast reconstruction with a pedicled TRAM Flap. In: Kroll SS, editor. Breast Reconstruction With Autologus Tissue. New York: Springer-Verlag; 1999. pp 167–182. 3. Towpik E, Rozycki-Gerlach W. Surgical delay of TRAM flaps for breast reconstruction. Eur J Surg Oncol 1991;17:595–597.
Microsurgery DOI 10.1002/micr
4. Restifo RJ, Ahmed SS. TRAM flap perforator ligation and the delay phenomenon: Development of an endoscopic/laparoscopic delay procedure. Plast Reconstr Surg 1998;101:1503–1511. 5. Restifo RJ, Syed SA, Ward B, Scoutt, LM, Taylor, K. Surgical delay in TRAM flap breast reconstruction: A comparison of 7- and 14-day delay periods. Ann Plast Surg 1997;38:330–334. 6. Hudson DA. The surgically delayed unipedicled TRAM flap for breast reconstruction. Ann Plast Surg 1996;36:238–245. 7. Semple JL. Retrograde microvascular augmentation (turbocharging) of a single-pedicle TRAM flap through a deep inferior epigastric arterial and venous loop. Plast Reconstr Surg 1994;93:109–117. 8. Atisha D, Alderman A, Janiga T, Singal B, Wilkins EG. The efficacy of surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg 2009;63:383–388. 9. Restifo RJ. The “Aesthetic Subunit” principle in late TRAM flap breast reconstruction. Ann Plast Surg 1999;42:235–239. 10. Codner MA, Bostwick J. The delayed TRAM flap. In: Kroll SS, editor. Breast reconstruction with autologus tissue. New York: Springer-Verlag; 1999. pp 183–189. 11. Harashina T, Sone T, Inoue T, Fukuzumi S, Enomoto K. Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery. Br J Plast Surg 1987;40: 367–370. 12. Beegle PH. Microvascular augmentation of TRAM flap circulation (“Supercharged TRAM”). In: Hartrampf CR, editor. Breast reconstruction in living tissues. New York: Raven Press; 1990. pp 175–182. 13. Fujiwara M, Nagata T, Matsushita Y, Ishikawa K, Yusuke O, Fukamizu H. Delayed distally based sural flap with temporary venous supercharging. Microsurgery 2013;33:534–538. 14. Numajiri T, Sowa Y, Nishino K, Fujiwara H, Nakano H, Shimada T, Hisa Y. Does a vascular supercharge improve the clinical outcome for free jejunal transfer. Microsurgery 2013;33:169–172. 15. Sano K, Hallock G, Rice D. Venous “supercharging” augments survival of the delayed rat TRAM flap. Ann Plast Surg 2003;51:398–402. 16. Buck DW, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: Indications, techniques, and outcomes. Plast Reconstr Surg 2009;124:1047–1054. 17. Restifo RJ, Ahmed SS, Isenberg JS, Thomson JG. Timing, magnitude and utility of surgical delay in the TRAM flap. I. Animal studies. Plast Reconstr Surg 1997;99:1211–1216. 18. Restifo RJ, Ward BA, Scoutt LM, Brown JM, Taylor KJ. Timing, magnitude and utility of surgical delay in the TRAM flap. II. Clinical studies. Plast Reconstr Surg 1997;99:1217–1223. 19. Hallock GG, Altobelli JA. The TRAM delay: Burning a lifeboat? Plast Reconstr Surg 1998;102:1301–1303. 20. Yenumula P, Rivas EF, Cavaness KM, Kang E, Lanigan E. The extraperitoneal laparoscopic TRAM flap delay procedure: An alternative approach. Surg Endosc 2011;25:902–905. 21. Aboutanos SZ, Spinos E, Blanchet NP. Angiographic delay, a viable alternative to surgical delay. Ann Plast Surg 2012;68:562–567.