Original Article
97
The Abdominal Fascial Closure in a Double-Breasted Jacket Pattern Following a TRAM Free Flap Breast Reconstruction Jong Won Hong, MD1
1 Department of Plastic and Reconstructive Surgery, Institute for
Human Tissue Restoration, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea J Reconstr Microsurg 2014;30:97–102.
Abstract
Keywords
► TRAM ► abdominal fascial closure ► abdominal bulging
Dae hyun Lew, MD, PhD1
Address for correspondence Tai Suk Roh, MD, PhD, Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, Republic of Korea 135-720 (e-mail: [email protected]).
The primary closure of abdominal fascia after breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap has been reported to be the most effective way to reduce these complications. A total of 108 patients who underwent immediate unilateral breast reconstruction with muscle-sparing TRAM flap were included in the study. We compared complications between 56 patients who underwent conventional primary fascial closure (group 1) and 52 who underwent fascial closure in a new doublebreasted jacket pattern (group 2), retrospectively. Abdominal bulging occurred in four patients (7.1%) in group 1 and one patient (1.9%) in group 2 (p ¼ 0.01). An abdominal wound dehiscence occurred in three (5.4%) patient in group 1 and two (3.8%) patient in group 2 (p ¼ 0.12). After conventional or muscle-sparing TRAM free flap reconstruction, closing the abdominal fascia in a double-breasted jacket pattern can help reinforce the lower abdominal fascia and prevent abdominal bulging caused by abdominal fascia tensional imbalance.
Approximately 25% of patients who have undergone mastectomy due to breast cancer undergo breast reconstruction using autologous tissue or implant tissue.1 Among various types of breast reconstruction, the transverse rectus abdominis myocutaneous (TRAM) flap has become a gold standard.1 Since Hartrampf et al developed the pedicled TRAM flap in 1982,2 it can provide soft, ptotic, and natural breast mounds. According to Mizgala et al, 93% of patients who have undergone breast reconstruction with the TRAM flap consider it valuable and 96% would recommend it.3,4 After breast reconstruction with a TRAM flap, abdominal donor site complications include abdominal hernia, bulging, partial skin loss, wound dehiscence, infection, hematoma, seroma, and discomfort.5–7 Among these, abdominal hernia and bulging are common late complications.8 According to Man et al, after breast reconstruction with a deep inferior
epigastric perforator (DIEP) versus a free TRAM flap, the incidence of abdominal hernia was 0.8 versus 3.9% and bulging was 3.1 versus 5.9%, respectively.9–11 Abdominal bulging was defined as a protuberance of the lower abdominal wall due to weakening of the musculofascial system around the abdominal fascia repair region,12 and was differentiated from a true hernia, which has fascial defect.13,14 Abdominal bulging has been important to differentiate from hernia because it does not require hernioplasty but rather simple abdominal plication or synthetic mesh reinforcement.6,15 Because the incidence of abdominal bulging is higher than that of hernia, reducing its occurrence has become a major concern.6,16 Several strategies to prevent abdominal bulging have been described, including primary closure and using a human acellular dermal matrix (HADM) graft or synthetic mesh graft.12,17–20 Boehmler et al compared
received February 27, 2013 accepted after revision August 6, 2013 published online January 7, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1357278. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Young Seok Kim, MD1 Han-Su Yoo, MD1 Tai Suk Roh, MD, PhD1
A Double-Breasted Jacket Pattern Fascial Closure
Kim et al.
Table 1 Patient demographics and history p
Group 1a
Group 2b
56
52
Average
42.9
42.5
Range
33–58
26–58
4
2.6
< 0.0001 0.96
No. of patients Age, years
Average follow-up, years
0.92
Smoking history, n (%) Nonsmoker or former smoker
53 (94.6%)
48 (92.3%)
Active smoker
3 (5.4%)
4 (7.7%)
50 (89.3%)
45 (86.5%)
6 (10.7%)
7 (13.5%)
Average
20.2 cm2
19.0 cm2
Range
11.8–27.5
14.1–27.5
Body mass index < 25 25
0.19
Fascial defect size
a
0.2
Group 1: Conventional primary closure. Group 2: Double-breasted jacket pattern.
b
the incidence of complications related to abdominal closure among various methods. They found that primary repair alone was associated with the lowest incidence of complications (abdominal bulging: 5%, any complication: 10%).12 The cases of abdominal bulging after primary closure were caused by tension imbalance between the upper and lower abdominal fascias,21 a factor known to cause abdominal bulging.22 In this study, we report the reduction of the incidence of abdominal bulging via an abdominal fascial closure in a double-breasted jacket pattern.
and fascial defect size were collected from the medical record review (►Table 1). For statistical analyses, a bivariate analysis of the patient characteristics was used to determine which variables were significantly predictive of abdominal complications. The sample t-test and Wilcox rank-sum test were used to compare the complication rate between the two groups. Statistical significance was set at p < 0.05. The software used for analysis was PASW Statistics 18.0 (SPSS Inc., Chicago, IL).
Surgical Technique: Double-Breasted Jacket Pattern
Patients and Methods The present study was approved by the Research Ethics Committee at the Gangnam Severance Hospital, Seoul, Korea and was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all the patients. We retrospectively analyzed medical records of 108 patients who underwent immediate breast mound reconstruction with muscle-sparing TRAM flap (MS-1: 5 patients, MS-2: 103 patients) on a unilateral breast. All patients underwent abdominal fascial closure performed by one plastic surgeon after elevation of the abdominal flap. Of the 108 patients, 56 underwent conventional primary closure (group 1) and 52 underwent primary closure in the double-breasted jacket pattern (group 2). Abdominal complications were assessed by physical examination and/or complaints of patients during follow-up period. Based on the preoperative and recent photographs and physical examinations, final diagnosis of abdominal complications was confirmed by three other plastic surgeons in the breast reconstruction team except the surgeon who performed an abdominal fascial closure. Patient demographic information, smoking history, body mass index (BMI), Journal of Reconstructive Microsurgery
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After elevation of a muscle-sparing TRAM flap, simple sutures were applied to close the spared rectus muscles with #2–0 Vicryl (Ethicon Inc., Somerville, NJ). Then vertical mattress sutures were applied to close the fascia from upper to lower area, using #2–0 Vicryl (►Fig. 1). Because the lower abdominal fascia was not excised, simple closure could result in a tension imbalance between fascia-excised region and lower abdominal fascia. Tension on the closed fascia-excised region was higher than on lower abdominal fascia. To evenly distribute the tension, the first horizontal mattress suture was applied on the region near the midline by sliding the lower lateral abdominal fascia into the lower medial fascia (►Fig. 2). The lower lateral fascia should include the internal oblique muscle. Subsequently, a second horizontal mattress suture was applied to the medial fascia to exert tension laterally (►Fig. 3), resulting in a double-layer fascial closure in the double-breasted jacket pattern (►Fig. 4). This suturing technique helps maintain a balance of tension between the lower abdominal fascia and fascia-excised region. Continuous plication suturing was conducted from the upper abdominal fascia to the end of the fascial excision area using # 1–0 loop PDS (Ethicon Inc., Somerville, NJ). This maintains a balance of tension throughout the whole abdomen.
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98
Fig. 1 Fascial excision. (a) The region of excised abdominal rectus fascia is encircled with the yellow dotted line. A and B are, respectively, points on the lateral and medial fascia inferior to the excised fascia. (b) A diagrammatic representation of (a).
Results The mean age was 42.9 years (range, 33–58 years) in group 1 and 42.5 years (range, 26–58 years) in group 2. The mean follow-up period was 4.0 years (range, 2.9–4.8 years) in group 1 and 2.6 years (range, 1.9–3.0 years) in group 2. The demographic data were similar between the two groups (►Table 1). Six (10.7%) in group 1 and 7 (13.5%) in group 2 had a BMI greater than or equal to 25. The difference was not statistically significant (p ¼ 0.19). The reconstruction with TRAM free flap was performed in 3 (5.4%) and 4 (7.7%) active
Kim et al.
smokers in groups 1 and 2, respectively. The difference was not statistically significant (p ¼ 0.96). The average fascial defect size of groups 1 and 2 were 20.2 cm2 (11.8–27.5 cm2) and 19.0 cm2 (14.1–27.5 cm2), respectively. The defect size was not statistically different (p ¼ 0.20). Among possible abdominal donor site complications, there was no abdominal hernia; however, four in group 1 (7.1%) and one in group 2 (1.9%) had abdominal bulging. This difference was statistically significant (p ¼ 0.01; ►Table 2). The relationship between BMI and the incidence of abdominal bulging was not statistically significant (correlation coefficient 0.098 in group 1 vs. 0.145 in group 2). In addition, patients with BMI 25 had more abdominal bulging than BMI < 25 in group 1 (33.3% [2/6] vs. 4% [2/50], p ¼ 0.01); however, only one patient with BMI < 25 had this in group 2 (2.2% [1/45]). Moreover, abdominal bulging occurred more in patients with BMI 25 (15.4% [2/13]) than with BMI < 25 (3.2% [3/95]), which was statistically significant (p ¼ 0.02). Abdominal tightness/discomfort occurred only patients with BMI < 25. The relationship between fascial defect size and the incidence of abdominal bulging was not statistically significant, too (correlation coefficient 0.165 in group 1 vs. 0.293 in group 2). Two patients with abdominal bulging in group 1 underwent an abdominal ultrasonography to confirm no fascial defect (hernia), and then surgical interventions using Prolene (Ethicon Inc., Somerville, NJ) mesh inlay graft were
Fig. 2 (a) A and B are, respectively, points along the lateral and medial fascia below the excised fascia. A is sutured to B with the first horizontal mattress suture. (b) A has slide under B. (c) A diagrammatic representation of (a) and (b).
Fig. 3 (a) A and B are, respectively, points on the lateral and medial fascia below the excised fascia, respectively. B is pulled toward A to cover the lateral fascia. (b) A diagrammatic representation of (a). B is sutured to A with the second horizontal mattress suture. Journal of Reconstructive Microsurgery
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A Double-Breasted Jacket Pattern Fascial Closure
A Double-Breasted Jacket Pattern Fascial Closure
Kim et al.
Fig. 4 (a) The abdominal fascia inferior to the arcuate line was reinforced twofold by using the double-breasted jacket pattern. (b) A diagrammatic representation of (a).
performed for the correction of severe abdominal fascia attenuation. The other three patients (two in group 1 and one in group 2) with abdominal bulging did not undergo surgical intervention because their symptoms were mild and/ or the compromised cosmesis was not of sufficient concern. An abdominal wound dehiscence occurred in three (5.4%) patients in group 1 and two (3.8%) patients in group 2 (p ¼ 0.12). These were resolved after a simple secondary repair of the wound dehiscence. Hematoma/seroma and skin infection were occurred in both groups; however, these complications were resolved by conservative management without significant sequelae (►Table 2).
Discussion Breast reconstruction with a TRAM flap has evolved from pedicled flap to free flap, and finally to muscle-sparing TRAM flap including DIEP flap. With these changes, the amount of harvested abdominal muscle and fascia has decreased. In addition, surgeons have been concerned about how it should be closed to reduce the risk of donor site complications. Among various methods for abdominal fascial closure, the inlay graft using synthetic mesh or HADM has the advantages of reducing tension on the closure, maintaining the midline position of the umbilical stalk and maintaining the lower abdominal wall contour without additional plication.12 However, the synthetic mesh increases infection risk, and there are several reports of complications caused by the mesh, such
as contracture or encapsulation due to long-term interaction with the host prosthesis.17 Despite the advantages of HADM, such as tolerability against infection and rapid repopulation and revascularization,17 increasing laxity caused by abdominal wall mobility has been a major concern.12,23 The conventional primary repair has been known as a good method for the abdominal fascial closure in multiple studies.12,13 However, there is concern for a tension imbalance because an excised-fascial region was closed more tighter than lower abdominal region (lower abdominal fascia was not excised, so closed loosely). Abdominal bulging is a common late complication that results from multiple factors. First, it may be due to attenuation of the abdominal fascia22 in cases of minimal fascial excision. In these cases, the bulging may occur inferior to the arcuate line (►Fig. 5). The attenuation may be a result from continuous abdominal pressure, especially in patients with intestinal obesity. The second contributing factor is increased laxity of the abdominal fascia due to an imbalance of tension. After harvest of a TRAM free flap, the normal contour of the abdominal wall is altered by the closure of excised-fascia region. The excised-fascia region was closed tightly; however, the lower abdominal fascia (without fascial excision) was closed less tightly. This imbalance of tension could cause a laxity of the lower abdominal fascia (►Fig. 6).21 According to the previously reported studies, the incidence of abdominal bulging was variable with the abdominal fascial closure methods. The high rates of bulging (20–44%)
Table 2 Complication following abdominal fascial closure Group 1a
Complication
a
Group 2b
p
n
% (n ¼ 56)
n
% (n ¼ 52)
Hernia
0
0
0
0
–
Abdominal bulging
4
7.1
1
1.9
0.01
Partial skin loss/dehiscence
3
5.4
2
3.8
0.12
Hematoma/seroma
2
3.6
1
1.9
0.19
Skin infection
2
3.6
2
3.8
0.96
Tightness/discomfort
3
5.4
1
1.9
0.02
Group 1: Conventional primary closure. Group 2: Double-breasted jacket pattern.
b
Journal of Reconstructive Microsurgery
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100
Fig. 5 A diagrammatic representation of the abdomen after simple primary repair of the abdominal fascia following a TRAM flap elevation. The attenuation of abdominal fascia, especially inferior to the arcuate line, could be caused by continuous abdominal pressure especially in cases with intestinal obesity. The black arrows indicate the direction of tension caused by abdominal pressure following the attenuation of the abdominal fascia.
Kim et al.
The double-breasted jacket pattern used in this study has several advantages that may decrease the incidence of abdominal bulging. First, the method maintains the tension balance between the excised-fascia region and the lower abdominal fascia (without fascial excision). Second, the abdominal fascia inferior to the arcuate line was reinforced by a double-layer closure. Third, the continuous fascial plication suture conducted from the upper abdomen to the fascial defect area also helps maintain tensional balance across the whole abdomen, especially in the upper abdomen. Nonetheless, this method also has several limitations. Excess tension on the fascial closing line may increase the risk of ischemia, necrosis, and dehiscence.8 However, an abdominal hernia due to the fascial ischemia, necrosis, or dehiscence has not been reported in this study. In the cases of abdominal bulging, according to Boehmler et al, various methods for the abdominal fascial closure resulted in the occurrence of abdominal bulging in approximately 10% of the patients within the first postoperative year, and in approximately 18% within 2 years after the operation.12 Thus, the shorter mean postoperative follow-up period in group 2 (2.6 years) than in group 1 (4.0 years) may have contributed to the lower measured incidence of abdominal bulging in group 2. Another limitation of the method is that it is not suitable or effective when the abdominal fascia excision is very small or a DIEP flap reconstruction is performed. In contrast, our method is indicated after a conventional or muscle-sparing TRAM free flap reconstruction with some fascial excision.
Conclusion
Fig. 6 A diagrammatic representation of the abdomen after simple primary repair of the abdominal fascia following a TRAM flap elevation. The tension in the closed fascia-excised region was higher than in the lower abdominal fascia. The laxity of the lower abdominal fascia increased due to this tension imbalance. The black arrows indicate the direction of tension on the abdominal fascia.
associated with primary closure were reported in the initial studies.13,24,25 However, a recent study reported a 5% rate of bulging with primary closure.12 The use of HADM was associated with bulging rate of 16.7 to 31%.12,17 Using the synthetic mesh, the rate of bulging was 1.7 to 10%.5,12,26 In this study, 7.1% rate of bulging associated with the conventional primary closure was reported. However, when the newly developed method (double-breasted jacket pattern) was done, the rate of bulging was shown to decrease from 7.1 to 1.9% (p ¼ 0.01).
After conventional or muscle-sparing TRAM free flap reconstruction, closing the abdominal fascia in a doublebreasted jacket pattern can help prevent abdominal bulging caused by abdominal fascia tensional imbalance or attenuation. As more patients undergo this procedure and more data are available on long-term follow-up, this technique may become an increasingly attractive option for abdominal closure after TRAM flap harvesting for breast reconstruction.
Acknowledgments The authors thank Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Republic of Korea) for help with figures.
Conflict of Interest The authors have indicated no significant interest with commercial supporters. Financial Disclosure and Products None of the authors has a financial interest in all products, devices, drugs, etc., used in the article. Journal of Reconstructive Microsurgery
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A Double-Breasted Jacket Pattern Fascial Closure
A Double-Breasted Jacket Pattern Fascial Closure
Kim et al.
References
14 Kroll SS, Schusterman MA, Reece GP, Miller MJ, Robb G, Evans G.
1 Vega S, Smartt JM Jr, Jiang S, et al. 500 Consecutive patients with
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free TRAM flap breast reconstruction: a single surgeon’s experience. Plast Reconstr Surg 2008;122(2):329–339 Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;69(2): 216–225 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(5):988–1002, discussion 1003–1004 Chun YS, Sinha I, Turko A, et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2010; 126(4):1133–1141 Ascherman JA, Seruya M, Bartsich SA. Abdominal wall morbidity following unilateral and bilateral breast reconstruction with pedicled TRAM flaps: an outcomes analysis of 117 consecutive patients. Plast Reconstr Surg 2008;121(1):1–8 Kroll SS, Schusterman MA, Mistry D. The internal oblique repair of abdominal bulges secondary to TRAM flap breast reconstruction. Plast Reconstr Surg 1995;96(1):100–104 Kim EK, Eom JS, Ahn SH, Son BH, Lee TJ. Evolution of the pedicled TRAM flap: a prospective study of 500 consecutive cases by a single surgeon in Asian patients. Ann Plast Surg 2009;63(4): 378–382 Rossetto LA, Abla LE, Vidal R, et al. Factors associated with hernia and bulge formation at the donor site of the pedicled TRAM flap. Eur J Plast Surg 2010;33(4):203–208 Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009;124(3):752–764 Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 2005;115(2):436–444, discussion 445–446 Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006;117(3):737–746, discussion 747–750 Boehmler JH IV, Butler CE, Ensor J, Kronowitz SJ. Outcomes of various techniques of abdominal fascia closure after TRAM flap breast reconstruction. Plast Reconstr Surg 2009;123(3):773–781 Kroll SS, Marchi M. Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg 1992;89(6):1045–1051, discussion 1052–1053
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Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction. Plast Reconstr Surg 1995;96(3):616–619 Nahabedian MY. Secondary operations of the anterior abdominal wall following microvascular breast reconstruction with the TRAM and DIEP flaps. Plast Reconstr Surg 2007;120(2):365–372 Hartrampf CR Jr. Abdominal wall competence in transverse abdominal island flap operations. Ann Plast Surg 1984;12(2): 139–146 Glasberg SB, D’Amico RA. Use of regenerative human acellular tissue (AlloDerm) to reconstruct the abdominal wall following pedicle TRAM flap breast reconstruction surgery. Plast Reconstr Surg 2006;118(1):8–15 Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic contouring of the abdomen following TRAM flap breast reconstruction by the use of polypropylene mesh. Plast Reconstr Surg 1995; 96(6):1346–1350 Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 2010;126(2):367–374 Israeli R, Hazani R, Feingold RS, DeNoto G III, Scheiner MS. Extended mesh repair with external oblique muscle reinforcement for abdominal wall contour abnormalities following TRAM flap. Ann Plast Surg 2009;63(6):654–658 Nahabedian MY, Momen B. Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction. Ann Plast Surg 2005;54(2):124–129 Vyas RM, Dickinson BP, Fastekjian JH, Watson JP, Dalio AL, Crisera CA. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg 2008;121(5): 1519–1526 Nahabedian MY. Does AlloDerm stretch? Plast Reconstr Surg 2007; 120(5):1276–1280 Lallement M, Missana MC, Bourgeon Y, Abbes M. Closure of the abdominal wall after removal of a mucocutaneous flap from the transverse rectus abdominis for breast reconstruction. Apropos of 48 cases. Review of the literature [in French]. Ann Chir Plast Esthet 1994;39(6):733–741 Suominen S, Asko-Seljavaara S, von Smitten K, Ahovuo J, Sainio P, Alaranta H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg 1996;36(6):629–636 Chun YS, Sinha I, Turko A, Lipsitz S, Pribaz JJ. Outcomes and patient satisfaction following breast reconstruction with bilateral pedicled TRAM flaps in 105 consecutive patients. Plast Reconstr Surg 2010;125(1):1–9
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97
The Abdominal Fascial Closure in a Double-Breasted Jacket Pattern Following a TRAM Free Flap Breast Reconstruction Jong Won Hong, MD1
1 Department of Plastic and Reconstructive Surgery, Institute for
Human Tissue Restoration, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea J Reconstr Microsurg 2014;30:97–102.
Abstract
Keywords
► TRAM ► abdominal fascial closure ► abdominal bulging
Dae hyun Lew, MD, PhD1
Address for correspondence Tai Suk Roh, MD, PhD, Department of Plastic and Reconstructive Surgery, Institute for Human Tissue Restoration, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonjuro, Gangnam-gu, Seoul, Republic of Korea 135-720 (e-mail: [email protected]).
The primary closure of abdominal fascia after breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flap has been reported to be the most effective way to reduce these complications. A total of 108 patients who underwent immediate unilateral breast reconstruction with muscle-sparing TRAM flap were included in the study. We compared complications between 56 patients who underwent conventional primary fascial closure (group 1) and 52 who underwent fascial closure in a new doublebreasted jacket pattern (group 2), retrospectively. Abdominal bulging occurred in four patients (7.1%) in group 1 and one patient (1.9%) in group 2 (p ¼ 0.01). An abdominal wound dehiscence occurred in three (5.4%) patient in group 1 and two (3.8%) patient in group 2 (p ¼ 0.12). After conventional or muscle-sparing TRAM free flap reconstruction, closing the abdominal fascia in a double-breasted jacket pattern can help reinforce the lower abdominal fascia and prevent abdominal bulging caused by abdominal fascia tensional imbalance.
Approximately 25% of patients who have undergone mastectomy due to breast cancer undergo breast reconstruction using autologous tissue or implant tissue.1 Among various types of breast reconstruction, the transverse rectus abdominis myocutaneous (TRAM) flap has become a gold standard.1 Since Hartrampf et al developed the pedicled TRAM flap in 1982,2 it can provide soft, ptotic, and natural breast mounds. According to Mizgala et al, 93% of patients who have undergone breast reconstruction with the TRAM flap consider it valuable and 96% would recommend it.3,4 After breast reconstruction with a TRAM flap, abdominal donor site complications include abdominal hernia, bulging, partial skin loss, wound dehiscence, infection, hematoma, seroma, and discomfort.5–7 Among these, abdominal hernia and bulging are common late complications.8 According to Man et al, after breast reconstruction with a deep inferior
epigastric perforator (DIEP) versus a free TRAM flap, the incidence of abdominal hernia was 0.8 versus 3.9% and bulging was 3.1 versus 5.9%, respectively.9–11 Abdominal bulging was defined as a protuberance of the lower abdominal wall due to weakening of the musculofascial system around the abdominal fascia repair region,12 and was differentiated from a true hernia, which has fascial defect.13,14 Abdominal bulging has been important to differentiate from hernia because it does not require hernioplasty but rather simple abdominal plication or synthetic mesh reinforcement.6,15 Because the incidence of abdominal bulging is higher than that of hernia, reducing its occurrence has become a major concern.6,16 Several strategies to prevent abdominal bulging have been described, including primary closure and using a human acellular dermal matrix (HADM) graft or synthetic mesh graft.12,17–20 Boehmler et al compared
received February 27, 2013 accepted after revision August 6, 2013 published online January 7, 2014
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1357278. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Young Seok Kim, MD1 Han-Su Yoo, MD1 Tai Suk Roh, MD, PhD1
A Double-Breasted Jacket Pattern Fascial Closure
Kim et al.
Table 1 Patient demographics and history p
Group 1a
Group 2b
56
52
Average
42.9
42.5
Range
33–58
26–58
4
2.6
< 0.0001 0.96
No. of patients Age, years
Average follow-up, years
0.92
Smoking history, n (%) Nonsmoker or former smoker
53 (94.6%)
48 (92.3%)
Active smoker
3 (5.4%)
4 (7.7%)
50 (89.3%)
45 (86.5%)
6 (10.7%)
7 (13.5%)
Average
20.2 cm2
19.0 cm2
Range
11.8–27.5
14.1–27.5
Body mass index < 25 25
0.19
Fascial defect size
a
0.2
Group 1: Conventional primary closure. Group 2: Double-breasted jacket pattern.
b
the incidence of complications related to abdominal closure among various methods. They found that primary repair alone was associated with the lowest incidence of complications (abdominal bulging: 5%, any complication: 10%).12 The cases of abdominal bulging after primary closure were caused by tension imbalance between the upper and lower abdominal fascias,21 a factor known to cause abdominal bulging.22 In this study, we report the reduction of the incidence of abdominal bulging via an abdominal fascial closure in a double-breasted jacket pattern.
and fascial defect size were collected from the medical record review (►Table 1). For statistical analyses, a bivariate analysis of the patient characteristics was used to determine which variables were significantly predictive of abdominal complications. The sample t-test and Wilcox rank-sum test were used to compare the complication rate between the two groups. Statistical significance was set at p < 0.05. The software used for analysis was PASW Statistics 18.0 (SPSS Inc., Chicago, IL).
Surgical Technique: Double-Breasted Jacket Pattern
Patients and Methods The present study was approved by the Research Ethics Committee at the Gangnam Severance Hospital, Seoul, Korea and was performed in accordance with the Declaration of Helsinki. Written informed consent was obtained from all the patients. We retrospectively analyzed medical records of 108 patients who underwent immediate breast mound reconstruction with muscle-sparing TRAM flap (MS-1: 5 patients, MS-2: 103 patients) on a unilateral breast. All patients underwent abdominal fascial closure performed by one plastic surgeon after elevation of the abdominal flap. Of the 108 patients, 56 underwent conventional primary closure (group 1) and 52 underwent primary closure in the double-breasted jacket pattern (group 2). Abdominal complications were assessed by physical examination and/or complaints of patients during follow-up period. Based on the preoperative and recent photographs and physical examinations, final diagnosis of abdominal complications was confirmed by three other plastic surgeons in the breast reconstruction team except the surgeon who performed an abdominal fascial closure. Patient demographic information, smoking history, body mass index (BMI), Journal of Reconstructive Microsurgery
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After elevation of a muscle-sparing TRAM flap, simple sutures were applied to close the spared rectus muscles with #2–0 Vicryl (Ethicon Inc., Somerville, NJ). Then vertical mattress sutures were applied to close the fascia from upper to lower area, using #2–0 Vicryl (►Fig. 1). Because the lower abdominal fascia was not excised, simple closure could result in a tension imbalance between fascia-excised region and lower abdominal fascia. Tension on the closed fascia-excised region was higher than on lower abdominal fascia. To evenly distribute the tension, the first horizontal mattress suture was applied on the region near the midline by sliding the lower lateral abdominal fascia into the lower medial fascia (►Fig. 2). The lower lateral fascia should include the internal oblique muscle. Subsequently, a second horizontal mattress suture was applied to the medial fascia to exert tension laterally (►Fig. 3), resulting in a double-layer fascial closure in the double-breasted jacket pattern (►Fig. 4). This suturing technique helps maintain a balance of tension between the lower abdominal fascia and fascia-excised region. Continuous plication suturing was conducted from the upper abdominal fascia to the end of the fascial excision area using # 1–0 loop PDS (Ethicon Inc., Somerville, NJ). This maintains a balance of tension throughout the whole abdomen.
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Fig. 1 Fascial excision. (a) The region of excised abdominal rectus fascia is encircled with the yellow dotted line. A and B are, respectively, points on the lateral and medial fascia inferior to the excised fascia. (b) A diagrammatic representation of (a).
Results The mean age was 42.9 years (range, 33–58 years) in group 1 and 42.5 years (range, 26–58 years) in group 2. The mean follow-up period was 4.0 years (range, 2.9–4.8 years) in group 1 and 2.6 years (range, 1.9–3.0 years) in group 2. The demographic data were similar between the two groups (►Table 1). Six (10.7%) in group 1 and 7 (13.5%) in group 2 had a BMI greater than or equal to 25. The difference was not statistically significant (p ¼ 0.19). The reconstruction with TRAM free flap was performed in 3 (5.4%) and 4 (7.7%) active
Kim et al.
smokers in groups 1 and 2, respectively. The difference was not statistically significant (p ¼ 0.96). The average fascial defect size of groups 1 and 2 were 20.2 cm2 (11.8–27.5 cm2) and 19.0 cm2 (14.1–27.5 cm2), respectively. The defect size was not statistically different (p ¼ 0.20). Among possible abdominal donor site complications, there was no abdominal hernia; however, four in group 1 (7.1%) and one in group 2 (1.9%) had abdominal bulging. This difference was statistically significant (p ¼ 0.01; ►Table 2). The relationship between BMI and the incidence of abdominal bulging was not statistically significant (correlation coefficient 0.098 in group 1 vs. 0.145 in group 2). In addition, patients with BMI 25 had more abdominal bulging than BMI < 25 in group 1 (33.3% [2/6] vs. 4% [2/50], p ¼ 0.01); however, only one patient with BMI < 25 had this in group 2 (2.2% [1/45]). Moreover, abdominal bulging occurred more in patients with BMI 25 (15.4% [2/13]) than with BMI < 25 (3.2% [3/95]), which was statistically significant (p ¼ 0.02). Abdominal tightness/discomfort occurred only patients with BMI < 25. The relationship between fascial defect size and the incidence of abdominal bulging was not statistically significant, too (correlation coefficient 0.165 in group 1 vs. 0.293 in group 2). Two patients with abdominal bulging in group 1 underwent an abdominal ultrasonography to confirm no fascial defect (hernia), and then surgical interventions using Prolene (Ethicon Inc., Somerville, NJ) mesh inlay graft were
Fig. 2 (a) A and B are, respectively, points along the lateral and medial fascia below the excised fascia. A is sutured to B with the first horizontal mattress suture. (b) A has slide under B. (c) A diagrammatic representation of (a) and (b).
Fig. 3 (a) A and B are, respectively, points on the lateral and medial fascia below the excised fascia, respectively. B is pulled toward A to cover the lateral fascia. (b) A diagrammatic representation of (a). B is sutured to A with the second horizontal mattress suture. Journal of Reconstructive Microsurgery
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A Double-Breasted Jacket Pattern Fascial Closure
A Double-Breasted Jacket Pattern Fascial Closure
Kim et al.
Fig. 4 (a) The abdominal fascia inferior to the arcuate line was reinforced twofold by using the double-breasted jacket pattern. (b) A diagrammatic representation of (a).
performed for the correction of severe abdominal fascia attenuation. The other three patients (two in group 1 and one in group 2) with abdominal bulging did not undergo surgical intervention because their symptoms were mild and/ or the compromised cosmesis was not of sufficient concern. An abdominal wound dehiscence occurred in three (5.4%) patients in group 1 and two (3.8%) patients in group 2 (p ¼ 0.12). These were resolved after a simple secondary repair of the wound dehiscence. Hematoma/seroma and skin infection were occurred in both groups; however, these complications were resolved by conservative management without significant sequelae (►Table 2).
Discussion Breast reconstruction with a TRAM flap has evolved from pedicled flap to free flap, and finally to muscle-sparing TRAM flap including DIEP flap. With these changes, the amount of harvested abdominal muscle and fascia has decreased. In addition, surgeons have been concerned about how it should be closed to reduce the risk of donor site complications. Among various methods for abdominal fascial closure, the inlay graft using synthetic mesh or HADM has the advantages of reducing tension on the closure, maintaining the midline position of the umbilical stalk and maintaining the lower abdominal wall contour without additional plication.12 However, the synthetic mesh increases infection risk, and there are several reports of complications caused by the mesh, such
as contracture or encapsulation due to long-term interaction with the host prosthesis.17 Despite the advantages of HADM, such as tolerability against infection and rapid repopulation and revascularization,17 increasing laxity caused by abdominal wall mobility has been a major concern.12,23 The conventional primary repair has been known as a good method for the abdominal fascial closure in multiple studies.12,13 However, there is concern for a tension imbalance because an excised-fascial region was closed more tighter than lower abdominal region (lower abdominal fascia was not excised, so closed loosely). Abdominal bulging is a common late complication that results from multiple factors. First, it may be due to attenuation of the abdominal fascia22 in cases of minimal fascial excision. In these cases, the bulging may occur inferior to the arcuate line (►Fig. 5). The attenuation may be a result from continuous abdominal pressure, especially in patients with intestinal obesity. The second contributing factor is increased laxity of the abdominal fascia due to an imbalance of tension. After harvest of a TRAM free flap, the normal contour of the abdominal wall is altered by the closure of excised-fascia region. The excised-fascia region was closed tightly; however, the lower abdominal fascia (without fascial excision) was closed less tightly. This imbalance of tension could cause a laxity of the lower abdominal fascia (►Fig. 6).21 According to the previously reported studies, the incidence of abdominal bulging was variable with the abdominal fascial closure methods. The high rates of bulging (20–44%)
Table 2 Complication following abdominal fascial closure Group 1a
Complication
a
Group 2b
p
n
% (n ¼ 56)
n
% (n ¼ 52)
Hernia
0
0
0
0
–
Abdominal bulging
4
7.1
1
1.9
0.01
Partial skin loss/dehiscence
3
5.4
2
3.8
0.12
Hematoma/seroma
2
3.6
1
1.9
0.19
Skin infection
2
3.6
2
3.8
0.96
Tightness/discomfort
3
5.4
1
1.9
0.02
Group 1: Conventional primary closure. Group 2: Double-breasted jacket pattern.
b
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Fig. 5 A diagrammatic representation of the abdomen after simple primary repair of the abdominal fascia following a TRAM flap elevation. The attenuation of abdominal fascia, especially inferior to the arcuate line, could be caused by continuous abdominal pressure especially in cases with intestinal obesity. The black arrows indicate the direction of tension caused by abdominal pressure following the attenuation of the abdominal fascia.
Kim et al.
The double-breasted jacket pattern used in this study has several advantages that may decrease the incidence of abdominal bulging. First, the method maintains the tension balance between the excised-fascia region and the lower abdominal fascia (without fascial excision). Second, the abdominal fascia inferior to the arcuate line was reinforced by a double-layer closure. Third, the continuous fascial plication suture conducted from the upper abdomen to the fascial defect area also helps maintain tensional balance across the whole abdomen, especially in the upper abdomen. Nonetheless, this method also has several limitations. Excess tension on the fascial closing line may increase the risk of ischemia, necrosis, and dehiscence.8 However, an abdominal hernia due to the fascial ischemia, necrosis, or dehiscence has not been reported in this study. In the cases of abdominal bulging, according to Boehmler et al, various methods for the abdominal fascial closure resulted in the occurrence of abdominal bulging in approximately 10% of the patients within the first postoperative year, and in approximately 18% within 2 years after the operation.12 Thus, the shorter mean postoperative follow-up period in group 2 (2.6 years) than in group 1 (4.0 years) may have contributed to the lower measured incidence of abdominal bulging in group 2. Another limitation of the method is that it is not suitable or effective when the abdominal fascia excision is very small or a DIEP flap reconstruction is performed. In contrast, our method is indicated after a conventional or muscle-sparing TRAM free flap reconstruction with some fascial excision.
Conclusion
Fig. 6 A diagrammatic representation of the abdomen after simple primary repair of the abdominal fascia following a TRAM flap elevation. The tension in the closed fascia-excised region was higher than in the lower abdominal fascia. The laxity of the lower abdominal fascia increased due to this tension imbalance. The black arrows indicate the direction of tension on the abdominal fascia.
associated with primary closure were reported in the initial studies.13,24,25 However, a recent study reported a 5% rate of bulging with primary closure.12 The use of HADM was associated with bulging rate of 16.7 to 31%.12,17 Using the synthetic mesh, the rate of bulging was 1.7 to 10%.5,12,26 In this study, 7.1% rate of bulging associated with the conventional primary closure was reported. However, when the newly developed method (double-breasted jacket pattern) was done, the rate of bulging was shown to decrease from 7.1 to 1.9% (p ¼ 0.01).
After conventional or muscle-sparing TRAM free flap reconstruction, closing the abdominal fascia in a doublebreasted jacket pattern can help prevent abdominal bulging caused by abdominal fascia tensional imbalance or attenuation. As more patients undergo this procedure and more data are available on long-term follow-up, this technique may become an increasingly attractive option for abdominal closure after TRAM flap harvesting for breast reconstruction.
Acknowledgments The authors thank Dong-Su Jang (Medical Illustrator, Medical Research Support Section, Yonsei University College of Medicine, Seoul, Republic of Korea) for help with figures.
Conflict of Interest The authors have indicated no significant interest with commercial supporters. Financial Disclosure and Products None of the authors has a financial interest in all products, devices, drugs, etc., used in the article. Journal of Reconstructive Microsurgery
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A Double-Breasted Jacket Pattern Fascial Closure
A Double-Breasted Jacket Pattern Fascial Closure
Kim et al.
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