The free TRAM versus extended latissimus dorsi flap in postmastectomy reconstruction: A comparative study

The free TRAM versus extended latissimus dorsi flap in postmastectomy reconstruction: A comparative study

Mahfouz Shehata Ibrahim, MD, MRCS; Ahmed MohamadAly,  MD Plastic Surgery Unit, General Surgery Department, Zagazig University, Egypt.

In currently avai!able literature the optimal flap choice for reconstructing post mastectomy breast has not  yet defined. The  free TRAM  and  extended  latissimus  dorsi  flaps have  been described  for  breast reconstruction. However  comparison  between  them  has  not  yet  been described in our community. The current study was carried out to evaluate the two modalities in our society

Patients and methods:  30 consecutive  patients who underwent immediate unilateral breast reconstruction were included in the study. 15 patients had undergone extended latissimus dorsi flap (group A) and the other 15 had undergone free TRAM (group B). All patients were evaluated operatively, clinically for complications, aesthetic results and patient's satisfaction during the mean follow up time 10.7(4-19) months for group A and 11.9(6-19) months for group B.

Results: The mean operative time, blood transfusion requirements, hospital stay and time to start post operative adjuvant therapy (3.67 hours, 666.6cc, 11.6days and 26.6days respectively) in group A  patients were  significantly less than for group B (8.8days,1666.6cc,17days and

39.2days respectively) withp value < 0.01.

The rate of complications in group B (one anastomosis revision, 2partialflap necrosis, one hernia and one fat necrosis/33.33%)  was higher than group A (one partial flap necrosis, one back scar disfigurement and 2seromas/26.67%).

Higher patient's satisfaction was achieved in group A (93.3% satisfied to very satisfied) than in group B (79.9% satisfied to very satisfied) while aesthetic scoring was nearly similar in both groups.

Conclusion: The extended latissimus dorsi flap could be as good as free TRAM regarding aesthetic  outcomes,  technically  feasible  flap  with  fewer  complications.  So  we  advocated offering the extended latissimus  dorsi flap as the 1st choice  for immediate  post mastectomy reconstructions to selected patients.

Key words: Mastectomy, free TRAM, extended LD.

Introduction:

Immediate post mastectomy breast reconstruction    yields    a   better    cosmetic result than delayed one because the breast landmarks  are  preserved  and  used. 1  Today most  of  plastic  surgeons  prefer  to  do  free flaps for breast reconstruction.  Since it was first described by Holstorm, 1979 the free TRAM flap has become considered by many to be the gold standard.2-4

These microvascular procedures are complex and have inherent risks that include;

total flap loss, partial flap loss, fat necrosis,

and abdominal  bulge or hernia.5  Because of this many surgeons consider that free flaps offer little advantage over that they currently do with more technically demanding, greater risk and longer patient recovery.6,7

Latissimus     dorsi      myocutaneous     flap

was one of the initial methods of breast reconstruction but due to the increased popularity of free TRAM it was gradually driven to backseat.8 However afterevolvement of extended latissimus dorsi myocutaneous (ELD) method  by Hokin et al, 1983 and its

further  modification  of  adding  more  fatty

Am-Shams] Surg 2014; 7(19):1-10

tissues from scapular and parascapular  areas it regained its popularity.9-ll

Our unit commonly perform both methods so  in  this  study  we  decided  to  compare these two types of breast reconstruction to determine  whether  there  are any  benefit to the patients.

Patients and methods:

Between   Jan   2011   and   July   2013   a total  of 30  female  patients  underwent  post mastectomy  immediate breast reconstruction (IBR)   for   unilateral   breast         cancer   after obtaining informed consents and approval of IBR. A thorough preoperative evaluation was done for all patients with special attention to breast  size,  previous  scares,  infraumbilical fat,  body mass  index  (BMI)  and pinch test for the back skin. The study inclusion criteria were patients with T1 or T2 lesions and who were  not  candidate  for  conserving  surgery because of small breast tumor ratio, centrally located  or multicentre  tumor, moderate  size breast, back tissue thickness more than 2 em, absent  scares  and  adequate  infraumbilical tissue.   Patients  were  randomized  into  two groups according to their sequence; group A included  15  patients with odd  number  who were  subjected  to  reconstruction   by  ELD flap, and group B which  included  the  other

15  patients  with  even  numbers   in  whom

free TRAM flap was the selected  procedure. Patient's  characteristics  were recorded in Table (1).

Surgical   technique   which   was   started

immediately after the mastectomy procedure. For free TRAM flap Baldwin, 2000 method was used but with the use of internal mammary as a recipient vessel in all cases.l2

Surgical technique of ELD flap described

by   Hokin   and   Silfverskiold11    was   used. Superficial dissection  of flaps were  done to include  fat  over  parascapular   and  lumber areas  to  maximize  the  flap  volume.  After identification of the flap pedicle the overlying tissue was dissected bluntly from the serratus anterior muscle.  Finally the flap was rotated anteriorly  and molded  inside the breast skin without  division  of  humeral  attachment  to protect from torsion and tension as described

by Chang and his collogues.l3

All cases of group B were kept in intensive care unit (ICU) during 1st 48 hours for close flap monitoring and for detection of any ischemia or thrombosis that necessitate immediate anastomosis revision.

Patients  were carefully  followed  up  and

all  their  data  were  reported  including  flap or donor site complications,  operative time, the length of hospital stay, blood transfusion requirement, the time to start adjuvant therapy and postoperative recurrences.

Patient's   satisfaction  was  estimated through questionnaire adopted from Michigan Breast     Reconstruction     Outcome     Study which was modified to meet the need of our study.l4 Item response was scored using five point  scale (strong  agree=  4, agree= 3, not sure = 2, not agree = 1, strong not agree = 0). The summation  of the  points dichotomized the results  into three groups,  a score 5 or 4 was classified as very satisfied, a score of 3 was  assorted  as  satisfied  and  any  response else was not satisfied.

The aesthetic scoring was obtained by reporting the opinion of 5 plastic surgeons regarding symmetry, shape, texture, mobility and  color matching.  Points  were  given excellent  = 4-5, good  = 3, fair = 2, poor  = 1 and very poor = 0, so the aesthetic  score of each case was the product of summation  of their opinions. Data analysis was done by student's t test with p value < 0.05 considered significant.

Secondary   procedures:  Two  patients  of

group A accepted to do nipple and areola reconstruction.    The   nipple   reconstruction was done by modified star flap.l5 For the new areola  reconstruction  a  full  thickness  skin graft was harvested from the labial skin.

Results:

Thirty consecutive breast reconstructions were performed  over  18 months.  Mean age for  group  A was  36.67  years  (range  from

27 to  42 years)  and 40.2 years for group  B

(range from 32 to 45 years). Mean follow up since surgery was 10.67 months in group A (range 4 -19 months) and 11.9 months (range

6 -19 months) in group B. There was obvious

Figure (1): Elevated extended LD.                         Figure (2): Postoperative LD.

Figure (3): Preoperative free TRAM.                     Figure (4): Postoperativefree TRA.i\1. Table (1) Patients characteristics.

Table(2) resu/Js ofELD and.free TRAM regarding operative time, blood transfusion, hospital stay, time to start radiotherapy therapy.

difference in the mean operative time between two groups; in group A it was 3.6 hours while it was 8.8 hours in group  B (p < 0.05). Also there was a notable difference regru·ding the need for blood transfusion which was a mean

of 666 cc in group A while it was a mean of

1666 cc in group B (p < 0.05). The mean hospital stay in group A was 11 days which was significantly longer in group B (17 days/ p < 0.05). The  time to strut  post operative

Table (3) Complications.

Table (4) Patient's satisfaction&  aesthetic score:

adjuvant  radiotherapy  was significantly  less in group A (mean, 26.6 days) than in group B  (mean,  39.2  days  I p  < 0.05)  Table(2). The  early  complications   were  revision  of one  anastomosis   in  group  B  but  the  late were developed in both groups. In group A there were one partial flap necrosis that was treated by debridement and repeated dressing followed  by  secondary  sutures,  two  donor site seromas treated with repeated aspiration and compression bandages and one ugly back donor scar treated by scar revision. While in group B two partial flap necrosis were treated same way as before, one fat necrosis  which was found  as firm mass  about 1.5 em three months after reconstruction confirmed by fine needle and treated by surgical excision under local  anesthesia  and  one  abdominal  hernia and this patient was sent to general surgeon who did mesh repair. There were no local recurrences in both groups during the follow up period Table (3).

Patient's       satisfaction      revealed      that

8(53.3%)   and   6(40%)   patients   of   group A were either very satisfied or satisfied respectively while 5(33.3%) and 7(46.67%) patients in group B were very satisfied and satisfied  respectively.  one  patient  (6.67%) from group A and 3(20%) patient from group

B were not satisfied from their constructions. Regarding the aesthetic scoring an excellent result  was  obtained  in  8(53.3%)  of  group A and 7(46.67%) of group B while good aesthetic result was obtained in 5(33.3%) of group A and 6(40%) of group B. The results were fair only in one patient (6.67%) of group B while poor aesthetic results were obtained in one patient (6.67%) from each group Table(4).

Discussion:

Breast reconstruction is considered an important   part  of  breast  cancer  treatment for the time being,l6 but currently available literature  regarding  optimal  flap  choice  is not broadly generalizable, and often reports conflicting results.l7

In this study a direct comparison was done between ELD flap and the free TRAM to determine use and outcomes. These outcome data could be used to guide future clinical decision-making  and  research  efforts in the field of breast reconstruction.

Since it was first described by Holmstorm,

19792 and again 1989 when Grotting and coworkers3  introduced  its  routine  use, the free TRAM flap has become one of the most popular and reliable methods of microsurgical

breast reconstructions.

Despite this many units still reluctant to offer  the  free  TRAM  because  of  possible fear  from  postoperative   complications  and long patient's  recovery. Also the complex performance   of   microvascular   procedures may not be possible.13,18

Latissimus       dorsi      musculocutaneous flap was one of the first methods of breast reconstruction but it does not give sufficient volume19_ Extended latissimus dorsi flap was first described  by Hokin et al, 19839 which was included the lumber fat. Multiple trials were then done to increase its volume by addition of scapular and parascapular fat.10,11

In current study there were significant decrease in operative time, blood transfusion requirements,  hospital stay and time to start postoperative  adjuvant  therapy  in  extended LD than free TRAM group.

Blood transfusion requirements for both groups  were similar to what reported  in the liteatures.20,21 The mean operative time for extended  LD was 3.67 hours and 8.8  hours for  free  TRAM  group  which  was  higher than  other  series   that  reported   2.9  hours for  extended  LD20 and 7-  8 hours for  free TRAM.1,22 The slight longer time operative time in the current study could be due to the learning curve that started long then improved afterwards.

Regarding   hospital   stay   in  this   study

(mean  lldays for extended LD and 17 days for  free  TRAM  group)  it  was  also  higher than other series which reported 7days for extended LD23,24 and 11-11.6 days for free TRAM.21,22 The  long  hospital  stay  could be due to management of early developed complications on an inpatient basis.

The time to  start post operative  adjuvant

therapy in this study (a mean of6.26 weeks for extended LD and 9.22 weeks in free TRAM group)  was  same  like  others  for  extended LD25 and for free TRAM.26,27 A delay of up to 12 weeks  postoperatively  will not affect

delivery of post operative adjuvant therapy. 28

In this study the free TRAM group developed more complications than the extended  LD  one.  The  free  TRAM  group

complications  were revision of anastomoses

(6.7%), partial flap necrosis (13.3%), abdominal hernia (6.7%) and fat necrosis (6.7%), these results are within the acceptable range reported in other series (6.5% required revision exploration, 4.5% complicated with hernia and 15.9% developed fat necrosis).1

The  extended   LD  group  complications were partial  flap necrosis  (6.7%),  and back scar  (6.7%)  which  were  similar to  a study done by misra et a1.,23 were partial necrosis in one out of 32 and back scar in 2 out of 32 patients.

Seroma formation is a well known donor site complication  after LD harvesting,29 two patients  in  our  study  (13.3%)  had  seroma which were less than that mentioned in other

studies; 64%, 62%,30,31 the lower incidence

of  seroma  in this  study  may  explained  by using sharp dissection, post operative tight crepe bandage and the kept suction 2-3 weeks postoperatively. In summery the cases with ELD showed low incidence of complication when   it   compared   with   cases   with   free TRAM, finding is supported by a multicenter study that four cohort of patient submitted to autologous breast reconstruction.10

Regarding   patient's   satisfaction   patients with extended LD group were more satisfied than free TRAM group but this was not significantly different. In this study 90.3% of extended LD and 79.9% of free TRAM cases were ranged from  very satisfied to satisfied and 20% offree TRAM and 6.7% of extended LD were unsatisfied.

The  results  of  this  study  regarding  free

TRAM  group  were  same  like  other  series

89.5-91.7% very satisfied to satisfied,32,33 while  for  extended   LD  group  there  were slight   differences   between   literatures   80-

92.8% very satisfied to satisfied1,27 and this

different incidences might be due differences in number of studied patients.

We found the extended LD sufficient tissue to build small and medium size breast and acceptable size matching of two breasts, this finding  is supported  by the  work  of Chang an co-worker who found that extended LD provide tissue  that  can make  breast  with  B and C cup size.13

Regarding     the     aesthetic     sconng     of reconstructed breasts there were no significant differences  between  both groups  instead  of that excellent to good was higher in extended LD group (86. 7%) than with free TRAM one (80%) these results also came comparable to other studies  on extended  LD)4,25 Also for free TRAM other series reported 77% from excellent to good. 21,22

Conclusion:

Breast  reconstruction  with  extended  LD has significantly less operative time, blood transfusion requirements,  hospital stay, and time to start post operative adjuvant therapy than reconstruction with free TRM flap. More complications  occurred  in free TRAM than in extended LD  but there is no significant difference regarding aesthetic grading and patient's satisfaction. Extended LD flap can offer  sufficient volume,  technically  feasible and reliable method with fewer complications. Extended LD could be as good as free TRAM for  patients  with  medium  sized  breasts.  So we advocate offering extended LD flap to be the 1st choice for immediate post-mastectomy breast reconstruction to selected patients.

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