가토의 유경 TRAM 피판술시 하복벽 동맥의 결찰이 대측 임의형 피판 생존율의 증가에 미치는 영향

민대홍,김승홍,백무현,홍기웅 大韓成形外科學會 1995 Archives of Plastic Surgery Vol.22 No.5

The transverse rectus abdominis myocutaneous(TRAM) flap technique has been a widely accepted method of breast reconstruction after mastectomy, since the first introduction in 1982. Although free TRAM flap technique has been a superior method of breast reconstruction in comparison with the conventional pedicled TRAM flap with the development of microsurgery, it goes without saying that pedicled TRAM flap is the first choice of breast reconstruction, when free TRAM flap is impossible due to the inappropriate recipient vessels. Blood supply to the contralateral side of both the free & pedicled TRAM flap (especially in zone Ⅳ) is often precarious with previous midline abdominal scars or with significant rectus devarication. Various techniques have been described to improve the reliability of the blood supply to the contralateral portion in free & pedicled TRAM flap, including prior delay, double pedicled flap, supercharged & turbocharged flap. To improve flap vascularity of contralateral portion in pedicled TRAM flap, we ligated the superficial & deep inferior epigastric artery of the contralateral portion two weeks prior to raising the conventional TRAM flap. This TRAM flap was based on superior epigastric vascular pedicle attached to the ipsilateral underlying rectus abdominis muscle with a contralateral & ipsilateral random portion of skin. The effectiveness of preoperative ligation of the contralateral superficial & deep inf. epigastric artery in augmentation of skin viabliity was compared to the sham manipulated control group after raising the flap. The results were as follows : 1. Experimental (previous ligation) group; mean total flap area = 227.8cm², mean survival area = 218.46cm², mean survival rate = 96.2% 2. control group ; mean total flap area = 235cm², mean survival area = 205.74cm²mean survival rate = 87.54% From the above results, the increase in skin viability seemed to be accompanied by increased area of viable skin in the treated flap compared to the controls. We postulate that hypoxia resulting from the ligation of the superficial & deep inferior epigastric vessel of contralateral portion prior to the flap surgery may expand vascular territory by the remaining ipsilateral vessels over the contralateral portion.

과급 횡복직근피판술(Supercharged TRAM)을 이용한 유방재건술

양정덕,송재민,이상윤,정호윤,조병채,박호용,정진향,Yang, Jung-Dug,Song, Jae-Min,Lee, Sang-Yun,Chung, Ho-Yun,Cho, Byung-Chae,Park, Ho-Yong,Jung, Jin-Hyang 대한성형외과학회 2010 Archives of Plastic Surgery Vol.37 No.5

Purpose: When reconstruction for patients who have the large contralateral breast or a following large defect after mastectomy is required, conventional pedicled TRAM flap shows the unpredictable occurrence of fat necrosis and skin flap loss in a relatively high percentage due to insufficient blood supply. In an effort to obtain more stable TRAM flap blood circulation, we have performed a supercharged technique using deep inferior epigastric perforators (DIEP) with conventional pedicled TRAM flap. Methods: From September of 2006 to December of 2008, Fourteen supercharged TRAM flap were performed for breast reconstruction after modified radical mastectomy. The contralateral DIEP was anastomosed to the internal mammary vessels in contralateral pedicled TRAM flap or thoracodorsal vessels in ipsilateral pedicled TRAM flap. Nutrient vessels were selected by Multi-Detector Computed tomography (MD-CT) modalities. For the nutrient vessel, we used deep inferior epigastric vessels (DIEV) of the ipsilateral side in 8 patients, DIEV of the contralateral side in 6 patients. In addition, for the recipient vessel, we used thoracodorsal vessels in 8 patients, internal mammary vessels in 5 patients, intercostals artery perforators in 1 patient. Results: The mean age was 46.8 years and the average follow-up interval was 14 months. There were 11 immediate and 3 delayed breast reconstructions. Fat necrosis incidence rate in supercharged TRAM group was lower than in conventional TRAM flap group. There were no differences of the incidences of abdominal hernia in both groups. Conclusion: The supercharged TRAM flap produces an improvement in vascularity that permits use of all four zones of the flap. The breast reconstruction with supercharged technique is reliable and valuable methods which provide sufficient soft tissue from abdomen without significant complications.

복부 지방흡입술을 시행받은 환자에서 횡복직근피판술을 이용한 유방재건 치험 2례

강병수,이택종 대한성형외과학회 2008 Archives of Plastic Surgery Vol.35 No.2

Purpose: TRAM flap reconstruction has settled down as a common method for breast reconstruction after mastectomy. There are a few surgical contraindication in TRAM flap surgery. Previous abdominal liposuction has been a relative contraindication in TRAM flap surgery. The authors present 2 patients of successful breast reconstruction using pedicled TRAM flaps, who previously underwent abdominal liposuction.Methods: Case 1: A 48-year-old woman with a right breast cancer visited for mastectomy and breast reconstruction. Her past surgical history was notable for abdominal liposuction 15 years ago. Skin sparing mastectomy and breast reconstruction with a pedicled TRAM flap was performed. Case 2: A 45-year-old woman with a left breast cancer visited us for mastectomy and autologous breast reconstruction. 3 years ago, she had an abdominal liposuction and augmentation mammaplasty in other hospital. Nipple sparing mastectomy and breast reconstruction was done using pedicled TRAM flap. Results: One year after the reconstruction, partial fat necrosis was developed in one case but there was no skin necrosis or donor site complication in both patients.Conclusion: As aesthetic surgery becomes more popular, increasing numbers of patients who have a prior abdominal liposuction history want for autologous tissue breast reconstruction. In these patients, TRAM flap surgery will be also used for breast reconstruction. But, the warning of fat necrosis and the use of preoperative Doppler tracing to evaluate the abdominal perforator may be beneficial to patients who had abdominal liposuction recently.

가토에서 강화된 신생혈관을 가진 이차적 근-피부피판에 대한 실험적 연구

한재식,김우경,김영조,이병일,한승규 大韓成形外科學會 1998 Archives of Plastic Surgery Vol.25 No.2

There are occasions when standard techniques of reconstructive surgery for traumatic injury, tumor resection, and correction of congenital anomalies cannot be used as a result of the unavailability of tissues, absence of healthy vascular pedicle or excessive morbidity in donor area. It is established that autogenous skin, muscle, bone, and other composite tissue can retain their viability in varying degree as a prefabricated `flap with vascular pedicle implantation and the survival rate of these flaps has increased with tissue expansion or PGE₁ infusion. The purpose of this study was to demonstrate the reliability of the secondary or prefabricated rectus abdominis musculocutaneous flap, and to evaluate the effect of the several factors on the survival routes of these flaps. Fifty New Zealand white rabbits weighing from 250 to 350 gm were used for the study. On the abdominal area bipedicled skin flaps are elevated as a random pattern flaps and were prefabricated using with rectus muscle. The fifty flaps were studied. They were divided into the five groups as follows; group I, 10 ×4 cm classic axial pattern transverse rectus abdominis muscle (TRAM ) flaps were made as a control group (n = 10); groupⅡ, 10 ×4 cm random pattern bipedicled skin flaps were prefabricated using right rectus muscle with the delay procedure(n = 10); group III, 5 ×4 cm prefabricated musculocutaneous flap were made same as group II on the right, side, tissue expansion was performed on the left side (n = 10); group IV, same procedure was performed as group II, and in addition postoperative intravenous infusion of PGE?? was given(n = 10); group V, same procedure was performed as group III, and in addition postoperative intravenous infusion of PGE₁ and tissue expansion was performed(n = 10). Flap survival rates of each group were evaluated and compared. The following results were obtained: 1. Survival rates of prefabricated flaps were lower than that of classic axial pattern flaps regardless of using tissue expansion and PGE₁ infusion(p < 0.05). 2. In making a comparison between flap with and without PGE₁ infusion, survival rates of prefabricated flaps infused with PGE₁ were higher than that of flaps without PGE₁ infusion. 3. The prefabricated flaps managed with tissue expansion had higher survival rates than that of flaps without using tissue expansion. 4. The survival rates of prefabricated flaps managed in combination with tissue expansion and PGE₁ infusion were significantly higher than that of other groups except control group. In conclusion, this study demonstrated the significance of combiring use of tissue expansion and PGE₁ infusion in a prefabricated musculocutaneous flaps as a reliable method.

복부 자가조직을 이용한 유방재건술의 진화

정재호 영남대학교 의과대학 2006 Yeungnam University Journal of Medicine Vol.23 No.1

Breast reconstruction provides dramatic improvement for patients with severe deformity. The reconstruction not only restores aesthetically acceptable breast for patients with mastectomy deformity but also recovers psychological trauma of 'losing feminity' after the cancer mastectomy. There are many options for breast reconstruction from simple prosthetic insertion to a flap operation using autologous abdominal tissue. The choice of operation method depends on the physical condition of the patient, smoking habits, and economic status. Among the many options, the method that uses the lower abdominal tissue is known as the TRAM (transverse rectus abdonimis myocutaneous) flap. Since the introduction of the TRAM flap in 1982 by Hartrampf, the art of breast reconstruction using lower abdominal tissue has been progressively refined to pedicle flap, muscle-sparinga TRAM flap, and recently there have been exciting and revolutionary changes associated with the adoption of the concept of perforator flap. This refined method of breast reconstruction utilizes lower abdominal tissue nourished by the deep inferior epigastric perforator (DIEP). With the DIEP free flap, almost all of the rectus muscle and anterior rectus sheath are preserved and the donor morbidity is minimized. Different from previous flap methods using lower abdominal tissue, DIEP free flap method preserves function of the rectus muscle completely. Understanding the entire progression of breast reconstruction methods using lower abdominal tissue is necessary for plastic surgeons; the understanding of each step of the exciting progression and the review of the past history of the TRAM flap may provide insight for future development.

유경횡복직근피판을 이용한 즉시 유방재건술 후 방사선 치료의 결과

이형철,김은기,안세현,이택종,안승도 대한성형외과학회 2011 Archives of Plastic Surgery Vol.38 No.6

Purpose: The safety of radiation therapy after breast reconstruction using transverse rectus abdominis myocutaneous (TRAM) flap is still being debated, and few studies exist on the outcome of irradiation after immediate TRAM breast reconstruction. Some authors presented satisfactory outcomes after adjuvant radiation therapy on reconstructed breast with pedicled TRAM flap, while others reported significant post radiation changes of the flap. Effect of radiation therapy on TRAM flap was evaluated to see whether adjuvant radiation therapy was tolerable. Methods: 1000 immediate TRAM breast reconstruction was done by a single surgeon from July, 2001 to December, 2009. Among them 105 patients required adjuvant radiation therapy because of advanced disease or locoregional recurrence. Fat necrosis, radiation fibrosis,mastectomy skin flap necrosis, need for secondary touch up procedures, patient satisfaction were evaluated. Results: The incidence of fat necrosis was 10.5% and significant radiation fibrosis occurred in only one patient. Delayed wound problem did not occur during or after irradiation. Secondary touch-up procedures were performed in 12.3%, the most common being fat graft (8.6%). Average patient satisfaction score was 8.62/10, which was not significantly different from the authors' previous report involving all the TRAM patients (8.50). Conclusion: Radiation therapy did not increase the complication rate significantly. Aesthetic result was affected but was tolerated in most cases. The fear of adjuvant radiation is not a negative factor in selecting immediate breast reconstruction with TRAM flap.

횡복직근 유리 피판술후 공여부 합병증과 이환율

안희창,성건용,조동인,최승석,Ahn, Hee Chang,Sung, Kun Yong,Jo, Dong In,Choi, Seung Suk 대한미세수술학회 2004 Archives of reconstructive microsurgery Vol.13 No.1

Transverse rectus abdominis muscle (TRAM) free flap is widely used for breast reconstruction, however donor-site morbidities such as abdominal wall weakness, hernia, bulging are troublesome. For the purpose of minimizing donor-site morbidity, there has been a surge in interests in muscle sparing free TRAM flap preserving the anatomy of rectus abdominis muscle, fascia, and motor nerve. The purpose of this study is to investigate complication and morbidity after muscle sparing free TRAM flap. Between August, 1995 and May, 2003, there were 108 cases of muscle sparing free TRAM flap of breast reconstruction. There was no abdominal hernia. There were 4 cases of dog ear, 3 cases of marginal necrosis of apron flap, 2 cases of asymmetry of umbilicus. At 1 year after operation, most patients feel comfortness in physical exercise. Muscle sparing free TRAM flap provides ample amount of well vascularized soft tissue with small inclusion of rectus abdominis muscle and fascia. Also it minimizes donor-site morbidity with rapid recovery of abdominal strength.

전자궁적출술을 시행받은 환자에서 횡복직근 유리피판을 이용한 유방재건술 후 발생한 소장 교액의 증례

김민호,진웅식,명유진,장학,민경원 대한성형외과학회 2011 Archives of Plastic Surgery Vol.38 No.4

Purpose: The rectus abdominis myocutaneous flap is currently the most commonly used donor site of immediate and delayed breast reconstruction surgery, for its versatility and ease of handling, as well as sufficient blood supply. Despite many advantages of rectus abdominis flap, morbidity of donor site is considered as inevitable shortcoming. The authors recently faced a devastating complication, small bowel obstruction that led to strangulation,after delayed breast reconstruction with free transverses rectus abdominis myocutaneous (TRAM) flap. And we would like to report it, because abdominal pain after TRAM flap is a common symptom and can be overlooked easily. Methods: A 56-year-old female patient who had history of receiving total abdominal hysterectomy 20 years ago underwent delayed breast reconstruction with TRAM flap transfer. She complained abdominal discomfort and pain from third postoperative day, postoperative small bowel obstruction that arose from strangulated bowel and prompt emergency operation was done. Results: After resection of the strangulated bowel and reanastomosis, quickly her symptoms were relieved, and there were no further problems during her hospital stay. 7 days after her emergency operation she was discharged. Conclusion: In patients with previous abdominal surgical history, prolonged ileus can lead to bowel strangulation, so surgeons should always consider the possibility, and must be aware of abdominal symptoms in patients who receive free TRAM flap operations.

유경 횡복직근 피판을 이용한 유방 절제술 후 지연 재건 150례 및 결과

정인욱,이택종 대한성형외과학회 2011 Archives of Plastic Surgery Vol.38 No.1

Purpose: This is a report on the results of 150 consecutive cases of delayed postmastectomy reconstruction with TRAM flap performed by single surgeon. The purpose of this study is to review the merits, demerits and other considerations of this method by analyzing the results. Methods: From July 2001 to July 2008, 150 patients who had breast reconstruction by single surgeon were reviewed prospectively. Reviewed factors included demographic factors, mastectomy method, adjuvant therapies (such as radiation, chemotherapy) complication rate, simultaneous contralateral breast procedure rate, secondary touch - up procedure rate and patients’ satisfaction. Results: Ovarall TRAM flap complication rate was 22.6 %. Among them, donor site complication rate was 36 %, simultaneous contralateral breast procedure rate was 44.6 %, secondary touch - up procedure rate was 40 %. All rate was higher compared to immediate reconstruction with TRAM flap. But the patients’ satisfaction was about the same as immediate reconstruction. Conclusion: Delayed postmastectomy reconstruction with TRAM flap can yield satisfactory results despite relatively high complication rate and concomitant procedure rate when it is performed by a experienced surgeon.

유경 횡복직근피판술을 이용한 유방재건 시 발견된 백색선의 결손: 증례보고

여관구,김준규 대한성형외과학회 2011 Archives of Plastic Surgery Vol.38 No.3

Purpose: The anatomical anomaly of the rectus abdominis muscle and it’s fascia is very rare. No case of the absence of the linea alba below the umbilicus has yet been reported. During breast reconstruction with pedicled TRAM flap, we experienced one case of absence of linea alba. Methods: The patient was a 38-years old female who underwent immediate breast reconstruction with pedicled TRAM flap after Right modified radical mastectomy in June 2010. While the TRAM flap was being elevated, bilateral twitching of the rectus abdominis muscle occurred when electrocautery was applied, and we found the absence of the linea alba below the umbilicus. Results: When the rectus abdominis muscle was exposed, the linea alba below the umbilicus was not observed, and the bilateral rectus abdominis muscle was indistinguishably fused in a gross observation. In addition,bilateral twitching of rectus abdominis muscle was simultaneously observed as one muscle unit when electrocautery was applied. As with both rectus abdominis muscles was bluntly dissected with scissors, the scanty fatty tissues were observed between the both rectus muscles, and the bilateral rectus abdominis muscle was easily separated. The flap was transposed into the corresponding defect to make breast mound. Midline fascia was fixed to the posterior rectus sheath to reconstruct smilar anatomic linea alba. Abdominal defect was reinforced by suturing between remaining anterior rectus sheath. Conclusion: As the unexpected anatomical anomaly may affect the operation outcome, surgeons should be careful when they unexpectedly encounter the anatomical anomaly during an operation. Here, we report a rare case of absence of the linea alba seen at the time of pedicled TRAM flap elevation for breast reconstruction.