Keywords: Mammaplasty - Abdominal wall - Abdominal cavity - Myocutaneous flap - Abdominal muscles
INTRODUCTION
The transverse rectus abdominis muscle flap (TRAM), described by Holmstrom in
1979[1 ], is a breast
reconstruction method composed of an ellipse of skin and fat based on an
isolated muscle in its vascular pedicle[1 ].
The use of autologous tissue allows breast reconstruction with good aesthetic
results and eliminates the need for silicone implants for better body
contouring[2 ]. It is
known that bulges and hernias arise mainly in the lower abdomen due to the
absence of posterior aponeurosis of the rectus abdominis muscle inferior to the
arcuate line of Douglas, making this region with high rates of
complications[3 ]. TRAM is
beneficial for the patient when it can ensure a strong abdominal wall that
allows the resumption of work activities[4 ]. Given several established techniques, Cunha et al., in
2021[5 ], described the
technique for systematizing the reconstruction of the abdominal wall with
polypropylene mesh, due to its easy reproduction and applicability[6 ], and can be effective in
preventing the occurrence of high rates of abdominal hernias and bulges in the
postoperative period described in the literature.
Due to different techniques, studies indicate difficulties in comparing hernia
and abdominal bulging. For Mizgala et al.[6 ], among 150 patients, none had a hernia, but 3
unipedicled and 8 bipediculated patients had a visible protuberance. Kroll &
Marchi[7 ] reported a
bulge or hernia in 21% of cases and a reduction to 5% when fascial closure in
two layers of the anterior rectus sheath was performed.
Some authors understand that mesh is necessary when primary synthesis is not
possible, due to the risk of infection and extrusion[8 ]. A suitable synthetic mesh must have the
following characteristics: not produce foreign bodies, not be carcinogenic or
allergenic, and be able to resist mechanical stress. Furthermore, the thread
must be inert, non-absorbable, and monofilament[7 ].
OBJECTIVE
To evaluate tomographically the behavior of the abdominal structure and the
incidence of complications in the abdominal wall in patients undergoing the same
type of post-TRAM abdominal reconstruction.
METHOD
The cohort and prospective study are based on the selection of patients who
underwent TRAM in the plastic surgery service of the Hospital Regional
de Sobradinho , DF, from January 2019 to December 2020 and who had
preoperative abdominal tomography scans performed 1 year after postoperative.
There were 14 patients operated on during this period, but only eight
participants met the inclusion factors. The patients underwent a monopedicled or
bipedicled TRAM flap, and the donor area was repaired using the technique
described and standardized in the previous work by Cunha et al.[5 ].
Among the 14 patients operated on during the period by the same plastic surgery
team at the Hospital Regional de Sobradinho , two were excluded
due to changes in pre-operative tomography scans; two did not undergo
postoperative CT scans, one did not sign the Consent Form and one was lost to
follow-up. After the exclusion factors, eight patients remained for the
research.
The evaluation of preand postoperative tomography scans was performed by the same
radiologist and reviewed by another assistant radiologist. In addition, all
patient demographic data were evaluated based on a review of medical records by
the responsible researcher, and authorization for research was approved by all
patients, through the Informed Consent Form.
The patients underwent the procedure and a minimum follow-up of 12 months with
the same surgical team. All of them had computed tomography scans of the abdomen
without contrast in the preoperative evaluation, and outpatient follow-up was
done 15 days, 1 month, 3 months, 6 months, and 1 year after surgery, and after
12 months new tomographic images were requested.
Assessments of abdominal hernia, bulging, or other deformities in the abdominal
wall were analyzed using computed tomography. The parameters evaluated in
comparative tomography scans before and after surgery were the presence of
hernia, abdominal cavity volume, abdominal wall thickness, bulging, mesh
extrusion, and the presence of granuloma.
The reference points used to measure the volume of the abdominal cavity in the CT
scans were the following: longitudinal diameter in the midline of the upper
limit of the pubic symphysis and units of measurement in centimeters,
transverse, and anteroposterior (AP) at the height of L3 (vertebral column) and
measurement unit in cm; the final volume in cubic centimeters from the
formula:
Longitudinal x transverse x AP x 0.56.
The reference point used to evaluate wall thickness was the paramedian to the
right at the height of the navel and measurement unit in millimeters.
The study inclusion factors were patients undergoing polypropylene mesh placement
in unilateral or bilateral breast reconstruction with a monopedicled or
bipedicled TRAM flap, patients with preoperative tomography, and 12 months after
surgery.
RESULTS
During the preoperative consultation, the demographic profile of the patients
undergoing surgery was assessed: two patients were hypertensive, and none were
diabetic or smokers ([Table 1 ]). The
average age of the eight patients was 42 years ([Table 1 ]).
Table 1.
Number of patients
8
(100%)
Age
range
32
- 54
Average Age
42
Smoking
0
(0%)
Hypertension
2 (25%)
Diabetes
0
(0%)
Monopedicled TRAM
1 (12.5%)
Bipedicled TRAM
7
(87.5%)
Immediate reconstruction
4 (50%)
Late
reconstruction
3
(37.5%)
Mixed reconstruction
1 (12.5)
Right breast
3
(37.5%)
Left breast
4 (50%)
Right and left breast
1
(12.5%)
Degree of satisfaction
7 (87.5%)
Of the eight patients, seven (87.5%) received bipedicled flaps and one (12.5%)
received monopedicled flaps ([Table 1 ]).
The left breast was operated on in four patients (50%), the right breast in
three patients (37.5%), and one patient (12.5%) underwent bilateral surgery
([Table 1 ]). Furthermore, four patients
underwent immediate reconstruction (50%), three patients underwent delayed
reconstruction (37.5%) and one patient (12.5%) underwent immediate
reconstruction on the left side and delayed reconstruction on the right side
([Table 1 ]). When asked about the
degree of satisfaction with the aesthetic appearance of the breasts, seven
patients responded that they were satisfied and one was dissatisfied.
Patients who underwent delayed reconstruction had a waiting time between
mastectomy and breast reconstruction of approximately 18 months. All patients
were diagnosed with invasive ductal carcinoma (IDC) on pathological examination
and only one patient presented metastasis to the axillary lymph node ([Table 2 ]). Furthermore, two patients
underwent only adjuvant radiotherapy (25%), one patient (12.5%) underwent
adjuvant radiotherapy and neoadjuvant chemotherapy, three patients (37.5%)
underwent adjuvant chemotherapy and radiotherapy ([Table 2 ]), and two patients did not undergo additional
treatments.
Table 2.
Oncological profile
Patients
Adjuvant RT
2
Adjuvant RT + neoadjuvant CT
1
Adjuvant QT + adjuvant RT
3
Anatomopathological (IDC)
8
Furthermore, one patient (12.5%) presented pulmonary thromboembolism (PTE) after
the first day of surgery, which was evidenced by chest CT angiography, and was
therefore hospitalized for 3 days. Only two patients (25%) required a new
operation, and the patient who presented PTE also developed an infection of the
flap on the right, requiring successive debridement. The other patient required
hematoma drainage.
In general, a reduction in the size of the average abdominal cavity of 14.5% was
evidenced in patients undergoing TRAM and 17.9% in patients undergoing
monopedicled TRAM ([Table 3 ]). Furthermore,
an average reduction of 14.2% in the thickness of the abdominal wall overall was
demonstrated, and the greatest reduction was in a patient with late bilateral
breast reconstruction, using a bipedicled flap, with 50.7% ([Table 3 ]). No patient presented bulging.
Table 3.
Variation
Reduction Average
Volume of the abdominal cavity (VAC)
23.8% - 8.9% (TV) 1165cm3 - 476cm3
14.5% (TAR)
Thickness of the abdominal wall (TAW)
50.7% - 5.6% (TV)
7.1mm - 0.4mm
14.2% (TAR)
Monopedicled (VAC)
6249cm3 - 5125cm3
17.9%
Monopedicled (TAW)
7mm - 6.5mm
7.1%
Bipedicled (VAC), (GV)
4880cm3 - 3715cm3
23.8%
Bipedicled (TAW), (GV)
14mm - 6.9mm
50.7%
Bipedicled (VAC), (LV)
5331cm3-4855cm3
8.9%
Bipedicled (TAW), (LV)
7.1mm - 6.7mm
5.6%
Table 4.
Patients
Hernias
Bulging
Extrusion of the mesh
Granuloma wire
Complications
Bipedicled
7
12.5%
0%
0%
12.5%
0%
Monopedicled
1
0%
0%
0%
0%
12.5% - Late seroma
Total
8
12.5%
0%
0%
12.5%
12.5%
Only one patient had an umbilical hernia measuring 2.04 cm on postoperative
tomography ([Figure 3 ]). Another patient
presented with a seroma 11 months after surgery in the supraumbilical region
between the aponeurosis and the mesh, measuring 9.55ml ([Figures 1 and 2 ]). Another patient presented fibrosis around
the mesh ([Figures 5 and 6 ]). Thread
granuloma was revealed in one patient (12.5%) by tomography at 6 months, without
clinical repercussions ([Figure 4 ]).
Figures 1 and 2. Computed tomography without contrast: Late seroma.
Figure 3. Computed tomography showing umbilical hernia.
Figure 4. Computed tomography: Granuloma.
Figures 5 and 6. Computed tomography: Perithellal fibrosis.
DISCUSSION
The rectus abdominis muscle originates from the pubis (between the pubic tubercle
and the symphysis) and is inserted into the fifth to seventh costal cartilage
and the xiphoid process of the sternum[9 ]. It has 3 to 4 horizontal tendinous insertions that are
adhered to the anterior layer of the rectum[10 ], and its irrigation is classified as type III by Mathes
and Nahai (superior and inferior epigastric artery), it has 6 to 10
perforators[11 ]
[12 ].
Although breast reconstructions with TRAM are generally successful, there is some
concern among surgeons when using TRAM, due to the need to maintain the
competence of the abdominal wall postoperatively. In 1976, D. Ralph Millard
pioneered the idea of reconstructing the female breast from a vertically
oriented island of abdominal skin, that is, with a vertical musculocutaneous
flap from the rectus abdominis[13 ].
The patients participating in this study are heterogeneous and, ideally, were
compared with the same type of pedicle, reconstruction time, and no changes in
the abdominal wall preoperatively. Only one patient had a small umbilical hernia
and only one had thread granuloma with inflammatory signs. Complications were
not evaluated in another study due to the systematization of the technique used
having been first applied to these groups of patients after 2019[5 ].
In monopedicled flaps, the smaller defect in the donor area and the preservation
of the contralateral rectus abdominis muscle influence the lower incidence of
hernias and bulging[14 ]. In this
study, 1 patient had a late seroma on computed tomography, while another had
perithellal fibrosis, but none of the radiological images in this group showed
bulging or large deformities in the abdominal wall. The first studies appeared
in 1987 with Hartrampf et al.[4 ],
who evaluated complications in 335 patients undergoing breast reconstruction
with TRAM. The general rate of abdominal wall complications was 1.5%, with 0.3%
referring to abdominal hernia, 0.6% to abdominal bulging, and 0.6% to a defect
in the upper sheath of the rectus abdominis muscle[4 ].
The use of polypropylene mesh with systematization of fixation points,
corroborated in another study with the same surgical team, provided a low rate
of hernia and no bulging or extrusion of the mesh[5 ].
This work was innovative, as it analyzed differences in the volume of the
abdominal cavity and the thickness of the abdominal wall, before and after
surgery. The average reduction in the volume of the abdominal cavity ranged from
8.9% to 23.8%, and the thickness of the abdominal wall ranged from 5.6% to
50.7%.
Due to the inflammatory reaction caused by the mesh, perithellal fibrosis is
triggered, which may justify, in some cases, the low rate of average reduction
in the thickness of the abdominal wall. The most significant change in the
reduction of abdominal wall thickness (50.7%) occurred in one patient, who
underwent a bipedicled flap, but there were no complications. However, the
patient with an umbilical hernia in the postoperative period presented a
variation of 9.2% of the abdominal wall.
Even with these data, there was no correlation between this reduction and changes
such as hernias, bulges, mesh extrusions, thread granulomas, or other
abnormalities.
Unlike previous published studies, in which they were evaluated primarily by
physical examination and, only in cases of doubt about whether to perform an
abdominal ultrasound post-operatively, the present study considered it relevant
to perform a pre-operative tomography examination, to analyze the existence of
previous deformities[15 ]
[16 ].
Only two patients showed changes in postoperative CT scans compatible with late
seroma and perithellal fibrosis. According to Baroudi & Ferreira[17 ], abdominal surgeries result in
seroma due to the dead space resulting from detachment and resulting in
incidences ranging from 2.1 to 9.4%7. According to Scevola et al.[18 ], analyzing 769 breast
reconstructions with TRAM, the use of two drains in the abdomen reduces the
incidence of seroma. And it has already been shown in several studies that the
use of polypropylene mesh to correct any defects in the abdominal wall induces
an intense inflammatory reaction, with the formation of fibrosis, and a decrease
in the elasticity of the wall[19 ]
[20 ].
CONCLUSION
In this study, tomography after surgery demonstrated an average reduction of
14.5% in the volume of the abdominal cavity and 14.2% in the thickness of the
abdominal wall. There was no evidence of an abdominal hernia, bulging, mesh
extrusion, or other deformities. Furthermore, although bipedicled flaps present
greater variation in abdominal wall thickness, there was no correlation in the
abdominal wall or complications.
Despite the evaluation of a small number of cases, satisfactory tomographic
results were found, avoiding the appearance of complications in the
reconstructive technique applied.
Bibliographical Record
