Clinical Research News
Refining Techniques to Make Breast Reconstruction Safer
Women recovering from breast cancer who choose breast reconstruction have a number of surgical options. Some of the most common procedures use tissue from the abdomen to reconstruct the breast, either through tissue transplant (known as free flap procedures) or by tunneling tissue up from the abdomen to the breast area (known as the pedicled technique). In a recent clinical study of breast reconstruction techniques, Dr. Jeffrey A. Ascherman, Associate Professor of Clinical Surgery at Columbia and Site Chief, Division of Plastic Surgery at NewYork-Presbyterian Hospital/Columbia University Medical Center, performed a careful examination of the pedicled method. Through his study of the technique, which avoids some of the complications that can be associated with free flaps, Dr. Ascherman confirmed its safety and effectiveness.
Over the past several years free flap options for breast reconstruction have increasingly come into favor because of claims that associated abdominal complications such as hernia, abdominal bulge, and abdominal weakness with pedicled breast reconstructions. Common free flap options include the deep inferior epigastric perforator (DIEP) flap and the free transverse rectus abdominis myocutaneous (TRAM) flap. In the pedicle option studied by Dr. Ascherman, abdominal tissue remains attached to the body and is tunneled up through the abdominal wall to reconstruct the breast.
The pedicled TRAM flap offers two significant advantages to patients. First, because the attached tissue retains its vascular structure, there is almost no risk of the reconstructed breast tissue dying after surgery due to loss of blood flow. Second, pedicled TRAM flaps require less time in surgery, reducing the chance of certain surgical and anesthetic complications.
Dr. Ascherman, who has been performing pedicled TRAM flap surgeries for more than 10 years, was concerned that women were accepting greater risks associated with free flap procedures for reported advantages that he believes are not significant. He embarked on a study to revisit the use of the pedicled TRAM flap in breast reconstruction. "You only want to do a longer, more complicated procedure if there's a proven benefit," he says. In addition, with breast reconstructions using DIEP and free TRAM flaps, even the best microsurgeons can lose reconstructed breasts due to loss of the flap's blood supply and resulting tissue death. "For patients who lose reconstructed breasts, it can be terrible," he says. "If only five out of 100 patients lose reconstructed breasts, that's still five women who need to undergo at least one additional procedure."
Between December 1998 and June 2005, Dr. Ascherman performed breast reconstruction surgery with the pedicled TRAM flap procedure in 117 women. Most of these women required reconstruction of only one breast, although 12 required bilateral breast reconstruction. In all cases, an onlay polypropylene mesh was used to supplement or reinforce the fascia repair and reduce possible abdominal complications. "Inserting mesh before closing the abdomen adds only 20 minutes or less to the surgery, but it is important in reducing possible complications," Dr. Ascherman says.
The women were followed and examined for complications for an average of two years after surgery. Of Dr. Ascherman's 117 patients, none complained of persistent abdominal weakness, and only nine experienced abdominal complications, all of which were easily treatable and only one of which required additional surgery. The hernia rate was less than 1%, no patient required mesh removal, and no patient lost a reconstructed breast. These results compare favorably with the longer and more complicated free flap procedures.
The study concluded that abdominal complication rates in surgeries using pedicled TRAM flaps with onlay polypropylene mesh are low, and that pedicled TRAM flaps remain a good option for many women seeking breast reconstruction.
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