Egypt. J. Plast. Reconstr. Surg., Vol. 27, No. 2, July: 271-279, 2003

Evaluation of Integrity After Using the Transverse Rectus Abdominis Myocutaneous Flap for Breast Reconstruction

FOUAD M. GHAREEB, F.R.C.S. (Ed)*; TAREK MAHBOUB, M.D.***; SAID G. ASKAR, M.D.**; TAREK F. KISHK, M.D.* and MOHAMAD MEGAHED, M.D.* The Plastic Surgery Unit*, Surgical Department**, Menoufiya University and The Surgical Department,*** Faculty of Medicine, Cairo University.

ABSTRACT of abdominoplasty, but in the other hand it will be vulnerable to donor site morbidity. Hartrampf, 24 cases of breast reconstruction have been achieved by the transverse rectus abdominis myocutaneous flap one of pioneers of this technique, reported a (TRAM), either as unipedicled (16 patients) or bipedicled very low complication rate by closing the ab- (8 patients) flaps. The abdominal wall is restored by either dominal wall without the use of prosthetic mesh. the direct myofascial release and approximation in cases However, his results are not reproducible as with preoperative lax abdominal wall and diastasis of the numerous authors, following his technique, have recti (6 patients) or by the use of prolene mesh reinforcement (18 patients) in patients with relatively preoperative tight reported abdominal hernias and started to use abdominal wall which do not allow easy myofascial release prosthetic reinforcement [3]. Kroll et al., [4] have and approximation or after bipedicled flap utilization. In studied the incidence of postoperative abdominal our series we have found out that 33% of the patients bulge, hernia and the ability to do sit-ups in a presented to us were complaining of either early mastectomy series of 268 patients who had undergone free wound complications as wound dehiscence, mastectomy flaps necrosis or severe infection (25%), or late as radion- TRAM or conventional TRAM flaps for breast ecrosis (8%). Primary or immediate breast reconstruction reconstruction. They found out that the incidence was done in only 25% of cases while secondary reconstruc- of abdominal bulge and hernias were 3.8% and tion is done in 38% of the cases and one case of Poland 2.6% respectively and he also found out that syndrome was treated in the same way (4%). Complications Synthetic mesh was required for reinforcement were 4.17% abdominal wound infection, 8.3% partial sloughing of the abdominal flap, 12.5% abdominal bulge of donor site closure twice as often in the con- and 4.17% abdominal hernia. We have not been encountered ventional TRAM patients than in the free TRAM with any complication with the mesh as regard exposure patients. He also concluded that the incidence or infection. Umbilical complications in the form of stenosis of abdominal bulge or hernia is relatively inde- and infection have occurred in 3 cases (12.5%). We conclude pendent of the type of TRAM flap used and the that abdominal closure after TRAM flap utilization in breast reconstruction is dictated by the preoperative condition of number of muscle pedicles harvested. Another the abdominal wall as myofascial release and approximation study reports 0% abdominal hernias and 10% is possible in lax as the stretched fascia allows, epigastric bulge after TRAM flaps in 48.5 month while the use of synthetic mesh reinforcement is indicated follow-up period [5]. The concept of partially tight abdomens to replace the fascia used in the flap. preserving the by split- INTRODUCTION ting the muscle and leaving the lateral portion in situ as advocated by Hartrampf is theoretically Breast reconstruction after mastectomy is attractive. If only part of the muscle is needed becoming increasingly popular as surgical tech- to maintain blood supply to the flap, it would niques improve, so patients achieve reconstruc- seem reasonable to leave the remainder in place tive results that allow them to live without hand- to preserve strength in the weakened abdominal icaps or limitations caused by their disease [1]. wall. By splitting the muscle and using only the The TRAM flap is used in breast reconstruction central or medial portion to supply blood to the in patients undergoing modified radical mastec- flap, part of the muscle remains in situ. Thereby tomy with very satisfactory results [2]. In one reducing the postoperative incidence of abdom- hand the as a donor site for this flap inal weakness, bulge and hernia. As evidence of is improved as regard the concomitant benefit the clinical effectiveness of this concept, Mizgala

271 272 Vol. 27, No. 2 / Evaluation of Abdominal Wall Integrity After TRAM et al., had reported a very low incidence of cases were referred to the authors for manage- postoperative abdominal wall problems. Even ment of unhealed mastectomy incisions due to though the muscle is deprived of its intercostal either mastectomy flaps necrosis or due to severe innervation by removal of the central portion infection with subsequent chronic ulceration of (which presumably contains the motor end the wound and adherence to the underlying plates), it would not be unreasonable to think muscle. 2 cases was referred to manage radion- that some functional connections between the ecrosis of the wounds after overdose with radi- severed intercostal nerve endings and viable ation. While 15 patients requested breast recon- muscle tissue could become reestablished. This struction either primarily at the same sitting with possibility was supported by Kroll et al. [6,7,8]. the mastectomy operation (6 cases) or later on they came for secondary reconstruction (9 cases). Abdominal compartment syndrome (ACS) One young lady 19 years old with Poland syn- is defined by the deleterious effects of intra drome had the same procedure. We utilized the abdominal hypertension on the pulmonary, car- TRAM flap either as a unipedicled (16 cases) diovascular, splanchnic, urinary and central or as bipedicled flap (8 cases) for the reconstruc- nervous systems. Abnormal and sudden increase tion of the breast. We preferred the bipedicled in the volume of any component of the intrap- TRAM flap in older patients or those who are eritoneal or retroperitoneal space occurring post- diabetics to augment the blood supply of the operatively causes intra-abdominal hypertension. flap, we had no patients who were smokers. Sustained intra-abdominal hypertension leads Preoperative routine laboratory and radiological to ACS which if left unrecognized or untreated investigations and oncologic consultation were is always fatal. Measurement of urinary bladder done for all patients before reconstruction. Pre- pressure is the best validated technique for diag- operative and postoperative photography was nosis of intra-abdominal hypertension. It should done for all the patients showing the donor and be used routinely for minimally invasive surveil- recipient areas (Tables 1,2,3 and Charts 1,2). lance of intra-abdominal pressure if ACS is suspected [9]. Surgical technique: Determinations of the bladder pressure rep- Flap elevation: resents an easy method for early recognition of The degree of preoperative abdominal wall ACS. Decompressive laparotomy should be laxity was determined preoperatively while the performed with a bladder pressure 30 cm of patient was standing, as well as the infra- water or more. Abdominal wall closure after mammary line which was recognized and marked transverse TRAM flap in breast reconstruction preoperatively as an important landmark in re- is often performed under considerable tension construction. The patient was placed in semi- and may theoretically cause a component of sitting position with the knees slightly bent to ACS. A transient component of ACS does exist facilitate abdominal closure. The recipient area after TRAM flap breast reconstruction. Bipedicle was prepared by debridement or scar excision flaps, nulliparous women and increased body followed by undermining of flaps in secondary mass index were considered risk factors for reconstruction. The amount of tissues required elevated intra-abdominal pressures while Ten- can be estimated. With a new sit of instruments sion-free mesh closure seemed to have a protec- to guard against possible implantation of tumor tive effect [10]. cells the abdominal skin was incised at its lower border down to the fascia, then the upper border A study clearly demonstrated that there is a was divided tangentially cutting obliquely in an significant and persistent reduction in abdominal upward direction to include as many perforators sensibility following TRAM flap surgery. The as possible but without hindering the blood distribution of the deficits is consistent and supply of the abdominal flap. We have found involves the midline supraumbilical and infraum- out that intraoperative Doppler ultrasound probes bilical regions [11]. were very helpful in many cases to determine PATIENTS AND METHODS and mark the perforating vessels to the rectus flap, which enabled us to spare as much as we From March of 1999 to February of 2002, can from the and facilitate abdom- twenty four cases of breast reconstruction by inal closure. The wings of the ellipse-shaped TRAM flaps have been done by the authors. 6 flap were dissected from lateral inwards till 3 Egypt, J. Plast. Reconstr. Surg., July 2003 273 cm medial to the lateral edge of the rectus sheath and exit anterior to it from the inner surface of where we can find the perforator vessels around the anterior sheath. This was done by continuous the umbilicus. The abdominal flap was dissected number one nylon sutures. The other anterior upwards to the costal margins on the contralateral rectus sheath is plicated to balance the forces side and to the inframammary line in the ipsilat- working in the abdomen and prevent shifting of eral side to create a tunnel for the flap to pass the umbilicus (Figs. 1,2). through. The rectus fascia was incised vertically Group 2 (18 cases): whenever there was tight about one to two centimeter lateral to the linea abdominal wall like in most nullipara or young alba from the costal margin to the umbilicus. ladies, trying to close the abdomen by the pre- The anterior rectus sheath was cut around the vious technique will not only be very difficult flap on its undersurface. Taking care that this technically but also hazardous as this will cut incision should be more lateral in lax abdomens through the tissues predisposing to hernias and where the is stretched and the rectus bulge. Umbilical shifting also may occur due to sheaths are laterally displaced especially in the inability to plicate the anterior rectus sheath in center of the abdomen around the umbilicus. the other side of the abdomen. Also, the theoret- The umbilicus was circumscribed and separated. ical presumption of development of ACS in very Then the muscle was dissected carefully by tight closure has lead us to replace the same area insinuating the hand below it and exposing its of removed anterior rectus sheath with synthetic posterior surface where the epigastric vessels mesh. We have used the polypropylene mesh can be seen and this is elevated. The flap is (Ethicon Co) universally in all these patients. separated from below by cutting the anterior Once the flap is used the mesh is held by hemo- rectus sheath and the muscle just above the stats and sutured to the remnants of the anterior lowermost tendinous intersection to prevent rectus sheath. We keep the mesh always 1 cm muscle retraction below and behind the pubis larger than the defect of the sheath and fix it by which well start abdominal weakness and possi- continuous number 0 nylon running sutures. This bly hernia. The flap was then transferred to the running sutures in our opinion well act as a purse breast for reconstruction. We have paid more string during instances of increased intra- attention for fascial conservation than muscle abdominal pressure like coughing (Figs. 3-7). sparing. In bilateral TRAM flap the same was done on the other side. In both groups after reconstruction of the Abdominal closure: myofascial layer we did the umbilicoplasty by coring it out through circular incision in the This was divided into two groups according abdominal flap after determining its position to the technique of abdominal closure: central and at the level of iliac crests like in Group 1 (6 cases): where direct abdominal abdominoplasty. This has led to constriction and repair was done without the use of mesh enforce- stenosis of the umbilical scar in some cases. So, ment, this was done whenever there was preop- in the last ten cases we did the V-umbilicoplasty erative abdominal wall laxity and rectus muscles through a V incision of the abdomen which is diastasis. In these cases there were stretched turned to Y by abdominal stretch in downwards linea alba and lateral displacement of the rectus direction and inserting the V flap in a notch in sheaths and so abdominal closure is achieved the umbilical stump. Suction drains were applied better by using the available fascia to restore and the incisions were closed in layers. Postop- abdominal competence. This was done by erative abdominal binders were used for 2 straightforward direct repair of the anterior rectus months. sheath by approximating the lateral edge of the anterior rectus sheath after its release to the linea Measurement of the intra abdominal pressure alba and the fascia deep to it. This midline fascia (IAP) was done in all patients by insertion of is accessible from inside the rectus sheath at the Foley catheter. 100 ml of sterile saline was transition from anterior to posterior sheath near injected into the empty bladder through the the midline it is very strong and resists tearing catheter and a T-piece connector was attached by the suture material. To include this fascia in between the catheter and the drainage bag. Water the repair the needle tip was inserted just poste- manometer was used to measure IAP. With the rior to the reflection between anterior and pos- patient in the supine position, the zero reference terior rectus sheaths, pass it through the fascia point was the symphysis pubis and the height 274 Vol. 27, No. 2 / Evaluation of Abdominal Wall Integrity After TRAM of the water column above this point represented was not exceeding more than 30 cm of water IAP in centimeters of water [12]. (Table 4). We have not seen any complications with the mesh which was used in 18 cases (10 RESULTS unipedicled and 8 bipedicled TRAM). Late com- Evaluation of the abdominal wall integrity plications as abdominal weakness leading to lower after using the TRAM flap for breast reconstruc- abdominal bulge has occurred in 3 cases (12.5%). tion was done in all the cases by examining the While true abdominal hernias occurred in one patients in the early and late postoperative follow case (4.17%) after bilateral TRAM and mesh up visits and assessment of their postoperative application and the hernia involved the lower photographs. The follow up ranged between 4 abdominal wall and necessitated repair by another months to 30 months. Early complications like prolene mesh application. Umbilical complications wound infection of the abdominoplasty incision has occurred in 3 cases in the form of necrosis in has occurred in one case (4.17%) and resolved one case and umbilical scar stenosis in 2 cases completely on antibiotics. Sloughing of the which required repeated dilatation to prevent its abdominal flap has occurred in 2 cases (8.3%) contraction (12.5%). This could be avoided in last in one case skin graft was required to coverage 10 cases by the new method of V-umbilicoplasty. the raw area, this lead to ugly abdominal scar We have been encountered with 2 cases of ugly (Figs. 8,9). This occurred in the diabetic patient abdominal scars, one case due to severe sloughing who had wound dehiscence after mastectomy of the abdominal flap and subsequent skin graft indicating compromised wound healing. While and another due to hypertrophic scar formation in the other case the indurated lower abdominal (Table 4). Abdominal sensation to superficial flap is repeatedly curetted and left to heal sponta- touch is affected in all cases and involved the neously. suprapubic, umbilical and frequently the epigastric regions. This was improved in the epigastric region Seroma of the abdominal wall occurred in 2 by 6 months. 19 patients were satisfied with the cases (8.3%) and managed by repeated aspiration cosmetic outcome of their abdomens, while 5 and antibiotics. ACS has not been detected in any patients were not happy with the abdominoplasty of our cases by monitoring of the intra abdominal incisions or the abdominal weakness or hernia pressure through urinary catheter as the pressure they have developed.

Table (1): Late abdominal complications after unipedicled or bipedicled TRAM flap for breast reconstruction after abdominal wall closure with or without synthetic mesh reinforcement.

Type of TRAM Mesh closure of Ugly Case Age bipedicle or abdominal Abdominal Abdominal Umbilical abdominal number unipedicle wall defect bulge hernia complications scar 1 33 Unipedicle + - - - 2 35 Unipedicle + - - - - 3 41 Bipedicle + - - - - 4 35 Unipedicle + - - Stenosis - 5 44 Bipedicle + - - Necrosis and ++ disappearance 6 56 Unipedicle - + - - - 7 43 Bipedicle + - - - - 8 41 Unipedicle + - - - - 9 19 Unipedicle - - - - - 10 43 Unipedicle - - - - 11 58 Bipedicle + - + - - 12 54 Unipedicle + - - Stenosis - 13 47 Bipedicle + - - - + 14 42 Unipedicle + - - - - 15 34 Unipedicle + - - - 16 49 Bipedicle + - - - - 17 40 Unipedicle + + - - - 18 39 Unipedicle + - - - 19 36 Unipedicle - + - - 20 56 Bipedicle + - - - - 21 62 Bipedicle + - - - - 22 35 Unipedicle - - - - - 23 34 Unipedicle + - - - - 24 32 Unipedicle - - - - Egypt, J. Plast. Reconstr. Surg., July 2003 275

Table (2): Number of patients with unipedicled and bipedicled TRAM flaps. Total number of cases Number of unipedicled TRAM Number of bipedicled TRAM 24 16 8

Table (3): Number of patients according to the type of breast reconstruction. Method of reconstruction Primary Secondary Poland Complicated in the 24 patients reconstruction reconstruction syndrome Radionecrosis mastectomy wound 69126

Table (4): Number of cases with early and late abdominal complications after TRAM flaps.

Early complications Late complications Abdominal complications Wound Skin Umbilical infection sloughing Seroma ACS Bulge Hernia complications 1 (4.17%) 2 (8.3%) 2 (8.3%) 0 (0%) 3 (12.5%) 1 (4.17%) 3 (12.5%)

25% 25%

70 62 60 58 56 56 54 49 8% 50 47 40 41 44 41 43 42 43 39 40 34 4% 35 35 35 34 36 38% 30 33 32 Primary reconstruction 20 Secondary reconstruction 19 age Poland syndrome 10 Radionecrosis 0 Complicated mastectomy wound 1233579111315171921 Chart number (1): Percentage of patients according to the Chart number (2): Age distribution of patients with breast presentation. reconstruction.

Fig. (1): Patient after modified radical mastectomy with lax Fig. (2): Same patient after reconstruction of the breast after abdominal wall. TRAM flap and abdominal wall repair by direct myo- fascial approximation. 276 Vol. 27, No. 2 / Evaluation of Abdominal Wall Integrity After TRAM

Fig. (3): Abdominal wall repair by replacing the Fig. (6): Same patient after breast reconstruction with bipedicled with prolene mesh. TRAM flap and abdominal wall repair with prolene mesh reinforcement.

Fig. (4): Patient after breast reconstruction with TRAM flap and abdominal wall repair with prolene mesh reinforcement. Fig. (7): Lateral view of the same patient.

Fig. (5): Patient with mastectomy wound dehiscence with failure Fig. (8): Diabetic patient with mastectomy wound dehiscence due of secondary tension sutures. to sloughing of the mastectomy flaps. Egypt, J. Plast. Reconstr. Surg., July 2003 277

abdominal wall bulge occur in patients with anatomical repair [7]. Drever et al., have stressed upon the fact that surgeons have to reestablish the function of the anterior abdominal wall by regaining the same widths and lengths of fascia removed with the rectus abdominis muscle by replacing this structure with a synthetic mesh claiming that repairing the area below the semi- circular line of Douglas is not enough as hernias can occur in the upper abdominal part, also the pull of the lateral edge of the remaining anterior rectus sheath on the removed side and suturing it to the edge of the linea alba will distort the abdominal midline and shift the umbilicus to the same side. Their opinion again is criticized by Hartrampf who indicated that available tissue repair is almost possible if a muscle and sheath sparing technique is followed. As a prove of the Fig. (9): Same patient after breast reconstruction with effectiveness of this repair he reported only one TRAM flap complicated by infra umbilical ab- hernia in 145 cases of unipedicled TRAM and dominal skin sloughing and grafting. 55 cases of bipedicled TRAM flaps without mesh application (78%). He had recorded that the incidence of using the mesh in his series of the bipedicled TRAM flaps is only 22%. Also, he adviced plication of the anterior rectus sheath DISCUSSION in the contralateral side to balance the forces on The chief disadvantage of the TRAM flap is the abdomen [13], however, Hartrampf results its potential for creating weakness in the abdom- could not be reproduced [3]. In our study we have proposed that the most important determin- inal wall [2,6]. Although most patients tolerate ing factor in whether to use the mesh or the the loss of these muscles without difficulty, some available myofascial tissues for the repair is the do not. Complaints of abdominal weakness, preoperative condition of the anterior abdominal bulging (stretching out of the lower abdominal wall. If the abdominal wall is lax with diastasis fascia without true hernia formation) and true of the recti and stretch of the fascial layers, then hernias were encountered by many surgeons the abdominal wall repair can be done easily by who perform the TRAM flap procedure. The using the available myofascial layers without concept of partially preserving the rectus abdo- difficulty in addition to plication of the contralat- minis muscle by its splitting and leaving the eral anterior rectus sheath to prevent unbalancing lateral portion in situ, as advocated by Hartrampf, of the abdomen and shifting of the umbilicus is theoretically attractive. If only part of the toward the ipsilateral side of the flap. Those are muscle is needed to maintain blood supply to the patients who are candidates for abdomino- the flap, it would seem reasonable to leave the plasty so there is no point of denying them the remainder in place to preserve strength in the benefits of the myofascial excision and plication weakened abdominal wall. Those who perform even if a lateral myofascial release is needed as the operation in this way believe that the pre- a modification of the “component separation served muscle will continue to function and will method” described by Ramirez et al. [14,15]. In improve the strength and integrity of the abdom- patients with no abdominal wall laxity or diastasis inal wall, thereby reducing the postoperative of the recti like most of young ladies and nulli- incidence of abdominal weakness, bulging and para, myofascial release and plication will not hernia. As an evidence of the clinical effective- be only difficult but hazardous due to repair ness of this concept, Mizgala et al., have reported under tension, which eventually leads to com- a very low incidence of postoperative abdominal plications as hernia, bulging and postoperative wall problems [8]. While Kroll et al., have con- pain, in addition to the possible occurrence of cluded that the lowest incidence of hernia and the theoretical previously unrecognized ACS. 278 Vol. 27, No. 2 / Evaluation of Abdominal Wall Integrity After TRAM

In our study the intra-abdominal pressure has We conclude that TRAM flap is still the best not increased more than 24 cm of water (normally method for autologous repair of the breast, its should not exceed 30 cm of water). We have donor site which is the abdominal wall should used the mesh in 18 cases (10 unipedicled and not be thought of as a morbidity but as an addi- 8 bipedicled TRAM). We had a total of 12.5% tional advantage which the patient can win in abdominal bulge and 4.17% abdominal hernia addition to breast reconstruction. This can be with no recorded complication in the mesh group made possible by proper understanding of its as regard exposure or infection. In the mesh condition preoperatively. group we had 4.17% bulge and 4.17% hernia compared to 4% bulge and 0% hernia by Drever REFERENCES et al. [13]. While in the group of patients with direct fascial repair we recorded 8.35% abdom- 1- Stephen S.K., Evans G.P., Michael M.J., Robb G.I., Baldwin B.J. and Schusterman M.A.: Comparison of inal bulge and 0% hernia, compared to 43% resource costs of free and conventional TRAM flap abdominal weakness, bulging and hernia after breast reconstruction. Plast. Reconstr. Surg., 98: 74, myofascial closure without mesh by Drever et 1996. al. [13]. Contrary to this Hartrampf reported a 2- Hartrampf C., Scheflan M. & Black P.: Breast recon- single lower abdominal hernia in 145 cases struction with transverse abdominal island flap. Plast. (0.7%) of unipedicled TRAM flaps without mesh Reconstr. Surg., 69: 216, 1982. utilization. Kroll et al., have reported 33% to 3- Lallement M., Missana M.C., Bourgeon Y. and Abbes 40% abdominal wall weakness and bulge after M.: Closure of the abdominal wall after removal of a myofascial closure without prolen mesh appli- myocutaneous flap from the transverse rectus abdominis cation [7]. We propose that the aim should be a for breast reconstruction. Apropos of 48 cases. (Review of the literature). Ann. Chir. Plast. Esthet., 39: 733, tension-free repair with correction of abdominal 1994. wall weakness if needed, so application of a mesh in a pendulous abdomen is neither logic 4- Kroll S.S., Schusterman M.A., Reece G.P., Miller M.J., Robb G. and Evans G.: Abdominal wall strength, nor cosmetic, while direct abdominal repair bulging and hernia after TRAM flap breast reconstruc- under tension to avoid the application of the safe tion. Plast. Reconstr. Surg., 96: 616, 1995. synthetic mesh is not convincing. 5- Mohamad S.A., Sakr M.F., El-Hammadi H.A., Moussa M.M. and El-Sharaky M.M.: The use of the “TRAM” Umbilical complications like stenosis and flap in some oncological problems. Int. Surg., 85 (4): infection have occurred in 3 cases (12.5%). 347, 2000. Prevention of stenosis of the umbilical scar was 6- Hartrampf C.G.: Abdominal wall competence in trans- possible in later cases by the use of the new verse abdominal island flap operations. Ann. Plast. technique of umbilicoplasty described by Surg., 12: 139, 1984. Ramirez [14]. In our study we have found out 7- Kroll S.S. and Marchi M.: Comparison of different that 33% of the patients presented to us were strategies for preventing of abdominal wall weakness complaining of either complicated mastectomy after TRAM flap breast reconstruction. Plast. Reconstr. wound (25%), or radionecrosis (8%). Recon- Surg., 89: 1045, 1992. struction of the breast after complicated mastec- 8- Mizgala C.L., Hartrampf C.R. and Bennett G.K.: tomy wound is associated with higher complica- Assessment of the abdominal wall after pedicled TRAM tions of the donor site due to two factors, first flap surgery: 5-7 year follow up of 150 consecutive the presence of ulceration, infection and radion- patients. Plast. Reconstr. Surg., 93: 988, 1994. ecrosis of the mastectomy wound may complicate 9- Decker G.: Abdominal compartment syndrome. J. the abdominal repair especially if synthetic mesh Chir., 138 (5): 259, 2001. is applied, second the fact that patients with 10- Losken A., Carlson G.W., Jones G.E., Hultman C.S., complicated mastectomy wound may be origi- Culbertson J.H. and Bostwick J.: 3rd. Significance of nally have compromised wound healing due to intra-abdominal compartment pressures following TRAM lowered immunity or diabetes. We are reporting flap breast reconstruction and the correlation of results. 4% abdominal wound infection and 8.3% partial Plast. Reconstr. Surg., 109 (7): 2257, 2002. sloughing of the abdominal flap which required 11- Spear S.L., Hess C.L. and Elmaraghy M.W.: Evaluation skin graft in one case (4.1%). Perhaps if we do of abdominal sensibility after TRAM flap breast recon- more primary reconstructions these results could struction. Plast. Reconstr. Surg., 106 (6): 1300, 2000. be improved. 12- Ivatury R.R., Diebel L., Porter J.M. and Simon R.J.: Egypt, J. Plast. Reconstr. Surg., July 2003 279

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