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. 1995 Jun;221(6):756–766. doi: 10.1097/00000658-199506000-00014

TRAM flap breast reconstruction after radiation treatment.

J K Williams 1, J Bostwick 3rd 1, J T Bried 1, G Mackay 1, J Landry 1, J Benton 1
PMCID: PMC1234708  PMID: 7794079

Abstract

OBJECTIVE: Patients with and without radiation treatment before their breast reconstruction were compared to study the relationship of radiation to flap-related complications. SUMMARY BACKGROUND DATA: The transverse rectus abdominis muscle (TRAM) flap for breast reconstruction involves a a vascular pedicle and recipient bed, both included in the radiated field of patients undergoing adjunctive therapy. Detailed reviews of flap-related complications in this subgroup of patients have been limited. METHODS: One hundred eight patients with radiation treatment who subsequently underwent a TRAM flap breast reconstruction were compared with 572 patients with no radiation treatment before similar reconstruction. Flap-related complications, radiation dosage, time, fields, relationships between risk factors, and complications were studied. RESULTS: Overall complication rates were comparable between the two groups. Only fat necrosis (> 10% of total reconstruction) was found to be statistically significant (17.6% vs. 10.1%, p = 0.03228). No difference was found for fat necrosis in unipedicled vs. bipedicled flaps controlled for radiation (17.7% vs. 17.4%). Obesity and radiation therapy were associated with fat necrosis and major infection in a logistic regression. Significant abdominal scarring was also associated with major infection (p = 0.0044). CONCLUSIONS: In this, the largest reported series, radiation therapy was associated with increased fat necrosis and major infection. The use of the TRAM flap was not found to be prohibitive in radiated patients and should still be the first choice in this subgroup of patients.

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Selected References

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  1. Berrino P., Santi P. Hemodynamic analysis of the TRAM. Applications to the "recharged" TRAM flap. Clin Plast Surg. 1994 Apr;21(2):233–245. [PubMed] [Google Scholar]
  2. Bloomer W. D., Hellman S. Normal tissue responses to radiation therapy. N Engl J Med. 1975 Jul 10;293(2):80–83. doi: 10.1056/NEJM197507102930206. [DOI] [PubMed] [Google Scholar]
  3. Bostwick J., 3rd, Jones G. Why I choose autogenous tissue in breast reconstruction. Clin Plast Surg. 1994 Apr;21(2):165–175. [PubMed] [Google Scholar]
  4. Bostwick J., 3rd, Paletta C., Hartrampf C. R. Conservative treatment for breast cancer. Complications requiring reconstructive surgery. Ann Surg. 1986 May;203(5):481–490. doi: 10.1097/00000658-198605000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bostwick J., Stevenson T. R., Nahai F., Hester T. R., Coleman J. J., Jurkiewicz M. J. Radiation to the breast. Complications amenable to surgical treatment. Ann Surg. 1984 Oct;200(4):543–553. doi: 10.1097/00000658-198410000-00015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Calvo W., Hopewell J. W., Reinhold H. S., van den Berg A. P., Yeung T. K. Dose-dependent and time-dependent changes in the choroid plexus of the irradiated rat brain. Br J Radiol. 1987 Nov;60(719):1109–1117. doi: 10.1259/0007-1285-60-719-1109. [DOI] [PubMed] [Google Scholar]
  7. Carlson G. W. Breast reconstruction. Surgical options and patient selection. Cancer. 1994 Jul 1;74(1 Suppl):436–439. doi: 10.1002/cncr.2820741332. [DOI] [PubMed] [Google Scholar]
  8. Dion M. W., Hussey D. H., Osborne J. W. The effect of pentoxifylline on early and late radiation injury following fractionated irradiation in C3H mice. Int J Radiat Oncol Biol Phys. 1989 Jul;17(1):101–107. doi: 10.1016/0360-3016(89)90376-3. [DOI] [PubMed] [Google Scholar]
  9. Dunn M. M., Drab E. A., Rubin D. B. Effects of irradiation on endothelial cell-polymorphonuclear leukocyte interactions. J Appl Physiol (1985) 1986 Jun;60(6):1932–1937. doi: 10.1152/jappl.1986.60.6.1932. [DOI] [PubMed] [Google Scholar]
  10. ELKIND M. M., SUTTON H. Radiation response of mammalian cells grown in culture. 1. Repair of X-ray damage in surviving Chinese hamster cells. Radiat Res. 1960 Oct;13:556–593. [PubMed] [Google Scholar]
  11. Fajardo L. F. Basic mechanisms and general morphology of radiation injury. Semin Roentgenol. 1993 Oct;28(4):297–302. doi: 10.1016/s0037-198x(05)80091-4. [DOI] [PubMed] [Google Scholar]
  12. Fajardo L. F., Berthrong M. Radiation injury in surgical pathology. Part I. Am J Surg Pathol. 1978 Jun;2(2):159–199. doi: 10.1097/00000478-197806000-00005. [DOI] [PubMed] [Google Scholar]
  13. Fajardo L. F., Berthrong M. Vascular lesions following radiation. Pathol Annu. 1988;23(Pt 1):297–330. [PubMed] [Google Scholar]
  14. Fajardo L. F. Morphologic patterns of radiation injury. Front Radiat Ther Oncol. 1989;23:75–84. doi: 10.1159/000416572. [DOI] [PubMed] [Google Scholar]
  15. Hartrampf C. R., Jr, Bennett G. K. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg. 1987 May;205(5):508–519. doi: 10.1097/00000658-198705000-00009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Hartrampf C. R., Scheflan M., Black P. W. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982 Feb;69(2):216–225. doi: 10.1097/00006534-198202000-00006. [DOI] [PubMed] [Google Scholar]
  17. Henderson B. W., Bicher H. I., Johnson R. J. Loss of vascular fibrinolytic activity following irradiation of the liver--an aspect of late radiation damage. Radiat Res. 1983 Sep;95(3):646–652. [PubMed] [Google Scholar]
  18. Hirst D. G., Denekamp J., Hobson B. Proliferation studies of the endothelial and smooth muscle cells of the mouse mesentery after irradiation. Cell Tissue Kinet. 1980 Jan;13(1):91–104. doi: 10.1111/j.1365-2184.1980.tb00452.x. [DOI] [PubMed] [Google Scholar]
  19. Hopewell J. W., Calvo W., Jaenke R., Reinhold H. S., Robbins M. E., Whitehouse E. M. Microvasculature and radiation damage. Recent Results Cancer Res. 1993;130:1–16. doi: 10.1007/978-3-642-84892-6_1. [DOI] [PubMed] [Google Scholar]
  20. Hornsey S., Myers R., Jenkinson T. The reduction of radiation damage to the spinal cord by post-irradiation administration of vasoactive drugs. Int J Radiat Oncol Biol Phys. 1990 Jun;18(6):1437–1442. doi: 10.1016/0360-3016(90)90319-f. [DOI] [PubMed] [Google Scholar]
  21. Jacobsen W. M., Meland N. B., Woods J. E. Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo clinic experience with 147 cases. Mayo Clin Proc. 1994 Jul;69(7):635–640. doi: 10.1016/s0025-6196(12)61339-1. [DOI] [PubMed] [Google Scholar]
  22. Kroll S. S., Schusterman M. A., Reece G. P., Miller M. J., Smith B. Breast reconstruction with myocutaneous flaps in previously irradiated patients. Plast Reconstr Surg. 1994 Mar;93(3):460–471. [PubMed] [Google Scholar]
  23. Mansfield C. Effects of radiation therapy on wound healing after mastectomy. Clin Plast Surg. 1979 Jan;6(1):19–26. [PubMed] [Google Scholar]
  24. Marcial V. A. The role of radiation therapy in the multidisciplinary management of recurrent and metastatic breast cancer. Cancer. 1994 Jul 1;74(1 Suppl):450–452. doi: 10.1002/cncr.2820741334. [DOI] [PubMed] [Google Scholar]
  25. Matzner Y., Cohn M., Hyam E., Razin E., Fuks Z., Buchanan M. R., Haas T. A., Vlodavsky I., Eldor A. Generation of lipid neutrophil chemoattractant by irradiated bovine aortic endothelial cells. J Immunol. 1988 Apr 15;140(8):2681–2685. [PubMed] [Google Scholar]
  26. Pierce L. J., Glatstein E. Postmastectomy radiotherapy in the management of operable breast cancer. Cancer. 1994 Jul 1;74(1 Suppl):477–485. doi: 10.1002/cncr.2820741337. [DOI] [PubMed] [Google Scholar]
  27. Prionas S. D., Kowalski J., Fajardo L. F., Kaplan I., Kwan H. H., Allison A. C. Effects of X irradiation on angiogenesis. Radiat Res. 1990 Oct;124(1):43–49. [PubMed] [Google Scholar]
  28. Scheflan M., Dinner M. I. The transverse abdominal island flap: part I. Indications, contraindications, results, and complications. Ann Plast Surg. 1983 Jan;10(1):24–35. doi: 10.1097/00000637-198301000-00005. [DOI] [PubMed] [Google Scholar]
  29. Schneider W. J., Hill H. L., Jr, Brown R. G. Latissimus dorsi myocutaneous flap for breast reconstruction. Br J Plast Surg. 1977 Oct;30(4):277–281. doi: 10.1016/0007-1226(77)90117-5. [DOI] [PubMed] [Google Scholar]
  30. Schuster R. H., Kuske R. R., Young V. L., Fineberg B. Breast reconstruction in women treated with radiation therapy for breast cancer: cosmesis, complications, and tumor control. Plast Reconstr Surg. 1992 Sep;90(3):445–454. [PubMed] [Google Scholar]
  31. Slavin S. A., Goldwyn R. M. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg. 1988 Feb;81(2):189–199. doi: 10.1097/00006534-198802000-00008. [DOI] [PubMed] [Google Scholar]
  32. Slavin S. A., Love S. M., Sadowsky N. L. Reconstruction of the radiated partial mastectomy defect with autogenous tissues. Plast Reconstr Surg. 1992 Nov;90(5):854–869. [PubMed] [Google Scholar]
  33. Stewart J. R., Fajardo L. F. Radiation-induced heart disease. Clinical and experimental aspects. Radiol Clin North Am. 1971 Dec;9(3):511–531. [PubMed] [Google Scholar]
  34. Ts'ao C. H., Ward W. F., Port C. D. Radiation injury in rat lung. III. Plasminogen activator and fibrinolytic inhibitor activities. Radiat Res. 1983 Nov;96(2):301–308. [PubMed] [Google Scholar]
  35. Ward W. F., Molteni A., Ts'Ao C. H., Solliday N. H. Pulmonary endothelial dysfunction induced by unilateral as compared to bilateral thoracic irradiation in rats. Radiat Res. 1987 Jul;111(1):101–106. [PubMed] [Google Scholar]
  36. Ward W. F., Solliday N. H., Molteni A., Port C. D. Radiation injury in rat lung. II. Angiotensin-converting enzyme activity. Radiat Res. 1983 Nov;96(2):294–300. [PubMed] [Google Scholar]

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