Citation for published version (APA): Benditte-Klepetko, H. C. (2014). Breast surgery: A problem of beauty or health?

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1 UvA-DARE (Digital Academic Repository) Breast surgery: A problem of beauty or health? Benditte-Klepetko, H.C. Link to publication Citation for published version (APA): Benditte-Klepetko, H. C. (2014). Breast surgery: A problem of beauty or health? General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 29 Nov 2018

2 Chapter V Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction Heike Benditte-Klepetko 1 Oliver Sommer 2 Gabriel Weiss 1 Helmut Czembirek 2 Maria Deutinger 1 1 Department of Plastic and Reconstructive Surgery Hospital Rudolfstiftung 2 Department of Radiology Hospital Hietzing Vienna, Austria Microsurgery 24(3):174-81, 2004

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4 Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 79 Introduction Since the original description by Carl R. Hartrampf jr. in the TRAM-flap has become a well established method for breast reconstruction. The aesthetic result by autologous breast reconstruction is superior to that by implant reconstruction. Nevertheless the main disadvantage is the potential risk for creating weakness of the abdominal wall 2. Despite technical improvement of harvesting by minimising the amount of muscle resection 3,4 and sufficient abdominal wall closure 5, until now the risk still remains. Therefore the integrity of the abdominal wall has to be evaluated in follow up examinations. In different recent studies clinical examinations 6-12 and dynamometry 8,11,12 as well as CT-scans 11,12 and MRI was performed. For morphological evaluation of the muscle function however, an imaging method has to be used which is able to proof functional properties of the remaining muscle. Methods like dynamometry or CT-scan are not always available in the clinical practice or even very expensive. Compared to methods used before, ultrasound imaging is an easily available method, visualising not only static images but also movements of the muscle. Therefore this study was undertaken in order to verify if ultrasound imaging is a reasonable method to examine muscle movements after TRAM-flap procedures in addition to clinical examination. Patients 22 patients have been evaluated. In 8 patients 11 DIEP-flaps (3 bilateral, 5 unilateral reconstructions), in 11 patients 11 unilateral free TRAM-flaps and in 3 patients 3 unilateral pedicled TRAM-flaps have been used for breast reconstruction. The patients were examined month (mean 32 month) after surgery. The mean age of patients after DIEP-flap reconstruction was 50,4 years (39-60 years) and the mean follow up period was 27 month postoperatively (10-47 month). In patients after free TRAM-flap the mean age was 53 years (37-62 years) and the follow up period was 32 month (10-72 month). The mean age of patients after pedicled TRAM-flap reconstruction was 45,3 years (43-53 years) and the follow up period was 35 month (13-55 month). Methods 1. Ultrasound imaging of the abdominal wall was performed in longitudinal as well as in cross sections (Siemens Elegra, Erlangen Germany, multifrequent, 13 Mhz,

5 80 Chapter V Siescape ). The diameter of the remaining muscle was measured 2 cm below the rib bow, at the level of the umbilicus and at the level of the skin scar. For exact measurements the diameter was defined between the inner layers of the Rectus muscle sheets. In case of unilateral breast reconstruction the operated side was compared to the non-operated contra-lateral side. 2. In order to evaluate the contractility of the remaining rectus muscle, the patients were asked to do straight curl-ups while ultrasound monitoring of muscle movements. Muscle contractility as well as muscle diameter was graded into four degrees from described the highest score with unchanged muscle diameter and normal muscle contractility. Score 2 was defined as reduced muscle diameter with remaining muscle contractility, Score 1 as remaining muscle tissue with reduced diameter and without movements, Score 0 described Scar tissue without contractibility. 3. Clinically the functional testing was performed by the well-known method of Janda The abdominal wall was examined for bulging or hernia formation by a plastic surgeon. 5. Additionally the patients answered a six-scale (0 = no impairment, 5 = very strong impairment) self-designed questionnaire concerning the impairment of daily living and pain. Results 1. Even in the longitudinal as in the cross section the Rectus Abdominis muscle is visible. Figures 1-5 show the ultrasound images of a patient after unilateral breast reconstruction by unilateral free TRAM-flap. At the level of the scar the reduced muscle amount after harvesting of a muscle sparing TRAM-flap is shown. The mean diameter of the Rectus Abdominis muscle after bilateral DIEPflap harvesting was 8.0 mm at the level 2 cm below the rib bow, 5.9 mm at the umbilical level and 5.1 mm at the level of the scar. In unilateral harvested flaps the operated side was compared to the non-operated contra-lateral side as described. In free TRAM-flaps the mean diameter at the level 2 cm below the rib bow was 8.1 mm compared to 8.5 mm at the non-operated side. At the umbilical level the mean diameter at the side of the muscle harvesting was 5.3 compared to 9,1 mm, at the level of the scar the mean diameter was 2.9 mm compared to 8.7 mm at the contralateral side. The measurements showed the following diameters for the unilateral pedicled TRAM-flaps: 2 cm below the rib bow the mean muscle diameter was 8.3 versus 8.0 mm at the non-operated

6 Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 81 Figure 1. Longitudinal section of the Rectus Abdominis muscle after free TRAM harvesting Figure 2. Longitudinal section of the Rectus Abdominis muscle without harvesting Figure 3. Cross section 2 cm below the ribcage after unilateral TRAM-flap harvesting Figure 4. Cross section at the umbilicus after unilateral TRAM-flap harvesting

7 82 Chapter V Figure 5. Cross section at the level of the scar after unilateral TRAM-flap harvesting Table 1. Criteria for scoring muscle power (Modified from Janda 1 ) Table 2. Mean muscle diameters at 2 cm below the rib cage, at the level of the umbilicus and at the level of the scar in different types of flaps

8 Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 83 Table 3. Intra-individual comparison of muscle diameters: bilateral DIEP-flap Table 4. Intra-individual comparison of muscle diameters: unilateral DIEP-flap side, at the umbilical level it was 5.4 mm at the operated side compared to 7.1 mm and at the level of the scar the mean diameter was 3.3 compared to 6.4 mm. The intra-individual comparison of the mean muscle diameters is shown in table In figures 6 and 7 the ultrasound images of the Rectus Abdominis muscle is shown while relaxation and contraction. Even in the static images the difference in muscle diameter are shown. During examination even the movements of the muscle tissue can be shown. Two of three bilateral DIEP-flaps showed degree 2 of muscle contractility, 1 reached a score of 1. 1 out of 5 unilateral DIEP-flaps reached a score of 0, 1 out of 5 reached a Score of 1, 2 out of 5 showed degree 2 and 1 out of 5 showed degree 3 of muscle contractibility. Two out of eleven unilateral free TRAM-flaps reached score 0, 3 out of 6 showed score 1 and 6 out of 11 unilateral TRAM-flaps showed degree 2. 1 out of 3 patients after unilateral pedicled TRAM-flap showed a score of 0 and 2 out of 3 patients score 1 (table 5).

9 84 Chapter V Figure 6. Diameter of Rectus Abdominis muscle in relaxed position Figure 7. Diameter of Rectus Abdominis muscle during contraction 3. In the clinical evaluation by Janda 2 of 3 patients after bilateral DIEP-flap reached a score of 5 and 1 patient score 3. After unilateral DIEP-flap 3 of 5 patients reached a Janda score 5, in 2/5 patients a score of 4 was found. Four of eleven patients after unilateral free TRAM-flap showed a Janda score 5, 5/11 patients Janda 4, 1/11 patients Janda 3 and 1/11 patients Janda 2. All 3 patients after unilateral pedicled TRAM-flap reached Janda score 5.

10 Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 85 Table 5a. Intra-individual comparison of muscle diameters: unilateral free TRAM-flap Table 5b. Intra-individual comparison of muscle diameters: unilateral free TRAM-flap 4. In 2 of 3 patients after bilateral DIEP-flap a bulging of the abdominal were found. 1 patient after unilateral DIEP flap had a hernia formation and one showed a bulging. Six of eleven patients after unilateral free TRAM-flap received a abdominal bulging and 1 of 3 patients after unilateral pedicled TRAM-flap. 5. One of three patients after bilateral DIEP-flap reported a severe impairment in daily live activity and 1/3 patients a moderate impairment. After unilateral DIEP-flap 3 of 5 patients rated their impairment at 0 and 1/5 patients specified their impairment as moderate, 1/5 patients as severe. 6 of 11 patients after unilateral free TRAM-flap harvesting had no impairment in daily life activity, 2/11

11 86 Chapter V had a moderate and 3/11 patients a severe impairment. 1 of 3 patients after unilateral pedicled TRAM-flap reported a moderate impairment. 2/3 patients after bilateral DIEP-flap, 1% patients after unilateral DIEP-flap, 3/11 patients after unilateral free TRAM-flap and 2/3 patients after unilateral pedicled TRAMflap reported to have pain. Table 6. Intra-individual comparison of muscle diameters: unilateral pedicled TRAM-flap Table 7. Contractility of remaining Rectus Abdominis Muscle* *Score: 0, no remaining muscle tissue 1, Reduced muscle diameter, no contractility 2. Reduced muscle diameter, remaining contractility 3. Muscle diameter not reduced, remaining contractility

12 Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 87 Table 8. Correlation between subjective impairment in daily life, activity, pain, Janda scores and findings a) bilateral DIEP-flaps Impairment in daily life activity (0-5) Pain (yes/no) Janda (0-5) Contractility (0-3) Patient 1 3 yes 5 1 Patient 2 5 yes 3 2 Patient 3 0 no 5 2 b) unilateral DIEP-flaps Patient 1 0 no 5 2 Patient 2 5 yes 4 0 Patient 3 0 no 4 1 Patient 4 0 no 5 2 Patient 5 3 no 5 3 c) unilateral TRAM-flaps Patient 1 4 no 4 1 Patient 2 4 yes 2 0 Patient 3 5 yes 4 1 Patient 4 0 no 5 0 Patient 5 0 no 4 2 Patient 6 0 no 5 2 Patient 7 0 no 5 2 Patient 8 2 yes 4 2 Patient 9 0 no 5 2 Patient 10 0 no 4 2 Patient 11 3 no 3 1 d) unilateral pedicled TRAM-flaps Patient 1 0 no 5 1 Patient 2 3 yes 5 0 Patient 3 0 yes 5 1 Discussion Functional testing of the abdominal wall as well as CT scans or MRI for evaluation of the remaining Rectus muscle are reported in literature As there is a clear need for reduction of costs in medical treatment we looked for a more cost effective evaluation method compared to CT scan or MRI. Functional ultrasound imaging of the donor site in order to evaluate the remaining Rectus Abdominis muscle is not yet reported in the literature. Our experience showed that ultrasound evaluation could show not just static images like MRI or CT-Scans, but even the movements of the tissue while contraction.

13 88 Chapter V In clinical examination 12 patients reached Janda 5 including all patients after pedicled TRAM-flap although no muscle contractility was left after pedicled flaps. Janda 4 (4/22) and Janda 5 (15/22) was reached mainly after unilateral free TRAM and DIEP-flaps. These findings are comparable with literature reports where permanent muscle damage is described also after muscle sparing techniques of TRAM and DIEP-flaps 2,5,7,9. Due to reports in literature the importance of careful abdominal wall closure and the influence of age on Janda functional testing is stressed 5,8,9-11,14. Therefore not just the way of harvesting is important to the postoperative abdominal wall function. The results of function of the abdominal wall have although to be interpreted in the context of age of the patients as well as stability of the abdominal wall by the way of abdominal wall closure after flap harvesting. No impairment in daily life activity was found in 12 out of 22 patients. The other patients were rated from score 2 to 5 of impairment whereas no more than one or two patients were gathered in each group. Muscle contractility due to grade 2 and 3 could be detected in 11 patients. Absent muscle contractility (degree 0 and 1) was found among all kinds of harvested flaps. In this context the question rises up, if the function of the abdominal wall and the impairment of daily life can be influenced by muscle training, if remaining muscle tissue with poor contractility is shown by Ultrasound evaluation. Further studies are necessary to answer this question. Ultrasound imaging can show contractility and movements of the remaining muscle. Therefore we consider ultrasound investigations to be superior to CT scan or MRI concerning functional evaluation and cost effectiveness.

14 Functional and ultrasound evaluation of donor-site morbidity after TRAM-flap for breast reconstruction 89 References 1. Hartrampf CR, Scheflan M and Black PW: Breast reconstruction following mastectomy with a transverse abdominal island flap. Plast. Reconstr. Surg. 69: 216; Lejour M, Dome M: Abdominal wall function after rectus abdominis transfer. Plast. Reconstr. Surg. 87: ; Koshima I, Moriguchi T, Soeda S, Tanaka H, Umeda D: Free thin paraumbilical perforatorbased flaps. Ann. Plast. Surg. 29: 12-17; Allen RJ, Treece P: Deep inferior epigastric perforator flap for breast reconstruction. Ann. Plast. Surg. 32: 32-38; Hartrampf C. R. jr.: Abdominal wall competence in transverse abdominal island flap operations. Ann. Plast. Surg. 12,2: ; Amez ZM, Khan U, Pogoretec D, Planinsek F: Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br. J. Plast. Surg. 52: ; Blondeel P. N.: One hundred free DIEP-flap breats reconstructions: a personel experience. Br. J. Plast. Surg. 52: ; Hamdi M, Weiler-Mithoff E, Webster M: Deep inferior epigastric perforator flap in breast reconstruction: Experience with the first 50 flaps. Plast. Reconstr. Surg. 103(1): 86-95; Futter CM, Webster MHC, Hagen S, Mitchell SL: A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br. J. Plast. Surg. 53: ; Kroll SS, Marchello M: Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction. Plast. Reconstr. Surg. 89 (6): ; Blondeel PN, Vanderstraeten GG, Monstrey SJ, Van Landuyt K, et al.: The donor site morbidity of free DIEP-flaps and free TRAM flaps for breast reconstruction. Br. J. Plast. Surg. 50: ; Blondeel PhN, Boeckx WD: Refinements in free flap breast reconstruction: the free bilateral deep inferior epigastric perforator flap anastomosed to the internal mammary artery. Br. J. Plast. Surg. 47: ; Janda V.: Muskelfunktionsdiagnostik 2 nd Ed. Berlin: Volk- und Gesundheit Zauner-Dungl A, Resch KL, Herzceg E, Piza-Katzer H: Funktionelle Defizite nach Entnahme des M. rectus abdominis. Handchirurgie Mikrochir Plast Chir 27: 83-88; 1995