Fayman Moshe S, Potgieter Estelle, Becker Piet J
Rosebank Clinic, Parklands, Johannesburg, South Africa.
Aesthetic Plast Surg. 2006 May-Jun;30(3):301-8. doi: 10.1007/s00266-005-0147-4.
The transverse rectus abdominis muscle (TRAM) flap technique is the most versatile and artistic procedure currently used for breast reconstruction. Several variations have been described in the past with regard to the aesthetic objectives of reconstruction and the technical steps to achieve these goals. This study aimed to analyze changes introduced by the authors to improve the aesthetic outcome of breast reconstruction using the pedicle TRAM flap in terms of three specific aesthetic goals: (1) better definition of the submammary fold, (2) improved reconstruction of the tail of the breast and anterior axillary wall after axillary clearance, and (3) improved projection of the lower pole of the reconstructed breast.
The design of the pedicle flap has been modified to accommodate four surgical scenarios: vertical orientations of the flap with either an ipsi or contralateral pedicle and horizontal orientation of the flap with either an ipsi or contralateral pedicle. In each of these variations, specific surgical steps were undertaken to produce extension of the flap into the axilla, better definition of the submammary fold, and folding of the flap in its lower part to increase lower pole projection. Postoperatively, standardized five-view images of the patients were taken and presented to blinded observers, who were requested to award a numeric score to the aesthetic outcome. The numeric scores then were analyzed statistically. An experimental group of 11 patients who underwent reconstruction using the modified/improved technique were compared with a control group of 17 patients who underwent reconstruction using the classic technique. The incidences of complications for the two groups were compared and analyzed as well.
The two groups of patients were comparable in terms of their age distribution and incidences of donor site and recipient site complications. A statistically significant difference was noted between the aesthetic scores awarded to patients who underwent surgery using the improved technique and those awarded to those who underwent surgery using the classic technique (p = 0.0006).
A model is presented for statistical analysis of the aesthetic outcome for breast reconstruction using an improved TRAM flap design as compared with using a classic TRAM flap design. This model offers an evidence-based decision-making process and uses the principle of aesthetic breast surgery adapted to breast reconstruction. On the basis of this model, the authors conclude that the aesthetic outcome of breast reconstruction can be improved by attention to details such as better projection of the breast's lower pole, improved sculpting of the submammary fold, and attention to filling contour deficits of the axilla after axillary clearance.
腹直肌横行肌瓣（TRAM）技术是目前用于乳房重建的最通用且最具艺术性的手术方法。过去针对重建的美学目标以及实现这些目标的技术步骤描述了多种变体。本研究旨在分析作者引入的改变，以从三个特定美学目标的角度改善使用带蒂TRAM瓣进行乳房重建的美学效果：（1）更好地界定乳房下皱襞，（2）在腋窝清扫术后改善乳房尾部和腋窝前壁的重建，（3）改善重建乳房下极的突出度。
对带蒂瓣的设计进行了修改，以适应四种手术情况：瓣的垂直方向（带同侧或对侧蒂）和瓣的水平方向（带同侧或对侧蒂）。在这些变体中的每一种中，都采取了特定的手术步骤，以使瓣延伸至腋窝、更好地界定乳房下皱襞，并在瓣的下部进行折叠以增加下极突出度。术后，拍摄患者的标准化五视图图像，并呈现给不知情的观察者，要求他们对美学效果给出数字评分。然后对数字评分进行统计分析。将11例采用改良/改进技术进行重建的患者组成的实验组与17例采用经典技术进行重建的患者组成的对照组进行比较。还对两组的并发症发生率进行了比较和分析。
两组患者在年龄分布以及供区和受区并发症发生率方面具有可比性。在对采用改进技术进行手术的患者的美学评分与对采用经典技术进行手术的患者的美学评分之间发现了统计学上的显著差异（p = 0.0006）。
提出了一种模型，用于对使用改进的TRAM瓣设计与使用经典TRAM瓣设计进行乳房重建的美学效果进行统计分析。该模型提供了基于证据的决策过程，并采用了适用于乳房重建的美学乳房手术原则。基于该模型，作者得出结论，通过关注诸如改善乳房下极的突出度、更好地塑造乳房下皱襞以及关注腋窝清扫术后腋窝轮廓缺陷的填充等细节，可以改善乳房重建的美学效果。
