Floor plan - 2013 Annual Meeting - American Association for Hand ...

Aesthetic Outcomes in the Free TRAM, DIEP and SIEA: Does Muscle Improve Projection
Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA
Jesse Creed Selber, MD, MPH; Mirar Bristol; Seema Sonnad; Joseph Serletti; University of Pennsylvania
BACKGROUND:
The free TRAM flap differs from the DIEP and SIEA flaps in that it retains a portion of the rectus abdominus muscle in the flap. This muscle
adds bulk in the antero-posterior vector, and some speculate that this bulk improves the projection and overall aesthetic appearance
of the reconstructed breast. This is the first study aimed at comparing the aesthetic characteristics of the TRAM, the DIEP and the
SIEA.
METHODS:
The authors performed a prospective, blinded, cohort study in which consecutive patients having undergone either bilateral or unilateral
autogenous breast reconstruction, were photographed in standard three view fashion. Ninety-two free TRAM flaps, thirty-two DIEP
flaps and sixteen SIEAs were compared. The photographs, devoid of patient identifiers, were evaluated by 2 plastic surgeons, and a
lay person, based on a validated, standardized rating sheet for aesthetic attributes. Patients also evaluated their own reconstructions.
Results were compared using Kruskal -Wallis tests for significance.
RESULTS:
Areas evaluated included vertical and horizontal positioning, projection, naturalness, quality of the infra-mammary fold, medial fullness
and overall appearance. The results demonstrate no significant difference in aesthetic outcomes among the three techniques based
on patient or physician ratings. The lay person, who was also the only person to see all the reconstructed breasts in person, rated the
free TRAM flap as having more projection (p = 0.02), less of the defect visible (p = 0.05) and better overall appearance (p = 0.08).
CONCLUSIONS:
The aesthetics of the reconstructed breast may be affected by multiple factors. The authors believe that projection is improved by the
muscle included in a free TRAM flap, a benefit not enjoyed by the DIEP and SIEA reconstructions. Out of four blinded evaluators, only
one found this to be the case. Interestingly, it was the only person to evaluate the breasts in three dimensions. Results of this study
demonstrate that the free TRAM flaps may have better projection than muscle sparing procedures. A larger series would help clarify
this question.
Free Fibular Graft for Post-Traumatic Upper Extremity Reconstruction :Report on 31 Cases
Institution where the work was prepared: Department of Orthopaedics University of Modena and CTO Florence,
Modena and Florence, Italy
Roberto Adani, MD1; Luca Delcroix, MD2; Luigi Tarallo1; Marco Innocenti, MD2; (1)University of Modena and Reggio
Emilia, (2)CTO Florence
PURPOSE:
Vascularized bone graft is most commonly applied for lower extremity reconstruction. However, indications for its use in the reconstruction
of the upper extremity have expanded in recent years, as the technique as become increasingly appreciated. The aim of this paper
is to review our experience with the use of vascularized fibular graft(VFG) in the treatment of large bone defects, after trauma or
osteomyelitis, located in the upper extremity.
METHOD:
Between 1993-2005, 31 patients with segmental bone defects following upper extremity trauma were managed with VFG. There were
22 males and 9 females, aged 39 years on average (range,16 to 65 years). The reconstructed site was clavicle(1 case), humerus (13 cases),
radius (11 cases) and ulna (6 cases). The length of bone defect ranged from 6 to 16 cm; in five cases the fibular graft was harvested and
used as a vascularized fibula osteoseptocutaneous flap.
RESULTS:
29 grafts were successful. The mean period to obtain radiographic bone union was 5.4 months(mean time in the humerus 6 months
and in the forearm 4.8 months). Three patients required additional bone grafts and two cases showed fractures of the grafted bone.
DISCUSSION:
The results obtained suggest that the use of the VFG to the arm is more complex than application to the forearm with a higher rate of
complications. A vascularized fibular graft is indicated in cases were conventional treatment has failed, and for reconstruction of bone
defects larger than 6-7 cm in the humerus or forearm bones. It is also indicated in cases involving osteomyelitis and infected nonunion.
CONCLUSIONS:
Fibular graft allow the use of a segmental of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length
to reconstruct skeletal defects of the arm.
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