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Reconstruction with Bilateral Pedicled TRAM Flap for Paraffinoma Breast Jin-Shyr Chen, M.D., Wen-Chung Liu, M.D., Kuo-Chung Yang, M.D., Lee-Wei Chen, M.D., Jer-Shyung Huang, M.D., and Hong-Tai Chang, M.D. Kaohsiung, Taiwan

cases. The breast softness satisfaction rate in primary cases was also 100 percent and nine of 11 for secondary cases. Excellent cosmetic results were achieved in all patients (42 breasts in total). The unfavorable results of the secondary cases (patients with previous treatments) indicate that it is impossible to completely remove all of the injected foreign body by resection. This also means that scar appearance can only be minimized if resection of the entire paraffinoma is performed through a periareolar incision. The excellent results of the primary cases show that immediate autogenous tissue reconstruction should be the first alternative and is the best option for treating foreign-body granuloma breast, given that autogenous tissue is available. Similarly, the results of the secondary cases also demonstrate that autogenous tissue reconstruction could be considered in reversing some unfavorable results of past treatments. (Plast. Reconstr. Surg. 115: 96, 2005.)

Although autogenous tissue can be used to replace unsatisfactory prosthetic breast reconstructions in mastectomy patients, because of the magnitude, complexity, and many potential complications associated with the procedure, combined with a longterm recovery, the use of an implant to replace the mastectomy defect is still the most common method for paraffinoma breast treatment. Between July of 1996 and June of 2003, 21 paraffinoma breast patients underwent bilateral pedicle transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. There were 10 primary cases that had never been treated before this visit, including a case of unilateral associated breast cancer. There were also 11 secondary cases that had prostheses implanted after removal of materials injected in other clinics. The diagnoses included unacceptable breast contour in 11 patients, breast hardening in 11 patients, palpable nodules in five patients, nipple malposition in four patients, prominent scarring in three patients, breast skin necrosis in one patient, and nipple necrosis in one patient. A 100 percent flap survival rate with no clinical fat necrosis was achieved. There were 11 of 21 abdominal hypertrophic scars, six of 21 prechest (anterior surface of the thorax) hypertrophic scars, and no abdominal hernia; the symmetry satisfaction rate was 100 percent among primary cases and nine of 11 in secondary

Autogenous tissue reconstruction or prosthesis insertion has long been an issue discussed widely,1–3 and its importance cannot be ignored, especially among mammaplasty patients injected with paraffin. Paraffin injection was widely used in breast augmentation until the long-term complication of paraffinoma was recognized. The injection of highly viscous fluids into the tissues for cosmetic body contour-

From the Department of Surgery, Kaohsiung Veterans General Hospital. Received for publication August 25, 2003; revised January 12, 2004. DOI: 10.1097/01.PRS.0000146035.74007.FF

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ing has been practiced in the past four decades in the east and southeast of Asia. In Hong Kong, Taiwan, and Japan, injection of liquid paraffin for mammary augmentation was widely practiced in the 1950s and 1960s. Unfortunately, most of these cases developed complications because of foreign-body reactions and resulted in a variety of paraffinomas, the impact of which ranges from a painless mass to a destructive ulcer simulating breast cancer. Histopathology of paraffinoma breast shows extensive fibrosis, dystrophic calcification, and a foreign-body reaction including chronic granulomatous inflammation with infiltration of lymphocytes, plasma cells, lipidcontaining foamy cells, cystic spaces containing paraffin oil, and calcification. Histochemistry reveals paraffin wax without silicone and inorganic components consisting mainly of calcium and phosphorus. Although satisfactory results can be achieved in most cases by using implants for breast reconstruction after subcutaneous mastectomy, there are many complications associated with treating patients with injected mammaplasty.4,5 This is because the depth of the foreign-body injection varies widely between the subcutaneous layer and the pectoris major muscle. Consequently, a simple subcutaneous mastectomy cannot completely remove the injected foreign body,6 leaving foreign-body residues in the

breast pocket even after resection of breast resection, inevitably causing problems such as capsular contracture and unsatisfactory breast contours after implantation. The resection process may also affect the circulation of the overlying skin. These are but a few of the unfavorable results of using implants to reconstruct injected breasts. This article discusses the use of autogenous tissue transfer to replace the implant.6 – 8 The procedure uses the extensibility and softness of autogenous tissue to supplement the many shortcomings of implantation, recovering both the volume and the shape of the breast pocket after resection. PATIENTS

AND

METHODS

From July of 1996 to June of 2003, a total of 21 patients with paraffinoma breast disease were evaluated and treated at Kaohsiung Veterans General Hospital in Taiwan. The patients who underwent reconstruction were divided into two groups, the primary group and the secondary group. The primary group consisted of 10 injected mammaplasty patients who had never been treated previously. Of these 10, seven had multiple palpable nodules without contour deformity, two had total breast hardness with contour deformity, and one suffered multiple palpable nodules without contour deformity on the left breast and multiple palpa-

TABLE I Patient Data Collected between July of 1996 and June of 2003

Patient

Primary 1–7

Left Breast Scenario

Right Breast Scenario

Multiple palpable nodules without contour deformity

8 and 9

Total breast hardness with contour deformity

10

Multiple palpable nodules without contour deformity

Secondary 11

Multiple palpable nodules with intraductal carcinoma (T1N0M0)

16–18

Grade IV capsular contracture with axillary and infraclavicular depressant deformity, with lateral deviation of the left nipple Grade III capsular contracture with obvious inframammary scar and downward gaze nipple Grade III capsular contracture with lateral deviation of nipple Grade III capsular contracture Grade III capsular contracture with palpable nodules with obvious axillary scar and depressant deformity Grade IV capsular contracture Grade IV capsular contracture with inframmary skin with inframmary skin necrosis and nipple necrosis necrosis and implant with implant exposure exposure Grade III capsular contracture with multiple palpable nodules

19–21

Grade III capsular contracture

12 13 14

15

Underwent Operation

Bilateral periareolar subcutaneous mastectomy and inset bilateral pedicle TRAM flap Left breast periareolar subcutaneous mastectomy; right breast skin-sparing mastectomy and inset the bilateral pedicle TRAM flap Removal of prosthesis and inset bilateral pedicle TRAM flap

Removal of prosthesis and inset the bilateral pedicle TRAM flap with reconstruction of the breast envelope Removal of prosthesis and inset the bilateral pedicle TRAM flap


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TABLE II Postoperative Complications and Results Primary Cases (n ⫽ 10)

Results

Flap survival Abdominal hypertrophic scar Prechest hypertrophic scar Abdominal hernia Symmetric satisfaction Breast softness satisfaction

10 4 0 0 10 10

(patients 1–10) (100%) (patients 1–3, 8) (40%)

(patients 1–10) (100%) (patients 1–10) (100%)

ble nodules with intraductal carcinoma (T1N0M0) on the right (Table I). The secondary group had 11 injected mammaplasty patients who had prostheses implanted after the removal of injected materials and granuloma tissue resection in other clinics, but all with unfavorable results. All of the 11 secondary group cases had unacceptable breast contour and breast hardening caused by capsular contracture, five of the 11 had palpable nodules, four had malpositioning of the nipples, three had prominent scarring, and one had bilateral lower hemisphere breast skin necrosis and unilateral nipple necrosis. All patients were women, with a mean age of 41 years (range, 36 to 54 years).

Secondary Cases (n ⫽ 11)

11 5 6 0 11 10

(patients 11–21) (100%) (patients 12–15, 21) (45%) (patients 11, 14–18) (55%) (patients 11–21) (100%) (patients 11–19, 21) (91%)

Preoperative evaluation included psychological status, previous abdominal surgery, smoking history, diabetes mellitus, obesity, and so forth. Both groups underwent immediate pedicled transverse rectus abdominis myocutaneous (TRAM) flap reconstructions; however, the primary group was first treated with bilateral skin-sparing mastectomy, whereas the secondary group had removal of the prosthesis and resection of the residual palpable nodules. The decision to proceed in both groups was made jointly by the patients, their family, the surgical oncologist, and the plastic surgeon. Preoperative planning, including the incision line design, the possible dissected area, and the arrangement to have the TRAM flaps raised

FIG. 1. Patient 15. (Above) Preoperative views showing grade IV capsular contracture, with inframammary skin necrosis and implant exposure in both breasts and nipple necrosis in the right breast. (Below) Postoperative views; the TRAM flaps were used to reconstruct the breast tissue defect and the skin defect.


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concurrently with the mastectomy procedure, was performed by the surgical oncologist and plastic surgeon team. Bilateral pedicle TRAM flaps were raised using part of the rectus abdominis muscle and preserving as much of the anterior rectus sheath as possible.9 –11 Each flap was tunneled ipsilaterally into the corresponding mastectomy site, and the ideal inframammary fold and lateral breast margin were recreated in sitting position. Then, the flap was inset, contoured, and deepithelialized. The anterior rectus fascia were bilaterally closed with 1-0 Prolene nonabsorbable suture, which was reinforced with onlay Gore-Tex mesh (W. L. Gore and Associates, Flagstaff, Ariz.), and then the donor-site skin was closed in layers. The flap was regularly monitored by color Doppler sonography postoperatively to follow up the vascularity of the TRAM flap after denervation of the eighth thoracic intercostal nerve. Patient data are listed in Table I. RESULTS

During the aforementioned interval, a total of 21 complete records of patients who underwent bilateral pedicle TRAM flaps were divided into primary (10 patients) and secondary (11 patients) groups (Table I). There was total flap

survival with no partial flap necrosis after 3 months. Patients were evaluated subjectively and objectively for abdominal wall function12,13 by examining the ability of the patient to get up from a supine position on a flat examining table to a fully upright position, without the assistance of the upper limbs. No hernia was found. Abdominal hypertrophic scar was noted in primary cases (four of 10) and secondary cases (five of 11). Prechest hypertrophic scar was noted only in secondary cases (six of 11). Total symmetrical satisfaction from patients was obtained from both groups (primary, 10 of 10; secondary, 11 of 11). Breast softness satisfaction of the patients was 10 of 10 for primary and 10 of 11 for secondary cases. The only case of unsatisfied breast softness occurred in one of the 11 secondary cases that had undergone two prior implant exchanges that resulted in thin and contractured breast skin envelope. Otherwise, all of the patients were extremely satisfied with the result of the procedure (Table II). DISCUSSION

This discussion focuses on the treatment of paraffinoma breasts. Immediate autogenous tissue reconstruction is the best and should be

FIG. 2. Patient 1. (Above) Preoperative views showing multiple palpable nodules without contour deformity. (Below) Images obtained approximately 3 months postoperatively showing effective breast augmentation, with the periareolar scars hidden and complete absence of the bulky rectus muscle pedicle over the medial part of inframammary fold.


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the first alternative to treat foreign-body granuloma breasts, given that autogenous tissue is available. This concept is supported by many secondary cases with unfavorable results caused by the presence of foreign bodies. It is impossible to completely remove all the injected foreign material during resection so that, even after resection, the body is still under the influence of foreign material. Obviously, the input of yet another artificial implant will lead to future unfavorable results, because it is impossible for an artificial implant to fully meet the irregular shape and volume of the defect after removal of breast tissues. Moreover, reconstruction of breast contouring after artificial implantation has long been a difficult challenge, in addition to the unnatural hardness of the breast after reconstruction. It is important to perform the resection of granuloma with an attitude similar to that preferred for a benign tumor, not for a malignant tumor. This means that there is no need for radical excision, and as much normal breast tissue should be preserved as possible during resection. Indeed, many unfavorable results such as marked scars and breast skin necrosis occur because of a radical excision procedure (Fig. 1). Thus, to minimize scar appearance, resection of the entire paraffinoma palpable

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nodule can only be done through a periareolar incision. It can be seen, by comparing the occurrence of prechest scars in the two groups (primary, zero of 10; secondary, six of 11), that periareolar incision is an effective procedure to improve the aesthetic result of the breast (Figs. 2 and 3). Moreover, wherever there is a tissue deficit, the autogenous tissue can be put into the defect. Ideal content within an ideal pocket is essential for an ideal reconstruction. An ideal pocket can be created by restoring a good inframammary fold and lateral margin of the breast. Shaping largely depends on putting the ideal content in that ideal pocket. Autogenous tissues offer the reconstructive surgeon considerable flexibility in flap sculpturing and insetting to achieve optimal contouring and symmetry (Fig. 4, below, left and right). The use of autogenous tissues to restore breast contour avoids the various complications associated with implants including rupture, extrusion, and capsular contracture, especially after the paraffinoma resection. The TRAM flap can provide immediate soft-tissue replacement and the breast skin envelope that resurfaces to the mastectomy site, without relying on prolonged tissue expansion (Fig. 1).

FIG. 3. Patient 9. (Above) Preoperative views showing total breast hardness, with contour deformity and downward gaze of bilateral nipples. (Below) Postoperative views showing effective breast augmentation and noticeable improvement of breast contour and texture, with hidden periareolar scars.


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FIG. 4. Patient 10. (Above) Preoperative views; both breasts have multiple palpable nodules, but the left breast has no contour deformity, whereas the right breast has intraductal carcinoma (T1N0M0). Thus, in treatment, the left breast underwent subcutaneous mastectomy through a lower hemisphere periareolar incision, and skin-sparing mastectomy was performed on the right breast. Note the left paramedian incision of the bilateral pedicle TRAM flap to accommodate for the different sizes of the ipsilateral breast defect (above, right). (Below) Five-month postoperative views; the two side views show symmetric expression of the breast contour, even though different size flaps were transferred.

Autogenous tissue transfer is a safe and viable option for paraffinoma breast reconstruction after mastectomy in both primary and secondary cases in our study. This can be seen in our results: 100 percent flap survival rate, 11 of 21 abdominal hypertrophic scars, six of 21 hypertrophic scars of prechest, no abdominal hernia, total symmetric satisfaction rate from both groups, and total texture satisfaction rate in primary cases and in 10 of 11 secondary cases (Table II). Excellent cosmetic results were achieved in all patients (42 breasts). The number of complications of these cases of simultaneous bilateral mastectomies and TRAM flaps was lower than expected. These encouraging results should be credited to effective teamwork during surgical resection and flap harvesting, all of which began with the preoperative planning. Postoperative clinical palpable induration is a main concern for most of the patients. In this study, no postoperative clinical palpable induration was observed in any of the patients. This

indicates the absence of residual paraffinoma nodule and clinical fat necrosis. Therefore, subcutaneous mastectomy with periareolar incision allows for resection of most paraffinoma tissues while preserving as much overlying skin as possible. Preoperative evaluation of induration in patients is monitored routinely by sonograms. These are used as references during the operation to locate and remove the induration, thus minimizing postoperative residuals of palpable nodules. Also, harvesting a flap without zone III and zone IV allows the bilateral pedicle TRAM flaps to be well vascularized, minimizing postoperative fat necrosis.14,15 To achieve satisfactory postoperative breast softness, there needs to be not only proper vascularization of the flap but also sufficient breast envelope skin. Patient 11 (Fig. 5) had received two implant replacements that resulted in a thin and contractured breast skin envelope. Because of the lack of sufficient skin envelope, a better result could have been achieved if patient


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FIG. 5. Patient 11. (Above) Preoperative views showing grade IV capsular contracture, with axillary and infraclavicular depressant deformity and lateral deviation of the left nipple. (Below) Images obtained approximately 7 months postoperatively showing good breast contour and correction of the nipple deviation but unsatisfied breast softness.

FIG. 6. Patient 12. (Above) Preoperative views showing grade IV capsular contracture, prosthesis migrating upward with obvious inframammary scar, and downward gazing nipple. (Below) Images obtained approximately 3 months postoperatively showing minimal inframammary scar, with mild ptosis of the breast and neutralization of the nipple.


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FIG. 7. Patient 13. (Above) Preoperative views showing grade III capsular contracture, with lateral deviation of the nipple, irregular midline abdominal scar, and contour deformity of the lower abdomen. (Below) Images obtained 8 months postoperatively showing effective breast augmentation, with neutralization of the nipple and a flattened abdominal wall.

11 had undergone tissue expansion before the autogenous tissue transfer. Even in cases without problems associated with a thin and contractured skin envelope, the use of implants should still be discouraged. In patient 12 (Fig. 6), the upward migration of the implant resulted in a downward gaze of nipples and obvious inframammary scar. Likewise, the medial migration of implants caused lateral deviation of the nipple in patient 13 (Fig. 7). Patient 10 (Fig. 4) had bilateral paraffinoma breast with multiple palpable nodules. However, the procedures for the left and right

breasts were different. The left breast underwent subcutaneous mastectomy with a lower hemisphere periareolar incision because it had no contour deformity, whereas the right breast underwent skin-sparing mastectomy because of intraductal carcinoma (T1N0M0). This led to a larger defect on the right breast, which required a larger ipsilateral flap for transfer. Thus, we made a left paramedian incision on the bilateral pedicle TRAM flap (Fig. 4, above, right). When making the paramedian incision, it is absolutely essential to preserve an adequate perforator on the left side (smaller


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PLASTIC AND RECONSTRUCTIVE SURGERY,

side) to allow sufficient blood supply to the left flap. However, because of the complicated technical and surgical demands, the use of the TRAM flap has the drawbacks of being expensive and possibly leading to severe complications. It also requires a longer hospitalization and recovery than other alternatives such as tissue expansion and latissimus dorsi flap reconstruction. If a TRAM flap is unavailable, the latissimus dorsi flap is a reliable alternative that has relatively few early complications or serious morbidity for breast reconstruction. CONCLUSIONS

Immediate autogenous tissue reconstruction could be considered as the first alternative for treating foreign-body granuloma breasts, provided that autogenous tissue is available. There is no need for radical excision, and as much normal breast tissue should be preserved as possible during resection. The flexibility of autogenous tissue allows a perfect fit between the content and the breast pocket, which is the key to achieving natural breast contour and shape. Autologous tissue reconstruction can provide not only the breast volume restoration but also the breast skin envelope. We conclude that autogenous tissue reconstruction could be deemed as an effective treatment option for all paraffinoma and/or foreign-body granuloma breasts in both primary and secondary cases. Jin-Shyr Chen, M.D Department of Surgery Kaohsiung Veterans General Hospital 386 Ta-Chung 1st Road Kaohsiung, Taiwan 813 jc0707@ms13.hinet.net REFERENCES 1. Kroll, S. S., and Baldwin, B. A comparison of outcomes using three different methods of breast reconstruction. Plast. Reconstr. Surg. 90: 455, 1992.

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2. Hartrampf, C. R., Scheflan, M., and Black, P. W. Breast reconstruction with a transverse abdominal island flap. Plast. Reconstr. Surg. 69: 216, 1982. 3. Gibney, J. The long-term results of tissue expansion for breast reconstruction. Clin. Plast. Surg. 14: 509, 1987. 4. Tinkler, L. F., and Stock, F. E. Paraffinomas of the breast. Aust. N. Z. J. Surg. 25: 142, 1995. 5. Ortiz-Monasterio, F., and Trigos, I. Management of patients with complications from injections of foreign materials into the breasts. Plast. Reconstr. Surg. 50: 42, 1972. 6. Yang, W. T., Suen, M., and Ho, W. S. Paraffinomas of the breast: Mammographic, ultrasonographic and radiographic. Clin. Radiol. 51: 130, 1996. 7. Aoki, R., Mitsuhashi, K., and Hyakusoku, H. Immediate reaugmentation of the breast using bilateral divided TRAM flap after removing injected silicone gel and granulomas. Aesthetic Plast. Surg. 21: 276, 1997. 8. Lai, Y. L., Weng, C. J., and Noordhoff, M. S. Breast reconstruction with TRAM flap after subcutaneous mastectomy for injected material (siliconoma). Br. J. Plast. Surg. 54: 331, 2001. 9. Lai, Y. L., Yu, Y. L., Centeno, R. F., and Weng, C. J. Breast augmentation with bilateral deepithelialized TRAM flaps: An alternative approach to breast augmentation with autologous tissue. Plast. Reconstr. Surg. 112: 302, 2003. 10. Noone, R. B., Murphy, J. B., Spear, S. L., and Little, J. W. A 6-year experience with immediate reconstruction after mastectomy for cancer. Plast. Reconstr. Surg. 76: 258, 1985. 11. Hartrampf, C. R. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast. Reconstr. Surg. 83: 842, 1989. 12. Kind, G. M., Rademaker, A. W., and Mustoe, T. A. Abdominal-wall recovery following TRAM flap: A functional outcome study. Plast. Reconstr. Surg. 99: 417, 1997. 13. Mizgala, C. L., and Hartrampf, C. R. Assessment of the abdominal wall after pedicled TRAM flap surgery: 5to 7-year follow-up of 150 consecutive patients. Plast. Reconstr. Surg. 93: 988, 1994. 14. Kroll, S. S., Cherardini, G., Martin, J. E., et al. Fat necrosis in free and pedicled TRAM flaps. Plast. Reconstr. Surg. 102: 1502, 1998. 15. Kroll, S. S. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast. Reconstr. Surg. 106: 576, 2000.

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