Breast Reconstruction with the transverse rectus abdominis flap: an alternative technique for the closure of abdominal defects

INTRODUCTION: The transverse rectus abdominis muscle (TRAM) flap, described by Drever in 1977, was subsequently modified and since then, has rapidly become an important alternative for breast reconstructions. However, bulges and abdominal hernias in the donor area are some of the complications arising from the TRAM flap. This study proposes an alternative technique for the repair of the abdominal defect that minimizes complications and provides better results. METHOD: The retrospective included 120 women who underwent breast reconstruction with TRAM with placement of an abdominal mesh between May 2003 and November 2012, with follow-up of at least six months. Patients were divided into two groups: Group 1 (53 cases) underwent reconstruction with polypropylene mesh positioned between the aponeurotic layers of the external and internal oblique muscles and Group 2 (67 cases) underwent closure of the arcuate Douglas' line and the remaining lower aponeurosis of the rectus abdominis muscle and reinforcement with mesh. RESULTS: The patients were evaluated by the same surgeon, according to the same criteria. The rate of bulging was 18.9% in group 1 and 3% in group 2, a statistically significant difference. Bulges and hernias in the hypogastrium varied from 20% to 44% and 12.5% to 20% respectively, when closed primarily. When synthetic mesh was used, these percentages decreased to 1.5% to 6%. The technical improvement and comparison of results aims to minimize such complications. CONCLUSION: The technique described is advantageous in that, it significantly reduced the occurrence of the most common complication, and increased the aesthetic and functional satisfaction of the patients. INTRODUCAO: O retalho do musculo reto abdominal, descrito por Drever em 1977, foi posteriormente modificado e, desde entao, se tornou rapidamente uma importante alternativa para reconstrucao da mama. Dentre as complicacoes do TRAM, citam-se os abaulamentos e hernias abdominais na area doadora. Este estudo vem propor uma tecnica alternativa de reparo do defeito abdominal, com o objetivo de minimizar tais inconvenientes e proporcionar melhores resultados. METODO: O estudo e de carater retrospectivo, totalizando 120 mulheres submetidas a reconstrucao mamaria com TRAM com colocacao de tela abdominal, e seguimento minimo de seis meses, entre Maio de 2003 e Novembro de 2012. As pacientes foram divididas em dois grupos: Grupo 1 (53 casos) reconstruidos com tela de polipropileno posicionada entre os folhetos aponeuroticos dos musculos obliquo externo e interno, e Grupo 2 (67 casos) realizado fechamento da linha arqueada de Douglas e o remanescente inferior da aponeurose do musculo reto abdominal e reforco com tela. RESULTADOS: As pacientes foram avaliadas pelo mesmo cirurgiao, obedecendo aos mesmos criterios. Os resultados obtidos foram 18,9% de abaulamentos no grupo 1 e 3% no grupo 2, estatisticamente significativo. Abaulamentos e hernias no hipogastrio variam de 20% a 44% e 12,5% a 20% respectivamente, quando fechados primariamente. Quando associado a aplicacoes de telas sinteticas, esses percentuais diminuem para 1,5% a 6%. O aprimoramento tecnico e a comparacao de resultados tem a finalidade de minimizar tais complicacoes. CONCLUSAO: A tecnica descrita mostra-se vantajosa, pois permitiu significativa diminuicao da complicacao mais comum, permitindo satisfacao estetica e funcional das pacientes.