An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars - results from a single surgeon's experience

Background: Breast reconstruction using the TRAM flap and its variations in patients with pre-existing abdominal scars is controversial. In our practice, abdominal scars are considered not to be a contraindication for such reconstruction. We therefore reviewed our experience and reconstructive strategies adopted in such patients over a 7-year period. Methods: Patients with previous abdominal scars undergoing abdominal flap breast reconstruction performed by a single surgeon (Jan 2000-Dec 2006) were retrospectively reviewed with respect to scar types, reconstructive approach, flap outcomes and donor-site complications. Results: Thirty patients (mean age = 52 years) with pre-existing scars (midline, Pfannenstiel, subcostal, appendicectomy, etc.) underwent unilateral (n = 24) or bilateral (n = 6) breast reconstruction (36 flaps). The flap design strategies employed included splitting the flap (hemi-TRAM), skewing it to avoid abdominal scars, minimal abdominoplasty flap undermining and selective use of DIEP, SIEA, free and pedicled TRAM flaps. There were no free flap failures (0/30), except for one pedicled TRAM flap failure (one out of six). One bilateral DIEP reconstruction patient developed an abdominal bulge requiring mesh repair. No significant wound dehiscence or frank abdominal hernias were recorded. Conclusion: Pre-existing scars are not an absolute contraindication to abdominal flap breast reconstruction. With careful preoperative planning and adoption of appropriate reconstructive strategies, it is possible to achieve satisfactory results comparable to patients without abdominal scars. An algorithmic approach to the selection of the relevant techniques is presented. (C) 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.