title: An algorithmic approach to abdominal flap breast reconstruction in patients with pre-existing scars--results from a single surgeon's experience.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Addenbrooke's University Hospital, Cambridge, UK.
authors.forename: Frank
authors.initials: F
authors.lastname: Hsieh
authors.forename: Devor
authors.initials: D
authors.lastname: Kumiponjera
authors.forename: Charles M
authors.initials: CM
authors.lastname: Malata
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000328:Adult; D000368:Aged; D000465:Algorithms; D002921:Cicatrix / Q000150:complications* / Q000473:pathology; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000009:adverse effects / Q000379:methods*; D008875:Middle Aged; D012189:Retrospective Studies; D013524:Surgical Flaps; D020858:Tissue and Organ Harvesting / Q000009:adverse effects / Q000379:methods; D016896:Treatment Outcome