BREAST Outcomes of Various Techniques of Abdominal Fascia Closure after TRAM Flap Breast Reconstruction James H. Boehmler, IV, M.D. Charles E. Butler, M.D. Joseph Ensor, Ph.D. Steven J. Kronowitz, M.D. Houston, Texas Background: There is no consensus regarding the optimal technique for clo- sure of the abdominal fascia after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. The authors reviewed outcomes with various techniques to identify the optimal one. Methods: The authors reviewed the charts of 81 consecutive patients who un- derwent TRAM flap breast reconstruction at their institution from 2002 to 2005. Various amounts of anterior rectus sheath fascia were harvested with the TRAM flap. Patients were divided into five groups based on fascia closure technique: (1) human acellular dermal matrix bridging inlay graft, (2) human acellular dermal matrix bridging inlay graft with primary closure of overlying anterior rectus sheath, (3) polypropylene mesh inlay graft, (4) polypropylene mesh inlay graft with primary closure, and (5) primary closure. For comparative analysis, three additional groups were created: all human acellular dermal matrix bridg- ing inlay graft (groups 1 and 2), all mesh (groups 3 and 4), and all inlay (groups 1 and 3). Rates of donor-site complications were compared between groups. Results: Rates of abdominal bulge formation were as follows: overall, 14.8 percent; human acellular dermal matrix bridging inlay graft alone, 31 percent; human acellular dermal matrix bridging inlay graft plus primary closure, 20 percent; mesh alone, 10 percent; mesh plus primary closure, 5 percent; and primary closure alone, 5 percent. Rates of any complication (including bulge) were as follows: overall, 23.5 percent; human acellular dermal matrix bridging inlay graft alone, 42 percent; human acellular dermal matrix plus primary closure, 20 percent; mesh alone, 30 percent; mesh plus primary closure, 10 percent; and primary closure alone, 5 percent. Time to bulge formation was longer for all human acellular dermal matrix versus all mesh (p  0.021. Time to any complication was longer for all inlay versus primary closure alone (p  0.048), human acellular dermal matrix alone versus primary closure alone (p  0.041). Conclusions: For abdominal fascia repair after TRAM flap breast reconstruction, primary closure, when feasible, is preferable to an inlay graft; polypropylene mesh is preferable to human acellular dermal matrix if an inlay graft is required; adding primary closure to a mesh or human acellular dermal matrix inlay graft reduces bulge formation and other complications; and bulge occurs later with human acellular dermal matrix than with synthetic mesh. (Plast. Reconstr. Surg. 123: 773, 2009.) I n patients undergoing transverse rectus abdo- minis myocutaneous (TRAM) flap breast re- construction, it is critical to limit donor-site complications, particularly postoperative abdom- inal bulge. The desire to minimize abdominal do- nor-site morbidity while maximizing aesthetic out- comes and safety has led plastic surgeons to use less invasive techniques for harvesting abdominal adipose tissue for breast reconstruction. The evo- lution from the original pedicled TRAM flap 1,2 to From the Department of Plastic Surgery and the Division of Quantitative Sciences, University of Texas M. D. Anderson Cancer Center. Received for publication July 29, 2008; accepted September 25, 2008. Copyright ©2009 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e318199ef4f Disclosures: James H. Boehmler, IV, M.D., Joseph Ensor, Ph.D., and Steven J. Kronowitz, M.D., have no commercial associations or financial associations that might pose or appear to pose a conflict of interest with information presented in this article. Charles E. Butler, M.D., serves on the speaker’s bureau for LifeCell Corp. www.PRSJournal.com 773