Use of Extended Pedicled Transverse Rectus Abdominis Myocutaneous Flap for Extensive Chest Wall Defect Reconstruction After Mastectomy for Locally Advanced Breast Cancer Yun-Nan Lin, MD, a Fu Ou-Yang, MD, PhD, b Meng-Chien Hsieh, MD, a Su-Shin Lee, MD, a Shu-Hung Huang, MD, PD, a Chieh-Han Chuang, MD, c Chih-Hau Chang, MD, a Yur-Ren Kuo, MD, PhD, a Ming-Feng Hou, MD, b and Sin-Daw Lin, MD a,c Background: The reconstruction of a large postmastectomy chest wall defect for patients with stage III/IV breast cancer is a challenge for plastic surgeons. In this study, we present the application of an extended transverse rectus abdominis myocutaneous (TRAM) flap to easily and safely reconstruct these defects. Patients and Methods: A retrospective review from November 1997 to November 2016 revealed that 65 patients with stage III/IV breast cancer immediately underwent postmastectomy TRAM flap reconstruction. In total, 16 patients were enrolled in this study based on the inclusion criteria of a postmastectomy chest skin defect size of greater than or equal to 100 cm 2 and a TRAM flap size of greater than or equal to 80% of the lower abdominal area for reconstruction. Results: Eleven (68.9%) and 5 patients (31.3%) were diagnosed with stage III and stage IV breast cancer, respectively. The chest wall skin defects ranged from 135 to 440 cm 2 . All flap areas exceeded 80% of the lower abdominal area. Over- all, 100% of the harvested flaps were used in 3 patients, and only 1 patient had marginal necrosis in zone IV. No total flap loss was observed. The average length of hospital stay was 5.8 days, and the mean follow-up duration was 46.6 months (range, 4.5–117.7 months). On a Likert scale, the mean follow-up satisfaction score of 10 patients was 4.7. Conclusions: Even when the flap area exceeded 80% of the lower abdominal area, the extended TRAM flap proved an effective and viable method for the immediate reconstruction of extensive postmastectomy chest wall skin defects, resulting in few minor complications and high follow-up satisfaction scores. Key Words: pedicled transverse rectus abdominis myocutaneous flap, chest wall defect reconstruction, locally advanced breast cancer (Ann Plast Surg 2019;00: 00–00) A fter its use for breast reconstruction by Hartrampf et al 1 in 1982, the transverse rectus abdominis myocutaneous (TRAM) flap has become a popular method for breast reconstruction using autologous tissue. 2,3 To enhance the vascularity and extend the flap size, this flap has been modified to produce the double-pedicled TRAM flap, 4 free TRAM flap, 5,6 deep inferior epigastric perforator flap, 7–9 muscle-sparing free flap, 10 superficial inferior epigastric artery flap, 11–13 and delayed flap procedure. 14–16 In this series, a delicate operative technique and in- traoperative preconditioning procedure were performed to increase the vascular territory. Extirpation of a large or locally advanced breast tumor frequently results in an extensive chest wall defect. Several methods have been used to reconstruct such defects, including a thoracoepigastric fasciocutaneous flap, 17,18 latissimus dorsi myocutaneous flap, 19 abdominal myocutaneous flap, 20,21 omental flap, 22,23 and skin graft. 24 In the present case series, we analyzed 16 patients who underwent reconstructive surgery using an extended unilateral TRAM flap, in which zones I, II, III, and IV were included. During the early dissection of the rectus pedicle, the deep in- ferior epigastric vessels along with the rectus muscle were clamped to stimulate the early opening of the choke vessels and to restore perfusion of the flap. An extended TRAM flap can be harvested to reconstruct extensive postmastectomy chest wall defects in patients with locally advanced breast cancer (LABC). PATIENTS AND METHODS A retrospective review was conducted with patients diagnosed with LABC who underwent immediate chest wall defect reconstruction with an extended pedicled TRAM flap between November 1997 and November 2016. Cancer staging was established as per the American Joint Committee on Cancer Staging Manual, Eighth Edition. 25 The inclusion criteria for the patients in this study were a diagno- sis of stage III or IV cancer, a postmastectomy skin defect size of greater than or equal to 100 cm 2 , and a TRAM flap size of greater than or equal to 80% of the lower abdominal area. Through a chart review, we obtained information about each patient's age, histological diagnosis, cancer status, preoperative or postoperative chemotherapy regimen, preoperative or postoperative radiotherapy regimen, postmastectomy skin defect size, reconstructed flap size, and postoperative complications. The patient satisfaction outcomes were followed up by telephone and classified as very satis- fied, satisfied, acceptable, dissatisfied, or very dissatisfied. Surgical Technique In this study, a pedicle based on the contralateral or ipsilateral rectus muscle was used. The main constituents of the regular flap were zones I and III (Hartrampf zones), which did not provide a sufficient area for patients with postmastectomy defects that require a signifi- cantly larger flap. Moreover, for severe cases in this study, the whole lower abdominal donor volume needed to be used for reconstruction. During dissection and elevation of the abdominal flap from the underlying fascia of the transverse abdominal muscle, the perforators of the medial and lateral rows of the rectus pedicle were preserved and included within the pedicle. During elevation of the upper abdom- inal skin and subcutaneous adipose tissue from the anterior fascia of the rectus muscle, the perforating vessels encountered were dissected, clipped, and divided with scissors. Dividing these delicate vessels with a unipolar electric coagulator may cause damage and jeopardize circu- lation. Caution was therefore required. The pedicle was centrally located at a width of approximately one third to one half of the rectus fascia and muscle, leaving a medial Received September 19, 2019 and accepted for publication, after revision September 30, 2019. From the a Division of Plastic and Reconstructive Surgery, Department of Surgery; b Division of Breast Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University; and c Department of Surgery, Kaohsiung Municipal Hsiaokang Hospital, Kaohsiung, Taiwan. Y.-N.L. and F.O.-Y. are cofirst authors. Conflicts of interest and sources of funding: none declared. Reprints: Sin-Daw Lin, MD, Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Shih-Chuan 1st Rd, Kaohsiung 807, Taiwan. E-mail: sidalin@kmu.edu.tw. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/19/0000–0000 DOI: 10.1097/SAP.0000000000002188 BREAST SURGERY Annals of Plastic Surgery • Volume 00, Number 00, Month 2019 www.annalsplasticsurgery.com 1 Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.