ORIGINAL ARTICLE

Immediate transverse rectus abdominis musculocutaneous(TRAM) flap breast reconstruction in underweight Asian patients

Eun Key Kim • Jin Sup Eom • Chang Heon Hwang •

Sei Hyun Ahn • Byung Ho Son • Taik Jong Lee

Received: 28 February 2012 / Accepted: 8 January 2013

� The Japanese Breast Cancer Society 2013

Abstract

Background TRAM breast reconstruction is commonly

thought to be inadequate for underweight patients and LD

flap with implant is usually recommended. However, it is

often difficult to find an appropriate implant for thin Asian

women with small breasts. The authors present the results

of using TRAM flap alone for immediate breast recon-

struction in underweight Asian patients.

Methods Between September 2001 and October 2006,

564 patients underwent immediate TRAM flap-only

breast reconstruction. Among these, 18 were underweight

(BMI\18.5 kg/m2) and 317 were normal weight (18.5 kg/

m2 B BMI \ 23.0 kg/m2). Complications were classified

as systemic, breast, and donor site. Complication rate,

oncologic outcome and overall satisfaction and recom-

mendation were compared between two groups. Standard-

ized postoperative photographs were also subject to a panel

for cosmetic assessment.

Results the overall complication rate was 22.2 % in

underweight group and 27.1 % in normal weight group

(p = 0.32). There was a tendency that the breast compli-

cation rate was higher in the normal weight group and the

abdominal complication rate was higher in the underweight

group. However, neither of these was statistically signifi-

cant. Mean satisfaction was not statistically different, either

(8.44 vs. 8.60, p = 0.54). Panel assessment for overall

cosmesis, symmetry and scarring showed no significant

between-group differences.

Conclusions Immediate breast reconstruction using

TRAM flap alone can be performed with acceptable com-

plication rates and comparable patients’ satisfaction score

in a well selected underweight Asian women as in a normal

weight group.

Keywords Breast reconstruction � Thinness �Underweight � TRAM flap

Introduction

Since Hartrampf et al. [1] first introduced it more than

30 years ago, the pedicled transverse rectus abdominis

musculocutaneous (TRAM) flap has been a popular and

reliable option in immediate breast reconstruction with its

undefeated merit of relative simplicity [2]. However, many

surgeons hesitate to use TRAM flap breast reconstruction

in underweight patients thinking that they would have

insufficient abdominal tissue. The common autologous

tissue reconstructive procedure in these patients has been

latissimus dorsi (LD) flap combined with implant, and

other sources such as buttock or thigh have also been

sought [3–5]. However, in lean Asian women with rela-

tively small breasts, it is difficult to find implants with

appropriate width and projection. In our experience, these

patients usually have small dense breasts with minimal

projection. Using conventional implants in these patients

usually results in breasts with insufficient width and

excessive projection (Fig. 1), which may be hard to cam-

ouflage even with covering latissimus dorsi. The intent of

this article is to present the results of using TRAM flap

E. K. Kim � J. S. Eom � C. H. Hwang � T. J. Lee (&)

Department of Plastic Surgery, Asan Medical Center,

University of Ulsan, Pungnap-2 dong, Songpa-gu, Seoul, Korea

e-mail: tjlee@amc.seoul.kr

S. H. Ahn � B. H. Son

Department of Surgery, Asan Medical Center,

University of Ulsan, Seoul, Korea

123

Breast Cancer

DOI 10.1007/s12282-013-0443-9

alone for immediate breast reconstruction in 18 under-

weight Asian patients.

Methods

The records of all patients who underwent immediate breast

reconstruction using TRAM flap alone for immediate breast

reconstruction between September 2001 and October 2006

by the senior author were prospectively collected. An

underweight patient was defined as having a Body Mass

Index (BMI) less than 18.5 kg/m2, and a normal weight

patient was defined as having BMI C18.5 kg/m2 and

\23.0 kg/m2 (by World Health Organization Asian Obesity

Criteria). A total of 564 patients underwent TRAM flap

reconstruction after skin or nipple-areolar skin sparing mas-

tectomy and 18 of those were underweight. Complication

rates, subjective satisfaction score and oncologic outcome

were prospectively compared between the underweight

(n = 18) and the normal weight patients (n = 317). Com-

plications were classified as systemic, breast, and donor site.

Additionally, the patients were asked to report their overall

satisfaction with the procedure and the outcome on a ten-

point scale (10, extremely satisfied; 0, extremely unsatisfied)

and to report whether they would recommend it to their

friend. Finally, postoperative photographs taken [2 years

after surgery were subject to panel to evaluate overall cos-

metic outcome. Five standardized views (frontal, two obli-

que-lateral, two lateral) were taken and scored by three blind

independent healthcare professionals: a male plastic surgery

resident, a female breast care nurse, and a male plastic sur-

gery clinical fellow, none of whom were involved in any

patient’s treatment. A comparison was made between all

available underweight patients (n = 16) and matched (age,

height, method of mastectomy, stage, adjuvant therapy) with

normal weight patients (n = 45) who were extracted among

those who underwent breast reconstruction in the same

month as each underweight woman. A four-point scale [6]

was used (4 = excellent, 3 = good, 2 = fair, 1 = poor) to

score overall cosmesis and specifically for symmetry of size,

shape, nipple-areolar complex and finally for scars of breast

and abdomen. The average follow-up period was 74 months

(range 45–106 months). Student’s t test and Fisher’s exact

test were used for data analysis. Statistical analyses were

performed using SPSS version 12.0 (SPSS Inc., Chicago, IL,

USA) and a p value less than 0.05 was considered as statis-

tically significant.

Results

Patients’ demographic as well as oncologic data are sum-

marized in Table 1. The mean age of the underweight

patients was 41.1 years (range 34–51) at the time of

operation and their mean BMI was 17.9 kg/m2 (range

15.7–18.5). The average weight of the removed breast

tissue of underweight group was 239.7 g. The nipple was

preserved in 6 out of 18 cases. The mean age of the normal

group patients was 40.7 years (range 34–51) at the time of

operation and their mean BMI was 21.0 kg/m2 (range

18.5–22.9). In the normal weight group, the average weight

of the removed breast tissue was 377.7 g; and the nipple

was preserved in 84 out of 317 cases. There was no sig-

nificant difference in average age and the ratio of nipple

preservation. As for the stage distribution, a Chi square

test revealed no significant between-group difference

(p = 0.905).

One underweight patient experienced distant metastasis

(5.6 %) and another died of ovarian cancer (second pri-

mary cancer). In normal weight group, seven local recur-

rences (2.2 %), six regional recurrences (1.9 %), and eight

distant metastases (2.5 %) were observed (overall 6.6 %).

A total of nine patients (2.8 %) died of breast cancer in the

normal weight group. Although no statistical comparison

was conducted due to the small number of patients in each

stage group of underweight patients, there was no signifi-

cant between-group difference regarding overall recur-

rence/metastasis rate (p = 0.44). As for the overall survival

rate, the underweight group (94.4 %) and the normal

weight group (97.2 %) showed no significant difference

(p = 0.25).

Overall complications rate in the underweight patients

was 22.2 % (4/18). No systemic complication was reported

in underweight patients. Partial (skin and/or fat) necrosis of

the abdominal flap developed in two cases and breast com-

plications occurred in two cases, including nipple necrosis.

In the normal weight patients, the overall complication rate

was 27.1 % (86/317). Systemic complications were reported

in four cases, including pulmonary thromboembolism.

Fig. 1 Postoperative 1 year picture of a 33-year-old woman

(BMI = 18.2 kg/m2) who underwent immediate implant-only breast

reconstruction with 200 mL smooth round saline implant. Her right

breast shows excessive projection compared with the contralateral

side

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Donor-site complications were reported in six cases and

breast complications were reported in 78 cases, the most

common being skin or nipple necrosis (Table 2). All breast

and donor site complications were resolved with conserva-

tive management. The data of each and overall complication

rate showed no statistically significant difference.

The mean overall satisfaction score was 8.44 (range

6–10, SD = 0.68) in the underweight patients and 8.60

(range 2–10, SD = 0.78) in the normal weight patients,

which was not significantly different between the two

groups (p = 0.54). All underweight patients and all but two

normal weight patients replied they would recommend the

procedure to their friends (p = 0.37; Figs. 2, 3).

The panel individually reviewed 305 photographs on

two separate occasions (total 610 views). The average

scores for overall cosmesis and each individual element

are shown in Table 3. None of the individual elements

nor the overall cosmesis showed significant between-group

difference.

Discussion

It has been the traditional dogma that women with a small

breast volume are better candidates for reconstruction

using a prosthetic device and that women with a large

breast volume are better candidates for reconstruction

using autologous tissue. However, the reality is that pros-

thetic or autologous reconstruction can safely be performed

in women with a variety of breast sizes and shapes [7].

Moreover, it is known that even submuscular augmentation

mammaplasty could be challenging in very thin women,

with a higher rate of implant palpability and need for

revisional surgery [8]. Therefore, one could assume that

implant visibility and palpability could be more significant

and even problematic in underweight women, although

some degree of this is almost inevitable in every implant-

based reconstruction.

An excessively thin body habitus is conventionally

considered as a relative contraindication for TRAM flap

breast reconstruction [9], and the preferred autologous

tissue reconstructive procedure in those patients is usually

latissimus dorsi combined with implant. Wang et al. [10]

presented their experience of using an implant alone for

breast reconstruction in Asian women and Engel et al. [11]

reported a satisfactory outcome of two-stage breast

reconstruction comprised of subcutaneous tissue expansion

and subsequent subpectoral implantation, both claiming

that Asian women have a breast which differs from its

Western counterpart in many areas, that they tend to

present younger and to have a smaller, nonptotic, highly

projected breast.

Table 1 Patients’ data (mean and range)

Underweight

(n = 18)

Normal weight

(n = 317)

p value

Age (years) 41.1 (34–51) 40.7 (26–63) 0.42

BMI (kg/m2) 17.9 (15.7–18.4) 21.0 (18.5–22.9) \0.01*

Mastectomy

specimen (g)

239.7 (85–550) 377.7 (127–745) 0.02*

% NSM 33.3 26.4 0.28

Stage

0 4 (22.2 %) 56 (17.7 %)

1 7 (38.9 %) 115 (36.3 %)

2a 4 (22.2 %) 75 (23.7 %) 0.905

2b 1 (5.6 %) 41 (12.9 %)

[3 2 (11.1 %) 30 (9.5 %)

There was no significant difference in average age, ratio of nipple

preservation, and stage distribution between the two groups

NSM nipple-areolar skin-sparing mastectomy

* Statistically significant difference

Table 2 Complication rate

Complication

category

Underweight

(n = 18)

No. (%)

Normal weight

(n = 317)

No. (%)

p value

Overall 4 (22.2) 86 (27.1) 0.32

Breast

Overall 2 (11.1) 78 (24.6) 0.27

Skin necrosis 2 40

Fat necrosis 0 33

Wound

dehiscence

0 1

Infection 0 2

Hematoma/

seroma

0 5

Abdomen

Overall 2 (11.1) 6 (1.9) 0.12

Skin necrosis 1 2

Fat necrosis 1 1

Wound

dehiscence

0 1

Hematoma/

seroma

0 3

Systemic

Overall 0 4 (1.3) 0.63

Pulmonary

embolism

0 3

Atelectasis 0 1

Overall complication rate was calculated from the number of patients

who experienced one or multiple complications. Each and overall

complication rate showed no statistically significant difference

between the two groups

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Our experiences revealed that thin Asian women usually

have small breasts with less projection. Using conventional

implants in these patients usually results in asymmetry with

insufficient width and excessive projection, which is hard

to camouflage even with a covering latissimus dorsi flap.

Conventional smaller-volume implants with lower projec-

tions have insufficient width, and larger ones with suffi-

cient width have excessive projections. Moreover, implants

with larger volumes increase tension, raising the risk of

wound dehiscence, mastectomy flap necrosis, and implant

exposure. Recently with the advance of reconstructive

microsurgery, more sophisticated surgical options such as

multiplying and/or stacking the flaps are also suggested

for extreme cases [12, 13]. However, in our experience,

the greater part of underweight Asian women could be

reconstructed with TRAM flap alone, which usually have

adequate dimension with matching projection. In this

study, we demonstrated that immediate breast reconstruc-

tion using TRAM flap alone in underweight Asian patients

yielded comparable outcomes with acceptable complica-

tion rates. It is true that underweight patients have less

abdominal tissue, but their smaller breasts usually allow for

satisfactory reconstruction. An LD or extended LD flap

alone could also be considered if the surgeon and the

patient prefer it, as an LD flap can be done without an

implant for women with a small breast [14]. However,

when an extended LD flap is planned, it should be con-

sidered that the fatty tissue under the fascia is even scantier

in the back of underweight patients.

There are some pitfalls in using TRAM flaps in under-

weight patients which may lead to unsatisfactory aesthetic

results. First, these patients commonly have a vague

inframammary fold. Careful reconstruction of the lateral

portion of the tunnel may reduce the related aesthetic

problem. Second, the thin subcutaneous tissue of under-

weight patients makes epigastric bulging more noticeable.

Sufficient back-cut at the lateral muscle belly and severing

of the eighth intercostal nerve are required to minimize the

bulging [15]. Tension on the abdominal closure site is

another problem in underweight patients with less

abdominal tissue, but most breast cancer patients are in

their 30s or more and usually have enough abdominal tis-

sue for breast reconstruction. The abdominal complication

rate showed a higher tendency in underweight patients (one

fat necrosis and one skin necrosis) which may be the result

of higher tension. Hypertrophic scarring did not differ

between the two groups, having an incidence of about 5 %

in both groups. On the contrary, breast fat necrosis did not

develop in any of our 18 underweight patients, which

probably resulted from their smaller, thin flap. These

findings failed to show a statistically significant difference

in both breast and abdominal complication rates; still the

small number in the underweight group remains as the

major limitation of our study. Further data with more

underweight patients would be required to verify these

assumptions. At any rate, it is true that hypertrophic

Fig. 2 A 41-year old woman (BMI = 17.5 kg/m2) who underwent

immediate breast reconstruction after nipple-areolar skin-sparing

mastectomy with TRAM flap. The photograph was taken 1 year after

the surgery

Fig. 3 Postoperative 1 year picture of a 33-year old woman

(BMI = 15.7 kg/m2) who underwent immediate breast reconstruction

with TRAM flap after nipple-areolar skin-sparing mastectomy

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scarring of the donor site could be problematic in lean

Asian patients [16, 17] and the possibility of developing

such a complication should be consulted with the patient

preoperatively. We think that careful patient selection may

reduce the donor site problems in underweight patients: we

do not recommend TRAM flap breast reconstruction for

patients with a tight abdomen who are too young or

nulliparous.

In conclusion, TRAM flap can be performed with

acceptable complication rates and comparable cosmetic

outcome as well as patients’ satisfaction score in well

selected underweight Asian women as in a normal weight

group, and it should not be preexcluded in planning a

breast reconstruction.

Conflict of interest The authors report no financial or other conflict

of interest relevant to the subject of this article.

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Table 3 Average panel assessment score of postoperative photo-

graph evaluation (standard deviation)

Underweight

(n = 16)

Matched normal weight

(n = 45)

p value

Overall

cosmesis

3.38 (0.65) 3.30 (0.55) 0.27

Symmetry of

size

3.22 (0.65) 3.20 (0.67) 0.81

Symmetry of

shape

3.42 (0.83) 3.29 (0.76) 0.17

Symmetry of

NAC

3.44 (0.71) 3.33 (0.71) 0.22

Breast scar 3.50 (0.73) 3.57 (0.67) 0.39

Abdomen

scar

3.33 (0.76) 3.20 (0.63) 0.10

None of the individual elements nor overall cosmesis showed a sig-

nificant between-group difference

NAC nipple-areolar complex

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