Trends in autologous breast reconstruction.

Several trends have influenced autologous breast reconstruction in the last decade. The development of the skin-sparing mastectomy has markedly improved the aesthetic results of autologous breast reconstruction. Modifications have included purse-stringing periareolar incisions and vertical reduction pattern incisions. The increasing use of postmastectomy has had a negative impact on transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction. Delayed reconstruction may be the best option when adjuvant radiation is planned. Careful anatomic studies of the blood supply to the abdominal wall and critical outcome analyses have resulted in many refinements in TRAM flap breast reconstruction. Careful patient selection is critical to avoid complications. Obesity, tobacco smoking, a history of chest wall radiation, and abdominal scars are known risk factors for wound complications. TRAM flap reconstruction should be considered a two-stage procedure regardless of nipple reconstruction. The first stage is building the foundation and framework of the breast. The second stage is essential for final adjustments to the volume, contour, and position of the breast mound.