eMedicine Specialties > Plastic Surgery > Breast

Breast Reconstruction, Free TRAM

Michael R Zenn, MD, FACS, Associate Professor, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Duke University Medical Center

Updated: Jul 7, 2009

Introduction

Breast reconstruction entered the modern era when Hartrampf, Scheflan, and Black introduced the transverse rectus abdominis myocutaneous (TRAM) flap in 1982.¹ This ingenious procedure reliably transfers autogenous tissue for reconstruction and has the added benefit of abdominal rejuvenation. The TRAM flap has proven to be the autogenous tissue of choice for breast reconstruction.

The main advantage of the procedure lies in the consistency of the reconstructed breast; it is similar to the natural breast in softness and in the way the tissue drapes on the chest. Because the tissue is part of the patient's body, it does not incite foreign-body reaction or capsular contractures, which have plagued implant reconstructions. Furthermore, since scars fade and tissues soften, the reconstruction only improves over time, which is not true of implant reconstructions.

Since the inception of the TRAM flap, surgeons have developed different methods to improve blood supply to the transferred abdominal tissues. These methods currently include use of a midabdominal TRAM flap, a bipedicled TRAM flap, a microvascular augmentation (supercharge) of a unipedicled TRAM flap, a "delay" of a unipedicled TRAM flap,² and a free-tissue transfer (or free) TRAM flap, which includes perforator flaps. Of these procedures, only the free TRAM flap takes full advantage of the primary blood supply (inferior epigastric blood vessels) of the TRAM flap tissues. This technique completely removes the abdominal tissues from the body and transplants them to the chest area.

Diagram of the blood supply to the free transverse rectus abdominis myocutaneous (TRAM) flap. Note that the deep inferior epigastric vessels supply the flap, the primary blood supply to the lower abdomen. The shaded areas of the flap are discarded.

Frequency

This procedure now accounts for approximately 20% of breast reconstructions performed in the United States.

Indications

Consider free TRAM flap reconstruction for any patient undergoing mastectomy, either as an immediate procedure (at the time of mastectomy) or as a delayed procedure (some time after mastectomy). Simultaneous bilateral breast reconstruction may be performed with 2 free TRAM flaps. The patient must be psychologically motivated and have adequate tissues in the abdominal area to be considered for a free TRAM flap. Implant reconstruction and tissue reconstruction may be considered for any patient, though the following relative indications favor the free TRAM flap procedure.

• Division of the superior epigastric blood supply by previous surgery, making a pedicled TRAM flap impossible
• Radical mastectomy defect with large tissue requirement
• History of radiation to the chest wall
• Large opposite breast (difficult to match with an implant)
• Small opposite breast (difficult to match with an implant)
• Previous failure of implant reconstruction
• Excess lower abdominal tissue and patient desires abdominoplasty
• Desire to maximize or preserve abdominal muscle function^3,4
• Desire to have the maximum possible blood supply to the TRAM tissues⁴

Relevant Anatomy

The flap skin and fat of a free TRAM flap reconstruction survive on perforators through the rectus abdominis muscle. Although this muscle has a dual blood supply (ie, the superior and inferior epigastric arteries), this operation relies only on the inferior epigastric arterial system. Since this is the primary blood supply of these tissues, excellent vascularity is noted over most of the TRAM flap, even in tissue not directly adjacent to the muscle perforators. Only a small cuff of rectus abdominis muscle is harvested with the flap, thereby limiting dissection of the abdominal wall and postoperative discomfort.

In patients with favorable anatomy, all muscle can be preserved and only the perforating vessels are taken with the flap (so-called perforator flaps). If the primary vessels used are the deep inferior epigastric artery and vein, the flap is called a deep inferior epigastric perforator (DIEP) flap.⁵ If the primary vessels used are the superficial inferior epigastric artery and vein, the flap is called a superficial inferior epigastric perforator (SIEP) flap.

Because ultimate abdominal discomfort and function can be similar for patients after operations involving traditional free TRAM flaps and perforator flaps, some microsurgeons do not believe the added operative time and risk of dissecting only the perforators are indicated. However, data suggest less abdominal morbidity and lower requirements for pain management for the perforator flap patient. In the final analysis, the type of free-tissue transfer performed depends on the patient's desires and anatomy and the surgeon's experience and preference.^5,6,7

Contraindications

The free TRAM flap operation is major surgery and should not be undertaken lightly by the patient or surgeon. Fifteen years' experience with these procedures enables the author to identify the following characteristics that place patients at higher risk for complications:

• Cardiac disease (ie, myocardial infarction, angina, congestive heart failure)
• Pulmonary disease (ie, emphysema, chronic obstructive pulmonary disease)
• History of pulmonary embolus or deep venous thrombosis
• Collagen-vascular disease, lupus, scleroderma, polyarteritis (small-vessel disease)
• Unstable psychiatric disease
• Obesity (>25% above ideal body weight)
• Age (physiologic age >70 y)
• Cigarette smoking and unwillingness to quit
• Previous surgery that has interrupted blood supply to the TRAM flap
• Previous surgery, irradiation, or anatomy that is unfavorable to harvesting the tissues or that makes reconnection at the recipient site impossible (often can be determined only at the time of surgery)
• Contraindication(s) to anticoagulation therapy

Because of the magnitude of the procedure and the degree of stress on the lungs and heart, this operation may unmask baseline cardiopulmonary disease and result in a complicated postoperative course. In addition, anything that causes small-vessel disease, such as the medical conditions listed above or cigarette smoking, may cause complications in the transferred tissue and in the abdominal donor site. Any of the above characteristics contraindicate a TRAM flap procedure; in such cases, the surgeon should seek another method of reconstruction.

Workup

Laboratory Studies

• Preoperative laboratory examination is directed by the patient's medical condition. At minimum, obtain the following:
  • CBC count
  • Electrolytes
  • Urinalysis
  • Blood type and screen

Imaging Studies

• Chest radiograph(s)
• Contralateral mammogram within 6 months

Other Tests

• ECGs

Treatment

Surgical Therapy

Multiple procedures are required for a successful free TRAM flap breast reconstruction.

Stage I - TRAM flap

This may be performed at mastectomy or afterward. If irradiation of the chest is planned, delaying the TRAM flap procedure is recommended in order to limit scarring and deformity of the flap from radiation injury, a phenomenon that has been documented even years later. Belly tissues are used to create the breast mound, and this stage may include a procedure on the opposite breast for optimal symmetry. The operation may last from 4-8 hours. Unlike with pedicled TRAM flaps, the surgeon must spend time finding recipient vessels, which usually involve the thoracodorsal, axillary, circumflex scapular, internal mammary, or thoracoacromial systems. Occasionally, vein grafts are necessary. During this procedure, 90% of the reconstructive work is performed.

Stage II - Revisions and nipple reconstruction

Approximately 3-4 months after the TRAM flap procedure, tissues settle enough and scar tissue relaxes sufficient to allow small revisions and reconstruction of the nipple. Often, these procedures can be performed in an office setting. Chemotherapy should be completed with a 4- to 6-week additional waiting period before further surgery.

Radiation therapy may result in an additional delay of 6 months or longer from the last radiation treatment. At this stage, if some loss of the transferred tissues results in fat necrosis, removing these firm areas and reshaping the mound (to allow a soft breast reconstruction) allows the patient to more easily perform self-examinations to monitor for cancer recurrence.

If the breast-mound revision is major, nipple reconstruction is delayed another 3-4 months to ensure accurate positioning. Nipple reconstruction can be performed as a local tissue rearrangement or as a graft from the opposite nipple. The anatomy of the patient and the preference of the surgeon dictate the choice.

Stage III - Nipple and areolar tattoo

This final procedure, which is performed in an office setting, adds color to the breast reconstruction. This finishing touch to the reconstruction helps make the reconstructed breast more symmetric with the opposite breast and minimizes the visual effect of other scars that may be present on the breast mound. The tattoo is usually performed 2 months after the nipple reconstruction, because scar tissues are softer at this juncture and can better accept the tattoo pigment.

Preoperative Details

Consultation is required for the patient to understand the magnitude of the procedure she is about to undergo. Consultation should include discussion of possible complications and unavoidable scars, along with the opportunity to view pictures of an average TRAM flap result. For some women, speaking to a patient who was once in a similar situation is helpful. Answer all questions so that the patient has realistic expectations.

The degree of preparation necessary for such a large procedure is often limited by the need to perform the mastectomy in a timely fashion. Preoperative instructions include the following:

1. Autogenous blood donation: Donation of 1-2 units up to 1 week preoperatively is recommended. This allows a nearly normal hematocrit value (blood count) postoperatively and induces the patient's body to "make" its own blood before the insult of surgery.
2. Abdominal conditioning: The patient should perform abdominal exercises to strengthen the muscle to be used and to improve blood supply to the muscle.
3. Perform bowel preparation the day before surgery.

Intraoperative Details

In planning the location of the TRAM flap, remember that it is advantageous to leave the scar as low as possible, similar to the scar left after an abdominoplasty. However, the patient should remember that the location of the fat ultimately dictates the location of the scar. If enough tissue to create a sufficient mound is not present over and immediately adjacent to the muscle, select an alternative technique.

• An ipsilateral or contralateral vascular pedicle may be used.
• A small cuff of rectus muscle may be included with the flap harvest. This section of the muscle will be denervated and its function possibly impaired. If the lower abdominal tissues are harvested as a DIEP flap, the muscle and most of the nerve supply may be spared. Although the abdominal wall is less violated with the DIEP flap than with the free TRAM technique, which takes a small cuff of muscle, there is a small risk of hernia and abdominal wall weakness. Because of its anatomy, the SIEP flap does not violate the abdominal wall and, theoretically, should not impair abdominal wall function or cause hernia.
• No tunnel is necessary to the mastectomy site, as the tissue is completely removed and replanted at the site. This allows the inframammary fold to be definitively set at the initial procedure without fear of compromising the pedicle.
• Begin abdominal closure with closure of the fascia. This can be performed primarily or with synthetic mesh, depending on the patient's anatomy and the preference of the surgeon.⁸
• Additional liposuction and skin tailoring may be necessary to achieve an optimal aesthetic result.
• In most patients, relocation of the umbilicus is necessary, and it appears as a new umbilicus in a position similar to the preoperative position.
• Shaping and creation of the breast mound expresses the surgeon's artistic abilities. Match the opposite mound by positioning the tissues, folding the flap, and other maneuvers. One advantage of free-tissue transfer is the added freedom to position tissues in any orientation. Pedicled TRAM techniques are tethered by the muscle pedicle and thus have some limitations in flap orientation. The surgeon must always anticipate the effects of healing, scar tissue, gravity, and mound shrinkage during the initial shaping in order to limit the need for revisions. These factors may vary greatly among patients, and the patient should expect revisions.
• In skin-sparing mastectomy, only the nipple and areola are removed with the breast tissue; the breast skin is spared. In certain patients with small peripheral tumors and negative retroareolar frozen-section biopsy results, the nipple-areolar complex may also be spared. The reconstructive burden is lessened, and most of the skin of the TRAM flap is removed, which allows the breast envelope to be filled with abdominal fat.

Patient 1. This patient has small breasts and has a small amount of abdominal tissue available. This is the perfect indication for a free transverse rectus abdominis myocutaneous (TRAM) flap to maximize the amount of tissue available for reconstruction.

Patient 1. Postoperative view. Note the natural ptosis of the reconstruction and the distinct inframammary fold, not distorted by a muscle pedicle from the abdomen. The patient does not desire nipple-areolar reconstruction.

Patient 2. This patient has a large opposite breast to match and does not desire a breast reduction. A free transverse rectus abdominis myocutaneous (TRAM) flap allows a large block of tissue to be transferred, matching the opposite breast.

Patient 2. Postoperative view. The breast envelope has been filled with the free transverse rectus abdominis myocutaneous (TRAM) flap. Note the abdominal improvement, an added benefit of the TRAM procedure. The patient still requires nipple-areolar reconstruction.

Patient 3. Preoperative markings. The patient has a large opposite breast and does not desire breast reduction. Note the large amount of skin that will be removed. A free transverse rectus abdominis myocutaneous (TRAM) allows a large reconstruction to match the opposite side.

Patient 3. Postoperative view. There is a good volume match, and the resected breast skin has been replaced with abdominal skin.

Patient 3. Postoperative view. In this view, note the natural droop of the reconstruction, unobtainable with breast implants. All of the patient's scars are below her tan lines.

Postoperative Details

• An uncomplicated free TRAM flap procedure requires 4 days of hospitalization.
• Close observation is required for the first 24-28 hours. Transferred tissues are completely reliant on the microvascular anastomoses; kinking or thrombosis of an artery or vein may mean complete loss of the transferred tissues. To avoid this, perform hourly monitoring by clinical observation and internal or external monitoring with Doppler, laser, or temperature devices. Evidence of compromise should prompt reexploration in the operating room.
• At no time during the first 2 months can the patient put pressure on the transferred tissues. She can only wear soft bras and cannot sleep on the reconstruction. Heating pads are also not allowed near the reconstruction, as the tissues are susceptible to burns because they are denervated.
• To prevent clot formation in the microsurgical anastomoses, the blood may be thinned during surgery or postoperatively with heparin, warfarin, dextran, or aspirin.
  • This practice varies with the clinical situation and the preference of the surgeon. The Virchow triad relates to the predisposition toward vascular thrombosis and includes intimal injury, diminished flow, and hypercoagulability.
  • Because of its nature, microsurgery routinely deals with injury of the vessel wall from scarring, surgery, and radiation. Diminished flow also occurs, since sutured anastomoses narrow and blood flow is never as good as in the original location.
  • In an attempt to overcome the risk of thrombosis, microsurgeons anticoagulate, or thin, the blood. Although never proven effective, some surgeons routinely use low molecular-weight dextran (25-30 mL/h), heparin (500-1000 U/h), aspirin (80 or 325 mg/d), or warfarin (1-5 mg/d) postoperatively. While heparin and warfarin work on intrinsic clotting factors, dextran and aspirin affect platelet function.
  • All blood thinners may increase bleeding at an operative site, and this occasionally requires discontinuation of the blood thinner. Other common complications include thrombocytopenia with heparin and GI upset and bleeding with aspirin.
• Ambulation begins on the first postoperative day.
• To remove tension on the abdominal closure, place the patient in a flexed position at the waist for the first few days; an upright position is possible by the end of the first week.
• Drain tubes are necessary and are usually kept in place for 1-2 weeks.
• The patient requires 6-12 weeks to regain her prior energy level and to resume normal activities.
• Full range-of-motion exercises for the shoulder are begun 10-14 days after the operation.
• Patients may resume abdominal exercises in 6 weeks or sooner if a perforator flap is performed.
• Anesthesia of the mastectomy site and central abdomen resolves over the next 6-12 months. The degree of sensory reinnervation to the TRAM flap is variable and patient dependent.⁹
• Because of the tight closure of the underlying muscle fascia of the abdomen, most patients experience a painless tight feeling for many months.
• Patients with preexisting back pain may experience an exacerbation of this pain from the procedure.
• Prolonged convalescence and discomfort coupled with a cancer diagnosis may be depressing and emotionally draining.

Follow-up

• Once the patient and surgeon are satisfied with the breast reconstruction, maintenance is minimal.
• Mammography of the reconstructed breast is generally not required, but some oncologists continue to use the study.
• The patient should continue self-examination.
• Examine new lumps or masses by physical examination, mammography, CT/MRI/position emission tomography (PET) scan, or, if indicated, biopsy.
• If present, fat necrosis is noted early as an area of firmness that does not resolve over time. During the first revision, remove all areas of fat necrosis to obtain a soft mound without palpable masses, allowing for surveillance for recurrent breast cancer.

For excellent patient education resources, visit eMedicine's Women's Health Center and Cancer and Tumors Center. Also, see eMedicine's patient education articles Mastectomy, Breast Lumps and Pain, Breast Self-Exam, and Breast Cancer.

Complications

The free TRAM flap procedure is performed daily and safely by plastic surgeons experienced with microsurgery. Because of the magnitude of the procedure, complications can occur even in the best hands. Possible complications from a free TRAM flap procedure are listed below. Fortunately, major complications are uncommon.

• Fat necrosis and/or partial flap loss (5-15% of patients)
• Complete loss of free TRAM tissue (2%)
• Seroma (fluid collection, usually in abdominal donor site)
• Hematoma (bleeding at chest or abdomen)
• Infection
• Hernia (1-5%)
• Abdominal bulge without hernia (5-15%)
• Deep venous thrombosis and/or pulmonary embolus (<1%)
• Death (<1%)

Multimedia

Media file 1: Diagram of the blood supply to the free transverse rectus abdominis myocutaneous (TRAM) flap. Note that the deep inferior epigastric vessels supply the flap, the primary blood supply to the lower abdomen. The shaded areas of the flap are discarded.

Media file 2: Patient 1. This patient has small breasts and has a small amount of abdominal tissue available. This is the perfect indication for a free transverse rectus abdominis myocutaneous (TRAM) flap to maximize the amount of tissue available for reconstruction.

Media file 3: Patient 1. Postoperative view. Note the natural ptosis of the reconstruction and the distinct inframammary fold, not distorted by a muscle pedicle from the abdomen. The patient does not desire nipple-areolar reconstruction.

Media file 4: Patient 2. This patient has a large opposite breast to match and does not desire a breast reduction. A free transverse rectus abdominis myocutaneous (TRAM) flap allows a large block of tissue to be transferred, matching the opposite breast.

Media file 5: Patient 2. Postoperative view. The breast envelope has been filled with the free transverse rectus abdominis myocutaneous (TRAM) flap. Note the abdominal improvement, an added benefit of the TRAM procedure. The patient still requires nipple-areolar reconstruction.

Media file 6: Patient 3. Preoperative markings. The patient has a large opposite breast and does not desire breast reduction. Note the large amount of skin that will be removed. A free transverse rectus abdominis myocutaneous (TRAM) allows a large reconstruction to match the opposite side.

Media file 7: Patient 3. Postoperative view. There is a good volume match, and the resected breast skin has been replaced with abdominal skin.

Media file 8: Patient 3. Postoperative view. In this view, note the natural droop of the reconstruction, unobtainable with breast implants. All of the patient's scars are below her tan lines.

References

1. Hartrampf CR Jr. The transverse abdominal island flap for breast reconstruction. A 7- year experience. Clin Plast Surg. Oct 1988;15(4):703-16. [Medline].

2. Hudson DA. The surgically delayed unipedicled TRAM flap for breast reconstruction. Ann Plast Surg. Mar 1996;36(3):238-42; discussion 242-5. [Medline].

3. Lejour M, Dome M. Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg. Jun 1991;87(6):1054-68. [Medline].

4. Schusterman MA. The free TRAM flap. Clin Plast Surg. Apr 1998;25(2):191-5. [Medline].

5. Allen RJ. DIEP versus TRAM for breast reconstruction. Plast Reconstr Surg. Jun 2003;111(7):2478. [Medline].

6. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg. Aug 2002;110(2):466-75; discussion 476-7. [Medline].

7. Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?. Plast Reconstr Surg. Feb 2005;115(2):436-44; discussion 445-6. [Medline].

8. Zienowicz RJ, May JW Jr. Hernia prevention and aesthetic contouring of the abdomen following TRAM flap breast reconstruction by the use of polypropylene mesh. Plast Reconstr Surg. Nov 1995;96(6):1346-50. [Medline].

9. Shaw WW, Orringer JS, Ko CY. The spontaneous return of sensibility in breasts reconstructed with autologous tissues. Plast Reconstr Surg. Feb 1997;99(2):394-9. [Medline].

10. Alderman AK, Wilkins EG. Radiation therapy in postmastectomy TRAM reconstruction. Plast Reconstr Surg. Mar 2002;109(3):1199-200. [Medline].

11. Bostwick J. Microsurgical techniques. In: Plastic and Reconstructive Breast Surgery. 2^nd ed. St. Louis: Quality Medical Publishing Inc; 2000:1147-1252.

12. Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg. Oct 2004;114(5):1077-83; discussion 1084-5. [Medline].

13. Grotting JC, Oslin BD. Free TRAM flap breast reconstruction. In: Spear SL. Surgery of the Breast: Principles and Art. Philadelphia, Pa: Lippincott-Raven Publishers; 1998:555-563.

14. Lindsey JT. Integrating the DIEP and muscle-sparing (MS-2) free TRAM techniques optimizes surgical outcomes: presentation of an algorithm for microsurgical breast reconstruction based on perforator anatomy. Plast Reconstr Surg. Jan 2007;119(1):18-27. [Medline].

15. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg. Nov 1988;82(5):815-32. [Medline].

16. Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg. Feb 1988;81(2):189-99. [Medline].

17. Thoma A, Veltri K, Khuthaila D, et al. Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis. Plast Reconstr Surg. May 2004;113(6):1650-61. [Medline].

18. Zenn MR. Control of breast contour by the use of Z-plasty in the irradiated breast reconstruction. Plast Reconstr Surg. Jul 2003;112(1):210-4. [Medline].

Keywords

breast reconstruction, transverse rectus abdominis myocutaneous flap, TRAM flap, autogenous tissue, free flap, microsurgery, deep inferior epigastric perforator flap, DIEP flap, superficial inferior epigastric perforator flap, SIEP flap, free-tissue transfer, TRAM flap breast reconstruction, mastectomy, chest irradiation, radiation injury, breast mount, belly tissues, breast symmetry, breast revision, nipple reconstruction, nipple tattoo, areolar tattoo

Contributor Information and Disclosures

Author

Michael R Zenn, MD, FACS, Associate Professor, Division of Plastic and Reconstructive Surgery, Program Director of Plastic Surgery Residency, Duke University Medical Center
Michael R Zenn, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Plastic Surgeons, American College of Surgeons, American Medical Association, American Society for Reconstructive Microsurgery, American Society of Plastic Surgeons, North Carolina Medical Society, Phi Beta Kappa, Plastic Surgery Research Council, Southeastern Society of Plastic and Reconstructive Surgeons, and World Society for Reconstructive Microsurgery
Disclosure: Nothing to disclose.

Medical Editor

Pankaj Tiwari, MD, Assistant Professor, Division of Plastic Surgery, Ohio State University
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Saleh M Shenaq, MD†, Former Director and Founder, The International Brachial Plexus Institute; Former Chief, Section of Plastic Surgery, Methodist Hospital, Houston
Saleh M Shenaq, MD† is a member of the following medical societies: American Academy of Anti-Aging Medicine, American Academy of Pediatrics, American Association for Hand Surgery, American Association for the Advancement of Science, American Association of Plastic Surgeons, American Burn Association, American College of Physician Executives, American College of Surgeons, American Congress of Rehabilitation Medicine, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, American Society of Gene Therapy, American Society of Law Medicine and Ethics, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Trauma Society, Association for Academic Surgery, International College of Surgeons, Lipoplasty Society of North America, Plastic Surgery Research Council, Society for Neuroscience, Society of Surgical Oncology, Southern Medical Association, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery
Disclosure: Ethicon  Consulting fee Consulting; QMP Royalty Book royalty; Insorb Stapler Consulting fee Consulting; Insorb Stapler Ownership interest None; Medicis Intellectual property rights None

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