• Users Online: 621
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 28  |  Issue : 2  |  Page : 98-103

Comparison of the early and late postoperative results in cases with pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction: Twenty-year follow-up


1 Department of Emergency and First Aid, Avrupa Vocational High School, Kazlıçeşme Ahmet Haşim Sk. 8/1 34010, Kazlıçeşme, Turkey
2 Department of Plastic and Reconstructive Surgery, İstanbul University, Topkapı, Turgut Özal Millet Caddesi 34093, Fatih, İstanbul, Turkey
3 Department of Medical Sciences, Hasan Kalyoncu University, Yeşilkent, 27900, Oğuzeli, Gaziantep, Turkey
4 Teşvikiye Caddesi 26/7-8, Nişantaşı, İstanbul, Turkey

Date of Submission24-Jun-2019
Date of Acceptance24-Jun-2019
Date of Web Publication18-Mar-2020

Correspondence Address:
Dr. Aret Cerci Ozkan
Incirli Caddesi Bayrak Apartment No 89/7, Bakirkoy, Istanbul
Turkey
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_31_19

Get Permissions

  Abstract 


Background: The TRAM flap has proven to be the autogenous tissue of choice for breast reconstruction. The progressive improvement of the aesthetic results in long-term follow-up of patients with well-executed TRAM flap breast reconstructions is observed to be highly satisfactory for both patients and the surgeon. Aims and Objectives: In this article, I aimed to present long term results of cases with pedicles TRAM flap reconstruction. Material and Methods: Between January 1999 and July 2001 period, 22 pedicled TRAM flap breast reconstructions were performed to 21 patients with breast carcinoma. The mean age of the patients was 42 (28-53) years. In this study, the contralateral rectus abdominis muscle was preferred as a pedicle in patients who had received adjuvant radiotherapy- (10 patients) and vertical or oblique flap inset was applied in most of them- (9 patients). In patients without adjuvant radiotherapy but with infraclavicular tissue losses, or with small opposite breast, again vertical or oblique flap inset was preferred- (4 patients). In all patients with vertical or oblique flap inset, the contralateral rectus abdominis muscle was used as a pedicle- (13 patients). In patients with full and attractive opposite breast, horizontal flap inset was preferred- (7 patients). In patients with horizontal flap inset, ipsilateral rectus abdominis muscle was used as a pedicle unless the patient had received adjuvant radiotherapy- (6 patients); contralateral rectus abdominis muscle was used as a pedicle if the patient had received adjuvant radiotherapy- (1 patient). Results: The follow-up period is 18-20 years for this series. During the early postoperative days, highly satisfactory results have been obtained. Eighteen of the cases were totally satisfied. Three of the cases had dissatisfactions mostly related to complications. During 18 to 20 years period follow-up of 12 patients has been performed regularly. Oncologic tracing, the degree of maintenance of the breast shape of the flap and symmetry, softness, and naturality of the reconstructed breast, maturational changes in surgical scars, abdominal strength, sensational changes over the flap skin, color and shape changes over nipple areola complex have all been periodically observed. Conclusion: TRAM flap is still the gold standard among all breast reconstruction modalities. Progressive improvement in all measures such as breast, symmetry, softness, and naturality of the reconstructed breast, maturational changes in surgical scars, abdominal strength, sensational changes over the flap skin are very satisfactory for patients and the surgeon.

Keywords: Contralateral, inset, ipsilateral, late, pedicle, pedicled, transverse rectus abdominis musculocutaneous


How to cite this article:
Ozkan AC, Cizmeci O, Aydin H, Emekli U, Ozden BC, Ulug BT. Comparison of the early and late postoperative results in cases with pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction: Twenty-year follow-up. Turk J Plast Surg 2020;28:98-103

How to cite this URL:
Ozkan AC, Cizmeci O, Aydin H, Emekli U, Ozden BC, Ulug BT. Comparison of the early and late postoperative results in cases with pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction: Twenty-year follow-up. Turk J Plast Surg [serial online] 2020 [cited 2020 Jun 2];28:98-103. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/2/98/280988




  Introduction Top


The transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be the autogenous tissue of choice for breast reconstruction. It is quite 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.

With the introduction of the TRAM flap in 1982 by Hartrampf, Scheflan, and Black, a woman's breast could be restored with her own abdominal tissues and she would receive the added benefit of an abdominoplasty.[1]

The progressive improvement of the aesthetic resul ts in long-term follow-up of patients with well-executed TRAM flap breast reconstructions is observed to be highly satisfactory for both patients and the surgeon. In this article, I aimed to present long term results of cases with pedicled TRAM flap reconstruction. The early postoperative results of the same cases of this study were formerly published in a comparative clinical study.[2]


  Materials and Methods Top


Between January 1999 and July 2001, 22 pedicled TRAM flap breast reconstructions were performed to 21 patients with breast carcinoma. This series is formed by the cases operated by the first author during his practice in a university hospital until the end of 2001. Of these, 15 patients received late, and 5 patients received immediate reconstruction. One patient received a bilateral breast reconstruction; late hemiflap reconstruction was applied to her left breast and immediate hemiflap reconstruction was applied to her right breast. The mean age of the patients was 42 (28–53) years.

In this study, the contralateral rectus abdominis muscle was preferred as a pedicle in patients who had received adjuvant radiotherapy - 10 patients and vertical or oblique flap inset was applied in most of them - 9 patients. In patients without adjuvant radiotherapy but with infraclavicular tissue losses, or with small opposite breast, again vertical or oblique flap inset was preferred - 4 patients. In all patients with vertical or oblique flap inset, the contralateral rectus abdominis muscle was used as a pedicle - 13 patients. In patients with full and attractive opposite breast, horizontal flap inset was preferred - 7 patients. In patients with horizontal flap inset, ipsilateral rectus abdominis muscle was used as a pedicle unless the patient had received adjuvant radiotherapy - 6 patients; contralateral rectus abdominis muscle was used as a pedicle if the patient had received adjuvant radiotherapy - 1 patient.

The abdominal wall repair was performed by two-layered primary closure plus onlay synthetic mesh. The lateral half of the nonpedicled side of the flap (zone 4) was discarded in all cases. A reduction mammaplasty - 1 patient and a mastopexy - 4 patients were applied to opposite breasts when needed, in order to achieve a good symmetry.

The skate flap - 4 patients and the modified fishtail flap - 7 patients were applied for nipple reconstruction. A full-thickness skin graft from upper medial thigh was used for areolar reconstruction.


  Results Top


The follow-up period is 18–20 years for this series. During the early postoperative days, highly satisfactory results have been obtained. Eighteen of the cases were totally satisfied. Three of the cases had dissatisfactions mostly related to complications.

I have observed partial flap loss in one case, major fat necroses (>20% of total flap) in two cases, minor fat necroses (<20% of total flap) in three cases, seroma at the operated breast in two cases, and minor abdominal hernia in one case. Incidences of complications observed in our series have been listed in [Table 1]. During 18–20 years' period, three of patients have been lost due to distant metastases. Seven of them have stopped the follow-up. Follow-up of 12 patients has been performed regularly. Oncologic tracing, the degree of maintenance of the breast shape of the flap and symmetry, softness, and naturality of the reconstructed breast, maturational changes in surgical scars, abdominal strength, sensational changes over the flap skin, and color and shape changes over nipple areola complex have all been periodically observed.
Table 1: Early postoperative complications of pedicled transverse rectus abdominis musculocutaneous flap reconstruction in our series

Click here to view


The maintenance of breast shape is highly satisfactory in all cases with late postoperative follow-up. The only drawback related to the maintenance of the shape is the formation of an indentation over the flap in the region of the scar caused by the repair of former umbilicus hollow.

The maintenance of flap symmetry is also satisfactory in most of the cases. Weight gain in years is well tolerated with a bilateral increase of volumes of both the normal and the reconstructed breast [Figure 1]. Ptosis of the normal breast has also tolerated to some degree with ptosis of the flap [Figure 2]. Nevertheless, in cases with extreme ptosis of normal breast, reconstructed breast stays above the ptotic breast [Figure 3].
Figure 1: Comparison of early and late postoperative results of a case reconstructed with ipsilateral pedicled transverse rectus abdominis musculocutaneous flap with horizontal inset. Breast symmetry is preserved despite considerable weight gain. (a) Preoperative anterior view, (b) early postoperative anterior view, (c) late postoperative anterior view, (d) preoperative lateral view, (e) early postoperative lateral view, (f) late postoperative lateral view

Click here to view
Figure 2: Comparison of early and late postoperative results of a case reconstructed with contralateral pedicled transverse rectus abdominis musculocutaneous flap with vertical inset. Breast symmetry is preserved despite slight ptosis of a normal breast. Radiation damaged skin was removed near totally. (a) Preoperative anterior view, (b) early postoperative anterior view, (c) late postoperative anterior view, (d) preoperative lateral view, (e) early postoperative lateral view, (f) late postoperative lateral view

Click here to view
Figure 3: Comparison of early and late postoperative results of a case reconstructed with contralateral pedicled transverse rectus abdominis musculocutaneous flap with vertical inset. Breast symmetry is not preserved due to considerable ptosis of the normal breast despite having mastopexy. (a) Preoperative anterior view, (b) early postoperative anterior view, (c) late postoperative anterior view, (d) preoperative lateral view, (e) early postoperative lateral view, (f) late postoperative lateral view

Click here to view


The softness of the reconstructed breasts was excellent in all followed patients. Softness and shape maintenance are the primary parameters of the naturality.

Scar maturation is also excellent after 18–20 years. All scars in followed patients are very inconspicuous, thin, and white.

Abdominal strength is sufficient in all cases even in a case reconstructed with a bilateral TRAM flap [Figure 4].
Figure 4: Comparison of early and late postoperative results of a case reconstructed with bilateral pedicled hemitransverse rectus abdominis musculocutaneous flaps with horizontal insets. (a) Preoperative anterior view, (b) early postoperative anterior view, (c) late postoperative anterior view, (d) Preoperative lateral view, (e) early postoperative lateral view, (f) late postoperative lateral view

Click here to view


All the followed patients have expressed the return of sensation of the skin at the 9th–10th year. Most of them expressed that they feel pain during depilation of hairs over the flap skin.

The most significant disappointment related with our results in breast reconstruction of this series is the near total faded colors of skin grafts harvested from the genital region for areola reconstruction and shrank and flattened the appearance of reconstructed nipple mound in all followed cases.


  Discussion Top


The most important issue in any flap surgery is doubtlessly adequate flap perfusion. The good perfusion of the TRAM flap is one of the most important parameters for a satisfactory esthetic outcome.

Utilization of deep inferior epigastric artery in free TRAM flap breast reconstruction has been a great concern for better flap perfusion, less venous congestion, and decreased donor site morbidity. Patients with free TRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pedicled TRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between free TRAM and pedicled TRAM flaps. No difference was noted in flap complications between deep inferior epigastric perforator (DIEP) and pedicled TRAM flaps except for hernia or bulge. Although pedicled TRAM flaps are being replaced by free TRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity.[3] In another study, it is stated that free TRAM has an increased risk of postoperative complications and resource utilization compared to pedicled TRAM on the current largest risk-adjusted analysis.[4] Thus, a comparison of the use of pedicled TRAM flap versus free TRAM flap is also still a matter of debate. In addition, as the use of internal mammary artery is one of the options for microsurgical anastomosis in free TRAM flap breast reconstruction, it may be wise to be conservative because the same artery is also one of the options for cardiac bypass surgery.

It is quite possible to reduce the risk of inadequate flap perfusion or increased venous congestion with meticulous patient selection and applying smart peroperative technical tricks.

First, it is imperative to eliminate patients with chronic pulmonary diseases, uncontrolled hypertension, morbid obesity, insulin-dependent diabetes mellitus, autoimmune diseases, previous abdominal scars in critical regions, and inappropriate attitudes. In addition, it is recommended to be cautious in cases that are in the postmenopausal period, carry abdominal striations, and smoke cigarette.

For us, a proper selection of the vascular pedicle is the most effective technical trick for good flap perfusion. In our series, if a vertical or oblique inset model was more appropriate for that specific case (e.g., small opposite breast, infraclavicular tissue loss), the contralateral pedicle has preferred in our series and vice versa; if the use of the contralateral pedicle was relatively wise (e.g., cases with adjuvant radiotherapy), the vertical or oblique inset has preferred. If a horizontal flap inset model was more appropriate for that specific case (e.g., patients with full and attractive opposite breast), the ipsilateral rectus abdominis muscle has been used as a pedicle unless the patient had received adjuvant radiotherapy [Figure 5].[2] The rationale of this selection is based on not to evoke a kink or stretch in the pedicle. This technical trick can be explained better in an illustration that compares the inset and pedicle options [Figure 6]. Saving the perforator vessels as much as possible, sacrificing the half of the nonpedicled side (Zone IV) of the flap, rising the patient's upper trunk to more sitting position, iv. hydration of the patient, warming up the flap and the patient after the transfer to the chest, and letting one of the deep epigastric veins to bleed temporarily are other measures to provide satisfactory perfusion and venous drainage. The emptying of the deep inferior epigastric vein into its superior counterpart requires a retrograde flow of blood against the venous valves. It appears that this temporary obstruction is overcome when the blood dilutes the veins and makes the valves incompetent. However, retrograde flow may not be optimal, and this phenomenon may explain why engorgement of the deep inferior epigastric vein and flap occurs more often than desired. The engorgement may be relieved by elevating the flap or temporary releasing the clamp on the deep inferior epigastric vein. These are temporary precautions. If these measures are not sufficient for improvement of circulation, then, of course, supercharge or super drainage options should be considered.[5]
Figure 5: Comparison of early and late postoperative results of a case reconstructed with ipsilateral pedicled transverse rectus abdominis musculocutaneous flap with horizontal inset. (a) Preoperative anterior view, (b) early postoperative anterior view, (c) late postoperative anterior view, (d) preoperative lateral view, (e) early postoperative lateral view, (f) late postoperative lateral view

Click here to view
Figure 6: Illustration showing the use of ipsilateral pedicle with horizontal inset and contralateral pedicle with vertical inset

Click here to view


Management of inset models and pedicle selection according to this rationale provides one additional benefit that is the settlement of nonpedicled zone either on infraclavicular or on axillary regions. As the nonpedicled zone of the TRAM flap is more prone to vascular complications such as partial flap loss and fat necrosis, settlement of this risky zone on infraclavicular or axillary region facilitates any revision option because any revision approach at these regions is easier compared to parasternal or inframammary fold areas.

Ipsilateral pedicle TRAM flap breast reconstruction is not a commonly reported procedure and is reserved for cases for which scars preclude the use of the contralateral pedicle. Simplicity and versatility of flap shaping, improved maintenance of the inframammary fold, and lack of disruption of the natural xiphoid hollow give ipsilateral TRAM flaps further advantages.[6]

The good perfusion of TRAM flap which is crucial for patient satisfaction in every aspect in the early postoperative period is also the most important decisive factor for patient satisfaction in the late postoperative period. The softness of the flap without any tissue loss is doubtlessly prerequisite for a fine result. The softness is also crucial for mild ptosis of the flap which will help for maintenance of symmetry in the late postoperative period. In addition, naturality of the reconstructed breast is also significantly determined by this softness.

Construction of a good breast shape with TRAM flap is also highly crucial for patient satisfaction in both early and late postoperative period. One of the most important technical tricks for successful molding is full-thickness excision of skin damaged by radiotherapy at the footprint of the flap being reconstructed on the mastectomized side. This is imperative especially for the lower two-thirds of this footprint area. Radiotherapy burn scar cannot expand enough to let the flap to flow naturally. The lower limit of this damaged skin excision should be exactly the inframammary fold. The upper limit may vary according to the conditions.

Proper folding of the flap to double the volume at the lower pole is also crucial for the construction of a natural shape. Here, the line that will correspond to inframammary fold is determined first over the flap. Then, the skin below this line is deepithelialized with scissors technique. The deepithelialized portion of the flap is folded back and gently sutured to flap for stabilization. Then, inset of the flap is initiated by fixation of this lower pole over the inframammary fold.

In the late postoperative period, mild ptosis of the flap results in a well-defined more natural inframammary fold with increased patient satisfaction.

Probably, the most dramatic difference between early and late postoperative results is the appearance of the scars. Maturation and fade of both abdominal and breast scars have amazingly changed the overall appearance and positively affected patient satisfaction. White-colored fine scars are well tolerated by patients.

One of the most commonly stated reasons to favor of the free TRAM or DIEP flap is the claim the presence of a less donor site morbidity.[7] However, the abdominal strength is highly satisfactory in all followed cases in our series, even in the case with bilateral pedicled TRAM flap reconstruction. You can watch this case while doing push-up exercises [Video 1]. In addition, technique of transversely dividing the anterior fascia and rectus abdominis combined with reinforcement above the arcuate line can reduce the occurrence of abdominal bulging and hernia.[8] Utilization of prolene mesh over the primary abdominal wall repair may boast the strength of the abdominal wall.

The most prominent drawback in our series is fading of the color in reconstructed areola and volume loss at the reconstructed nipple in all of the followed cases in the late postoperative period. In the early postoperative period, they were all pink enough to create contrast with normal breast tissue, but in the late postoperative period, they are all highly inconspicuous and hardly discriminated from normal breast tissue. It may be concluded from this drawback that using a tattoo for areola coloration instead of full-thickness graft from the genital area may be wiser and less traumatic for patients. In addition, the tattoo can also stain the reconstructed nipple. It is very interesting to evaluate that none of the followed cases in this series wanted to accept tattoo for their nipple-areola area despite the offer free of charge. This is probably because all of them have fed up with any kind of additional medical intervention.

All of the complications mentioned in [Table 1] have been encountered in preliminary cases of this series. Thus for me, these complications are highly associated with the learning curve. After learning all the technical details properly, performing this operation with fewer complications is feasible.

For us, the long-term benefits of autologous TRAM flap reconstruction cannot be comparable with prosthesis reconstruction. Settlement of at least 400–500 ccs huge implants under a pectoral muscle and thinned-skin (subpectoral settlement) or settlement of them under thinned-skin only (prepectoral) cannot provide very longterm patient satisfaction. Neither its long-term results nor its cost can be better than autologous reconstruction. In a recent meta-analysis, it is stated that prior irradiation significantly increases the risk of complications in patients undergoing prosthetic reconstruction, and using an autologous flap or combining it with an implant can be considered to reconstruct previously irradiated breasts.[9] Again in a recent study, it is stated that nineteen of thirty-one patients who received direct-to-implant immediate breast reconstruction after mastectomy for primary or recurrent cancers breasts required revision surgery after 6 months.[10] In one comparative study between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods, it is stated that compared to the expander/prosthesis method, breast reconstruction using the DIEP method is more cost-effective and involves fewer serious complications that result in reconstruction failure or undesirable esthetic results. Expander/prosthesis reconstruction presents a higher number of complications that may cause surgical failure or poor outcomes.[11] In a multicenter, prospective analysis, the authors found no significant acellular dermal matrix effects on complications, time to exchange, or patient-reported outcome in immediate expander/implant breast reconstruction.[12] If this is the situation, how we will thrust to the efficiency of prepectoral implants covered by an acellular matrix?


  Conclusion Top


TRAM flap is still one of the most important techniques among all breast reconstruction modalities. Progressive improvement in all measures such as breast, symmetry, softness, and naturality of the reconstructed breast, maturational changes in surgical scars, abdominal strength, and sensational changes over the flap skin are very satisfactory for patients and the surgeon.[13] The most prominent long-term drawback is fading of the color in reconstructed areola and volume loss at the reconstructed nipple in the late postoperative period.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We thankfully and gratefully commemorate our deceased lovely teacher Prof. Dr. Yavuz Bozfakioǧlu. He has great contribution in formation of our series. May the Mercy of God be with him.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bostwick J. Plastic and Reconstructive Breast Surgery. St. Louis, MO: Quality Medical Publishing; 1990. p. 760-84.  Back to cited text no. 1
    
2.
Çerçi Özkan A, Çizmeci O, Aydın H, Ozden BC, Cag BT, Emekli U, et al. The use of ipsilateral versus contralateral pedicle and vertical versus horizontal flap inset models in TRAM flap breast reconstruction and the aesthetic Aesthetic Plastic Surgery 2002;26:451-6.  Back to cited text no. 2
    
3.
Jeong W, Lee S, Kim J. Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps. Breast 2018;38:45-51.  Back to cited text no. 3
    
4.
Golpanian S, Gerth DJ, Tashiro J, Thaller SR. Free versus pedicled TRAM flaps: Cost utilization and complications. Aesthetic Plast Surg 2016;40:869-76.  Back to cited text no. 4
    
5.
Georgiade GS, Riefkohl R, Levin LS, Carl R. TRAM flap reconstruction. In: Hartrampf C, Anton MA, Bried JT, editors. Plastic, Maxillofacial, and Reconstructive Surgery. 3rd ed. Baltimore: William and Wilkins; 1997.  Back to cited text no. 5
    
6.
Clugston PA, Gingrass MK, Azurin D, Fisher J, Maxwell GP. Ipsilateral pedicled TRAM flaps: The safer alternative? Plast Reconstr Surg 2000;105:77-82.  Back to cited text no. 6
    
7.
Garvey PB, Buchel EW, Pockaj BA, Casey WJ 3rd, Gray RJ, Hernández JL, et al. DIEP and pedicled TRAM flaps: A comparison of outcomes. Plast Reconstr Surg 2006;117:1711-9.  Back to cited text no. 7
    
8.
Rietjens M, De Lorenzi F, Andrea M, Petit JY, Chirappapha P, Hamza A, et al. Technique for minimizing donor-site morbidity after pedicled TRAM-flap breast reconstruction: Outcomes by a single surgeon's experience. Plast Reconstr Surg Glob Open 2015;3:e476.  Back to cited text no. 8
    
9.
Lee KT, Mun GH. Prosthetic breast reconstruction in previously irradiated breasts: A meta-analysis. J Surg Oncol 2015;112:468-75.  Back to cited text no. 9
    
10.
Lam TC, Hsieh F, Salinas J, Boyages J. Immediate and long-term complications of direct-to-implant breast reconstruction after nipple- or skin-sparing mastectomy. Plast Reconstr Surg Glob Open 2018;6:e1977.  Back to cited text no. 10
    
11.
Lagares-Borrego A, Gacto-Sanchez P, Infante-Cossio P, Barrera-Pulido F, Sicilia-Castro D, Gomez-Cia T. A comparison of long-term cost and clinical outcomes between the two-stage sequence expander/prosthesis and autologous deep inferior epigastric flap methods for breast reconstruction in a public hospital. J Plast Reconstr Aesthet Surg 2016;69:196-205.  Back to cited text no. 11
    
12.
Sorkin M, Qi J, Kim HM, Hamill JB, Kozlow JH, Pusic AL, et al. Acellular dermal matrix in immediate expander/Implant breast reconstruction: A multicenter assessment of risks and benefits. Plast Reconstr Surg 2017;140:1091-100.  Back to cited text no. 12
    
13.
Christensen BO, Overgaard J, Kettner LO, Damsgaard TE. Long-term evaluation of postmastectomy breast reconstruction with the pedicled transverse rectus abdominis musculocutaneous flap. J Plast Surg Hand Surg 2013;47:374-8.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed130    
    Printed21    
    Emailed0    
    PDF Downloaded41    
    Comments [Add]    

Recommend this journal