AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

A Comparison of Postoperative Sequelae in Free TRAM and DIEP Flaps for Breast Reconstruction
Institution where the work was prepared: Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Constance M. Chen, MD, MPH; Eric Halvorson; Joseph J. Disa; Babak J. Mehrara; Andrea L. Pusic; Peter G. Cordeiro; Memorial Sloan-Kettering Cancer Center
BACKGROUND:
Although the DIEP flap is a major advance in breast reconstruction, many surgeons are reluctant to use it due to concerns about a higher flap loss rate when
compared to free TRAM flaps. The DIEP flap involves a more technically challenging dissection and a learning curve associated with perforator selection. This
study evaluates our institutional experience with immediate postoperative complications following DIEP and free TRAM flaps.
METHODS:
Results of 200 consecutive free TRAM and DIEP breast reconstructions performed at a single institution between 2003 and 2005 were reviewed using a prospectively
maintained database. The incidence of flap complications following free TRAM and DIEP breast reconstructions was compared. Patient demographics,
procedure type, diagnosis, adjuvant treatment, and complications were recorded. Outcome variables included total and partial flap loss, infection, seroma,
hematoma, wound healing problems, fat necrosis, and mastectomy flap necrosis.
RESULTS:
Two hundred patients were treated with 159 free TRAM flaps (n=159) and 41 DIEP flaps (n=41). No statistically significant differences were seen in mean age, BMI,
radiation status, prior lymph node dissection, timing of surgery, smoking history, or systemic disease (p = 0.05). Thoracodorsal anastomoses were more prevalent in
the free TRAM group, reflecting a bias in this center's early clinical practice. Fisher's exact test demonstrated significantly more wound healing problems in free TRAMs
than in DIEPs (p = 0.01). Patients with wound healing problems exhibited a trend towards obesity (p = 0.07), but no statistically significantly difference in smoking
status. Interestingly, despite lower wound healing problems, the DIEP patients also exhibited a trend toward older age, greater BMI, and higher prevalence of cardiovascular
disease. No statistically significant differences were noted for any other complications including total or partial flap loss (Table 1).
Table 1. Complications
Complication TRAM (Flaps=159) DIEP (Flaps=41) 2-tailed Fisher's exact test
Total flap loss 1 (0.6%) 0 n/s
Partial flap loss 2 (1.3%) 0 n/s
Infection 6 (3.8%) 1 (2.4%) n/s
Seroma 12 (7.5%) 2 (4.9%) n/s
Hematoma 11 (6.9%) 1 (2.4%) n/s
Wound healing problems 21 (13.2%) 0 p = 0.01
Fat Necrosis 20 (12.8%) 5 (12.2%) n/s
Mastectomy flap necrosis 24 (15.1%) 6 (14.6%) n/s
CONCLUSIONS:
In comparing two statistically similar patient populations, we found that the DIEP flap did not result in more postoperative flap-related complications when
compared to the free TRAM flap. In the properly selected patient, the DIEP flap is a safe and reliable procedure for breast reconstruction.
A Meta-Analysis of Complication Rates in Free DIEP versus Free TRAM Flaps for Breast Reconstruction
Institution where the work was prepared: Div of Plastic Surgery, Hosp of the University of Pennsylvania, Philadelphia, PA, USA
Li-Xing Man, MD, MSc; Jesse C. Selber, MD, MPH; Joseph M. Serletti, MD, FACS; University of Pennsylvania
Introduction:
Several studies comparing free transverse rectus abdominis myocutaneous (TRAM) flaps to free deep inferior epigastric perforator (DIEP) flaps for breast reconstruction
have found no significant differences in flap-related complications and donor-site morbidity. Many of these studies were case series performed at
single institutions and may lack the power to demonstrate an effect. The object of this meta-analysis was to develop pooled comparisons of the risk of fat
necrosis, partial and total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after DIEP and free TRAM surgery.
Methods:
A MEDLINE and manual search of English-language articles on DIEP or free TRAM surgery published up to April 2006 yielded 289 citations. Two levels of
screening with predefined criteria identified 30 relevant studies.
Results:
Six studies reporting both DIEP and TRAM flap outcomes were used to estimate pooled relative risks (RR) of complications and confidence intervals (CIs). A
muscle-sparing free TRAM technique was used in three of these studies. There was a 2-fold increase in risk for fat necrosis (RR 1.94; 95% CI 1.28, 2.93) and
partial or total flap loss (RR 2.05; 95% CI 1.16, 3.61) in DIEP flap patients compared to those with TRAM flaps. However, there was no difference in the risk
for fat necrosis when the analysis was limited to muscle-sparing free TRAM flaps (RR 0.91; 95% CI 0.47, 1.78). Patients receiving DIEP flaps had one-half the
risk of developing abdominal bulge or hernia (RR 0.49; 95% CI 0.28, 0.86). This result was not altered when limiting the comparison to muscle-sparing free
TRAM flaps. Twelve studies reporting DIEP flap outcomes and 19 studies reporting free TRAM flap outcomes were identified and used to estimate pooled complication
rates using a random effects model to account for between-study heterogeneity. Pooled flap-related complication rates were similar for free DIEP and
TRAM flaps, while donor-site morbidity was higher in the free TRAM flaps.
Summary:
The DIEP flap appears to reduce abdominal morbidity but may increase flap-related complications compared to the free TRAM flap.
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