Floor plan - 2013 Annual Meeting - American Association for Hand ...

The SIEA, DIEP and Free TRAM flaps: A Comparison of Abdominal Wall and Flap
Complications and a Surgical Algorithm
Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA
Jesse Creed Selber, MD, MPH; Fares Samra, BA; Lauren Hill, BA; Mirar Bristol; Seema Sonnad; Joseph Serletti;
University of Pennsylvania
PURPOSE:
Attempts to limit the impact of autogenous breast reconstruction on the abdominal wall have lead to the use of the muscle sparing
free TRAM, the DIEP and more recently, the SIEA flap. These procedures differ in complication profile, particularly with respect to the
abdominal wall, and flap related complications such as fat necrosis and flap loss. The purpose of this study is to compare these three
methods across a spectrum of such clinical outcomes to weigh the relative risks and benefits of each, and better refine their respective
roles in autogenous breast reconstruction.
METHODS:
A retrospective cohort study of 72 SIEA flaps, 50 DIEP flaps, and 569 free TRAM flaps was performed. Outcome variables included
wound infection, hematoma, seroma, fat necrosis, abdominal flap necrosis, mastectomy flap necrosis, abdominal hernia or bulge, vessel
thrombosis, partial flap loss and total flap loss. Chi square and Fisher's Exact tests were used to determine significant differences in
patient population characteristics as well as complication rates among groups.
RESULTS:
There was no difference in age, past medical history, length of follow-up or recipient vessels in the 3 groups. In the SIEA and DIEP
groups, there were higher percentages of obese patients (p = 0.0001), bilateral cases (p = 0.0001), and immediate reconstructions (p =
0.001), and in the DIEP group, there was a higher percentage of smokers (p = 0.0001). The rate of flap loss was 3.0% in the SIEA group,
2% in the DIEP group, and 0.2% in the free TRAM group (p = 0.05). The rate of vessel thrombosis was 17% in the SIEA group, 10% in
the DIEP group, and 6% in the free TRAM group (p < .05). The hernia rate was 0% in both the SIEA and DIEP groups, and 2% in the
free TRAM group.
CONCLUSION:
The SIEA has the highest rate of flap loss and vessel thrombosis, followed by the DIEP, followed by the free TRAM. The SIEA and DIEP
both enjoy less donor site morbidity than the free TRAM. These results are consistent with theoretical risks and benefits in which donor
site morbidity is decreased at the expense of reliability. Because of this relationship, the authors recommend that muscle preserving
techniques be undertaken judiciously by microsurgeons experienced in the successful management of vessel thrombosis. The authors
present a surgical algorithm that leads to consistently successful results in autogenous breast reconstruction.
A New Composite Flap: Rectus Abdominis Muscle Flap Harvested with Pubic Bone Segment
(Anatomic Considerations)
Institution where the work was prepared: Gulhane Military Medical Academy, Ankara, Turkey
Serdar Ozturk; Mustafa Sengezer; Unsal Coskun; Fatih Zor; Gulhane Military Medical Academy
The aim of this study is to incorporate a segment of pubic bone to rectus abdominis muscle(RAM). Eight RAM flaps from four fresh
cadavers were used. During surgical dissection utmost care was paid to enclose the areolar tissue between the main DIE vessels and
the pubic bone. A bone segment, 1.5x5cm in dimension, with an intact periosteum was included in RAM. Surgical dissections revealed
two major vascular branches.The first branch arising from the DIEA at a distance of 5.2±1.4 cm from the origin gave rise to two consistent
sub-branches. The second major branch originated from DIEA at a distance of 8.4±1.8 cm from the origin. The first branch gave
off two sub-branches. The second sub-branch coursed antero-medially and nourished the periosteum of the pubic bone.
Microangiographies showed a similar branching pattern of the vessels that create two significant networks. The x-rays confirmed a rich
vascular network around the periosteum of the pubic bone. This wealthy nourishment of the pubic periosteum comes mainly from the
perpendicular descending branches. In conclusion, a vascularized part of pubic bone can be incorporated to the RAM flap by preserving
the delicate vascular network between the DIE vessels and the pubic periosteum.
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