Breast Reconstruction with the Free TRAM or DIEP Flap: Patient Selection, Choice of Flap, and Outcome

Abstract

Recent reports of breast reconstruction with the deep inferior epigastric perforator (DIEP) flap indicate increased fat necrosis and venous congestion as compared with the free transverse rectus abdominis muscle (TRAM) flap. Although the benefits of the DIEP flap regarding the abdominal wall are well documented, its reconstructive advantage remains uncertain. The main objective of this study was to address selection criteria for the free TRAM and DIEP flaps on the basis of patient characteristics and vascular anatomy of the flap that might minimize flap morbidity. A total of 163 free TRAM or DIEP flap breast reconstructions were performed on 135 women between 1997 and 2000. Four levels of muscle sparing related to the rectus abdominis muscle were used. The free TRAM flap was performed on 118 women, of whom 93 were unilateral and 25 were bilateral, totaling 143 flaps. The DIEP flap procedure was performed on 17 women, of whom 14 were unilateral and three were bilateral, totaling 20 flaps. Morbidities related to the 143 free TRAM flaps included return to the operating room for 11 flaps (7.7 percent), total necrosis in five flaps (3.5 percent), mild fat necrosis in 14 flaps (9.8 percent), mild venous congestion in two flaps (1.4 percent), and lower abdominal bulge in eight women (6.8 percent). Partial flap necrosis did not occur. Morbidities related to the 20 DIEP flaps included return to the operating room for three flaps (15 percent), total necrosis in one flap (5 percent), and mild fat necrosis in two flaps (10 percent). Partial flap necrosis, venous congestion, and a lower abdominal bulge were not observed. Selection of the free TRAM or DIEP flap should be made on the basis of patient weight, quantity of abdominal fat, and breast volume requirement, and on the number, caliber, and location of the perforating vessels. Occurrence of venous congestion and total flap loss in the free TRAM and DIEP flaps appears to be independent of the patient age, weight, degree of muscle sparing, and tobacco use. The occurrence of fat necrosis is related to patient weight (p Ͻ 0.001) but not related to patient age or preservation of the rectus abdominis muscle. The ability to perform a sit-up is related to patient weight (p Ͻ 0.001) and patient age (p Ͻ 0.001) but not related to preservation of the muscle or intercostal nerves. The incidence of lower abdominal bulge is reduced after DIEP flap reconstruction (p Ͻ 0.001). The DIEP flap can be an excellent option for properly selected women. (Plast. Reconstr. Surg. 110: 466, 2002.)

Trends in breast reconstruction practices in a specialized breast tertiary referral centre

“…Earlier in the study period, autologous flaps were the most widely used. However, over time, implant‐based reconstructions have become more common3 7, 22 34, 35, 36. This may be explained by implant reconstructions requiring less complicated operations and shorter operating times, lack of donor‐site morbidity and no requirement for microvascular surgery expertise as in the case of some autologous procedures (DIEP flaps).…”

“…This may be explained by implant reconstructions requiring less complicated operations and shorter operating times, lack of donor‐site morbidity and no requirement for microvascular surgery expertise as in the case of some autologous procedures (DIEP flaps). Complex patient selection and the requirement for preoperative CT (in DIEP flap surgery) also make autologous reconstructions a less attractive reconstructive technique35, 36, 37. ADMs were first reported in 200538.…”

Anatomy of Free Flap Failures: Dissection of a Series

“…In the new millennium, we have resurrected the anatomy phase with the development of perforator flaps. The development of the DIEP followed by SGAP and subsequent perforator flaps has created a new phase of microsurgery [2,[13][14][15][16][17]. The next phase would seem to be poised for that of allotransplantation [18].…”

Double Venous System Drainage in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

“…[2] Other large series have reported similar results with respect to major complications. [2][3][4][5][6][7]13,16] With regards to vascular problems, venous congestion tends to be the primary concern for microsurgeons who perform DIEP flap breast reconstruction. Complications due to the venous drainage or venous anastomosis have been shown to be eight times more common than issues arising from arterial insufficiency or arterial anastomotic complications.…”

“…[2] These problems can lead not only to the rare total flap failure but more commonly to the need to return to the operating room in the immediate postoperative period to correct venous insufficiency and even partial flap failure and fat necrosis in the long-term. [3][4][5][6][7] Anatomic studies have shown that the deep inferior epigastric vein (DIEV) connects with the superficial inferior epigastric vein (SIEV) through a system of choke vessels within the flap. [8] In numerous studies, the superficial venous system has been used to adequately decongest the flap in cases where venous congestion was clinically observed [9][10][11][12][13].…”