Immediate Breast Reconstruction: Why the Free TRAM Over the Conventional TRAM Flap?

Abstract

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required postoperative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications. Partial flap necrosis occurred in 8 of 48 (17 percent) conventional TRAM flaps and none of the free TRAM flaps, and this was a statistically significant difference (p = 0.05). Fat necrosis occurred in 11 of 48 (23 percent) conventional TRAM flap patients and in 0 of 20 free TRAM flap patients (p = 0.015). Patients reconstructed with the free TRAM flap have had a lower incidence of partial flap necrosis and less of a delay in receiving adjuvant chemotherapy. The free TRAM flap is therefore recommended for selected patients in whom immediate reconstruction with autogenous tissue is being contemplated.