Integrating the DIEP and Muscle-Sparing (MS-2) Free TRAM Techniques Optimizes Surgical Outcomes: Presentation of an Algorithm for Microsurgical Breast Reconstruction Based on Perforator Anatomy

Abstract

Optimal surgical outcomes in autogenous breast reconstruction require a balance between the reliability of older transverse rectus abdominis musculocutaneous (TRAM) flap techniques and the decreased donor-site morbidity of the newer deep inferior epigastric perforator (DIEP) flap techniques. This article presents an approach to autogenous breast reconstruction that uses principles of both techniques. One hundred twenty patients receiving 140 breast reconstructions (100 unilateral and 20 bilateral) using the DIEP or the muscle-sparing (MS-2) free TRAM techniques were retrospectively reviewed over a 5-year period. All patients before January of 2004 (group 1, n = 107 flaps) received the DIEP flap. Patients after January of 2004 (group 2, n = 33 flaps) were approached using an integrated technique and received either the DIEP or the muscle-sparing (MS-2) free TRAM based on the perforator anatomy identified at the time of surgery. Average follow-up was 27 months for group 1 (range, 5.2 to 43 months) and 8 months for group 2 (range, 3 to 18 months). By applying the surgical technique according to the algorithm presented, the success rate has been increased to 100 percent (33 of 33 flaps, p = 0.0425, group 2) over the past 18 months without increasing donor-site morbidity. This compares with a success rate of only 92 percent (98 of 107 flaps, group 1) when the DIEP was attempted nonselectively in every case. By integrating DIEP and MS-2 surgical techniques and selectively applying the surgical technique according to the perforator anatomy, microsurgical breast reconstruction can be more reliably offered to patients while still minimizing donor-site morbidity.