A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function?
BACKGROUND
Attempts to limit the impact of autogenous breast reconstruction on the abdominal wall have led to the use of the muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM), the deep inferior epigastric artery perforator (DIEP), and the superficial inferior epigastric artery (SIEA) flaps. The purpose of this study was to compare the SIEA flap with the muscle-sparing free TRAM flap to determine whether gains in abdominal wall function are offset by flap-related complications.


METHODS
Seventy-two consecutive SIEA flaps were compared with 569 consecutive muscle-sparing free TRAM flaps. Outcomes included arterial and venous thrombosis, reoperation, abdominal hernia/bulge, seroma, hematoma, fat necrosis, delayed wound healing, infection, partial flap loss, and total flap loss. Chi-square and Fisher's exact tests were used to determine significant differences.


RESULTS
In the SIEA group, there was a higher percentage of overweight patients (p = 0.0001), bilateral cases (p = 0.0001), and smokers (p = 0.0003). Among SIEA flaps, there were two total flap losses (2.9 percent) and no abdominal morbidity. In the muscle-sparing free TRAM flap group, there was one total flap loss (0.18 percent), and a hernia/bulge rate of 1.9 percent (n = 11). The difference in flap loss rate was significant (p = 0.03). There was a higher incidence of vessel thrombosis requiring anastomotic revision in the SIEA group, 17.4 percent (n = 12), compared with the free TRAM group, 6.0 percent (n = 34) (p = 0.0005).


CONCLUSIONS
The SIEA flap has a lower rate of hernia/bulge and a higher rate of thrombotic complications. Because of the emotional and financial cost of these complications, the SIEA flap should be undertaken only if strict criteria are met.
Selber
Jesse C
JC
Philadelphia, Pa.; and Rochester, N.Y. From the Division of Plastic Surgery and the Department of Surgery, University of Pennsylvania, and the Division of Plastic Surgery, Strong Memorial Hospital.
Samra
Fares
F
Bristol
Mirar
M
Sonnad
Seema S
SS
Vega
Stephen
S
Wu
Liza
L
Serletti
Joseph M
JM
D034861:Abdominal Wall / Q000503:physiopathology*; D000328:Adult; D001943:Breast Neoplasms / Q000601:surgery*; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D005260:Female; D006085:Graft Survival / Q000502:physiology*; D046449:Hernia, Abdominal / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D016462:Mammaplasty / Q000379:methods*; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000503:physiopathology* / Q000601:surgery; D012086:Reoperation / Q000706:statistics & numerical data; D013524:Surgical Flaps / Q000098:blood supply*; D013927:Thrombosis / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology; D020858:Tissue and Organ Harvesting / Q000379:methods*; D014945:Wound Healing / Q000502:physiology*