A Comparison between DIEP and muscle-sparing free TRAM flaps in breast reconstruction: a single surgeon's recent experience.

Background: Discussions of abdominal donor-site morbidity and risk of flap loss continue to surround free flap breast reconstruction. The authors performed a head-to-head comparison of deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps performed by a single senior surgeon at a single institution.

Methods: The senior author's (J.M.S.) recent experience with DIEP and muscle-sparing free TRAM flaps between July of 2006 and July of 2008 was reviewed retrospectively. The choice of flap was dictated by an intraoperative algorithm based on number, size, and location of perforator vessels. Variables assessed included intraoperative and postoperative complications. Three groups were analyzed: DIEP reconstructions, muscle-sparing free TRAM reconstructions, and bilateral reconstructions in which one of each flap type was performed.

Results: Ninety-one patients underwent 123 muscle-sparing free TRAM flap reconstructions, 53 patients underwent 71 DIEP flap reconstructions, and 31 patients underwent bilateral reconstruction with one DIEP and one muscle-sparing free TRAM flap. There were no significant differences in intraoperative complications or in minor postoperative complications. There was, however, a significant increase in total major postoperative complications in the DIEP study group (DIEP=3.9 percent, muscle-sparing free TRAM=0 percent, p=0.03). No significant difference was noted in hernia formation (DIEP=0, muscle-sparing free TRAM=4, p=0.15).

Conclusions: This study demonstrates that both of these flaps may be reliably performed with an extremely low risk of complications. The choice of flap should be made intraoperatively, based on anatomic findings on a patient-by-patient basis, so as to optimize flap survivability while minimizing donor-site morbidity to the greatest extent possible.