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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?

Selber, Jesse C. M.D., M.P.H.; Samra, Fares B.S.; Bristol, Mirar M.A.; Sonnad, Seema S. Ph.D.; Vega, Stephen M.D.; Wu, Liza M.D.; Serletti, Joseph M. M.D.

Plastic & Reconstructive Surgery: August 2008 - Volume 122 - Issue 2 - pp 348-355
doi: 10.1097/PRS.0b013e31817d60b0
Breast: Original Articles

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.

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.

Received for publication July 27, 2007; accepted November 29, 2007.

Presented at the 86th Annual Meeting of the American Association of Plastic Surgeons, in Coeur d’Alene, Idaho, May 19 through 22, 2007.

Disclosure: None of the authors has any commercial associations that might pose or create a conflict of interest with information presented in this article. Such associations include consultancies, stock ownership or other equity interests, patent licensing arrangements, and payments for conducting or publicizing a study described in the article. No intramural or extramural funding supported any aspect of this work.

Jesse Selber, M.D., M.P.H., Division of Plastic Surgery, University of Pennsylvania, 10 Penn Tower, 3400 Spruce Street, Philadelphia, Pa. 19104 jesse.selber@uphs.upenn.edu

©2008American Society of Plastic Surgeons