We appreciate the thoughtful comments by Dr. Blondeel in response to our recently published study comparing bilateral transverse rectus abdominis myocutaneous (TRAM) flap and bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstructions. The letter primarily reiterates the limitations of the study described in the article with regard to its retrospective nature, relatively small sample size, and comparison of two surgeons with different postoperative follow-up periods.
Although the observed difference in surgeon experience and clinical follow-up limits the true comparative nature of the study, this difference is to be expected given the more recent introduction and popularization of the DIEP flap technique. We agree with Dr. Blondeel's suggestion that if the bilateral DIEP flap group had consisted of patients from the DIEP surgeon's later experience, the rate of complications, such as fat necrosis, could have been lower. However, this does not impact the low complication rates already observed in the bilateral TRAM flap reconstruction group, and would not change the overall conclusion that the two reconstruction modalities are comparable. Although the criticism regarding the difference in follow-up times between the two groups surveyed is a legitimate one, the same survey-based results were demonstrated when additional subgroup analysis was performed specifically looking at the TRAM and DIEP flaps performed within the same time period.
Dr. Blondeel also emphasizes the difference between the 3 percent hernia rate in the bilateral TRAM flap group compared with 0 percent in the bilateral DIEP flap group, and describes his observations of patients seen with “severe functional deficits” following bilateral TRAM flaps leading to lifelong “catastrophes.” The difference in the abdominal donor-site complication rate was not statistically significant in our study sample, and it is possible that a larger sample size would have made this difference statistically significant. However, for a given complication with an estimated rate of 3 percent as noted in our hernia rate, it would require a total study sample size of 5034 patients to detect a 50 percent reduction in the complication rate with 80 percent power. It is unlikely that such a large-scale single study will be conducted, and it reinforces the fact that the observed complication rate, such as abdominal hernia, is low. Nonetheless, as the number of reported series such as ours increases, the possibility of performing a meaningful meta-analysis would increase and provide further useful data. Importantly, it should be noted that many surgeons who have performed innumerable TRAM flaps successfully would strongly disagree with Dr. Blondeel's observation regarding devastating consequences following bilateral TRAM flaps. Our observation is that the vast majority of women continue to resume normal physical activities, including sports without limitations, following bilateral TRAM flap reconstruction, and many have even demonstrated ability to perform sit-ups during follow-up. It may be important to note that although pedicled TRAM flaps are routinely performed as part of plastic surgery training and breast reconstructive practice in the United States, many European plastic surgery residents complete their training without having seen or performed a single pedicled TRAM flap for breast reconstruction. It is common knowledge that the relatively few pedicled TRAM flaps that are performed in Europe are frequently performed by surgeons other than plastic surgeons, and one can wonder whether such regional differences in training and practice impact the potential difference in observed clinical outcomes.
Reconstructive outcomes will inevitably vary depending on the surgical training and experience, resources, and technical execution regardless of the chosen method of reconstruction. Thus, the primary goal of any breast reconstruction surgeon should be to provide a treatment option that can create a natural, symmetric breast mound with minimal donor-site morbidity following mastectomy. Bilateral pedicled TRAM flap surgery certainly fulfills this reconstructive goal, and there are no data to support the notion that this technique should be “abandoned” for any clinical indications. Our study was not intended to be the final word on the ongoing controversy between pedicled TRAM and DIEP flap breast reconstruction. However, it presents important clinical outcomes from the largest series of bilateral pedicled TRAM flap and bilateral DIEP flap breast reconstructions published to date, and undoubtedly illustrates that bilateral TRAM flap remains a good alternative to microsurgical reconstruction modality.
Yoon S Chun, M.D.
Julian J Pribaz, M.D.
Division of Plastic Surgery
Department of Surgery
Brigham and Women's Hospital
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