Ischemic Complications in Pedicle, Free, and Muscle Sparing Transverse Rectus Abdominis Myocutaneous Flaps for Breast Reconstruction

Abstract

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.

Decision Regret following Breast Reconstruction

“…38 Lastly, similar to other reports, we also found a significant relationship between the presence of major complications and higher decision regret (OR, 2.51; 95 percent CI, 1.23 to 5.11) in our patient sample. 39 Although this research has important implications for increasing our awareness of the association between satisfaction with obtaining information during the preoperative surgical decision-making phase and posttreatment regret following breast reconstruction, some limitations to the study design exist. Because of the cross-sectional study design, there is inherent recall bias, and conclusions about causality and determination about how regret status may change over time cannot be made.…”

Patient satisfaction and health‐related quality of life after autologous tissue breast reconstruction

“…41 Our findings are in contrast to those reported by Andrade et al, who identified postoperative complication as an important indicator of patient dissatisfaction with reconstruction. 42 The initial physical well being chest score declined significantly at 3 weeks postoperatively compared with the baseline score (P < .001), although the score returned to baseline levels by 3 months. The initial decline may be related to early postoperative discomfort associated with operative procedure.…”

The Effects of Perioperative Tamoxifen Therapy on Microvascular Flap Complications in Transverse Rectus Abdominis Myocutaneous/Deep Inferior Epigastric Perforator Flap Breast Reconstruction

“…While fat necrosis occurs secondary to tissue ischemia, no other sequelae of ischemia such as wound dehiscence or partial/total flap necrosis were elevated. 18 The high rate of fat necrosis may have been secondary to methods of documentation, as any indication of fat necrosis in follow-up notes was included, the majority of which were clinically insignificant and conservatively managed. Of the cases of fat necrosis, only 28.6% in the tamoxifen cohort and 31.1% in the control required excision during revision procedures.…”