DIEP Flaps are better than Pedicled TRAM Flaps

Comparison of four types of abdominal flaps used for autologous breast shows reconstruction shows differences in some key outcomes—notably related to problems related to hernias or bulging at the abdominal “donor site,” according to the new research by Dr. Sheina A. Macadam of University of British Columbia, Vancouver, and colleagues.

Researchers looked at nearly 1,800 women undergoing autologous breast reconstruction after mastectomy at five US and Canadian university hospitals. The reconstructions were done using different types of abdominal flaps:

  • Traditional flaps incorporating the rectus muscle of the abdomen—called the free transverse abdominis myocutaneous flap (f TRAM) or pedicled transverse abdominis myocutaneous flap (p TRAM)
  • Newer flaps that avoid or use only a part of the rectus muscle—called the deep inferior epigastric artery perforator flap (DIEP) or muscle-sparing free transverse abdominis myocutaneous flap (msf TRAM)

The p-TRAM flap was also associated with the highest rate of abdominal hernia or bulging: nearly 17 percent. The risk of these donor-site complications was about eight percent with the msf-TRAM flap, six percent with the f-TRAM flap, and four percent with the DIEP flap.

That was consistent with the BREAST-Q responses, which showed better scores on a subscale reflecting physical issues related to the abdomen with the DIEP flap compared to the p-TRAM flap. Scores on the other BREAST-Q subscales—reflecting overall satisfaction with the breasts, and psychosocial and sexual well-being—were similar across groups.

About 20 percent of women undergoing breast reconstruction choose autologous reconstruction, which is most often done using abdominal flaps. Muscle-sparing flaps such as the DIEP and msf-TRAM have been developed to reduce complications at the abdominal donor site. While more women are interested in these muscle-sparing approaches, it hasn’t been clear whether the longer operative times and increased costs of these procedures are justified by improved outcomes.

The new study shows some differences in complications and patient-reported outcomes with different abdominal flaps. The DIEP was associated with the best abdominal wall recovery and function compared to the p-TRAM. Interestingly, it did not differ from msf-TRAM and f-TRAM.

The scientific results further support my personal strategy in preference to reconstructive patients with DIEP flaps whenever possible compared to any other type of flap. Many women are also candidates for an implant reconstruction and I’ll discussed in another blog.

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