Breast Reconstruction Using Abdominal Tissue: Differences in Outcome With Four Techniques
In women undergoing breast reconstruction using autologous tissue, newer muscle-sparing abdominal flaps can reduce complications while improving some aspects of quality of life, according to a study by Macadem et al in Plastic and Reconstructive Surgery.
Comparison of four types of abdominal flaps used for autologous breast reconstruction shows differences in some key outcomes—notably, problems related to hernias or bulging at the abdominal “donor site,” according to the new research by Sheina A. Macadam, MD, of The University of British Columbia, Vancouver, and colleagues.
The researchers identified nearly 1,800 women undergoing autologous breast reconstruction after mastectomy at five U.S. and Canadian university hospitals. The reconstructions were done using different types of abdominal flaps:
- Traditional flaps incorporating the rectus muscle of the abdomen—called (1) the free transverse abdominis myocutaneous flap (f TRAM) or (2) pedicled transverse abdominis myocutaneous flap (p TRAM)
- Newer flaps that avoid or use only a part of the rectus muscle—called (3) the deep inferior epigastric artery perforator flap (DIEP) or (4) muscle-sparing free transverse abdominis myocutaneous flap (msf TRAM)
Hospital records were used to compare complication rates across the four flap types. In addition, about half of the women completed the BREAST-Q© questionnaire, which assesses various aspects of quality of life after breast reconstruction. Average follow-up time was 5.5 years.
Study Findings
The most serious types of complications—including total flap loss and abnormal blood clots—were not significantly different between groups. Both the DIEP and msf-TRAM flaps were associated with lower rates of fat necrosis, compared to the p-TRAM flap.
The p-TRAM flap was also associated with the highest rate of abdominal hernia or bulging: nearly 17%. The risk of these donor-site complications was about 8% with the msf-TRAM flap, 6% with the f-TRAM flap, and 4% 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% 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 highest abdominal well being and the lowest abdominal morbidity when compared to the p-TRAM, but did not differ from msf-TRAM and f-TRAM,” Dr. Macadam and coauthors wrote.
While formal randomized trials would be needed to confirm these results, the researchers believe their findings provide important evidence on the outcomes of current options for autologous breast reconstruction. They concluded, “The differences we have found in patient-reported symptoms and abdominal donor site outcomes may shift the practice of plastic surgeons towards utilizing methods with lower donor site [complications] and higher patient-reported satisfaction.”
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