TRAM Flap Anatomy Correlated with a 10-Year Clinical Experience with 556 Patients

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Abstract
This study examines the vascular anatomy of the TRAM flap and evaluates risk factors associated with complications among 556 women who had TRAM flap breast reconstruction. Fifty-nine patients (10.6 percent) developed fat necrosis involving 10 percent or more of their breast. Risk factors associated with fat necrosis were a history of chest-wall irradiation (p = 0.001), significant abdominal scar (p < 0.01), and obesity (p < 0.02). Among unipedicle reconstructions, patients with multiple risk factors had three times the incidence of fat necrosis (24.7 versus 8.3 percent) compared with patients with one or no risk factors (p < 0.002). Patients with multiple risk factors who had bipedicled TRAM flap reconstruction had no associated increased incidence of fat necrosis (p > 0.18). Forty-nine patients (8.8 percent) developed abdominal hernias. Risk factors associated with hernia formation included smoking at the time of surgery (p = 0.00001) and abdominal-wall repair with interposed mesh (p < 0.00001). The overall complication rate for this series was 23.7 percent (132 of 556). Risk factors associated with any complication included smoking (p < 0.002), history of chest-wall irradiation (p < 0.002), significant abdominal scar (p < 0.005), and obesity (p < 0.02). Patient selection is a fundamental determinant of successful TRAM flap breast reconstruction. Among patients with multiple risk factors, the risk of tissue loss in the reconstructed breast may be diminished by use of a bipedicled TRAM flap.

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