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Autologous Breast Reconstruction with DIEP Or Pedicled TRAM Abdominal Flaps

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Autologous Breast Reconstruction with DIEP Or Pedicled TRAM Abdominal Flaps EVIDENCE-BASED GUIDELINES AND MEASURES Evidence-Based Clinical Practice Guideline: Autologous Breast Reconstruction with DIEP or Pedicled TRAM Abdominal Flaps Bernard T. Lee, M.D., M.B.A., Summary: The American Society of Plastic Surgeons commissioned a multi- M.P.H. stakeholder Work Group to develop recommendations for autologous breast Jayant P. Agarwal, M.D. reconstruction with abdominal flaps. A systematic literature review was per- Jeffrey A. Ascherman, M.D. formed and a stringent appraisal process was used to rate the quality of rel- Stephanie A. Caterson, M.D. evant scientific research. The Work Group assigned to draft this guideline Diedra D. Gray, M.P.H. was unable to find evidence of superiority of one technique over the other Scott T. Hollenbeck, M.D. (deep inferior epigastric perforator versus pedicled transverse rectus abdomi- Seema A. Khan, M.D. nis musculocutaneous flap) in autologous tissue reconstruction of the breast Lauren D. Loeding, M.P.H. after mastectomy. Presently, based on the evidence reported here, the Work Raman C. Mahabir, M.D. Group recommends that surgeons contemplating breast reconstruction on Archibald S. Miller, M.D., M.S. their next patient consider the following: the patient’s preferences and risk Galen Perdikis, M.D. factors, the setting in which the surgeon works (academic versus commu- Jaime S. Schwartz, M.D. nity practice), resources available, the evidence shown in this guideline, and, Beth A. Sieling, M.D. equally important, the surgeon’s technical expertise. Although theoretical 2017 Achilles Thoma, M.D., M.Sc. superiority of one technique may exist, this remains to be reported in the Judith A. Wolfman, M.D. literature, and future methodologically robust studies are needed. (Plast. Jean L. Wright, M.D. Reconstr. Surg. 140: 651e, 2017.) Boston, Mass.; Salt Lake City, Utah; New York, N.Y.; Arlington Heights, Ill.; Durham, N.C.; Chicago, Ill.; Phoenix, Ariz.; Tulsa, Okla.; Jacksonville, Fla.; Beverly Hills, Calif.; Southbury, Conn.; Baltimore, Md.; and Hamilton, Ontario, Canada ccording to the American Cancer Soci- According to procedural statistics from the ety, approximately one in eight women American Society of Plastic Surgeons, member Ain the United States will develop invasive surgeons performed 106,338 breast reconstruc- breast cancer in their lifetime, and an estimated tion procedures in 2015, a 35 percent increase 246,600 will be newly diagnosed in 2016 alone.1 from 2000. Among these procedures, 20,325 When breast-conserving surgery is not a viable were performed with autologous tissue, or option, a single or double mastectomy may be “flaps” taken from the abdomen, back, buttocks, performed. After mastectomy, several recon- or thigh to form the reconstructed breast.2 The structive treatment options are available to American Society of Plastic Surgeons Tracking patients. Operations and Outcomes for Plastic Surgeons3 program reports a consistent record of free From Beth Israel Deaconess Medical Center and Brigham flap and pedicled transverse rectus abdominis and Women’s Hospital; \University of Utah Health Care; Co- myocutaneous flap breast reconstruction pro- lumbia University Medical Center; American Society of Plas- cedures relative to the total number of proce- tic Surgeons; Duke University Medical Center; Northwestern dures entered annually. The American Society Memorial Hospital; Mayo Clinic; Oklahoma University; of Plastic Surgeons published the first clinical Beverly Hills Body Institute; Saint Mary’s Health System; Johns Hopkins University; and McMaster University. Received for publication February 17, 2017; accepted May Official Peer-Reviewed Publication 31, 2017. from the AMERICAN SOCIETY of Copyright © 2017 by the American Society of Plastic Surgeons PLASTIC SURGEONS. DOI: 10.1097/PRS.0000000000003768 www.PRSJournal.com 651e Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • November 2017 practice guideline on breast reconstruction with (TRAM) flap—to treat breast defects associated expanders and implants in 2013.4 The present with the diagnosis or treatment of breast can- publication intends to expand on the breast cer. This guideline is intended to be used by reconstruction treatment options available by the multidisciplinary team that provides care providing evidence-based recommendations for for patients with breast cancer through the use the two most commonly performed autologous of breast cancer treatment, mastectomy, and breast reconstruction procedures based on the breast reconstruction. Health care practitioners Tracking Operations and Outcomes for Plastic should evaluate each case individually, consider- Surgeons program. ing these evidence-based treatment recommen- dations and patient values and preferences, to Scope and Intended Users determine the optimal treatment plan for each This evidence-based guideline is based on patient. This guideline is also intended to serve a systematic review of evidence and specifi- as a resource for health care practitioners and cally addresses the complications and patient developers of clinical practice guidelines and satisfaction of patients undergoing breast recommendations. reconstruction with autologous abdominal flap—specifically, the deep inferior epigas- Disclaimer tric perforator (DIEP) flap and the pedicled Evidence-based guidelines are strategies for transverse rectus abdominis musculocutaneous patient management, developed to assist physi- cians in clinical decision-making. This guideline was developed through a comprehensive review Disclosure: This clinical practice guideline was of the scientific literature and consideration funded exclusively by the American Society of Plas- of relevant clinical experience, and describes tic Surgeons; no outside commercial funding was a range of generally acceptable approaches to received to support the development of this article. diagnosis, management, or prevention of specific All contributors and preparers of the guideline, diseases or conditions. This guideline attempts including ASPS staff and consultants, disclosed to define principles of practice that should gen- all relevant conflicts of interest via an online dis- erally meet the needs of most patients in most closure reporting database. In accordance with circumstances. the Institute of Medicine’s recommendations for However, this guideline should not be con- guideline development, members with a conflict strued as a rule, nor should it be deemed inclu- of interest represented less than half of the guide- sive of all proper methods of care or exclusive line Work Group. Bernard T. Lee, M.D., M.B.A., of other methods of care reasonably directed M.P.H., Work Group Chair, has no relevant dis- at obtaining the appropriate results. It is antici- closures; Jayant P. Agarwal, M.D., has received pated that it will be necessary to approach some research support from Mentor Corporation, Life- patients’ needs in different ways. The ultimate Cell Corporation, DePuy Synthes, and NIH, as judgment regarding the care of a particular the PI in grants funded by DSM Biomedical, and patient must be made by the physician in light of served as a consultant for DonJoy Orthopedics; all the circumstances presented by the patient, Jeffrey A. Ascherman, M.D., Stephanie A. Ca- the available diagnostic and treatment options, terson, M.D., Diedra D. Gray, M.P.H., Scott T. and available resources. Hollenbeck, M.D., Seema A. Khan, M.D., Lauren This guideline is not intended to define or D. Loeding, M.P.H., Raman C. Mahabir, M.D., serve as the standard of medical care. Standards and Archibald S. Miller, M.D., have no relevant of medical care are determined on the basis of disclosures; Galen Perdikis, M.D., has served as all the facts or circumstances involved in an indi- a teacher for IHE; Jaime S. Schwartz, M.D., has vidual case and are subject to change as scientific received research support from Covidien, Ltd, and knowledge and technology advance and as prac- served on the Advisory Board of Mentor Corpora- tice patterns evolve. This guideline reflects the tion, receiving honorarium; Beth A. Sieling, M.D., state of current knowledge at the time of publi- has served as a consultant for Myriad and Genom- cation. Given the inevitable changes in the state ic Health; Achilles Thoma, M.D., has no relevant of scientific information and technology, this disclosures; Judith A. Wolfman, M.D., has served guideline will be considered relevant for a period on the Advisory Board of Hologic; Jean L. Wright, of 5 years after publication, in accordance with M.D., has no relevant disclosures. the inclusion criteria of the National Guideline Clearinghouse. 652e Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 140, Number 5 • Breast Reconstruction Guideline BACKGROUND which may have an effect on the breast and chest Autologous breast reconstruction using abdomi- wall. Related insurance coverage criteria can be nal tissue is a common reconstructive procedure with found in Appendix 1. widespread acceptance and a long history of success. Over the past 50 years, the techniques for perform- Physical Examination ing abdominally based breast reconstruction have Physical examination of the breast defect evolved. Historically, pedicled TRAM flap breast should include documentation of breast size and reconstruction was first described in the 1980s. The configuration of any missing tissue. The presence
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