Breast Reconstruction with the Free TRAM or DIEP Flap: Patient Selection, Choice of Flap, and Outcome Maurice Y. Nahabedian, M.D., Bahram Momen, Ph.D., Gregory Galdino, M.D., and Paul N. Manson, M.D. Baltimore and College Park, Md. Recent reports of breast reconstruction with the deep bulge is reduced after DIEP flap reconstruction (p Ͻ inferior epigastric perforator (DIEP) flap indicate in- 0.001). The DIEP flap can be an excellent option for creased fat necrosis and venous congestion as compared properly selected women. (Plast. Reconstr. Surg. 110: 466, with the free transverse rectus abdominis muscle (TRAM) 2002.) flap. Although the benefits of the DIEP flap regarding the abdominal wall are well documented, its reconstructive advantage remains uncertain. The main objective of this study was to address selection criteria for the free TRAM Current methods of microvascular breast re- and DIEP flaps on the basis of patient characteristics and construction using abdominal tissue include vascular anatomy of the flap that might minimize flap the free transverse rectus abdominis muscle morbidity. A total of 163 free TRAM or DIEP flap breast reconstructions were performed on 135 women between (TRAM) and deep inferior epigastric perfora- 1997 and 2000. Four levels of muscle sparing related to the tor (DIEP) flaps. These techniques have rectus abdominis muscle were used. The free TRAM flap evolved in an attempt to reduce the morbidity was performed on 118 women, of whom 93 were unilateral related to the abdominal wall and improve the and 25 were bilateral, totaling 143 flaps. The DIEP flap procedure was performed on 17 women, of whom 14 were aesthetics of the reconstructed breast. How- unilateral and three were bilateral, totaling 20 flaps. Mor- ever, because of the complexity of these micro- bidities related to the 143 free TRAM flaps included re- vascular procedures, there are inherent risks turn to the operating room for 11 flaps (7.7 percent), total that include total flap loss, partial flap loss, fat necrosis in five flaps (3.5 percent), mild fat necrosis in 14 flaps (9.8 percent), mild venous congestion in two flaps necrosis, and abdominal bulge or hernia. A (1.4 percent), and lower abdominal bulge in eight women review of the literature is provided in Table I. (6.8 percent). Partial flap necrosis did not occur. Mor- The incidence of complications after free bidities related to the 20 DIEP flaps included return to the TRAM reconstruction related to the breast operating room for three flaps (15 percent), total necrosis in one flap (5 percent), and mild fat necrosis in two flaps ranges from 8 to 13 percent, and that related to 1–8 (10 percent). Partial flap necrosis, venous congestion, and the abdomen ranges from 1 to 82 percent. a lower abdominal bulge were not observed. Selection of Early reports with the DIEP flap were encour- the free TRAM or DIEP flap should be made on the basis aging, demonstrating an equally low flap loss of patient weight, quantity of abdominal fat, and breast volume requirement, and on the number, caliber, and rate with improved strength and contour of the 9–11 location of the perforating vessels. Occurrence of venous abdominal wall. However, more recent re- congestion and total flap loss in the free TRAM and DIEP ports after DIEP flap reconstruction have dem- flaps appears to be independent of the patient age, weight, onstrated an increased incidence of breast- degree of muscle sparing, and tobacco use. The occur- rence of fat necrosis is related to patient weight (p Ͻ related morbidity that includes fat necrosis 0.001) but not related to patient age or preservation of the ranging from 6 to 62.5 percent and venous rectus abdominis muscle. The ability to perform a sit-up congestion in 4 percent.12–15 This has led many is related to patient weight (p Ͻ 0.001) and patient age (p to question whether the added time and effort Ͻ 0.001) but not related to preservation of the muscle or intercostal nerves. The incidence of lower abdominal required in dissecting the DIEP flap is of ben- From the Johns Hopkins Medical Institutions, Plastic and Reconstructive Surgery, and the Department of Natural Resource Sciences, University of Maryland. Received for publication June 15, 2001; revised November 20, 2001. 466 Vol. 110, No. 2 / BREAST RECONSTRUCTION 467 TABLE I Review of Literature Author Year Flap Fat Necrosis (%) Venous Congestion (%) Bulge (%) Blondeel et al.10 1997 Free TRAM NA NA 2 /20 (10) DIEP NA NA 0 /18 (0) Kroll26 1998 Pedicle TRAM 18/67 (26.9) NA NA Free TRAM 4/49 (8.2) NA NA Blondeel13 1999 DIEP 6/100 (6) NA 1/87 (1.1) Hamdi et al.11 1999 DIEP 3/50 (6%) NA 2/42 (4.8) Blondeel et al.12 2000 Free TRAM NA 0/271 NA DIEP NA 5/240 (2.1) NA Kroll14 2000 Free TRAM 36/279 (12.9) NA NA DIEP (group 1) 5/8 (62.5) NA NA DIEP (group 2) 4/23 (17.4) NA NA NA, not applicable. efit when compared with the muscle-sparing flap is known as a muscle-sparing free TRAM free TRAM flap. flap and also incorporates a small segment of The purpose of this study is to establish se- anterior rectus sheath (Fig. 1). The free TRAM lection criteria for the free TRAM and DIEP flap contains a variable number of perforators flaps on the basis of patient characteristics and (generally three to six). The DIEP flap incor- the vascular anatomy of the flap and to provide porates no muscle or anterior rectus sheath, an outcome analysis. Flap morbidity is analyzed and the number of perforators included gen- on the basis of the degree of sparing of the erally ranges from one to three (Fig. 2). The rectus abdominis muscle, tobacco use, patient anatomic features of the deep inferior epigas- age, and patient body weight. Abdominal mor- tric artery and vein and its perforators have bidity is analyzed on the basis of the amount of been described be means of cadaver dissec- muscle used and sparing of the intercostal in- tions and color-flow duplex scanning.20–23 The nervation and its association with the ability to average mean diameter of the deep inferior perform a sit-up and occurrence of a lower abdominal bulge. More specifically, we in- tended to quantify whether venous congestion, total flap loss, fat necrosis, lower abdominal bulge, or the ability to perform a sit-up would be related to the patient’s age, weight, tobacco use, nerve sparing, or the muscle-sparing method used during the operation. An algo- rithm for selecting the free TRAM or DIEP flap will be provided. PATIENTS AND METHODS Anatomic Basis of the Free TRAM and DIEP Flaps The anatomy, preoperative markings, tech- nique of elevation, and choice of recipient ves- sels for the free TRAM and DIEP flaps have been previously described.16–19 The defining and differentiating features of the free TRAM and DIEP flaps include the presence or ab- sence of rectus abdominis muscle and the number of perforating vessels perfusing the flap. The amount of rectus abdominis muscle incorporated into a free TRAM flap is variable and ranges from a short length and entire ϫ width of the muscle to a small 2 2-cm seg- FIG. 1. Free TRAM flap with small central segment of ment of muscle. The latter type of free TRAM rectus abdominis muscle (MS-2). 468 PLASTIC AND RECONSTRUCTIVE SURGERY, August 2002 struction, whereas women with a breast volume greater than 1000 cc are better candidates for the free TRAM flap. This is because large- volume (Ͼ1000 cc) breast reconstruction may be at increased risk for flap-related morbidity because of inadequate vascular perfusion. Al- though the DIEP flap has been demonstrated clinically to provide adequate perfusion based on one or two perforators, its benefit for large- volume reconstruction has not been estab- lished. Therefore, it may be helpful to estimate or calculate the breast volume to choose a flap that will be capable of adequate perfusion for the entire flap. For the majority of women in this study, breast volume was estimated on the basis of the primary surgeon’s personal experience. For 22 women (32 breasts), breast volumes were cal- culated preoperatively using the Rainbow three-dimensional digital imaging system (Genex Technologies, Inc., Kensington, Md.) to assist with the decision-making process.29 The imaging was performed during initial con- FIG. 2. DIEP flap (MS-3). Note that the rectus abdominis sultation. Postoperative volume measurements muscle and anterior rectus sheath are not incorporated into were not obtained. Mean preoperative breast the flap. volume for the 32 breasts was 493 cc (range, 185 to 1109 cc). Mean preoperative volume for epigastric artery is 3.6 mm (range, 2.8 to 5 the six breasts that were reconstructed using a mm). The number of perforators with a caliber DIEP flap was 493 cc (range, 311 to 753 cc) and greater than 1 mm ranges from one to three. the mean preoperative volume for the 26 The majority of perforators are located within breasts that were reconstructed using a free 8 cm of the umbilicus. TRAM flap was 492 cc (range, 185 to 1109 cc). In the remaining 113 women that included 14 Patient and Flap Selection DIEP flaps and 117 free TRAM flaps, breast The decision to use a free TRAM or DIEP volumes were not obtained. In these women, flap is made on the basis of preoperative and the decision was made on the basis of body intraoperative factors.24–29 Although a woman habitus and qualitative estimation of tissue may be a good candidate for a DIEP flap on the requirements.