TRAM fat necrosis in a young surgeon's practice: is it experience, technique, or blood flow?

Fat necrosis, the most common postoperative complication in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, affects 12% to 35% of patients. Despite its common occurrence, few studies have commented on the location within the reconstructed breast. Struck by the recurrent appearance of fat necrosis in the medial breast mound, the authors reviewed retrospectively 50 consecutive single-side TRAM flaps performed by the same surgeon during his first 5 years in practice to evaluate location, frequency, and severity of fat necrosis, as well as technique (pedicled vs. free), inset method, and patient risk factors. Fat necrosis of any amount was seen in 17 of 50 patients (34%). Significant fat necrosis (>5 cm) and/or ischemic partial flap loss occurred in 11 of 50 patients (22%), appearing in 9 of 30 pedicled flaps and 2 of 20 free TRAM flaps (pedicled vs. free; p<0.05). Fifteen of 17 ischemic areas occurred within the medial (zone II) portion of the flap. Preoperative obesity (>125% ideal body weight) correlated strongly with fat necrosis (p<0.009), whereas smoking and cup size did not. The authors' review has prompted the preferential use of free TRAM in obese patients, and has caused them to consider zone II to be less reliable than previously appreciated.