A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution

Several reports concluded that free tissue transfer of the transverse rectus abdominis muscle (TRAM) flap for breast reconstruction is superior to pedicled transfer of the flap. In an effort to compare the various parameters of both techniques, the authors took advantage of a unique experience at one hospital where one surgeon (D.L.L.) used only the pedicled method and the other (N.J.Y.) used only free tissue transfer. Additionally, the authors compared the findings of the study with the experiences of other surgeons by surveying active members of the American Association of Plastic Surgeons. The records of 119 patients who underwent TRAM flap reconstruction between January of 1988 and July of 1997 were reviewed. Of these, 33 patients received free TRAM flaps, and 86 received pedicled TRAM flaps. To provide an adequate number of patients for statistical analysis, only those with unilateral, single-muscle reconstructions were considered (immediate or delayed). This provided 61 patients in the pedicled flap group and 26 in the free tissue group. Parameters examined included length of operation and of hospitalization, amount of pain medication used, amount of blood lost and received, and complications. A small subset of the patients had hospital records available to compare hospital charges; the comparison of 17 pedicled and 12 free TRAM flaps showed a mean difference of $15,637 (p < 0.001) in favor of the pedicled flap. On the basis of the findings from this study, it seems that the pedicled TRAM flap has significant economic and clinical advantages over the free TRAM flap. There is less need for blood, a shorter operating time and hospital stay, and a need for less pain medication. However, both methods of transfer have indications and contraindications in certain clinical settings. It will always remain the responsibility of the surgeon to evaluate all issues and select a method that is economically responsible and within the abilities of the surgeon, while producing a satisfactory outcome that best serves the patient. The information provided in this report should aid in accomplishing this goal.