TRAM flap for immediate post mastectomy reconstruction: comparison between pedicled and free transfer

Breast reconstruction after mastectomy is primarily carried out to improve the patients' quality of life. The most commonly used autologous tissue for reconstruction is the transverse rectus abdominis musculocutaneous flap (TRAM). The TRAM flap could be transferred either as pedicled or a free flap with microvascular anastomosis. The following work was carried out to evaluate the two techniques.

Thirty-one female patients with operable breast cancer consented to immediate breast reconstruction during the period from June 1998 to December 2000. Fifteen patients had a free TRAM flap reconstruction. In sixteen patients, a pedicled TRAM flap was used. Three patients in the pedicled group underwent bilateral breast reconstruction, thus there were 19 pedicled flaps available for evaluation. Four patients in the pedicled flap group underwent reduction mammoplasty of the normal breast and in five other patients a bipedicled flap was used to achieve size matching with the reconstructed breast. Criteria for analysis included operative data, hospital stay, donor site morbidity, abdominal wall integrity, flap related complications, fat necrosis and final aesthetic result.

There was no difference between the two groups as regards age and, operative time. The pedicled flap group had shorter hospital stay and less blood loss than the free flap group, which was statistically significant (p=0.007 and p=0.001, respectively). In the pedicled flap group, two patients (10.5%) experienced partial flap loss and fat necrosis was detected in two other patients. For the free flap group, two patients (13.3%) developed complete flap loss, but none suffered fat necrosis. Donor site morbidity was equal in both groups. The total number of complications was higher in the pedicled group (7/19) (36.8.8%) than in the free flap group (5/15) (33.3 degrees k) but this was not statistically significant (p=0.27). None of the patients in both groups developed abdominal wall hernia, but abdominal wall weakness was evident in eight patients in the pedicled flap group that gradually improved over 2-3 months. Aesthetic results were comparable in both groups with a slightly better figure for the free flap group, but this was not statistically significant (p=0.23).

Although free TRAM flap seems to provide several advantages over the pedicled group, namely skin volume available for harvesting, preservation of abdominal wall integrity, and better flap contouring, yet the pedicled TRAM flap is a reliable and easy technique that will produce matching aesthetic results.