Technical variations of the bipedicled TRAM flap in unilateral breast reconstruction: Effects of conventional versus microsurgical techniques of pedicle transfer on complications rates

In cases of unilateral breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap, poorly perfused tissue, which is normally excised to avoid subsequent fat necrosis, must sometimes be used to achieve adequate breast size and projection. In such cases, incorporation of a second vascular pedicle into the flap design improves perfusion. The authors retrospectively examined their experience with bipedicled TRAM flap-based unilateral breast reconstruction to determine whether the use of microsurgical rather than conventional (nonmicrosurgical) techniques for flap transfer resulted in lower incidences of flap-site fat necrosis and donor-site hernia/bulge. The authors retrospectively reviewed the medical records of all patients who underwent unilateral breast reconstruction with a bipedicled TRAM or deep inferior epigastric perforator flap between January of 1991 and March of 2001. Group 1 consisted of patients who had undergone flap transfer using a conventional technique for both pedicles; group 2, patients who had flap transfer using a conventional technique for one pedicle and a microsurgical technique for the other; and group 3, patients who had flap transfer using a microsurgical technique for both pedicles. Of the 863 patients identified, 72 (8.3 percent) had undergone reconstruction using a bipedicled flap. There were 43 patients in group 1, 24 patients in group 2, and five patients in group 3. Only one case of total flap loss had occurred (group 1). Partial flap loss occurred in two patients in group 1 (5 percent) and three patients in group 2 (13 percent). Fat necrosis occurred more frequently in groups 1 (23 percent) and 2 (29 percent) than in group 3 (0 percent) (p = 0.5, Fisher's exact test). Similarly, bulge or hernia was more common in groups 1 (12 percent) and 2 (4 percent) than in group 3 (0 percent) (p = 0.6, Fisher's exact test). In this study, patients who received a bipedicled TRAM flap using microsurgical techniques alone (group 3) appeared to have better flap perfusion and less frequent hernia/bulge than did patients who underwent flap transfer using conventional (group 1) or combined techniques (group 2). However, these differences were not statistically significant, and this trend must be verified in a larger study.