Five Hundred Consecutive Patients with Free TRAM Flaps for Breast Reconstruction: A Single Surgeon's Experience

TRAM flaps have been shown to provide a soft, naturally textured, warm, and ptotic breast reconstruction. This report reviewed a single surgeon's experience with 500 consecutive fTRAM patients over a 12-year period, adding comprehensive clinical data to the application and usefulness of the TRAM flap.

Hospital records and office charts were reviewed for patients who underwent fTRAM breast reconstruction between 1991 and 2003 at the six teaching hospitals of the authors' medical center performed by a single microsurgeon.

Five hundred consecutive TRAM patients were reviewed. The mean age of patients was 49.3 years (range: 24 to 78 years). The preoperative comorbidities included HTN (20.4%), DM (4.4%), obesity (50.0%), heart disease (9.0%), preoperative chemotherapy (8.8%), preoperative radiation (7.8%), and smoking (11.2%). A total of 569 fTRAM flaps were performed in this patient series: 431 (86.2%) patients underwent unilateral and 69 (13.8%) underwent bilateral fTRAM reconstructions; 389 (77.8%) patients had immediate and 111 (22.2%) had delayed reconstructions. One hundred eighty-eight flaps were performed at the university hospital and 381 were performed at community hospitals. The average operative time for unilateral fTRAMs was 5.9 hr and for bilateral fTRAMs was 7.8 hr. There were no statistically significant differences in operative time between the immediate and delayed fTRAMs or between the university hospital and community hospitals. The thoracodorsal system was used in 477 (83.6%) flaps, 55 (9.6%) flaps the internal mammary, and 37 (6.8%) flaps used other systems.

There were 16 (2.8%) arterial thromboses and 8 (1.4%) venous thromboses identified intraoperatively and repaired without flap compromise. Three (0.5%) arterial thromboses occurred postoperatively and were repaired with vein grafts resulting in flap success. Eight (1.4%) venous thromboses occurred postoperatively, 6 of which were salvaged with vein graft and thrombolysis; 2 flaps were lost. Significant postoperative complications occurred in 67 (11.9%) patients: 16 (2.8%) wound infections, 15 (2.6%) fat necrosis, 13 (2.3%) delayed healing, 8 (1.4%) donor-site contour deformity, 7 (1.2%) partial flap loss, 4 (0.7%) mastectomy flap compromise. The average length of hospital stay was 5 days. Seventy-two (14.4%) patients underwent further revision of the TRAM flap. The overall fTRAM success rate was 99.7%.

Anastomotic complications were quite low, as were flap complications, including flaps suffering a thrombosis. Fat necrosis and partial flap loss were also low despite the broad patient selection. The fTRAM flap provides a reliable method of autogenous breast reconstruction and, in particular, allows for safe reconstruction in those patients considered to be at high risk for the pedicled TRAM flap.