- Email: [email protected]
Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps
The Breast 38 (2018) 45e51
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Review
Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps Woonhyeok Jeong, MD, PhD *, Seongwon Lee, MD, Junhyung Kim, MD, PhD Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2017 Received in revised form 27 September 2017 Accepted 4 December 2017
Objectives: The transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies. Materials and methods: A literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate. Results: Eleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge.. Conclusion: Although pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors.. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Pedicled TRAM flap Free TRAM flap DIEP flap Meta-analysis Complications
Contents 1. 2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.1. Data search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.2. Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.4. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.1. Total flap necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.2. Partial flap necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 3.3. Fat necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 3.4. Ventral hernia or abdominal bulge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Author contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
* Corresponding author. Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Medical Center, 194 Dongsan-dong, Daegu, South Korea. E-mail address: [email protected] (W. Jeong). https://doi.org/10.1016/j.breast.2017.12.003 0960-9776/© 2017 Elsevier Ltd. All rights reserved.
46
W. Jeong et al. / The Breast 38 (2018) 45e51
Financial disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
1. Introduction The use of a transverse rectus abdominis musculocutaneous (TRAM) flap has become an important option for breast reconstruction since its introduction by Hartrampt et al. [1] TRAM flaps are harvested using a pedicled flap method that sacrifices the rectus abdominis muscle. Hence, a pedicled TRAM (pTRAM) flap has inevitable limitations, such as abdominal wall weakness and ventral hernia. Furthermore, pTRAM flaps are inherently prone to ischemic conditions because they are supplied by a superior epigastric artery that is a non-dominant vessel to the lower abdomen [2]. To improve flap blood supply and decrease abdominal wall morbidity, the free TRAM (fTRAM) flap was introduced [3]. However, fTRAM flaps can cause abdominal wall weakness due to atrophy of the rectus abdominis muscle resulting from intercostal nerve damage [4]. Consequently, operative techniques have shifted to include muscle-sparing fTRAM flaps and complete musclepreserving deep inferior epigastric artery perforator (DIEP) flaps. TRAM flaps are regarded as the gold standard for autologous breast reconstruction [5]. Although there has been remarkable progress in surgical techniques for fTRAM and DIEP flaps, pTRAM flaps remain a popular option among surgeons in North America [6]. The reasons underlying this preference primarily relate to several advantages associated with pTRAM flaps, including the ease of the associated surgical technique, the lack of need for microsurgery, and the reduced operative time compared to that required for fTRAM or DIEP flaps [7]. In addition, the latter two flap types have the potential risk of flap failure as a result of microsurgical anastomosis. Several recent studies have evaluated whether pedicled flaps are associated with a greater number of complications than free or DIEP flaps [8e13]. Because variable results regarding postoperative complications have been reported, we performed an objective meta-analysis of published studies.
following: (1) case reports or case series reporting one surgical method without comparison; (2) studies written in a language other than English; and (3) no clear description of the surgical technique used to create fTRAM and DIEP flaps. 2.3. Data extraction Data collection was performed by a single author. The following data were extracted: first author, publication year, follow-up length, surgical technique, smoking status, mesh material for donor site closure, and postoperative complications. The surgical techniques were divided into three groups: pTRAM, fTRAM, and DIEP flaps. The fTRAM flap group included fTRAM and musclesparing fTRAM flaps. The postoperative complications included total flap necrosis, partial flap necrosis, fat necrosis of the flap, and ventral hernia or bulge. A meta-analysis was performed to compare each type of postoperative complication when a minimum of 3 relevant articles were available. 2.4. Statistical analysis For the pooled data, odds ratios were used to assess the relative risk (RR), and 95% confidence intervals (CIs) were calculated using the original data. The Q statistic for heterogeneity and the I2 index were calculated. For the I2 index, the percentage of total variation due to heterogeneity was classified into 3 intervals: 0 < I2 < 50, 50 < I2 < 75, and I2 > 75, representing low, moderate, and severe heterogeneity, respectively. A random effects model was used the variances of the random effects model were obtained with the method of DerSimonian and Laird [14]. In each analysis, pTRAM flaps and fTRAM or DIEP flaps were classified as the control and experimental groups, respectively. The pooled odds ratio and CI are presented as the outcome. Analyses were conducted using the R statistics package (http://www.r-project.org).
2. Materials and methods 3. Results 2.1. Data search A systematic literature search was conducted using the PubMed, Embase, Scopus, and Cochrane databases from January 1, 1990, to January 1, 2017. The following keywords were searched: “breast reconstruction” AND “transverse rectus abdominis musculocutaneous flap” OR “TRAM flap” AND “pedicled transverse rectus abdominis musculocutaneous flap” OR “pedicled TRAM flap” AND “free transverse rectus abdominis musculocutaneous flap” OR “free TRAM flap” AND “deep inferior epigastric perforator free flap” OR “DIEP flap” AND “postoperative complications”. The literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P; Fig. 1). 2.2. Inclusion and exclusion criteria The inclusion criteria for this review consisted of the following: (1) use of a TRAM flap for breast reconstruction; (2) a clear description of postoperative complications; and (3) comparison of postoperative complications between a pTRAM flap and fTRAM or DIEP flaps. The exclusion criteria for this review consisted of the
The literature search for this systematic review retrieved 586 studies from the PubMed, EMBASE, Scopus, and Cochrane databases. After deleting duplicate studies, 443 studies were selected for screening. After screening, 52 studies were selected for a detailed full-text review. Finally, 11 studies were included in the systematic review (Fig. 1). A total of 3968 flaps were included in this study, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. The selected studies were carefully reviewed and summarized to conduct the meta-analysis (Table 1). 3.1. Total flap necrosis Total flap necrosis including flap loss, flap failure, and total flap loss was extracted from the included studies. For this comparison, 4 studies with 943 pTRAM flaps and 587 fTRAM flaps were assessed. The pooled odds ratio was 1.2425 (95% CI: 0.5256e2.9376; p ¼ 0.6208) with no heterogeneity (p ¼ 0.9693; I2 ¼ 0% (95% CI: 0.0e0.0%)). This result was obtained using a fixed effects model (Fig. 2). For comparison between pTRAM and DIEP flaps, 5 studies with 1434 pTRAM flaps and 1182 DIEP flaps were assessed. The pooled odds ratio was 1.6153 (95% CI: 0.4375e5.9636; p ¼ 0.4718)
W. Jeong et al. / The Breast 38 (2018) 45e51
47
Fig. 1. Flow diagram used to identify and select studies.
Table 1 Summary of Studies Included in Meta-analysis. Study Author No. 1 2 3 4 5
6 7 8 9 10 11
Gherardini et al. [15]
Year
Surgical Type Follow-up (n; flaps)
1994 pTRAM (28) fTRAM (11)a Kroll et al. [16] 1995 pTRAM (100) fTRAM (168)a Serletti et al. [13] 1997 pTRAM (62) fTRAM (75)a Alderman et al. [17] 2002 pTRAM (179) fTRAM (67)a Nahabedian et al. [18] 2002 pTRAM (37) fTRAM (108)b DIEP (10) Garvey et al. [11] 2006 pTRAM (94) DIEP (96) Momoh et al. [8] 2012 pTRAM (179) DIEP (167) Tan et al. [10] 2013 pTRAM (16) DIEP (16) Wu et al. [19] 2014 pTRAM (69) DIEP (69) Knox et al. [9] 2016 pTRAM (444) DIEP (183) Macadam et al. [20] 2016 pTRAM (683) fTRAM (437)b DIEP (670)
Smoker Abdominal Total Flap Partial Flap Fat Hernia / Abdominal Bulge (n) Mesh Necrosis (n) Necrosis (n) Necrosis (n)
NA NA NA NA 20 mo 19 mo 2 yr
8 4 NA NA 9 8 NA NA 19.8 mo (6e24) 7 23 0 41.9 mo (3.8e104.1) 27 15.2 mo (3.1e35.1) 26 74.4 mo (4.8e144.3) 9 51.2 mo (4.1e106.6) 10 2 yr NA NA 2.2 yr 6 1.3 yr 4 831.7 ± 691.5 days 22 608.5 ± 421.1 days 4 71.2 ± 28.8 mo 42 87.1 ± 36.7 mo 26 53.7 ± 27.8 mo 69
4 0 NA NA NA NA NA NA 10 9 0 13 0 67 0 NA NA NA NA 157 10 232 206 123
1 0 NA NA 1 1 2 1 NA NA NA 8 3 0 4 0 0 NA NA 1 3 8 7 11
9 1 NA NA 5 3 29 10 NA NA NA NA NA 3 3 NA NA 15 7 6 3 60 24 47
NA NA NA NA 2 3 29 10 NA NA NA 55 17 23 33 3 4 37 12 63 25 171 68 109
3 4 7 10 3 4 14 8 11 7 0 29 10 24 5 0 0 NA NA 80 4 113 32 28
pTRAM, pedicled transverse rectus abdominis musculocutaneous flap; fTRAM, free transverse rectus abdominis musculocutaneous flap; DIEP, deep inferior epigastric perforator flap. a MS-0 fTRAM. b MS-0, MS-1, and MS-2 fTRAM.
with medium heterogeneity (p ¼ 0.0583; I2 ¼ 59.8% (95% CI: 0.0e86.6%)). This result was determined using a random effects model (Fig. 3). 3.2. Partial flap necrosis Partial flap necrosis including partial flap necrosis, partial necrosis, and partial flap loss was extracted from the included studies. For this comparison, 4 studies with 943 pTRAM flaps and 587
fTRAM flaps were assessed. The pooled odds ratio was 0.6305 (95% CI: 0.4256e0.9339; p ¼ 0.0214) with no heterogeneity (p ¼ 0.5483; I2 ¼ 0% (95% CI: 0.0e78.3%)). This result was obtained with a fixed effects model (Fig. 4). For comparison between pTRAM and DIEP flaps, 4 studies with 1393 pTRAM flaps and 1139 DIEP flaps were assessed. The pooled odds ratio was 0.7449 (95% CI: 0.5263e1.0542; p ¼ 0.0965) with no heterogeneity (p ¼ 0.5526; I2 ¼ 0% (95% CI: 0.0e78.1%)). This result was determined using a fixed effects model (Fig. 5).
48
W. Jeong et al. / The Breast 38 (2018) 45e51
Fig. 2. Meta-analysis of total flap necrosis between fTRAM (experimental) and pTRAM (control) flaps.
Fig. 3. Meta-analysis of total flap necrosis between DIEP (experimental) and pTRAM (control) flaps.
3.3. Fat necrosis Fat necrosis including fat necrosis and major fat necrosis was extracted from the included studies. For this comparison, 3 studies with 915 pTRAM flaps and 576 fTRAM flaps were assessed. The pooled odds ratio was 0.5999 (95% CI: 0.4509e0.7982; p ¼ 0.0005) with no heterogeneity (p ¼ 0.4082; I2 ¼ 0% (95% CI: 0.0e88.4%)). This result was determined with a fixed effects model (Fig. 6). For comparison between pTRAM and DIEP flaps, 6 studies with 1503 pTRAM flaps and 1251 DIEP flaps were included. The pooled odds ratio was 0.5298 (95% CI: 0.2763e1.0160; p ¼ 0.0559) with large heterogeneity (p < 0.0001; I2 ¼ 86.6% (95% CI: 73.1e93.3%)). This result was determined with a random effects model (Fig. 7). 3.4. Ventral hernia or abdominal bulge Ventral hernia or abdominal bulge including hernia/abdominal laxity, hernia/bulge, and abdominal bulge was extracted from the included studies. For this comparison, 6 studies comprising 1080 pTRAM patients and 863 fTRAM patients were assessed. The pooled odds ratio was 0.7481 (95% CI: 0.3390e1.6508; p ¼ 0.4723) with severe heterogeneity (p ¼ 0.0013; I2 ¼ 75.0% (95% CI: 43.4e89.0%)).
This result was determined using a random effects model (Fig. 8). For comparison between pTRAM and DIEP flaps, 6 studies with 1471 pTRAM flaps and 1192 DIEP flaps were assessed. The pooled odds ratio was 0.2012 (95% CI: 0.1446e0.2800; p < 0.0001) with no heterogeneity (p ¼ 0.6126; I2 ¼ 0% (95% CI: 0.0e69.0%)). This result was determined using a fixed effects model (Fig. 9). 4. Discussion Our meta-analysis evaluated postoperative complications associated with fTRAM or DIEP flaps compared with traditional pTRAM flaps. Although partial necrosis and fat necrosis were less likely to develop in fTRAM flaps than pTRAM flaps, total flap necrosis and hernia complications did not significantly differ between these groups. When comparing pTRAM with DIEP flaps, partial necrosis, fat necrosis, and total flap necrosis showed similar odds ratios for both groups with no significant differences. The only significant difference was a lower hernia rate for DIEP flaps than pTRAM flaps. After the introduction of the TRAM flap by Hartrampt et al. [1], the associated surgical technique markedly evolved to reduce donor site morbidity and improve flap circulation. Microsurgery,
Fig. 4. Meta-analysis of partial flap necrosis between fTRAM (experimental) and pTRAM (control) flaps.
W. Jeong et al. / The Breast 38 (2018) 45e51
49
Fig. 5. Meta-analysis of partial flap necrosis between DIEP (experimental) and pTRAM (control) flaps.
Fig. 6. Meta-analysis of fat necrosis between fTRAM (experimental) and pTRAM (control) flaps.
Fig. 7. Meta-analysis of fat necrosis between DIEP (experimental) and pTRAM (control) flaps.
Fig. 8. Meta-analysis of ventral hernia or abdominal bulge between fTRAM (experimental) and pTRAM (control) flaps.
which has the theoretical benefits of improved blood supply due to source-vessel proximity and reduced sacrifice of the rectus abdominis muscle, has become common. As time has progressed, the use of pTRAM flaps has been replaced by fTRAM, musclesparing fTRAM, and DIEP flaps [21,22]. Most surgeons believe that fTRAM and DIEP flaps have superior advantages regarding blood
supply and donor site morbidity. Therefore, we performed a metaanalysis to compare the postoperative complications associated with pTRAM and fTRAM or DIEP flaps. In 1989, Grotting et al. [23] reported that fTRAM flaps have the advantages of a decreased need for rectus muscle harvesting, an improved medial contour of the breast due to the lack of tunneling,
50
W. Jeong et al. / The Breast 38 (2018) 45e51
Fig. 9. Meta-analysis of ventral hernia or abdominal bulge between DIEP (experimental) and pTRAM (control) flaps.
and a potentially healthier flap due to the utilization of large donor vessels. The rectus abdominis muscle is supplied by a double vascular channel that contains the deep superior epigastric and deep inferior epigastric vessels [2]. Due to the proximity of the deep inferior epigastric vessels to the lower abdomen, fTRAM and DIEP flaps using these vessels can provide a more robust blood supply than pTRAM flaps, which are supplied by deep superior epigastric vessels [2]. Because the survival of the pTRAM flap relies on choked vessels, the potential risk of ischemic complications, such as fat necrosis, partial flap necrosis, and total flap necrosis, could be increased compared to that associated with fTRAM or DIEP flaps. By contrast, additional risks for flap ischemia, such as anastomotic thrombosis, exist in microsurgical breast reconstruction. Several studies on microsurgical breast reconstruction have reported that venous congestion and anastomotic thrombosis occur at a rate of 2.4e6.3% [24e26]. These ischemic events could potentially lead to the development of fat necrosis, partial flap necrosis, and total flap necrosis. Our results showed inconsistent outcomes regarding fat necrosis and partial flap necrosis when comparing fTRAM and DIEP flaps with pTRAM flaps. Although fTRAM flaps demonstrated a decreased risk for fat necrosis and partial flap necrosis, there were no differences in odds ratios for partial flap necrosis and flap necrosis between pTRAM and DIEP flaps, despite the presence of severe heterogeneity when assessing fat necrosis. A potential risk exists for the development of ischemia in DIEP flaps because a perforator flap has a reduced chance of containing small vessels in the muscle fascia and is vulnerable to pedicle kinking and compression. Compared to fTRAM flaps, DIEP flaps demonstrated a twofold increase in flap loss and fat necrosis in another metaanalysis [27]. Furthermore, the substantial heterogeneity in fat necrosis among the included studies for DIEP flaps could have been due to variability in surgical expertise, as the surgical technique used to create these flaps is highly refined. Donor site morbidity is also a major concern when harvesting TRAM flaps. Although sacrificing the rectus abdominis muscle will not result in complete loss of function, an abdominal bulge or ventral hernia could develop [18]. Therefore, the technique used to create TRAM flaps has evolved from muscle-sparing surgery to the use of perforator flaps to reduce donor site morbidity. However, debate exists regarding the capacity of muscle-sparing surgery to reduce abdominal bulging or hernia because denervated muscle can easily atrophy [28,29]. The rectus abdominis muscle is innervated from two types of intercostal nerves: small nerves (type 1) innervating small longitudinal strips of muscle and large nerves (type 2) at the level of the arcuate line innervating the entire width and length of muscle [30]. Intercostal nerves interact with muscle at the lateral row perforator and are vulnerable to damage during either pedicle dissection or segmental muscle harvest [30]. If the musculocutaneous perforator of the deep inferior epigastric artery
is near a type 2 intercostal nerve, this nerve could not be preserved during harvesting of the segmental muscle in fTRAM. In DIEP flaps, there was a greater chance to preserve the intercostal nerves because the pedicle was completely skeletonized. In particular, the possibility of nerve damage was decreased when the medial row of the perforator was chosen because nerve's site of entry was located near the lateral row perforator [30]. In this regard, only the DIEP flap demonstrated a significant difference in the prevalence of hernia compared to pTRAM flaps. Additionally, a previous study reported that fTRAM was not different from pTRAM with regard to hernia prevalence and abdominal muscle function [4]. The ideal flap for breast reconstruction can simultaneously provide improved vascularity and reduce donor site morbidity. However, the surgeon's preference was another important factor to achieve constant and steady results. When a surgeon is unfamiliar with microsurgery, pTRAM is a better option rather than either fTRAM or DIEP flaps for autologous breast reconstruction. If a surgeon is familiar with fTRAM and DIEP flaps as well as pTRAM, flap selection could be decided based on the patient's characteristics. Our results suggest that fTRAM could be suitable in patients with a large breast volume and a low risk of hernia. Partial flap necrosis and fat necrosis are negative factors that prevent increases in volume. DIEP flaps could be suitable in patients at higher risk of hernia, such as those with obesity and older age [31e33]. pTRAM could be applied in patients with a smaller breast volume and a lower risk of hernia. Our results demonstrated that the most technically demanding option was not always superior to the traditional option. Compared with fTRAM and DIEP flaps, pTRAM flaps are decreasing in popularity because they are generally believed to decrease vascularity and increase abdominal morbidity. However, pTRAM flaps are a considerable option because they have several advantages over fTRAM and DIEP flaps, including a lack of need for microsurgery, a reduced operation time, a shorter hospital stay, and lower costs [13]. Therefore, surgeons do not need to insist on using fTRAM or DIEP flaps and excluding pTRAM because one flap could not guarantee superior results with regard to flap vascularity and donor site. One limitation of this study is that we did not compare the aesthetic results for the breast or patient satisfaction, which are important factors when choosing surgical options. pTRAM flaps are believed to have less favorable aesthetic results because tunneling at the epigastric region induces an epigastric bulge, and creation of a medial mound of breast tissue is difficult. However, Schwitzer et al. reported that pTRAM flaps produce greater initial breast satisfaction and equal long-term satisfaction compared with fTRAM and DIEP flaps [34]. Furthermore, several techniques for planning pTRAM flaps have been reported to improve surgical outcomes and donor site morbidity; these include muscle reduction in the epigastric region and muscle and anterior sheath-sparing
W. Jeong et al. / The Breast 38 (2018) 45e51
techniques [35,36]. Another limitation of this study is that fTRAM included muscle-sparing TRAM flaps in two studies. Although distinguishing muscle-sparing free TRAM and free TRAM flaps improves the accuracy of results, there were limited data available that compared pTRAM with muscle-sparing free TRAM flap to analyze meta-analysis in enrolled study. In conclusion, although the use of pTRAM flaps has generally not been considered a favorable method for breast reconstruction, these flaps could be a good option for breast reconstruction when the patient's perforator state, general condition, financial state, and surgeon's microsurgical skill are adequate. Author contributions WH Jeong searched the literature, analyzed the data, wrote sections of the manuscript, and edited the figures. SW Lee searched the literature and analyzed the data. JH Kim supervised the progress of the manuscript and supported the statistical analysis. Conflicts of interest None of the authors have any conflicting or potentially influential interests with respect to this research. Financial disclosure The authors have no proprietary or commercial interest in any materials discussed in this article. References [1] Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;69(2):216e25. [2] Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82(5):815e32. [3] Friedman RJ, Argenta LC, Anderson R. Deep inferior epigastric free flap for breast reconstruction after radical mastectomy. Plast Reconstr Surg 1985;76(3):455e60. [4] Suominen S, Asko-Seljavaara S, von Smitten K, Ahovuo J, Sainio P, Alaranta H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg 1996;36(6):629e36. [5] Jones G. The pedicled TRAM flap in breast reconstruction. Clin Plast Surg 2007;34(1):83e104. abstract vii. [6] Kulkarni AR, Sears ED, Atisha DM, Alderman AK. Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons. Plast Reconstr Surg 2013;132(3):534e41. [7] Nahabedian MY, Patel K. Autologous flap breast reconstruction: surgical algorithm and patient selection. J Surg Oncol 2016;113(8):865e74. [8] Momoh AO, Colakoglu S, Westvik TS, Curtis MS, Yueh JH, de Blacam C, et al. Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2012;69(1):19e23. [9] Knox AD, Ho AL, Leung L, Tashakkor AY, Lennox PA, Van Laeken N, et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg 2016;138(1):16e28. [10] Tan S, Lim J, Yek J, Ong WC, Hing CH, Lim TC. The deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap in breast reconstruction: a comparative study. Aesthetic Plast Surg 2013;40(3): 187e91. ndez JL, et al. [11] Garvey PB, Buchel EW, Pockaj BA, Casey Iii WJ, Gray RJ, Herna DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006;117(6):1711e9. [12] Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000;106(3): 576e83.
51
[13] Serletti JM, Moran SL. Free versus the pedicled TRAM flap: a cost comparison and outcome analysis. Plast Reconstr Surg 1997;100(6):1418e24. discussion 25e27. [14] DerSimonian R, Laird N. Meta-analysis in clinical trials. Contr Clin Trials 1986;7(3):177e88. [15] Gherardini G, Arnander C, Gylbert L, Wickman M. Pedicled compared with free transverse rectus abdominis myocutaneous flaps in breast reconstruction. Scand J Plast Reconstr Surg Hand Surg 1994;28(1):69e73. [16] Kroll SS, Schusterman MA, Reece GP, Miller MJ, Robb G, Evans G. Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction. Plast Reconstr Surg 1995;96(3):616e9. [17] Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002;109(7):2265e74. [18] Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109(1):91e101. [19] Wu C, Clayton JL, Halvorson EG. Racial differences in ischemic complications of pedicled versus free abdominal flaps for breast reconstruction. Ann Plast Surg 2014;72(6):S172e5. [20] Macadam SA, Zhong T, Weichman K, Papsdorf M, Lennox PA, Hazen A, et al. Quality of life and patient-reported outcomes in breast cancer survivors: a multicenter comparison of four abdominally based autologous reconstruction methods. Plast Reconstr Surg 2016;137(3):758e71. [21] Buck 2nd DW, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg 2009;124(4):1047e54. [22] Conner AJ, Morrison WA, Gunter GC, Neligan PC. Plastic surgery. Saunders Elsevier; 2013. [23] Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 1989;83(5):828e41. discussion 42e44. [24] Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006;117(3):737e46. discussion 47e50. [25] Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 2005;115(2):436e44. [26] Vega S, Smartt Jr JM, Jiang S, Selber JC, Brooks CJ, Herrera HR, et al. 500 Consecutive patients with free TRAM flap breast reconstruction: a single surgeon's experience. Plast Reconstr Surg 2008;122(2):329e39. [27] Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009;124(3):752e64. [28] Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109(1):91e101. [29] Duchateau J, Declety A, Lejour M. Innervation of the rectus abdominis muscle: implications for rectus flaps. Plast Reconstr Surg 1988;82(2):223e8. [30] Rozen WM, Ashton MW, Kiil BJ, Grinsell D, Seneviratne S, Corlett RJ, et al. Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 2008;122(5): 1321e5. [31] Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg 2007;119(3):788e95. [32] Chirappapha P, Trikunagonvong N, Prapruttam D, Rongthong S, Lertsithichai P, Sukarayothin T, et al. Donor-site complications and remnant of rectus abdominis muscle status after transverse rectus abdominis myocutaneous flap reconstruction. Plast Reconstr Surg Glob Open 2017;5(6):e1387. [33] Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury R, Cromwell DA. Donorsite hernia repair in abdominal flap breast reconstruction: a population-based cohort study of 7929 patients. Plast Reconstr Surg 2015;136(1):1e9. [34] Schwitzer JA, Miller HC, Pusic AL, Matros E, Mehrara BJ, McCarthy CM, et al. Satisfaction following unilateral breast reconstruction: a comparison of pedicled TRAM and free abdominal flaps. Plast Reconstr Surg Glob Open 2015;3(8):e482. [35] Jeong W, Son D, Yeo H, Jeong H, Kim J, Han K, et al. Anatomical and functional recovery of neurotized remnant rectus abdominis muscle in muscle-sparing pedicled transverse rectus abdominis musculocutaneous flap. Arch Plast Surg 2013;40(4):359e66. [36] Kim EK, Eom JS, Hwang CH, Ahn SH, Son BH, Lee TJ. Immediate transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction in underweight Asian patients. Breast Cancer 2014;21(6):693e7.
Contents lists available at ScienceDirect
The Breast journal homepage: www.elsevier.com/brst
Review
Meta-analysis of flap perfusion and donor site complications for breast reconstruction using pedicled versus free TRAM and DIEP flaps Woonhyeok Jeong, MD, PhD *, Seongwon Lee, MD, Junhyung Kim, MD, PhD Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University College of Medicine, Daegu, South Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 June 2017 Received in revised form 27 September 2017 Accepted 4 December 2017
Objectives: The transverse rectus abdominis musculocutaneous (TRAM) flap is an important option for breast reconstruction. Several studies have recently evaluated whether a greater number of complications result from the use of pedicled TRAM (pTRAM) flaps versus either free TRAM (fTRAM) flaps or deep inferior epigastric artery perforator (DIEP) flaps. To clarify the evidence regarding this issue, we performed an objective meta-analysis of published studies. Materials and methods: A literature search of articles published between January 1, 1990, to January 1, 2017 was performed using the PubMed, EMBASE, Scopus, and Cochrane databases. Heterogeneity was statistically analyzed, and fixed effects and random effects models were used as appropriate. Results: Eleven articles comparing pedicled TRAM (pTRAM) flaps with either free TRAM (fTRAM) or DIEP flaps were included. The articles evaluated a total of 3968 flaps, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. Patients with fTRAM flaps had a significantly lower risk of fat necrosis and partial flap necrosis than those with pTRAM flaps. No difference was observed in total flap necrosis and hernia or bulge between fTRAM and pTRAM flaps. No difference was noted in flap complications between DIEP and pTRAM flaps except for hernia or bulge.. Conclusion: Although pTRAM flaps are being replaced by fTRAM and DIEP flaps, which exhibit fewer complications related to flap ischemia and donor site morbidity, it was unclear from the literature which flap type was most beneficial regarding flap vascularity and donor site morbidity. Hence, surgeons should choose the appropriate option based on their preferences and on patient factors.. © 2017 Elsevier Ltd. All rights reserved.
Keywords: Pedicled TRAM flap Free TRAM flap DIEP flap Meta-analysis Complications
Contents 1. 2.
3.
4.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.1. Data search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.2. Inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.3. Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 2.4. Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.1. Total flap necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.2. Partial flap necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 3.3. Fat necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 3.4. Ventral hernia or abdominal bulge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Author contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
* Corresponding author. Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Medical Center, 194 Dongsan-dong, Daegu, South Korea. E-mail address: [email protected] (W. Jeong). https://doi.org/10.1016/j.breast.2017.12.003 0960-9776/© 2017 Elsevier Ltd. All rights reserved.
46
W. Jeong et al. / The Breast 38 (2018) 45e51
Financial disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
1. Introduction The use of a transverse rectus abdominis musculocutaneous (TRAM) flap has become an important option for breast reconstruction since its introduction by Hartrampt et al. [1] TRAM flaps are harvested using a pedicled flap method that sacrifices the rectus abdominis muscle. Hence, a pedicled TRAM (pTRAM) flap has inevitable limitations, such as abdominal wall weakness and ventral hernia. Furthermore, pTRAM flaps are inherently prone to ischemic conditions because they are supplied by a superior epigastric artery that is a non-dominant vessel to the lower abdomen [2]. To improve flap blood supply and decrease abdominal wall morbidity, the free TRAM (fTRAM) flap was introduced [3]. However, fTRAM flaps can cause abdominal wall weakness due to atrophy of the rectus abdominis muscle resulting from intercostal nerve damage [4]. Consequently, operative techniques have shifted to include muscle-sparing fTRAM flaps and complete musclepreserving deep inferior epigastric artery perforator (DIEP) flaps. TRAM flaps are regarded as the gold standard for autologous breast reconstruction [5]. Although there has been remarkable progress in surgical techniques for fTRAM and DIEP flaps, pTRAM flaps remain a popular option among surgeons in North America [6]. The reasons underlying this preference primarily relate to several advantages associated with pTRAM flaps, including the ease of the associated surgical technique, the lack of need for microsurgery, and the reduced operative time compared to that required for fTRAM or DIEP flaps [7]. In addition, the latter two flap types have the potential risk of flap failure as a result of microsurgical anastomosis. Several recent studies have evaluated whether pedicled flaps are associated with a greater number of complications than free or DIEP flaps [8e13]. Because variable results regarding postoperative complications have been reported, we performed an objective meta-analysis of published studies.
following: (1) case reports or case series reporting one surgical method without comparison; (2) studies written in a language other than English; and (3) no clear description of the surgical technique used to create fTRAM and DIEP flaps. 2.3. Data extraction Data collection was performed by a single author. The following data were extracted: first author, publication year, follow-up length, surgical technique, smoking status, mesh material for donor site closure, and postoperative complications. The surgical techniques were divided into three groups: pTRAM, fTRAM, and DIEP flaps. The fTRAM flap group included fTRAM and musclesparing fTRAM flaps. The postoperative complications included total flap necrosis, partial flap necrosis, fat necrosis of the flap, and ventral hernia or bulge. A meta-analysis was performed to compare each type of postoperative complication when a minimum of 3 relevant articles were available. 2.4. Statistical analysis For the pooled data, odds ratios were used to assess the relative risk (RR), and 95% confidence intervals (CIs) were calculated using the original data. The Q statistic for heterogeneity and the I2 index were calculated. For the I2 index, the percentage of total variation due to heterogeneity was classified into 3 intervals: 0 < I2 < 50, 50 < I2 < 75, and I2 > 75, representing low, moderate, and severe heterogeneity, respectively. A random effects model was used the variances of the random effects model were obtained with the method of DerSimonian and Laird [14]. In each analysis, pTRAM flaps and fTRAM or DIEP flaps were classified as the control and experimental groups, respectively. The pooled odds ratio and CI are presented as the outcome. Analyses were conducted using the R statistics package (http://www.r-project.org).
2. Materials and methods 3. Results 2.1. Data search A systematic literature search was conducted using the PubMed, Embase, Scopus, and Cochrane databases from January 1, 1990, to January 1, 2017. The following keywords were searched: “breast reconstruction” AND “transverse rectus abdominis musculocutaneous flap” OR “TRAM flap” AND “pedicled transverse rectus abdominis musculocutaneous flap” OR “pedicled TRAM flap” AND “free transverse rectus abdominis musculocutaneous flap” OR “free TRAM flap” AND “deep inferior epigastric perforator free flap” OR “DIEP flap” AND “postoperative complications”. The literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P; Fig. 1). 2.2. Inclusion and exclusion criteria The inclusion criteria for this review consisted of the following: (1) use of a TRAM flap for breast reconstruction; (2) a clear description of postoperative complications; and (3) comparison of postoperative complications between a pTRAM flap and fTRAM or DIEP flaps. The exclusion criteria for this review consisted of the
The literature search for this systematic review retrieved 586 studies from the PubMed, EMBASE, Scopus, and Cochrane databases. After deleting duplicate studies, 443 studies were selected for screening. After screening, 52 studies were selected for a detailed full-text review. Finally, 11 studies were included in the systematic review (Fig. 1). A total of 3968 flaps were included in this study, including 1891 pTRAM flaps, 866 fTRAM flaps, and 1211 DIEP flaps. The selected studies were carefully reviewed and summarized to conduct the meta-analysis (Table 1). 3.1. Total flap necrosis Total flap necrosis including flap loss, flap failure, and total flap loss was extracted from the included studies. For this comparison, 4 studies with 943 pTRAM flaps and 587 fTRAM flaps were assessed. The pooled odds ratio was 1.2425 (95% CI: 0.5256e2.9376; p ¼ 0.6208) with no heterogeneity (p ¼ 0.9693; I2 ¼ 0% (95% CI: 0.0e0.0%)). This result was obtained using a fixed effects model (Fig. 2). For comparison between pTRAM and DIEP flaps, 5 studies with 1434 pTRAM flaps and 1182 DIEP flaps were assessed. The pooled odds ratio was 1.6153 (95% CI: 0.4375e5.9636; p ¼ 0.4718)
W. Jeong et al. / The Breast 38 (2018) 45e51
47
Fig. 1. Flow diagram used to identify and select studies.
Table 1 Summary of Studies Included in Meta-analysis. Study Author No. 1 2 3 4 5
6 7 8 9 10 11
Gherardini et al. [15]
Year
Surgical Type Follow-up (n; flaps)
1994 pTRAM (28) fTRAM (11)a Kroll et al. [16] 1995 pTRAM (100) fTRAM (168)a Serletti et al. [13] 1997 pTRAM (62) fTRAM (75)a Alderman et al. [17] 2002 pTRAM (179) fTRAM (67)a Nahabedian et al. [18] 2002 pTRAM (37) fTRAM (108)b DIEP (10) Garvey et al. [11] 2006 pTRAM (94) DIEP (96) Momoh et al. [8] 2012 pTRAM (179) DIEP (167) Tan et al. [10] 2013 pTRAM (16) DIEP (16) Wu et al. [19] 2014 pTRAM (69) DIEP (69) Knox et al. [9] 2016 pTRAM (444) DIEP (183) Macadam et al. [20] 2016 pTRAM (683) fTRAM (437)b DIEP (670)
Smoker Abdominal Total Flap Partial Flap Fat Hernia / Abdominal Bulge (n) Mesh Necrosis (n) Necrosis (n) Necrosis (n)
NA NA NA NA 20 mo 19 mo 2 yr
8 4 NA NA 9 8 NA NA 19.8 mo (6e24) 7 23 0 41.9 mo (3.8e104.1) 27 15.2 mo (3.1e35.1) 26 74.4 mo (4.8e144.3) 9 51.2 mo (4.1e106.6) 10 2 yr NA NA 2.2 yr 6 1.3 yr 4 831.7 ± 691.5 days 22 608.5 ± 421.1 days 4 71.2 ± 28.8 mo 42 87.1 ± 36.7 mo 26 53.7 ± 27.8 mo 69
4 0 NA NA NA NA NA NA 10 9 0 13 0 67 0 NA NA NA NA 157 10 232 206 123
1 0 NA NA 1 1 2 1 NA NA NA 8 3 0 4 0 0 NA NA 1 3 8 7 11
9 1 NA NA 5 3 29 10 NA NA NA NA NA 3 3 NA NA 15 7 6 3 60 24 47
NA NA NA NA 2 3 29 10 NA NA NA 55 17 23 33 3 4 37 12 63 25 171 68 109
3 4 7 10 3 4 14 8 11 7 0 29 10 24 5 0 0 NA NA 80 4 113 32 28
pTRAM, pedicled transverse rectus abdominis musculocutaneous flap; fTRAM, free transverse rectus abdominis musculocutaneous flap; DIEP, deep inferior epigastric perforator flap. a MS-0 fTRAM. b MS-0, MS-1, and MS-2 fTRAM.
with medium heterogeneity (p ¼ 0.0583; I2 ¼ 59.8% (95% CI: 0.0e86.6%)). This result was determined using a random effects model (Fig. 3). 3.2. Partial flap necrosis Partial flap necrosis including partial flap necrosis, partial necrosis, and partial flap loss was extracted from the included studies. For this comparison, 4 studies with 943 pTRAM flaps and 587
fTRAM flaps were assessed. The pooled odds ratio was 0.6305 (95% CI: 0.4256e0.9339; p ¼ 0.0214) with no heterogeneity (p ¼ 0.5483; I2 ¼ 0% (95% CI: 0.0e78.3%)). This result was obtained with a fixed effects model (Fig. 4). For comparison between pTRAM and DIEP flaps, 4 studies with 1393 pTRAM flaps and 1139 DIEP flaps were assessed. The pooled odds ratio was 0.7449 (95% CI: 0.5263e1.0542; p ¼ 0.0965) with no heterogeneity (p ¼ 0.5526; I2 ¼ 0% (95% CI: 0.0e78.1%)). This result was determined using a fixed effects model (Fig. 5).
48
W. Jeong et al. / The Breast 38 (2018) 45e51
Fig. 2. Meta-analysis of total flap necrosis between fTRAM (experimental) and pTRAM (control) flaps.
Fig. 3. Meta-analysis of total flap necrosis between DIEP (experimental) and pTRAM (control) flaps.
3.3. Fat necrosis Fat necrosis including fat necrosis and major fat necrosis was extracted from the included studies. For this comparison, 3 studies with 915 pTRAM flaps and 576 fTRAM flaps were assessed. The pooled odds ratio was 0.5999 (95% CI: 0.4509e0.7982; p ¼ 0.0005) with no heterogeneity (p ¼ 0.4082; I2 ¼ 0% (95% CI: 0.0e88.4%)). This result was determined with a fixed effects model (Fig. 6). For comparison between pTRAM and DIEP flaps, 6 studies with 1503 pTRAM flaps and 1251 DIEP flaps were included. The pooled odds ratio was 0.5298 (95% CI: 0.2763e1.0160; p ¼ 0.0559) with large heterogeneity (p < 0.0001; I2 ¼ 86.6% (95% CI: 73.1e93.3%)). This result was determined with a random effects model (Fig. 7). 3.4. Ventral hernia or abdominal bulge Ventral hernia or abdominal bulge including hernia/abdominal laxity, hernia/bulge, and abdominal bulge was extracted from the included studies. For this comparison, 6 studies comprising 1080 pTRAM patients and 863 fTRAM patients were assessed. The pooled odds ratio was 0.7481 (95% CI: 0.3390e1.6508; p ¼ 0.4723) with severe heterogeneity (p ¼ 0.0013; I2 ¼ 75.0% (95% CI: 43.4e89.0%)).
This result was determined using a random effects model (Fig. 8). For comparison between pTRAM and DIEP flaps, 6 studies with 1471 pTRAM flaps and 1192 DIEP flaps were assessed. The pooled odds ratio was 0.2012 (95% CI: 0.1446e0.2800; p < 0.0001) with no heterogeneity (p ¼ 0.6126; I2 ¼ 0% (95% CI: 0.0e69.0%)). This result was determined using a fixed effects model (Fig. 9). 4. Discussion Our meta-analysis evaluated postoperative complications associated with fTRAM or DIEP flaps compared with traditional pTRAM flaps. Although partial necrosis and fat necrosis were less likely to develop in fTRAM flaps than pTRAM flaps, total flap necrosis and hernia complications did not significantly differ between these groups. When comparing pTRAM with DIEP flaps, partial necrosis, fat necrosis, and total flap necrosis showed similar odds ratios for both groups with no significant differences. The only significant difference was a lower hernia rate for DIEP flaps than pTRAM flaps. After the introduction of the TRAM flap by Hartrampt et al. [1], the associated surgical technique markedly evolved to reduce donor site morbidity and improve flap circulation. Microsurgery,
Fig. 4. Meta-analysis of partial flap necrosis between fTRAM (experimental) and pTRAM (control) flaps.
W. Jeong et al. / The Breast 38 (2018) 45e51
49
Fig. 5. Meta-analysis of partial flap necrosis between DIEP (experimental) and pTRAM (control) flaps.
Fig. 6. Meta-analysis of fat necrosis between fTRAM (experimental) and pTRAM (control) flaps.
Fig. 7. Meta-analysis of fat necrosis between DIEP (experimental) and pTRAM (control) flaps.
Fig. 8. Meta-analysis of ventral hernia or abdominal bulge between fTRAM (experimental) and pTRAM (control) flaps.
which has the theoretical benefits of improved blood supply due to source-vessel proximity and reduced sacrifice of the rectus abdominis muscle, has become common. As time has progressed, the use of pTRAM flaps has been replaced by fTRAM, musclesparing fTRAM, and DIEP flaps [21,22]. Most surgeons believe that fTRAM and DIEP flaps have superior advantages regarding blood
supply and donor site morbidity. Therefore, we performed a metaanalysis to compare the postoperative complications associated with pTRAM and fTRAM or DIEP flaps. In 1989, Grotting et al. [23] reported that fTRAM flaps have the advantages of a decreased need for rectus muscle harvesting, an improved medial contour of the breast due to the lack of tunneling,
50
W. Jeong et al. / The Breast 38 (2018) 45e51
Fig. 9. Meta-analysis of ventral hernia or abdominal bulge between DIEP (experimental) and pTRAM (control) flaps.
and a potentially healthier flap due to the utilization of large donor vessels. The rectus abdominis muscle is supplied by a double vascular channel that contains the deep superior epigastric and deep inferior epigastric vessels [2]. Due to the proximity of the deep inferior epigastric vessels to the lower abdomen, fTRAM and DIEP flaps using these vessels can provide a more robust blood supply than pTRAM flaps, which are supplied by deep superior epigastric vessels [2]. Because the survival of the pTRAM flap relies on choked vessels, the potential risk of ischemic complications, such as fat necrosis, partial flap necrosis, and total flap necrosis, could be increased compared to that associated with fTRAM or DIEP flaps. By contrast, additional risks for flap ischemia, such as anastomotic thrombosis, exist in microsurgical breast reconstruction. Several studies on microsurgical breast reconstruction have reported that venous congestion and anastomotic thrombosis occur at a rate of 2.4e6.3% [24e26]. These ischemic events could potentially lead to the development of fat necrosis, partial flap necrosis, and total flap necrosis. Our results showed inconsistent outcomes regarding fat necrosis and partial flap necrosis when comparing fTRAM and DIEP flaps with pTRAM flaps. Although fTRAM flaps demonstrated a decreased risk for fat necrosis and partial flap necrosis, there were no differences in odds ratios for partial flap necrosis and flap necrosis between pTRAM and DIEP flaps, despite the presence of severe heterogeneity when assessing fat necrosis. A potential risk exists for the development of ischemia in DIEP flaps because a perforator flap has a reduced chance of containing small vessels in the muscle fascia and is vulnerable to pedicle kinking and compression. Compared to fTRAM flaps, DIEP flaps demonstrated a twofold increase in flap loss and fat necrosis in another metaanalysis [27]. Furthermore, the substantial heterogeneity in fat necrosis among the included studies for DIEP flaps could have been due to variability in surgical expertise, as the surgical technique used to create these flaps is highly refined. Donor site morbidity is also a major concern when harvesting TRAM flaps. Although sacrificing the rectus abdominis muscle will not result in complete loss of function, an abdominal bulge or ventral hernia could develop [18]. Therefore, the technique used to create TRAM flaps has evolved from muscle-sparing surgery to the use of perforator flaps to reduce donor site morbidity. However, debate exists regarding the capacity of muscle-sparing surgery to reduce abdominal bulging or hernia because denervated muscle can easily atrophy [28,29]. The rectus abdominis muscle is innervated from two types of intercostal nerves: small nerves (type 1) innervating small longitudinal strips of muscle and large nerves (type 2) at the level of the arcuate line innervating the entire width and length of muscle [30]. Intercostal nerves interact with muscle at the lateral row perforator and are vulnerable to damage during either pedicle dissection or segmental muscle harvest [30]. If the musculocutaneous perforator of the deep inferior epigastric artery
is near a type 2 intercostal nerve, this nerve could not be preserved during harvesting of the segmental muscle in fTRAM. In DIEP flaps, there was a greater chance to preserve the intercostal nerves because the pedicle was completely skeletonized. In particular, the possibility of nerve damage was decreased when the medial row of the perforator was chosen because nerve's site of entry was located near the lateral row perforator [30]. In this regard, only the DIEP flap demonstrated a significant difference in the prevalence of hernia compared to pTRAM flaps. Additionally, a previous study reported that fTRAM was not different from pTRAM with regard to hernia prevalence and abdominal muscle function [4]. The ideal flap for breast reconstruction can simultaneously provide improved vascularity and reduce donor site morbidity. However, the surgeon's preference was another important factor to achieve constant and steady results. When a surgeon is unfamiliar with microsurgery, pTRAM is a better option rather than either fTRAM or DIEP flaps for autologous breast reconstruction. If a surgeon is familiar with fTRAM and DIEP flaps as well as pTRAM, flap selection could be decided based on the patient's characteristics. Our results suggest that fTRAM could be suitable in patients with a large breast volume and a low risk of hernia. Partial flap necrosis and fat necrosis are negative factors that prevent increases in volume. DIEP flaps could be suitable in patients at higher risk of hernia, such as those with obesity and older age [31e33]. pTRAM could be applied in patients with a smaller breast volume and a lower risk of hernia. Our results demonstrated that the most technically demanding option was not always superior to the traditional option. Compared with fTRAM and DIEP flaps, pTRAM flaps are decreasing in popularity because they are generally believed to decrease vascularity and increase abdominal morbidity. However, pTRAM flaps are a considerable option because they have several advantages over fTRAM and DIEP flaps, including a lack of need for microsurgery, a reduced operation time, a shorter hospital stay, and lower costs [13]. Therefore, surgeons do not need to insist on using fTRAM or DIEP flaps and excluding pTRAM because one flap could not guarantee superior results with regard to flap vascularity and donor site. One limitation of this study is that we did not compare the aesthetic results for the breast or patient satisfaction, which are important factors when choosing surgical options. pTRAM flaps are believed to have less favorable aesthetic results because tunneling at the epigastric region induces an epigastric bulge, and creation of a medial mound of breast tissue is difficult. However, Schwitzer et al. reported that pTRAM flaps produce greater initial breast satisfaction and equal long-term satisfaction compared with fTRAM and DIEP flaps [34]. Furthermore, several techniques for planning pTRAM flaps have been reported to improve surgical outcomes and donor site morbidity; these include muscle reduction in the epigastric region and muscle and anterior sheath-sparing
W. Jeong et al. / The Breast 38 (2018) 45e51
techniques [35,36]. Another limitation of this study is that fTRAM included muscle-sparing TRAM flaps in two studies. Although distinguishing muscle-sparing free TRAM and free TRAM flaps improves the accuracy of results, there were limited data available that compared pTRAM with muscle-sparing free TRAM flap to analyze meta-analysis in enrolled study. In conclusion, although the use of pTRAM flaps has generally not been considered a favorable method for breast reconstruction, these flaps could be a good option for breast reconstruction when the patient's perforator state, general condition, financial state, and surgeon's microsurgical skill are adequate. Author contributions WH Jeong searched the literature, analyzed the data, wrote sections of the manuscript, and edited the figures. SW Lee searched the literature and analyzed the data. JH Kim supervised the progress of the manuscript and supported the statistical analysis. Conflicts of interest None of the authors have any conflicting or potentially influential interests with respect to this research. Financial disclosure The authors have no proprietary or commercial interest in any materials discussed in this article. References [1] Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;69(2):216e25. [2] Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1988;82(5):815e32. [3] Friedman RJ, Argenta LC, Anderson R. Deep inferior epigastric free flap for breast reconstruction after radical mastectomy. Plast Reconstr Surg 1985;76(3):455e60. [4] Suominen S, Asko-Seljavaara S, von Smitten K, Ahovuo J, Sainio P, Alaranta H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg 1996;36(6):629e36. [5] Jones G. The pedicled TRAM flap in breast reconstruction. Clin Plast Surg 2007;34(1):83e104. abstract vii. [6] Kulkarni AR, Sears ED, Atisha DM, Alderman AK. Use of autologous and microsurgical breast reconstruction by U.S. plastic surgeons. Plast Reconstr Surg 2013;132(3):534e41. [7] Nahabedian MY, Patel K. Autologous flap breast reconstruction: surgical algorithm and patient selection. J Surg Oncol 2016;113(8):865e74. [8] Momoh AO, Colakoglu S, Westvik TS, Curtis MS, Yueh JH, de Blacam C, et al. Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2012;69(1):19e23. [9] Knox AD, Ho AL, Leung L, Tashakkor AY, Lennox PA, Van Laeken N, et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg 2016;138(1):16e28. [10] Tan S, Lim J, Yek J, Ong WC, Hing CH, Lim TC. The deep inferior epigastric perforator and pedicled transverse rectus abdominis myocutaneous flap in breast reconstruction: a comparative study. Aesthetic Plast Surg 2013;40(3): 187e91. ndez JL, et al. [11] Garvey PB, Buchel EW, Pockaj BA, Casey Iii WJ, Gray RJ, Herna DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006;117(6):1711e9. [12] Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg 2000;106(3): 576e83.
51
[13] Serletti JM, Moran SL. Free versus the pedicled TRAM flap: a cost comparison and outcome analysis. Plast Reconstr Surg 1997;100(6):1418e24. discussion 25e27. [14] DerSimonian R, Laird N. Meta-analysis in clinical trials. Contr Clin Trials 1986;7(3):177e88. [15] Gherardini G, Arnander C, Gylbert L, Wickman M. Pedicled compared with free transverse rectus abdominis myocutaneous flaps in breast reconstruction. Scand J Plast Reconstr Surg Hand Surg 1994;28(1):69e73. [16] Kroll SS, Schusterman MA, Reece GP, Miller MJ, Robb G, Evans G. Abdominal wall strength, bulging, and hernia after TRAM flap breast reconstruction. Plast Reconstr Surg 1995;96(3):616e9. [17] Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002;109(7):2265e74. [18] Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109(1):91e101. [19] Wu C, Clayton JL, Halvorson EG. Racial differences in ischemic complications of pedicled versus free abdominal flaps for breast reconstruction. Ann Plast Surg 2014;72(6):S172e5. [20] Macadam SA, Zhong T, Weichman K, Papsdorf M, Lennox PA, Hazen A, et al. Quality of life and patient-reported outcomes in breast cancer survivors: a multicenter comparison of four abdominally based autologous reconstruction methods. Plast Reconstr Surg 2016;137(3):758e71. [21] Buck 2nd DW, Fine NA. The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg 2009;124(4):1047e54. [22] Conner AJ, Morrison WA, Gunter GC, Neligan PC. Plastic surgery. Saunders Elsevier; 2013. [23] Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 1989;83(5):828e41. discussion 42e44. [24] Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006;117(3):737e46. discussion 47e50. [25] Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 2005;115(2):436e44. [26] Vega S, Smartt Jr JM, Jiang S, Selber JC, Brooks CJ, Herrera HR, et al. 500 Consecutive patients with free TRAM flap breast reconstruction: a single surgeon's experience. Plast Reconstr Surg 2008;122(2):329e39. [27] Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg 2009;124(3):752e64. [28] Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002;109(1):91e101. [29] Duchateau J, Declety A, Lejour M. Innervation of the rectus abdominis muscle: implications for rectus flaps. Plast Reconstr Surg 1988;82(2):223e8. [30] Rozen WM, Ashton MW, Kiil BJ, Grinsell D, Seneviratne S, Corlett RJ, et al. Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 2008;122(5): 1321e5. [31] Spear SL, Ducic I, Cuoco F, Taylor N. Effect of obesity on flap and donor-site complications in pedicled TRAM flap breast reconstruction. Plast Reconstr Surg 2007;119(3):788e95. [32] Chirappapha P, Trikunagonvong N, Prapruttam D, Rongthong S, Lertsithichai P, Sukarayothin T, et al. Donor-site complications and remnant of rectus abdominis muscle status after transverse rectus abdominis myocutaneous flap reconstruction. Plast Reconstr Surg Glob Open 2017;5(6):e1387. [33] Mennie JC, Mohanna PN, O'Donoghue JM, Rainsbury R, Cromwell DA. Donorsite hernia repair in abdominal flap breast reconstruction: a population-based cohort study of 7929 patients. Plast Reconstr Surg 2015;136(1):1e9. [34] Schwitzer JA, Miller HC, Pusic AL, Matros E, Mehrara BJ, McCarthy CM, et al. Satisfaction following unilateral breast reconstruction: a comparison of pedicled TRAM and free abdominal flaps. Plast Reconstr Surg Glob Open 2015;3(8):e482. [35] Jeong W, Son D, Yeo H, Jeong H, Kim J, Han K, et al. Anatomical and functional recovery of neurotized remnant rectus abdominis muscle in muscle-sparing pedicled transverse rectus abdominis musculocutaneous flap. Arch Plast Surg 2013;40(4):359e66. [36] Kim EK, Eom JS, Hwang CH, Ahn SH, Son BH, Lee TJ. Immediate transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction in underweight Asian patients. Breast Cancer 2014;21(6):693e7.