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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Comparing the SIEA and Muscle Sparing Free TRAM: Is the Rate of Flap Loss Worth the Gains in Abdominal Wall Function?<
Jesse C. Selber, MD, MPH1, Stephen Vega, MD2, Seema S. Sonnad, PhD1, Joseph M. Serletti, MD1.
1University of Pennsylvania, Philadelphia, PA, USA, 2University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.

Purpose: As evidence increasingly indicates a relatively small functional difference in abdominal wall donor site morbidity between the muscle sparing free TRAM and the DIEP flap, microsurgeons continue to search for the “perfect flap” with respect to both reliability and donor site morbidity. Is the SIEA that flap? The purpose of this study is to compare the SIEA to the muscle sparing free TRAM across a spectrum of clinical outcomes to determine whether gains in abdominal wall function are off-set by a higher complication rate.
Methods: Fifty-two consecutive SIEA flaps in 44 patients are compared to 569 consecutive free TRAMs in 500 patients. A database was compiled prospectively. Chi square and Fisher’s Exact tests were used to determine significant differences in preoperative risk factors as well as complications in the two groups.
Results: There was no significant difference in age, past medical history, history of smoking , length of follow-up or recipient vessels between the two groups. In the SIEA group, there was a significantly higher percentage of obese patients (p = 0.004), bilateral cases (p = 0.0001), and immediate reconstructions (p = 0.0025). Outcomes included rate of intraoperative and post operative arterial and venous thrombosis, reoperation, abdominal hernia, seroma, hematoma, fat necrosis, delayed wound healing, infection, partial flap loss, and total flap loss. In the SIEA group, there was 1 instance of total flap loss (2.2%) and no clinically relevant abdominal morbidity. In the free TRAM group, there were two total flap losses (0.2%), and a hernia rate of 1.9%. The difference in the rate of flap loss was significant (p = 0.04). There was a higher incidence of intraoperative and post-operative vessel thrombosis requiring anastomotic revision in the SIEA group (11.5%) compared to the free TRAM group (6.0%).
Conclusion: The SIEA flap has the clear advantage of leaving the abdominal wall completely unviolated. This comes at the cost of a substantially higher rate of thrombotic complications. Because of these complications, the SIEA flap should be limited to patients in whom the arterial pedicle is greater than 1.5 mm in diameter, non-smokers, moderate obesity, patients unlikely to require postoperative radiation, breast reconstruction volumes requiring only half of the typical skin island, and patients undergoing bilateral reconstructions. In addition, the SIEA flap should be performed by those experienced in the management of intraoperative and postoperative thrombosis. Certain patient factors such as activity level and risk aversion should be considered in addition to the above mentioned clinical factors. Careful patient selection is critical to the success of this operation.

A comparison of surgical complications between the MS fTRAM and SIEA
ComplicationsSIEA %(n)fTRAM % (n)p-value
Fat Necrosis3.3%(19)3.8%(2)0.85
Hernia1.9%(11)0%(0)0.32
Total Flap Loss0.2%(1)1.9%(1)0.04
Wound infection3.5%(20)1.9%(1)0.5
Abdominal flap necrosis3.3%(19)0%(0)0.18
Mastectomy flap necrosis3.0%(17)1.9%(1)0.65
Hematoma0.5%(3)1.9%(1)0.22
Seroma1.2%(7)1.9%(1)0.66
Thrombotic events6%(34)11.5%(6)0.12

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