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2008 Annual Meeting Abstracts

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Comparing the Functional Impact of the Muscle Sparing Free TRAM, DIEP and SIEA on the Abdominal Wall
Jesse C. Selber, MD, MPH1, Vivian Hsu, MD1, Mirar Bristol, MA1, Seema S. Sonnad, PhD1, Jesse Goldstein, MD, MPH2, Joseph M. Serletti, MD1.
1University of Pennsylvania, Philadelphia, PA, USA, 2Georgetown University, Georgetown, DC, USA.

Purpose: One of the most controversial subjects in autogenous breast reconstruction is the degree of donor site morbidity accompanying the various procedures using the abdominal skin island. Various methods have been used to evaluate donor site impact, including MRI, ultrasound, EMG, and dynamometer force, but strict clinical correlation has not been performed. There is a theoretical continuum along which reliability is increased at the expense of donor site morbidity progressing from SIEA to DIEP to muscle sparing free TRAM, but this relationship has not been definitively demonstrated to date.
Methods: A prospective study to examine abdominal wall function following free flap breast reconstruction was designed. Inclusion criteria included all patients scheduled for free flap breast reconstruction from the abdomen. Three abdominal muscle tests were performed preoperatively, and repeated at 1, 3, 6, and 12 months post operatively, at which time a patient satisfaction survey was also completed. There were three abdominal muscle tests: 1) the Manual Muscle Function test for the upper rectus muscle 2) the Manual Muscle Function test for the lower rectus muscle 3) the Functional Independent Muscle evaluation. The previously validated patient satisfaction questionnaire asked the patient’s degree of satisfaction with cosmetic result, shape, size, sensation, scars, donor site, symmetry and abdominal wall function, on a scale of 1 -6. All data was collected, tabulated and analyzed using the Wilcoxon Sign Rank, Mann-Whitney and Kruskal Wallis tests for significance.
Results: The unilateral group consists of 27 TRAMs, 17 DIEPs and 3 SIEAs. The bilateral group consists of 17 bilateral TRAMs, 10 TRAM/DIEPs and 5 DIEP/SIEAs.
For unilateral procedures, in the upper abdomen, fTRAM patients experienced the smallest drop from preoperative performance and achieved the highest overall scores. In the lower abdomen, SIEA patient scores improved the most from early post operative disability, and achieved the highest overall scores. From the standpoint of functional independence, fTRAM patients had the smallest drop from preoperative performance and scores improved the most from early post operative disability. DIEP patients had the steepest drop from preoperative performance, and improved least over the study period, while SIEA patients achieved the highest overall scores. In the bilateral group, for the upper abdomen, all patient groups showed similar drops from preoperative to early post-operative functioning, but DIEP/SIEA combination patients achieved the highest overall scores. In the lower abdomen, DIEP/SIEA patients had the smallest drop from preoperative performance and achieved the highest overall scores, and for functional independence, DIEP/SIEA patients improved the most from early post operative disability and achieved the highest overall scores. The patient satisfaction survey yielded no measurable difference among procedures over any time interval.
Conclusion: For unilateral breast reconstruction, no procedure presented clear advantages over any other in terms of abdominal performance or function. For bilateral procedures, DIEP/SIEA combinations presented advantages over bilateral TRAMs and TRAM/DIEP combinations. These results suggest that the type of procedure selected for unilateral breast reconstruction is less important than for bilateral reconstruction, in which case increased muscle sparing seems to forecast better function.


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