AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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2008 Annual Meeting Abstracts

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Perforator Number Predicts Fat Necrosis in a Prospective Analysis of Breast Reconstruction with Free TRAM, DIEP and SIEA Flaps
Donald P. Baumann, MD, Yan H. Lin, Ph.D., Pierre M. Chevray, M.D., Ph.D..
University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA.

PURPOSE: Breast reconstruction using autologous tissues from the lower abdomen can be compromised by fat necrosis of the flap. The muscle-sparing free TRAM flap, DIEP flap, and SIEA flap are techniques that have evolved in an effort to decrease abdominal donor site morbidity. However, each flap in this evolution includes fewer perforating blood vessels. We hypothesized that flaps with fewer perforators are less well perfused, and therefore more likely to suffer fat necrosis.
METHODS: We prospectively evaluated 228 consecutive free ms-TRAM, DIEP, and SIEA flap breast reconstructions performed by the senior author between May 2001 and April 2006. Flaps were divided into four groups based on the number of perforators: Group 1 (0 perforators, SIEA flaps) n=37, Group 2 (1-2 perforators) n=64, Group 3 (3-5 perforators) n=101, and Group 4 (>5 perforators) n=26. The incidence and quantitative measure of fat necrosis at a minimum 6 weeks of follow-up, age, body mass index, bra size, ischemia time, flap laterality, recipient vessels, smoking status, radiation therapy and inclusion of zone 2 were analyzed. The mean follow-up time was 13.5 months.
RESULTS: The incidence of fat necrosis was 13.5%, 25%, 5.0%, and 19.2% in Groups 1, 2, 3, and 4, respectively. Multivariate analysis showed a statistically significant association (p=0.007) between the number of perforators in a flap and the incidence of fat necrosis. Compared to flaps with 3-5 perforators (group 3, ms-TRAM flaps), flaps with 1-2 perforators (Group 2, DIEP flaps) had a 7.7 fold higher risk of fat necrosis, and flaps with 0 perforators (group 1, SIEA flaps) had a 4.7 fold greater risk of fat necrosis. Analysis also revealed that the incidence of fat necrosis was significantly associated with the use of Zone 2 of flaps (p= 0.05), and smoking (p=0.02).
CONCLUSIONS: The risk of fat necrosis in breasts reconstructed with free ms-TRAM, DIEP and SIEA flaps increases as the number of cutaneous perforators supplying the flap decreases. Flaps with 3-5 perforators (mainly free ms-TRAM flaps) have the lowest risk of fat necrosis. Flaps with 1 or 2 perforators (mainly DIEP flaps) have the highest risk of fat necrosis, followed by flaps with poor perforators in which greater than 5 perforators had to be included. SIEA flaps had an intermediate risk of fat necrosis. Breast reconstruction using DIEP and SIEA flaps may decrease abdominal donor site morbidity compared to ms-TRAM flap techniques, but they also carry a higher risk of fat necrosis that can compromise the breast reconstruction. This trade-off must be considered when selecting a flap technique for breast reconstruction.


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