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

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The Efficacy of the Surgical Delay Procedure in Pedicle TRAM Reconstruction
Dunya M. Atisha, M.D.1, Amy K. Alderman, M.D., M.P.H.1, Tim Janiga, M.D.2, Edwin G. Wilkins, M.D., M.S.1.
1University of Michigan, Department of Surgery, Section of Plastic and Reconstructive Surgery, Ann Arbor, MI, USA, 2The University of Toledo Medical Center, Department of Surgery, Toledo, OH, USA.

PURPOSE:
Despite the known aesthetic superiority of autogenous tissue procedures in breast reconstruction, the risk of tissue necrosis and flap loss remains a major concern. The preliminary surgical delay procedure for pedicle TRAM procedures is commonly used to improve the vascularity of the TRAM flap via ligation of the inferior epigastric vessels prior to definitive breast reconstruction. Although experimental evidence suggests that surgical delay physiologically improves the circulation of the TRAM flap, there are no published controlled studies evaluating the clinical outcomes associated with this procedure. The purpose of this study was to evaluate the efficacy of the surgical flap delay versus no delay in patients having pedicle TRAM breast reconstruction.
METHODS:
This was a retrospective cohort study of breast cancer patients at the University of Michigan who had pedicle TRAM reconstruction from July 2004 to June 2007. All patients prior to September 2005 received pedicle TRAM reconstruction without the surgical delay procedure. All patients presenting for pedicle TRAM reconstruction after Sept. 2005 received the delay procedure prior to definitive flap reconstruction. Descriptive statistics were used to compare demographic data, comorbidities, and complication rates between the two cohorts. Regression analysis was used to determine the effects of the surgical delay procedure on the incidence of ischemia related flap complications (acute flap losses and fat necrosis) and on the incidence of major and minor complications, while controlling for age, BMI, and procedure timing.
RESULTS:
Seventy-one patients had ipsilateral pedicle TRAM breast reconstruction from July 2004 to June 2007 in which 94 flaps were reconstructed. The non-delay cohort consisted of 36 consecutive patients before September 2005 (45 flaps) and the delay cohort consisted of 35 consecutive patients after September 2005 (49 flaps). Analyses revealed no significant differences in medical comoborbidities, mean age, mean BMI or major and minor complication rates between the two cohorts. Twenty percent of the non-delay group experienced at least one ischemic flap complication compared to 8.2% of the delay group (p = 0.09). On regression analysis, the surgical delay procedure was found to significantly decrease the incidence of any ischemic related complication of the flap (p = 0.024, OR = 0.164). In addition, the delay procedure did not affect the incidences of major or minor complication rates. Increasing age and obesity were associated with an increase in the incidence of major complications (p= 0.053 and 0.053 respectively) and ischemic related complications of the flap (0.004, and 0.045 respectively). Obesity was also associated with a higher incidence of minor complications (p= 0.027).
CONCLUSION:
The surgical delay procedure is an effective means of diminishing ischemia-related flap complications in pedicle TRAM reconstruction. Although an additional surgical procedure is required, there were no significant differences in major or minor complication rates between the delay and non-delay groups. These data support the use of the preliminary surgical delay procedure to decrease ischemic complications of the flap in pedicle TRAM reconstruction.


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