|89th Annual Meeting Abstracts
Comparing the Functional Impact of the SIEA, DIEP and MS Free TRAM on the Abdominal Wall: An Update on a Prospective Study
Jesse C. Selber, M.D. M.P.H.1, Jonas A. Nelson, B.A.2, Jesse Goldstein, M.D.3, Meredith Bergey, MSc2, Joshua Fosnot, M.D.2, Seema S. Sonnad, Ph.D.2, Joseph M. Serletti, M.D.2.
1MD Anderson Cancer Center, Houston, TX, USA, 2University of Pennsylvania, Philadelphia, PA, USA, 3Georgetown University, Washington, DC, USA.
PURPOSE: Two diametrically opposed forces have shaped the evolution of free flap breast reconstruction: abdominal wall morbidity and blood supply. The risk/benefit profile for the free TRAM, DIEP and SIEA flaps, however, has been difficult to define. To this point, we find a lack of a definitive, evidence based foundation for operative decision making with the major limitation of many studies being a retrospective nature or descriptive case-series. The purpose of our study was to generate meaningful data on the effect of free flap breast reconstruction on the abdominal wall for each of the three standard unilateral techniques and various bilateral combinations.
METHODS: This is a blinded prospective cohort study involving patients of the senior author (JMS) between 2006 and 2009. Unilateral and bilateral reconstructions were included and followed for one year postoperatively. At each study encounter, including pre and post operatively, patients underwent objective abdominal strength testing using the Upper and Lower Rectus Manual Muscle Function Test, Functional Independence Measure (FIM), and psychometric testing utilizing the Short Form 36 questionnaire. At all postoperative visits, patients also completed a patient satisfaction questionnaire. To simplify analysis, follow up data was grouped into two categories: early, meaning up to 120 days post operatively and late, meaning all subsequent follow up. Data was collected and stored prospectively and analyzed using proven statistical methods.
RESULTS: During this time, 234 patients were consented and enrolled in the study. Of these, 157 underwent free flap breast reconstruction, completed follow-up, and were included in the analysis. In unilateral reconstruction, there was a significant difference in the decline of upper abdominal strength between the fTRAM and DIEP in early (p = 0.01) and late follow up (p = 0.02), DIEP faring more favorably. Unilateral SIEA procedures (n = 3) were too few in number to reach a conclusion. Lower abdominal and FIM scores showed no significant difference. Psychometric testing showed that there was no appreciable difference in overall score between treatment groups nor overall patient satisfaction. In bilateral reconstruction, there was a significant difference in decline of upper (p = 0.02) and lower (p = 0.05) abdominal strength between bilateral fTRAM vs. bilateral DIEP. Likewise, when comparing bilateral fTRAM vs. bilateral SIEA, there was a significant difference in decline of function of upper (0.055) and lower (p = 0.04) abdominal strength. Although other combinations did not reach statistical significance, the overall trend in residual muscle function is as follows: fTRAM/fTRAM < fTRAM/DIEP < DIEP/DIEP < DIEP/SIEA < SIEA/SIEA. Although the psychometric testing showed a few sporadic differences, taken as a whole, there was no significant difference between treatment groups in SF36 testing or overall patient satisfaction.
CONCLUSION: The post operative physical testing of abdominal wall strength follows closely with theoretical predictions of muscle function based upon degree of intraoperative muscle violation. Although this result can be elicited on physical examination, from the patient’s perspective, these subtle differences may not be appreciable.