Moran S L, Serletti J M
Division of Plastic Surgery, University of Rochester Medical Center, NY 14642, USA.
Plast Reconstr Surg. 2001 Dec;108(7):1954-60; discussion 1961-2. doi: 10.1097/00006534-200112000-00017.
Obesity can be a contraindication for TRAM flap breast reconstruction. This study reviewed the authors' experience with free TRAM and pedicled TRAM flap breast reconstruction in the obese patient to examine the complication rates associated with each reconstructive method and to determine whether TRAM flap reconstruction can safely be used in these high-risk patients. The records of 221 consecutive TRAM flap reconstructions were reviewed. Preoperative risk factors for morbidity were noted, as well as the incidence of TRAM flap success, operative time, length of hospital stay, and postoperative complications. Patients were categorized as obese if their body mass index was greater than 25.8 kg/m2. Data were tabulated using contingency tables and analyzed using chi-squared statistics. Multiple logistic regression was used to determine risk factors for flap complications. Of the 221 patients studied, 114 patients were found to be obese (body mass index >25.8 kg/m2). Of these 114 patients, 78 were reconstructed with free TRAM flaps and 36 were reconstructed with pedicled flaps. In these obese patients, the average body mass index was 32 kg/m2 in the free TRAM and 30 kg/m2 in the pedicled TRAM flap reconstructions. There were no significant differences between groups with regard to age or preoperative risk factors. Length of hospital stay and operative time did not differ significantly between the two reconstructive methods. The average duration of follow-up was 24 months in both groups. Complications occurred in 26 percent of free TRAM flap reconstructions and 33 percent of pedicled reconstructions. There was no significant difference between reconstructive methods with regard to overall complication rates. Increasing body mass index was found to have a significant effect on free TRAM flap complications (p = 0.008) but not on pedicled TRAM flap complications. There were no partial or total flap losses in obese free TRAM flap patients; however, there was one case of total flap loss and four cases of partial flap loss in the obese pedicled TRAM flap group. The incidence of flap loss was significantly higher when pedicled TRAM flaps were used for reconstruction in obese patients (p = 0.04). Obese patients who underwent reconstruction with pedicled TRAM flaps were more likely to experience a complication if they also smoked (p = 0.001). There was no significant difference in operating time or length of stay when pedicled and free TRAM flap reconstructions in obese patients were compared. There were more cases of flap necrosis in the pedicled TRAM flap group. Free TRAM flaps may provide some benefit in reducing partial flap loss in obese patients, but overall complication rates were not significantly different between reconstructive methods. Of 114 patients, there was only one case of total reconstructive failure. From these findings, it seems that the free or pedicled TRAM flap can be used successfully for breast reconstruction in the majority of patients with obesity. Surgeons should use the technique with which they are most familiar to obtain consistent results.
肥胖可能是横行腹直肌肌皮瓣（TRAM瓣）乳房重建的禁忌证。本研究回顾了作者在肥胖患者中应用游离TRAM瓣和带蒂TRAM瓣乳房重建的经验，以检查每种重建方法相关的并发症发生率，并确定TRAM瓣重建能否安全地用于这些高危患者。回顾了221例连续TRAM瓣重建的记录。记录了术前发病的危险因素，以及TRAM瓣成功的发生率、手术时间、住院时间和术后并发症。如果患者的体重指数大于25.8kg/m²，则将其归类为肥胖。数据用列联表列表，并使用卡方统计分析。采用多因素logistic回归确定皮瓣并发症的危险因素。在研究的221例患者中，发现114例患者肥胖（体重指数>25.8kg/m²）。在这114例患者中，78例采用游离TRAM瓣重建，36例采用带蒂皮瓣重建。在这些肥胖患者中，游离TRAM瓣重建患者的平均体重指数为32kg/m²，带蒂TRAM瓣重建患者的平均体重指数为30kg/m²。两组在年龄或术前危险因素方面无显著差异。两种重建方法的住院时间和手术时间无显著差异。两组的平均随访时间均为24个月。游离TRAM瓣重建中有26%发生并发症，带蒂重建中有33%发生并发症。两种重建方法在总体并发症发生率方面无显著差异。发现体重指数增加对游离TRAM瓣并发症有显著影响（p=0.008），但对带蒂TRAM瓣并发症无影响。肥胖游离TRAM瓣患者中没有部分或全部皮瓣丢失的情况；然而，肥胖带蒂TRAM瓣组中有1例全部皮瓣丢失和4例部分皮瓣丢失。在肥胖患者中使用带蒂TRAM瓣进行重建时，皮瓣丢失的发生率显著更高（p=0.04）。接受带蒂TRAM瓣重建的肥胖患者如果吸烟，更有可能发生并发症（p=0.001）。比较肥胖患者带蒂和游离TRAM瓣重建的手术时间和住院时间，没有显著差异。带蒂TRAM瓣组皮瓣坏死的病例更多。游离TRAM瓣可能在减少肥胖患者部分皮瓣丢失方面有一定益处，但两种重建方法的总体并发症发生率无显著差异。在114例患者中，只有1例完全重建失败。从这些发现来看，游离或带蒂TRAM瓣似乎可以成功地用于大多数肥胖患者的乳房重建。外科医生应使用他们最熟悉的技术以获得一致的结果。
