Philadelphia, Pa.; and Providence, R.I. From the Division of Plastic Surgery, University of Pennsylvania School of Medicine, and the Division of Plastic Surgery, Warren Alpert Medical School of Brown University.
Plast Reconstr Surg. 2010 Nov;126(5):1428-1435. doi: 10.1097/PRS.0b013e3181ef8b20.
Discussions of abdominal donor-site morbidity and risk of flap loss continue to surround free flap breast reconstruction. The authors performed a head-to-head comparison of deep inferior epigastric perforator (DIEP) and muscle-sparing free transverse rectus abdominis musculocutaneous (TRAM) flaps performed by a single senior surgeon at a single institution.
The senior author's (J.M.S.) recent experience with DIEP and muscle-sparing free TRAM flaps between July of 2006 and July of 2008 was reviewed retrospectively. The choice of flap was dictated by an intraoperative algorithm based on number, size, and location of perforator vessels. Variables assessed included intraoperative and postoperative complications. Three groups were analyzed: DIEP reconstructions, muscle-sparing free TRAM reconstructions, and bilateral reconstructions in which one of each flap type was performed.
Ninety-one patients underwent 123 muscle-sparing free TRAM flap reconstructions, 53 patients underwent 71 DIEP flap reconstructions, and 31 patients underwent bilateral reconstruction with one DIEP and one muscle-sparing free TRAM flap. There were no significant differences in intraoperative complications or in minor postoperative complications. There was, however, a significant increase in total major postoperative complications in the DIEP study group (DIEP=3.9 percent, muscle-sparing free TRAM=0 percent, p=0.03). No significant difference was noted in hernia formation (DIEP=0, muscle-sparing free TRAM=4, p=0.15).
This study demonstrates that both of these flaps may be reliably performed with an extremely low risk of complications. The choice of flap should be made intraoperatively, based on anatomic findings on a patient-by-patient basis, so as to optimize flap survivability while minimizing donor-site morbidity to the greatest extent possible.
游离皮瓣乳房重建术仍围绕着腹部供区并发症和皮瓣坏死风险展开讨论。作者对一位资深外科医生在同一机构进行的腹壁下动脉穿支皮瓣（DIEP）和保留肌肉的游离横行腹直肌肌皮瓣（TRAM）进行了头对头比较。
回顾性分析了高级作者（J.M.S.）在 2006 年 7 月至 2008 年 7 月期间最近的 DIEP 和保留肌肉的游离 TRAM 皮瓣经验。皮瓣的选择取决于基于穿支血管数量、大小和位置的术中算法。评估的变量包括术中及术后并发症。分析了三组：DIEP 重建、保留肌肉的游离 TRAM 重建和双侧重建，每侧各进行一种皮瓣类型。
91 例患者行 123 例保留肌肉的游离 TRAM 皮瓣重建术，53 例患者行 71 例 DIEP 皮瓣重建术，31 例患者行单侧 DIEP 和单侧保留肌肉的游离 TRAM 皮瓣双侧重建。术中并发症或轻微术后并发症无显著差异。但 DIEP 研究组总严重术后并发症显著增加（DIEP=3.9%，保留肌肉的游离 TRAM=0%，p=0.03）。无疝形成显著差异（DIEP=0，保留肌肉的游离 TRAM=4，p=0.15）。
本研究表明，这两种皮瓣都可以可靠地进行，并发症风险极低。应根据患者的解剖学发现，在术中选择皮瓣，以最大限度地提高皮瓣存活率，同时将供区并发症降至最低。
