What are the possible complications of a unipedicled TRAM breast reconstruction procedure?

Updated: Jun 25, 2021
  • Author: Michael R Zenn, MD, MBA, FACS; Chief Editor: James Neal Long, MD, FACS  more...
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The TRAM flap procedure is performed daily and safely by plastic surgeons for many grateful patients. [11, 12] Because of the magnitude of the procedure, complications can occur even in the best of hands. Possible complications from a TRAM flap procedure are listed below. Fortunately, major complications are uncommon.

  • Fat necrosis and/or partial flap loss (5-15% of patients) [13]

  • Complete loss of TRAM tissue (< 1% of patients)

  • Seroma (fluid collection, usually in abdominal donor site)

  • Hematoma (bleeding at either chest or abdomen)

  • Infection

  • Hernia (1-5% of patients) [14, 15]

  • Abdominal bulge without hernia (5-15% of patients) [16]

  • Deep venous thrombosis and/or pulmonary embolus (< 1% of patients) [16]

  • Death (< 1% of patients)

A study by Shubinets et al indicated that surgical repair of abdominal hernia within a 4-year postoperative period is more common among patients who undergo pedicled TRAM flap breast reconstruction than among those who undergo free TRAM or DIEP flap reconstruction (7.0% vs 5.7% and 1.8%, respectively). The study also suggested that the development of a surgical-site infection within 30 days of discharge is a risk factor for subsequent surgical repair of abdominal hernia. The study involved 8246 women. [17]

Similarly, in a literature review comparing the use of pedicled TRAM flaps to DIEP flap surgery, Leyngold reported pedicled TRAM flaps to be associated with a statistically higher rate of abdominal bulge and/or hernia. Moreover, several studies indicated that patients who underwent the DIEP flap procedure experienced greater overall postoperative satisfaction, although length of hospital stay, overall complication rates, and operative times did not differ significantly between DIEP flap procedures and unilateral pedicled TRAM flap surgeries. The investigators concluded that use of the unipedicled TRAM flap is warranted in carefully selected patients when microsurgery is considered a suboptimal approach. [18]

A literature review by He et al also indicated that in breast reconstruction, the risk of abdominal bulge/hernia is higher with pedicled TRAM flaps than with DIEP flaps (with this being most pronounced in low-volume hospitals), with the relative risk being 2.82. In addition, general satisfaction among patients was found to be lower with pedicled TRAM flaps than with DIEP flaps, but emotional well-being was reportedly comparable between the two flap types. [19]

In a study using data from the National (Nationwide) Inpatient Sample database, Kwok et al reported that for patients in whom unilateral mastectomy and abdominally based autologous flap surgery were performed during the same hospital admission, those who were treated with a pedicled TRAM flap procedure had a lower rate of return to the operating room for vascular anastomosis revision (0.0%) than did patients who underwent free TRAM flap (1.72% rate of return), DIEP flap (2.66% rate of return), and SIEA flap (5.64% rate of return) surgery. [20]

A retrospective study by Yoon et al found that among 88 patients who underwent island-type pedicled TRAM flap surgery (86 owing to mastectomy for breast cancer, and two as a result of paraffinoma), 9.1% experienced mild fat necrosis, while 5.7% suffered mild inframammary or epigastric bulging. Of the 55 patients in whom the aesthetic outcome of the inframammary fold was assessed, 53 (96%) obtained good overall scores. The investigators concluded that the island-type pedicled TRAM flap is an effective reconstructive tool that does not carry a greater risk of vascular compromise. [21]

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