Comparing Free TRAM and DIEP Flaps for Breast Reconstruction: A Meta-analysis Examining Flap Complication Rates and Donor Site Morbidity
Alexander M. Sailon, B.A., Jeffrey S. Schachar, B.S., Jamie P. Levine, M.D..
New York University Medical Center, New York, NY, USA.
Free transverse rectus abdominis myocutaneous (TRAM) flaps and deep inferior epigastric perforator (DIEP) flaps offer significant advantages in breast reconstruction, resulting in their increasing popularity. Although several retrospective, small scale studies comparing these two flaps have been described, no prospective, large scale studies have been completed. These studies have failed to find a significant difference in complication rates or donor site morbidity between these two flaps, potentially because they are lacking in statistical power. In order to overcome this obstacle, we sought to perform a meta-analysis using the currently available data in the literature.
A systematic literature search was performed in the Ovid Medline, Pubmed, and Cochrane Library databases over the period January 1980 to April 2008. Studies that examined free TRAM and/or DIEP flaps were reviewed. Included studies reported flap complications and/or donor site morbidities (Table 1). Data were then extracted from the included studies, pooled, and analyzed for statistical significance between the two flaps. Patient characteristics (unilateral vs. bilateral, mean age, etc.) from each included study were also collected.
Seventeen studies, consisting of over 2,500 free TRAM and DIEP flaps, met the inclusionary criteria. No study provided data for all the variables examined. Therefore, the data collected for each variable were extracted from a portion of the total studies. For flap complications, there was a statistically significant difference (p<0.05) in rates of partial necrosis (TRAM 1.55%, DIEP 3.82%), total necrosis (TRAM 1.56%, DIEP 3.54%), and fat necrosis (TRAM 10.76%, DIEP 19.30%). There was no statistically significant difference between flaps regarding incidence of venous congestion, hematoma, or seroma. For donor site morbidity, there was a statistically significant difference in rates of abdominal bulge (TRAM 10.15%, DIEP 5.42%). No difference existed for hernia rates.
A number of studies have alluded to differences between free TRAM and DIEP flaps. However, due to a lack of sufficient sample size, these differences have remained statistically invalidated. Our meta-analysis concludes that DIEP flaps have increased rates of partial necrosis, total necrosis, and fat necrosis. Free TRAM flaps have an increased rate of abdominal bulge. Large scale, prospective studies are needed to further investigate differences between these flap options.
|PATIENT CHARACTERISTICS||FLAP COMPLICATIONS||DONOR SITE MORBIDITY|
|Unilateral/Bilateral/Both||Partial Necrosis||Abdominal Bulge|
|# Patients/#Flaps||Total Necrosis||Hernia|
|Mean Age||Fat Necrosis|
|Mean BMI||Venous Congestion|