One advantage of autogenous breast reconstruction is the creation of a natural, symmetric breast mound that can provide substantial psychosocial benefits over implant reconstruction. An advantage of free flap breast reconstruction is better vascular perfusion to the skin island, allowing for broader patient selection including those at high risk for complications with a pedicled TRAM flap. This presentation reviewed the potential relationship between preoperative risk factors and the development of surgical complications in patients undergoing free TRAM flap breast reconstruction.
The authors retrospectively analyzed 500 cases of free TRAM flap breast reconstructions by the senior author between 1992 and 2003. The cohort was split into subpopulations based on preoperative risk factors, including smoking, obesity, preoperative chemotherapy or radiation therapy, peripheral vascular disease, COPD, and hypertension. These groups were compared with respect to surgical complication rate. Measured complications included fat necrosis, mastectomy and abdominal flap necrosis, partial flap loss, wound infection, hematoma, seroma, and abdominal hernia.
Significant differences were as follows. In smokers, there was an increased incidence of fat necrosis (p < .01); wound infection (p < .01); abdominal flap necrosis (p = .033); and mastectomy flap necrosis (p = .015). In obese patients, there was an increased incidence of mastectomy flap necrosis (p < .01) and hematoma (p < .01). In patients with preoperative radiation therapy, there was an increased incidence of seroma (p < .01). In patients with peripheral vascular disease, there was an increased incidence of wound infection (p = .031). Preoperative chemotherapy, COPD, and hypertension had no effect on postoperative complications. Because a history of smoking led to the highest complication rate, this factor was analyzed for any effect on a variety of outcome variables. Smokers and non-smokers were matched for age, gender, ethnicity, and other risk factors (HTN, DM, PVD, Obesity, COPD). There was no difference in OR time, intraoperative venous or arterial thrombosis, intraoperative heparin, perioperative returns to the OR, or postoperative arterial or venous thrombosis. Smokers received postoperative heparin more frequently (p = .001), received transfusion of blood products more frequently (p = .017), had more surgical complications (p = .005), and more revision surgery (p = .001).
Free TRAM flaps remain the gold standard for autogenous breast reconstruction in high risk patients. Smoking is the greatest risk factor for postoperative surgical complications, but obesity, preoperative radiation, and peripheral vascular disease also play a role. Awareness of these risk factors and their associated complications will lead to better postoperative patient management, modification of surgical technique to limit these complications, and improved outcomes.
