Secondary Operations of the Anterior Abdominal Wall Following Microvascular Breast Reconstruction with the TRAM and DIEP Flaps

Secondary operations of the anterior abdominal wall following breast reconstruction with abdominal flaps are sometimes performed to improve outcome. These may be considered necessary to correct a complication or elective to improve on the cosmetic result. The purpose of this study was to review a single surgeon's experience with secondary abdominal operations following breast reconstruction with the DIEP and free TRAM flap.

Over a 7-year period, 330 women had microvascular breast reconstruction using abdominal flaps. This included 162 women who had a free TRAM flap [123 unilateral (UFT) and 39 bilateral (BFT)] and 168 women who had a DIEP flap [120 unilateral (UD) and 48 bilateral (BD)] totaling 419 flaps. Indications for secondary abdominal operations that were considered necessary included bulge, abdominal skin necrosis (wound), hematoma, neuroma, and seroma. Indications that were considered elective included lateral dog-ear scars and lipodystrophy. Mean follow-up was 40 months (range: 3–84 months).

Secondary abdominal operations were performed in 59 women (17.9%) for 64 indications (19.3%). The indications were considered necessary in 33 (10%) and elective in 31 (9.4%). The number of indications was 33 (10%) for the free TRAM group and 31 (9.4%) for the DIEP group. Lower abdominal bulge was the most common necessary indication and repaired in 9.3% of free TRAM flaps and 4.7% of DIEP flaps. The relative rate of occurrence was 6.5% (UFT), 17.9% (BFT), 4.2% (UD) and 10.4% (BD). All bulges were confirmed by the patient and surgeon and all, except one (true hernia following UFT), were secondary to attenuation of the anterior rectus sheath. Dog-ear scars were the most common elective indication and revised in 29 women (8.8%). The relative frequency was 7.3% (UFT), 10.3% (BFT), 9.2% (UD), and 10.4% (BD). A neuroma of the ilioinguinal nerve was diagnosed in 3 women (0.9%) and appropriately treated. Secondary procedures for abdominal skin necrosis (n = 3), hematoma (n = 3), seroma (n = 1), and lipodystrophy (n = 2) were rare in this series.

The incidence of secondary procedures of the abdominal wall following microvascular breast reconstruction using abdominal flaps approximates 20%, with an equal distribution between necessary and elective procedures. Lower abdominal bulge was the most significant indication, but dog-ear scars were the most common. Women considering breast reconstruction using a free TRAM or DIEP flap should be advised of these statistics.