Ipsilateral pedicled TRAM flaps: The safer alternative?

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction has become a commonly performed procedure in the 1990s. The original descri ption of the procedure was that of an ipsilaterally based pedicle procedure . Concerns about potential folding of the pedicle with possible compromise of the vascular supply led many surgeons to prefer the contralateral pedicl e. Subsequently, there have been several large clinical series of pedicled TRAM flaps showing a relatively high complication rate related to flap vasc ularity problems. Partial flap necrosis rates in pedicled TRAM series range from 5 to 44 percent. These findings resulted in many centers favoring fre e TRAM flap breast reconstruction, despite an increase in resource-use and negligible differences in complication rates. Ipsilateral pedicle TRAM flap breast reconstruction is not a commonly reported procedure and is reserved for cases for which scars preclude use of the contralateral pedicle. Simpl icity and versatility of flap shaping, improved maintenance of the inframam mary fold, and lack of disruption of the natural xiphoid hollow give ipsila teral TRAM flaps further advantages. This study reports on a series of 252 consecutive ipsilateral TRAM flap rec onstructions in 190 patients. The majority of patients underwent muscle-spa ring procedures with preservation of a medial and a lateral strip of rectus muscle. Immediate reconstruction was done in 104 of the 190 patients. Skin -sparing (69 patients) or skin-reduction procedures (21 patients) were used in 90 of the 104 patients (87 percent) undergoing immediate reconstruction , Complication rates were comparable to those of series reported for contra lateral TRAM flaps, except that partial flap necrosis (2.0 percent) was les s in this series. Risk factors were analyzed with regard to the most common complications seen in this study. Ipsilateral TRAM flap breast reconstruct ion is our preferred method, if available, because we believe that it has s everal advantages over the: contralateral pedicled TRAM and this report sug gests slower partial flap necrosis rate than previously reported.