Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 310 breasts reconstructed by a single surgeon using free transv erse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perf orator (DIEP) flaps,vas reviewed to see If there were ally differences in t he incidence of fat necrosis and/or partial flap loss between the two techn iques. During the study period, 279 breasts were reconstructed with free TR AM flaps and 31 breasts were reconstructed with DIEP flaps. In the breasts reconstructed with free TRAM flaps, the incidence of partial flap loss was 2.2 percent and the incidence of fat necrosis was 12.9 percent The DIEP fla ps were divided into two groups. For the first eight flaps, patients were s elected using the same criteria normally used to choose patients for free T RAM flaps. In this unselected early group, the incidence of partial flap lo ss was 37.5 percent and the incidence of fat necrosis tvas 62.5 percent. Because of the high incidence of partial flap loss and fat necrosis in the first eight naps, subsequent selection was modified to limit the use of DIE P flaps to patients who had at least one sufficiently large perforator in e ach flap (a palpable pulse and a vein at least 1 mm in diameter) and who di d not require more than 70 percent of the flap to create a breast of adequa te Size. In this later (selected) group, fat necrosis (17.4 percent) and pa rtial flap loss (8.7 percent) were reduced to a level only moderately highe r than that found in the free TRAM flap group. From these data, it can be concluded that the incidence of partial flap los s and fat necrosis is higher in DIEP flaps than in free TRAM flaps, probabl y because the blood flow to the former nap is less robust. This difficulty can be circumvented to some extent, however; by careful patient selection. Factors that should be considered include tobacco use, size of the perforat ors (especially the vein), and tin unilateral reconstructions) the amount o f flap tissue across the midline needed to create an adequately sized breas t. If these factors are properly considered when planning the operation, fa t necrosis and partial nap loss can be reduced to an acceptable level. For selected patients, the DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-si te morbidity. For patients who are not good candidates for reconstruction w ith this flap, the free TRAM flap remains a good alternative.