EASO2011 BRS 3 Petit

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EASO2011 BRS 3 Petit

  1. 1. breast reconstruction: TRAM vs DIEP a difficult challange Petit JY Manconi A Division of Reconstructive Surgery EIO Milan
  2. 2. Why I prefer Pedicled TRAM ? <ul><li>The main reason: </li></ul><ul><li>I am not a microsurgeon ! </li></ul><ul><li>But what about the microsurgical facilities in the world? </li></ul>
  3. 3. Lower abdominal flaps <ul><li>Indications: </li></ul><ul><li>Patient needs for autologus breast reconstructions </li></ul><ul><li>Implant contraindications </li></ul><ul><li>Huge breast skin loss </li></ul><ul><li>PED TRAM </li></ul><ul><li>FREE TRAM </li></ul><ul><li>DIEP </li></ul><ul><li>SIEA </li></ul>
  4. 4. Ped. TRAM pros <ul><li>No prosthetic complications </li></ul><ul><li>Natural shape with natural ptosis </li></ul><ul><li>Less contralateral surgery </li></ul><ul><li>Available in poor local conditions </li></ul><ul><li>Stable results </li></ul><ul><li>.... </li></ul>Same for free flaps
  5. 5. TRAM cons <ul><li>Technical difficulty: well trained surgeons </li></ul><ul><li>Blood loss </li></ul><ul><li>Flap partial necrosis </li></ul><ul><li>Phlebitis-emboly </li></ul><ul><li>Operating time (medium 4 hours) </li></ul><ul><li>Abdominal scarring and complications </li></ul><ul><li>Abdominal sequelea (pain, morphology) </li></ul>same problemes for free flaps
  6. 6. TRAM vs DIEP <ul><li>TRAM pros </li></ul><ul><li>Faster procedure </li></ul><ul><li>Less total flap failure </li></ul><ul><li>DIEP pros </li></ul><ul><li>Less donor-site complications abdominal wall function preserved </li></ul><ul><li>Less partial flap necrosis </li></ul>
  7. 7. Technique
  8. 10. Ped TRAM flap modelling length of the vascular peduncle in free flaps can make it difficult
  9. 11. Reconstructive Outcomes <ul><li>Aesthetic outcomes can be considered similar </li></ul><ul><li>Same flap tissues, same shaping </li></ul><ul><li>Good results are possible using both techniques </li></ul><ul><li>statistical analysis is required for aesthetic results evaluation </li></ul>
  10. 12. IEO series <ul><li>749 TRAM (1994-2008) and 21 DIEP (2001-2009) </li></ul><ul><li>Donor site complications </li></ul><ul><li>Flap complications </li></ul><ul><li>Other complications </li></ul><ul><li>Surgical time </li></ul>
  11. 13. TRAM (IEO 1994-2008) <ul><li>512 MONO-PED. TRAM </li></ul><ul><li>57 MONO- PED. + PROSTHESIS </li></ul><ul><li>190 BI-PED. TRAM </li></ul>
  12. 14. Evolution of TRAM indication at the IEO in 2005 30 % 6 %
  13. 15. Ped. TRAM immediate complications hematomas : (2%) transfusions: (4.5%) pulmonary emboly: (0.4%) mortality 0
  14. 16. Ped. TRAM Partial flap necrosis 12% sponta.heal. 31% revision. AL. 62% AG 7%
  15. 17. Flap Complications DIEP with preoperative angio-tc scan series (11 consecutive cases): Partial flap necrosis*: 0% Total flap necrosis: 0% *more than 5%   Mono TRAM Bi TRAM DIEP Partial necrosis* 21% 5,79% 14,28% Flap Failure 0,30% 0% 4,17%
  16. 18. Free flaps : flap necrosis fat necrosis Free flap : 2.2% 12.9% DIEP 1 : 37.5% 62.5% DIEP 2 : 8.7% 17.4% Kroll SS Plast Reconstr Surg 2000 sep 106 (3) 576
  17. 19. Other complications and surgical time <ul><li>The higher surgical time the higher risk of other complication (surgical bleeding, lung effusion, trombosis etc) </li></ul><ul><li>Higher risk of blood transfution in DIEP </li></ul>TRAM time: from 2:30 to 6 hours DIEP time from 8 to 14 hours
  18. 20. DONOR SITE COMPLICATIONS <ul><li>Ped TRAM DIEP </li></ul><ul><li>% </li></ul><ul><li>mesh + - </li></ul><ul><li>4.2 5.45 0 </li></ul><ul><li>2.92 4.24 0 </li></ul><ul><li>2.19 0 0 </li></ul><ul><li>Abdominal infections </li></ul><ul><li>Bulges and Herniae </li></ul><ul><li>Back pain and </li></ul><ul><li>Functional disorders </li></ul>
  19. 21. PRE-OP DIEP POST-OP TRAM POST-OP TRAM POST-OP
  20. 22. Bulging or herniae? Physiological disturb Pain
  21. 23. Obesity Risk factor +++
  22. 24. Ped. TRAM BR Abdominal necrosis umbilicus supra pubic total : 8 %
  23. 25. Fistula with infected mesh behind the rectus fascia fistula
  24. 26. Abdominal strength after pedicled or free TRAM No statistical difference in the immediate follow up The difference between the two procedures is small as compared to the individual variations (other factors) More bulging in free flaps …. Edsander-Nord A Wickman M et al Plast Reconstr Surg 1998 Oct 102 (5) 1508
  25. 27. Angiogenic cytokines perioperative levels increased by extent of surgery Induces perioperative stimulation of residual cancer cells
  26. 28. PED TRAM or FREE ? <ul><li>Patient’s needs </li></ul><ul><li>(motivated patients) </li></ul><ul><li>Abdominal perforators (angio-tc scan) </li></ul><ul><li>Young and active patient </li></ul><ul><li>medium general conditions </li></ul><ul><li>Advanced tumors </li></ul><ul><li>Obese patient? </li></ul>TRAM DIEP
  27. 29. conclusion when the conditions are favorable DIEP is the best choice Unfortunatly, it is too late for me to learn microsurgery ! Thanks for your attention

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