The document compares pedicled transverse rectus abdominis myocutaneous (TRAM) flaps and deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. TRAM flaps have faster procedures and lower total flap failure rates, while DIEP flaps have fewer donor site complications and preserve abdominal wall function with less partial flap necrosis. Either technique can achieve good aesthetic outcomes, but DIEP may have fewer complications due to shorter operating times and less disruption of the abdominal wall. Patient factors like perforator anatomy, tumor status, and obesity should be considered to determine the best flap for each individual.

1. breast reconstruction: TRAM vs DIEP a difficult challange Petit JY Manconi A Division of Reconstructive Surgery EIO Milan

2. Why I prefer Pedicled TRAM ? The main reason: I am not a microsurgeon ! But what about the microsurgical facilities in the world?

3. Lower abdominal flaps Indications: Patient needs for autologus breast reconstructions Implant contraindications Huge breast skin loss PED TRAM FREE TRAM DIEP SIEA

4. Ped. TRAM pros No prosthetic complications Natural shape with natural ptosis Less contralateral surgery Available in poor local conditions Stable results .... Same for free flaps

5. TRAM cons Technical difficulty: well trained surgeons Blood loss Flap partial necrosis Phlebitis-emboly Operating time (medium 4 hours) Abdominal scarring and complications Abdominal sequelea (pain, morphology) same problemes for free flaps

6. TRAM vs DIEP TRAM pros Faster procedure Less total flap failure DIEP pros Less donor-site complications abdominal wall function preserved Less partial flap necrosis

7. Technique

10. Ped TRAM flap modelling length of the vascular peduncle in free flaps can make it difficult

11. Reconstructive Outcomes Aesthetic outcomes can be considered similar Same flap tissues, same shaping Good results are possible using both techniques statistical analysis is required for aesthetic results evaluation

12. IEO series 749 TRAM (1994-2008) and 21 DIEP (2001-2009) Donor site complications Flap complications Other complications Surgical time

13. TRAM (IEO 1994-2008) 512 MONO-PED. TRAM 57 MONO- PED. + PROSTHESIS 190 BI-PED. TRAM

14. Evolution of TRAM indication at the IEO in 2005 30 % 6 %

15. Ped. TRAM immediate complications hematomas : (2%) transfusions: (4.5%) pulmonary emboly: (0.4%) mortality 0

16. Ped. TRAM Partial flap necrosis 12% sponta.heal. 31% revision. AL. 62% AG 7%

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%

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

19. Other complications and surgical time The higher surgical time the higher risk of other complication (surgical bleeding, lung effusion, trombosis etc) Higher risk of blood transfution in DIEP TRAM time: from 2:30 to 6 hours DIEP time from 8 to 14 hours

20. DONOR SITE COMPLICATIONS Ped TRAM DIEP % mesh + - 4.2 5.45 0 2.92 4.24 0 2.19 0 0 Abdominal infections Bulges and Herniae Back pain and Functional disorders

21. PRE-OP DIEP POST-OP TRAM POST-OP TRAM POST-OP

22. Bulging or herniae? Physiological disturb Pain

23. Obesity Risk factor +++

24. Ped. TRAM BR Abdominal necrosis umbilicus supra pubic total : 8 %

25. Fistula with infected mesh behind the rectus fascia fistula

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

27. Angiogenic cytokines perioperative levels increased by extent of surgery Induces perioperative stimulation of residual cancer cells

28. PED TRAM or FREE ? Patient’s needs (motivated patients) Abdominal perforators (angio-tc scan) Young and active patient medium general conditions Advanced tumors Obese patient? TRAM DIEP

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