TRAM flap anatomy correlated with a 10-year clinical experience with 556 patients.

This study examines the vascular anatomy of the TRAM flap and evaluates risk factors associated with complications among 556 women who had TRAM flap breast reconstruction. Fifty-nine patients (10.6 percent) developed fat necrosis involving 10 percent or more of their breast. Risk factors associated with fat necrosis were a history of chest-wall irradiation (p = 0.001), significant abdominal scar (p < 0.01), and obesity (p < 0.02). Among unipedicle reconstructions, patients with multiple risk factors had three times the incidence of fat necrosis (24.7 versus 8.3 percent) compared with patients with one or no risk factors (p < 0.002). Patients with multiple risk factors who had bipedicled TRAM flap reconstruction had no associated increased incidence of fat necrosis (p > 0.18). Forty-nine patients (8.8 percent) developed abdominal hernias. Risk factors associated with hernia formation included smoking at the time of surgery (p = 0.00001) and abdominal-wall repair with interposed mesh (p < 0.00001). The overall complication rate for this series was 23.7 percent (132 of 556). Risk factors associated with any complication included smoking (p < 0.002), history of chest-wall irradiation (p < 0.002), significant abdominal scar (p < 0.005), and obesity (p < 0.02). Patient selection is a fundamental determinant of successful TRAM flap breast reconstruction. Among patients with multiple risk factors, the risk of tissue loss in the reconstructed breast may be diminished by use of a bipedicled TRAM flap.