Is Unipedicled Transverse Rectus Abdominis Myocutaneous Flap Obsolete Owing to Superiority of DIEP Flap?

BACKGROUND: Pedicled transverse rectus abdominis myocutaneous (TRAM) flap was developed by Hartrampf in 1982 for breast reconstruction. Since deep inferior epigastric perforator (DIEP) flap was popularized, it has become the criterion standard for abdominally based breast reconstruction owing to its low donor site morbidity, excellent cosmetic outcomes, and high success rates. The purpose of this review is to determine if a unilateral pedicle TRAM flap has become obsolete to DIEP flap.

METHODS: Literature review was performed with key words DIEP flap, pedicled TRAM flap, and comparison of DIEP flap to unilateral pedicled TRAM flap. Specific journals reviewed were Plastic and Reconstructive Surgery and Annals of Plastic Surgery. Flaps were compared in the studies with respect to donor site morbidity, flap-related complications, operative time, length of hospital stay, patient satisfaction, and cost.

RESULTS: Abdominal bulge and/or hernia were found to be statistically higher in pedicled TRAM patients in most of the studies reviewed. Also, uniformly flap fat necrosis rate was lower in DIEP patients. Rate of partial flap necrosis, total flap loss, hematoma, seroma, delayed healing, and infection varied in the studies with respect to both flaps without definitive trend towards specific flap technique. Overall patient satisfaction appeared to be higher in DIEP group in several studies. No significant differences between length of hospital stay, overall complication rates, and operative times between DIEP and unilateral pedicled TRAM patients were noted, and the results varied across different studies. Deep inferior epigastric perforator flap reconstructions were associated with higher overall cost in one study.

CONCLUSIONS: In a carefully selected patient and circumstances where microsurgery is suboptimal, unipedicled TRAM flap can be a safe and viable option with satisfactory outcomes. It should continue to remain as part of core plastic surgery training and armamentarium of plastic surgeons in autologous breast reconstruction.