Comparative Outcomes of Pedicled vs. Free TRAM Flaps Following Post-Reconstruction Radiation Therapy: Is There a Difference?

The optimal timing of autogenous breast reconstruction for patients who require post-mastectomy radiation therapy is controversial. Opponents of immediate reconstruction have cited significantly higher rates of late complications, including significant fat necrosis, flap contracture, and flap displacement leading to gross asymmetry. Immediate reconstruction after mastectomy, however, provides both aesthetic and psychological advantages over delayed reconstruction. This study reviewed the aesthetic outcomes of pedicled vs. free TRAM flap immediate breast reconstruction in patients treated with post-reconstruction radiation therapy.

This was a retrospective review of patients who underwent immediate TRAM flap breast reconstruction followed by radiation therapy by two surgeons at two institutions, comparing the outcomes of pedicled vs. free TRAM flaps following post-reconstruction radiation therapy. Thirty-five patients underwent skin-sparing mastectomy, immediate pedicled TRAM flap breast reconstruction, and post-reconstruction radiation therapy between 1995 and 2004 by a single surgeon. All of these patients had a flap delay procedure. Thirty-two patients received skin-sparing mastectomy, immediate free TRAM flap breast reconstruction, and post-reconstruction radiation therapy by a different surgeon at a separate institution during a similar study period. Data were collected from physical examination and medical history. Patients were examined on average 3 years after initial surgery. The minimum follow-up was 2 years. Patients were scored on degree of fibrosis, fat necrosis, breast symmetry, skin changes, and complication rates. In addition, the radiation technique, dose, and timing after reconstruction were recorded and compared.

Results showed significantly lower complication rates in both groups compared to previous trials of patients with immediate reconstruction followed by radiation. There were no significant differences in aesthetic outcomes or complication rates between the two groups of patients. The authors believe their outcomes are multifactorial and result from good skin-sparing mastectomy techniques and improved radiation therapy techniques, in addition to reconstruction with a well-vascularized flap, either a free or a delayed pedicled flap. The advances in oncological surgery and radiation have made a positive impact on patient outcome. Primary reconstruction should be considered a viable option in patients who require post-reconstruction radiation therapy.