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Comparing Clinical Outcomes For TRAM, DIEP, And Latissimus Dorsi Flap Breast Reconstructions: A Systematic Review And Meta-Analysis
Waverley Y. He, B.A.1, Leen El Eter, B.S.1,2, Pooja Yesantharao, M.S.1, Razvan Azamfirei, M.S.1, Haley Owens3, Justin M. Sacks, M.D., M.B.A.1.
1Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2St. George's, University of London, London, United Kingdom, 3University of Maryland, Baltimore County, Baltimore, MD, USA.

PURPOSE: Breast reconstruction following mastectomy presents many options. To avoid implants, patients may choose to undergo autologous reconstruction, of which options commonly include transverse rectus abdominis (TRAM) flap, deep inferior epigastric perforator (DIEP) flap, and latissimus dorsi (LD) flap. Because complication rates and patient-reported outcomes of these flap types are seldom compared, patients often rely on surgeons' preference to select donor site. With increasing public concern surrounding breast implant-associated illness and anaplastic large cell lymphoma, we anticipate increased interest in autologous reconstruction, heightening the need for evidence-based patient education material. We therefore aim to (1) review literature describing clinical outcomes of TRAM, DIEP, and LD flaps and (2) conduct a meta-analysis comparing outcomes to determine flap type superiority. METHODS: A comprehensive literature search was conducted in June 2019 according to PRISMA guidelines. PubMed, EMBASE, Cochrane, Web of Science, and Scopus were queried. Resulting articles were screened by two independent reviewers. Original comparative studies published after 2000 with clinical outcomes of patients undergoing TRAM, DIEP, or LD flap reconstructions were included. Reviews, meta-analyses, and case series were excluded. Data on study size, population characteristics, surgical characteristics (including flap timing), and complication rates were analyzed. Meta-analysis comparing TRAM to DIEP flaps, TRAM to LD flaps, and pedicled (pTRAM) to free TRAM (fTRAM) flaps were pooled using a random effects model. For each study, risk of bias was assessed using Cochrane's Risk of Bias tool and ROBINS-I for non-randomized and randomized studies, respectively. RESULTS: 5040 unique articles were identified. Title and abstract screening yielded 1292 studies, and full-text screening yielded 21 studies meeting inclusion criteria. Twenty-one studies were included for narrative review and a further subset of 15 studies were included for meta-analysis. Random effects modeling demonstrated that TRAM flaps were less likely than LD flaps to result in donor-site complications such as seroma (OR 0.05, p=0.001), but more likely to result in breast fat necrosis (OR 3.39, p=0.003), and total flap loss (OR 2.47, p<0.001). TRAM flaps were also less likely than DIEP flaps to result in delayed wound healing (OR 0.253, p<0.001), but more likely to result in abdominal bulge/hernia (OR 3.554, p<0.001) and flap necrosis (OR 3.057, p<0.001). As expected, pTRAM and fTRAM flaps are similar in complication profiles, but pTRAM flaps do result in higher rates of abdominal bulge/hernia (OR 1.702, p=0.008), breast fat necrosis (1.883, p<0.001), and partial flap loss (OR 1.801, p=0.006). CONCLUSIONS: Compared to LD and DIEP, TRAM flaps have lower rates of short-term complications but higher rates of long-term complications such as fat/flap necrosis and abdominal bulge/hernia, respectively. fTRAM flaps lead to fewer complications than pTRAM flaps. These results are critical for the development of a decision-making tool based on highest-quality studies. This will aid women and their surgeons in choosing the autologous breast reconstruction modalities most appropriate and specific for their goals, rather than biased by surgeon-specific heuristics.



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