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A Systematic Review Of The Impact Of Timing On Complications In TRAM And DIEP Flap Reconstructions
Waverley Y. He, B.A.1, Leen El Eter, B.S.1,2, Pooja Yesantharao, M.S.1, Bethany Hung, B.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: Many women undergoing mastectomy for breast cancer now opt to pursue immediate breast reconstruction because it is more convenient and less psychologically stressful than delayed breast reconstruction. However, the differences in surgical morbidity between immediate and delayed reconstructions have not yet been summarized for specific flap types such as transverse rectus abdominis (TRAM) flaps and deep inferior epigastric perforator (DIEP) flaps. Knowledge of these differences would help women and their surgeons determine the best timing for reconstruction, especially if they have already decided which donor site to use. The aim of this systematic review is to assess the effect of timing on recipient- and donor-site complications for TRAM and DIEP flap reconstructions. METHODS: A literature search was conducted in June 2019 according to PRISMA guidelines. PubMed, EMBASE, Cochrane, Web of Science, and Scopus were queried using keywords including "breast reconstruction," "myocutaneous flap," and "perforator flap." Two independent reviewers completed each stage of screening as well as quality assessment and data extraction. Randomized clinical trials and cohort studies in English published after 2000 were included if they compared complication rates for immediate and delayed autologous breast reconstruction. Reviews, meta-analyses, and case series were excluded. Risk of bias was evaluated using Cochrane's Risk of Bias tool for non-randomized studies and ROBINS-I for randomized studies. For each study, methodology and population characteristics, and clinically-reported outcomes such as hematoma/seroma, delayed wound healing, necrosis, and flap loss were extracted. Meta-analyses comparing these outcomes for immediate to delayed TRAM flaps, and immediate to delayed DIEP flaps were pooled using a random-effects model. RESULTS: Our search strategy yielded a total of 5040 unique articles. Title and abstract screening identified 1292 studies for full-text screening, out of which 8 studies which met inclusion criteria and were reviewed for narrative synthesis. Data extracted from 5 studies were included for meta-analysis. Unadjusted random-effects modeling demonstrated that immediate TRAM flaps were less likely than delayed TRAM flaps to result in mastectomy skin flap necrosis (MSFN) (OR 0.219, p=0.03). Patients who underwent immediate DIEP reconstruction were less likely than those who underwent delayed DIEP reconstruction to experience wound healing complications at the breast site (OR 0.535, p=0.002), but more likely to experience seroma (OR 3.776, p=0.015). Differences between flap loss and donor-site complication rates including abdominal bulge/hernia were not significant in this unadjusted analysis. CONCLUSIONS: Our findings suggest that patients who undergo immediate and delayed flap reconstructions experience similar incidences of breast-site complications. However, it is notable that while immediate flaps have a higher likelihood of short-term postoperative complications, immediate TRAM and DIEP flaps are less likely to lead to ischemic complications such as MSFN and delayed wound healing. Therefore, immediate TRAM and DIEP flaps are clinically superior to their delayed counterparts in the long-term. Future analyses controlling for postmastectomy radiation therapy (PMRT) and smoking may further elucidate differences in other complication rates. An improved understanding of how breast reconstruction timing influences clinical outcomes will support the surgical decision-making process for patients and physicians.


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