Risk factors and blood flow in free TRAM flap Introduction Breast cancer is the most common cancer in women in the world and the second most common cancer in Western societies.1 Breast reconstruction is considered a valuable tool in treatment of breast cancer. Restoring health‐related quality of life, body image, and cosmetic outcome are important issues in the treatment of breast cancer.2–5 The use of autologous tissue is preferred due to more natural‐appearing reconstructed breasts. Furthermore, it avoids the complications inherent in the use of implants, such as infection and capsular contracture. Due to high success rates, reconstructive surgeons include patients with various risk factors. Reports regarding the risk factors on the clinical outcome are not unambiguous. The purpose of this study was to elucidate the effect of the risk factors on the microcirculation and clinical outcome. The pedicled transverse rectus abdominis (TRAM) flap was first introduced and popularized by Hartrampf et al..6 Although proven to be reliable, flap complications (FC) such as partial flap loss and fat necrosis (FN) occurred frequently as a result of folding, tunneling, and poor blood supply to the distal part of the flap.7 Although several modifications have been made to increase flap perfusion and reduce donor site morbidity,7–10 recent studies still report FC with these flaps (Table 5.1;8,11–19). There is an inconsistent FC incidence report between these studies, which may be related to several confounding factors. First, patient demographics and prevalence of the risk factors were different and/or not reported. Second, whether or not zone IV was included in the reconstructed breast is not reported consistently (Table 5.1). Third, the size and zone location of the complications within the flap are not systematically reported in the literature. These confounding factors may be the reason for the wide range of FC (0%–37%) described in the literature (Table 5.1). The risk factors described in the literature have been shown to be inconsistent as significant factors for FC (Table 5.2). Reus et al suggested that smokers are at increased risk for FC not at the site of the anastomosis but at the flap interface with the wound.20 The effect of obesity is also controversial regarding complications. Obesity is considered to be a risk factor with the pedicled TRAM flap for donor‐site morbidity.12 Reports on obesity as a risk factor for FC have also been unambiguous (Table 5.2). At first it was believed that a large and heavy abdominal flap may stretch and attenuate the perforators, thereby compromising the blood flow to the flap.21 Recently, studies reported large flaps (zones I–IV) using the perforator technique, with similar complication rates.22,23 In a previous study, we have shown in the free TRAM flap a delayed increase of blood flow in zone IV compared with zone I. In addition, a delayed increase of microcirculatory blood flow was associated with FC.24 Our hypothesis is that some risk factors such as smoking and high flap weight may cause insufficient increase of blood flow in zone IV during the acclimatization period. The purpose of this study was to 71
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