Timing and Causes of Vascular Compromise in Breast Reconstruction with Free TRAM Flap

Kim, Ji Yeon; Chang, Hak; Minn, Kyung Won

Abstract

PURPOSE
The high success rate of free flap transfers is well documented in previous literature, and is possible due to the early detection of vascular compromise and timely reoperation. We specifically analyzed the operative results of immediate and delayed reconstruction with free transverse rectus abdominis musculocutaneous(TRAM) flap respectively in order to reveal its distinctive features on timing and causes of vascular compromise.
METHODS
The senior author operated on 158 patients, 161 cases of free TRAM flap for breast reconstruction. 51 patients underwent delayed reconstruction, whilst immediate reconstruction was performed in the other 107 patients. All patients were monitored every 3 hours for the first 3 days. We reviewed medical records of all patients, and tested statistical significance with the Fisher's test.
RESULTS
Reoperation was performed in 20 cases, but the cases include hematoma with bleeding focus and arterial anastomosis site rupture due to abrupt arm abduction. We performed reoperation in 15 cases of suspicious vascular compromise. Flap compromise was noticed mostly within 24 hours, but not longer than 72 hours. Venous compromise was dominant by 11 cases(73.3%). There was difference in the timing of flap compromise between immediate and delayed reconstruction. All the cases of delayed reconstruction did not show signs of vascular compromise after 12 hours postoperatively. On the other hand, cases of vascular compromise were observed until 72 hours postoperatively in cases of immediate reconstruction.
CONCLUSION
Delayed reconstruction showed vascular compromise within 12 hours postoperatively, while immediate reconstruction showed compromised until the 3rd postoperative day. If more aggressive monitoring is maintained during this period, we believe salvage of flaps may be increased with more efficiency.