The purpose of this study was to identify factors influencing the selection of thoracodorsal
(TD) and internal mammary (IM) vessels as recipient vessels in free TRAM breast reconstruction.
Second, to compare both groups with respect to vessel conversion, complications, and
secondary revisions.
This was a single-institution multi-surgeon analysis of all 1483 free TRAM breast
reconstructions performed from 1994 to 2004. Factors influencing the selection of
recipient vessels such as timing of reconstruction, radiotherapy, axillary node dissection
(AND), sentinel node biopsy (SNB) were measured. Vessel usability, conversion rate,
reasons for conversion, complications and secondary revision rates were also analyzed.
Statistical analysis was performed using Pearson's chi-square, Student's t-test, and
multivariate logistic analysis.
The mean age and follow-up were 48 years and 1.5 years, respectively. The TD and IM
vessels were used in 71.5% and 28.5% of cases, respectively, in a 78.1% immediate
and 21.9% delayed setting. Immediate reconstructions (87.7%) at time of surgery (73.5%)
were associated with higher odds of using TD vessels (odds ratio 9.3 and 4.2, p = 0.000,
respectively). The conversion rate was 2.8% (30/1061) for the TD group vs. 1.9% (8/422)
for the IM group, and 2.6% overall, p > 0.05. Preoperative radiotherapy (43.3%, or
7.8), and (36.7%), and unilateral reconstruction (73.3%) were significantly associated
with vessel conversion (for TD group only), p < 0.05. Small vessel size (50%) and
scarring (33.3%) were common reasons for TD conversion vs. friability (50%) and small
vein size (37.5%) for IM conversion. Complications were significantly greater in the
TD group (12.6%) compared to the IM group (8.5%), p = 0.025. All complications were
comparable between both groups except for seroma formation: 4.0% TD group vs. 0.7%
IM group, p = 0.001. Flap loss was 3%, TD group 2.6% vs. IM group 3.8%, p = 0.24.
Secondary revisions were required in 50% of patients, with no difference in the number
of secondary revisions between both groups, p = 0.93. The most common reason for revision
was lateral fullness which was significantly higher in the TD group, TD (33.2%) vs.
IM (24%), p = 0.01.
With increased use of SNB with mastectomy, IM vessels have become the primary recipient
vessels for microsurgical autologous tissue breast reconstruction at the authors'
institution. In their experience, use of the IM vessels resulted in fewer overall
complications with less lateral fullness compared to the TD group.
