Delay of transverse rectus abdominis myocutaneous flap reconstruction improves flap reliability in the obese patient

Background: Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has been a mainstay of breast reconstruction. However, in certain high-risk individuals, such as the obese, smokers, and irradiated patients, flap reliability is decreased, which leads to a higher rate of flap complications. The authors hypothesized that although the nonflap complication rate is increased in the obese patient, flap complications are not increased in those who undergo a delayed TRAM procedure. Methods: From 1995 to 2003, 107 consecutive patients who underwent a delayed TRAM procedure were examined in a retrospective study. The delayed TRAM procedures were all performed by the senior author (Georgiade) at a single institution. Patients were classified by their body mass index (weight in kilograms and height in square meters). Results: No patient had complete loss of her flap regardless of body mass index. Patients with an index of 30 kg/m² and under had a partial fat necrosis rate of 11.4 percent (10 of 88 patients), whereas two of 19 patients (10.5 percent) with an index of greater than 30 kg/m2 had partial fat necrosis of their flap (not significant). The average body mass index of the group with flap complications was 27.8 ± 4.3 kg/m², whereas that of the group-with no flap complications was 26.5 ± 4.3 kg/m ² (not significant). The rate of non-flap-related complications, such as deep venous thrombosis and pulmonary embolism, was 8 percent (seven of 88 patients) for those with a body mass index of less than 30 kg/m² and 31.6 percent (six of 19 patients) for those with an index greater than 30 kg/m² (p = 0.0112). The average body mass index of the group with nonflap complications was 29.9 ± 4.9 kg/m², compared with 26.3 ± 4.0 kg/m² for the group with no non-flap-related complications (p = 0.031). Of note, patients with a history of smoking and those who had received radiation therapy did not show a statistically significant increase in flap complications. Conclusions: Despite a progressively increasing overall complication rate for patients with a higher body mass index, there was not a similar trend for flap-related complications. The authors' data support the idea that the delayed TRAM procedure is a safe and reliable technique for obese and morbidly obese patients.