TRAM and DIEP Flaps

R.J. Allen, MD
N.E. Rogers, BA

Background

A relatively new modification of breast reconstruction with the free transverse rectus abdominis musculocutaneous (TRAM) flap is the use of the deep inferior epigastric perforator (DIEP) flap, in which branches of the deep inferior epigastric artery and vein are dissected from the rectus abdominis muscle so that only blood vessels, and no muscle, are harvested. The use of DIEP flaps has been found to minimize donor-site morbidity and reduce postoperative pain. Patients who have undergone reconstruction with IDEP flaps recover more quickly from the surgery and seem to require less pain medication than those undergoing alternative procedures. The hypothesis that use of the DIEP flap causes less postoperative pain than does use of the standard free TRAM flap was tested. Investigators also determined whether there was a difference in the length of hospital stay between patients with the different flaps and whether any difference was clinically or statistically significant.

Methods

A chart review was conducted for 158 patients who had undergone breast reconstruction with a TRAM or DIEP flap and who were treated for postoperative pain with morphine administered by means of a patient-controlled analgesia pump. Investigators measured the total dose of morphine administered during the hospitalization for the reconstruction, using the amount of narcotic medication consumed by the patient as a rough indicator of the amount and duration of postoperative pain. Patients whose treatments were supplemented by other IV narcotics were not included in the study.

Findings

Patients who had undergone reconstruction with the DIEP flap required significantly less morphine and significantly less morphine per kilogram than did patients who had undergone reconstruction with the TRAM flap (50.96 mg vs. 107.04 mg. P < .001, respectively). The hospital stay for patients with a DIEP flap was shorter than for patients with a TRAM flap, but the difference was less than 1 full day (mean, 4.73 days vs. 5.21 days).

Conclusions

Use of the DIEP flap reduced the requirement for postoperative pain medication, which was presumed to be indicative of reduced postoperative pain. Use of the DIEP flap also resulted in a slightly shorter hospital stay. This study deserves praise for its simple design and conclusive results. The authors identified the amount of patient-controlled analgesia as an objective measure of the degree of postoperative pain experienced after breast reconstruction. We have long believed the advantages of the DIEP flap to be self-evident: By preserving the rectus abdominis muscle, patients should experience significantly less pain and donor-site morbidity during recovery. However, this assumption has been difficult to prove given the subjective nature of pain. The results of this study provide measurable evidence that patients who underwent DIEP flap reconstruction experienced significantly less postoperative pain and morbidity than did patients with TRAM flap reconstruction, as indicated by consumption of less self-administered narcotic pain medication. The authors' other objective measure, number of inpatient days, also supports our own findings1 that patients with DIEP flaps recover more quickly for discharge than do patients with TRAM flaps. The role of the present article is very important. It provides one of the first conclusive pieces of evidence that patients have less pain after reconstruction with the DIEP flap than with the TRAM flap.

Reference