Introduction

Breast cancer stays one of the leading causes of cancer-related morbidity among women worldwide, significantly affecting both physical health and psychological well-being. The evolution of breast reconstruction techniques has become pivotal in improving the quality of life for patients undergoing mastectomy. Autologous breast reconstruction, particularly using abdominal flaps, has appeared as a preferred method due to its ability to deliver natural aesthetic outcomes while using the patient’s own tissue.

Among the techniques available, the Transverse Rectus Abdominis Myocutaneous (TRAM) flap and the Deep Inferior Epigastric Perforator (DIEP) flap are two of the most popular techniques in reconstructive surgeries. The TRAM flap, which includes a part of the rectus abdominis muscle, had been widely used historically been favored for its reliable vascularity but can lead to higher donor-site morbidity, such as abdominal weakness and hernia formation [1]. In contrast, the DIEP flap is a muscle-sparing technique that preserves the abdominal muscles by using perforator vessels, which can reduce postoperative complications and preserve abdominal wall function [2, 3].

Recent studies have highlighted the advantages of DIEP over TRAM flaps, noting significantly higher patient satisfaction in terms of aesthetic outcomes and physical well-being. For instance, in the comparison of these methods, DIEP flaps were associated with fewer complications and improved quality of life scores [4]. Furthermore, patients undergoing DIEP flap reconstruction reported higher physical well-being scores and lower rates of herniation compared to those with TRAM flaps [5].

This study aims to further investigate these findings by assessing clinical, aesthetic and quality of life impact outcomes associated with TRAM and DIEP flap reconstructions. By focusing on patient-reported satisfaction and complication rates, the research wants to recommend the benefits and limitations of each method.

Material and methods

All patients diagnosed with stage I, II, and IIIA breast cancer underwent mastectomy followed by breast reconstruction with either TRAM or DIEP flaps immediately or delayed by the same chief surgeon at Cho Ray Hospital from Jan 2014 to Jan 2022. There were 28 patients with at least 2 years followed up after surgery met the selection criteria, with 18 undergoing DIEP flap and 10 receiving TRAM flap reconstructions.

Flap harvesting

TRAM Flap: In the TRAM flap procedure, an elliptical incision was designed below the umbilicus, encompassing the rectus abdominis muscle along with skin and subcutaneous fat. The flap was moved tunneled subcutaneously to the chest where it was used to reconstruct the breast. The muscle, along with part of the anterior rectus sheath was included to ensure robust vascular supply (Fig. 1).

Fig. 1. TRAM flap after dissection (a) and moved tunneled subcutaneously to the breast (b).

DIEP Flap: The DIEP flap involves careful dissection to preserve the rectus abdominis muscle, using only the skin and fat supplied by the deep inferior epigastric perforators. The perforator vessels are meticulously dissected and anastomosed to the internal mammary vessels to establish adequate blood flow, offering a muscle-sparing choice that reduces donor site morbidity (Fig. 2).

Fig. 2. Harvesting DIEP flap.

Data Collection: All the patients were followed up at least 2 years post-op. During examination, the patient’s data relating to complication, aesthetic outcome, quality of life and satisfaction rates were examined.

For the aesthetic outcome, we used Garbay/Lowery 5-subscale method, and the aesthetic outcome were classified as beautiful, good, moderate and poor. (An updated systematic review of esthetic grading tools in postmastectomy breast reconstruction). For the quality of life, we used the Breast-Q Version 2.0: Quality of Life impact. The questionnaire module consists of 8 questions, each question has 4 answers from 1 to 4. Accordingly, the minimum amount is 15 and the maximum amount is 32 points. Following the instructions of the authors, we converted the points into the Rasch system using a conversion table (from 0 to 100 points).

Analysis: Statistical analyses, including descriptive statistics and inferential tests (such as t-tests and chi-square tests), were employed to find significant differences in outcomes between TRAM and DIEP groups, focusing on aesthetic outcome, complication rates, satisfaction of breasts in the postoperative period. The results were processed in Excel Office 2013 and IBM SPSS Statistics 22 software, using the Student’s, Kruskal-Wallis and Fisher’s criteria.

Results

Demographics features

From Jan 2014 to Jan 2022, there were 28 cases that met our research selection criteria. The analysis data were as follows:

The average age of the study sample was 45.9±8.9 years. The youngest in the study group was 29 years old and the oldest was 70 years old. In 53.6% of menstruating cases, most patients had children. There were six cases of comorbidities: 4 hypertension, 2 type 2 diabetes. The proportion of obese patients with a BMI of >25 accounts for ¹/₃ of all cases of the diseases.

Within these 28 cases underwent breast reconstruction surgery, 18 (64.3%) cases using DIEP flaps and 10 (35.7%) cases using TRAM flaps, the difference between the two kinds of techniques were below:

There was no significant difference relating to position and time of reconstruction between the two techniques (Table 1).

Table 1. Clinical features

There was 1 case of total necrosis and 2 cases of partial necrosis in the DIEP flap (Fig. 3). There were 4 cases of flap ischemia, of which 3 cases of DIEP flap and 1 case of TRAM flap. The complications relating to flap blood supply in the DIEP flap was higher in TRAM flap, but this difference was not statistically significant (Table 2).

Table 2. Complications

Fig. 3. Total DIEP flap’s necrosis.

In the DIEP reconstruction group, a higher proportion of patients (approximately 72.2%) reported good result with their aesthetic outcomes, while about 30% of patients reported similar result, suggesting a relatively lower level of aesthetic outcome compared to the DIEP group (Fig. 4, 5). However, the observed difference in aesthetic outcome rates between the two groups is not statistically significant (Table 3).

Fig. 4. Good aesthetic resutl of breast reconstruction using DIEP flap.

Fig. 5. Good aesthetic result of breast reconstruction using DIEP flap.

Table 3. Aesthetic outcomes

When assessing the quality of life depending on the flap used, we see clearly higher scores in the group of patients with the DIEP flap (94.5 points, on average, compared to 82.0 points in patients with the TRAM flap) (Fig. 6). But we were unable to establish statistically significant differences (p=0.198) (Table 4).

Fig. 6. Poor aesthetic result of breast reconstruction using TRAM flap.

Table 4. Quality of Life impact.

When assessing the quality of life during complications, we noted that the presence of а complications directly depends on the assessment of the quality of life in both groups of patients (Table 5).

Table 5. Assessment of Quality of life depending on the presence of a complication

Discussion

Epidemiology features

The average age of patients was around mid-40s, reflecting a common demographic for women undergoing reconstruction post-mastectomy. Age can significantly affect both surgical outcomes and recovery times, with younger patients potentially experiencing more robust healing and older patients having increased risks of complications.

The provided documents likely explore age-related complications in breast reconstruction surgeries, specifically focusing on DIEP and TRAM flaps. In general, older patients undergoing DIEP flap reconstruction face increased risks due to vascular changes associated with aging. These changes can lead to issues such as flap ischemia, as older blood vessels may not provide as robust a blood supply as needed for the healing process. Consequently, older patients might experience delayed wound healing and a higher risk of infections [6]. For TRAM flap reconstruction, which involves using part of the abdominal muscle, can result in greater donor site morbidity for elderly patients. This can manifest as complications like hernias or weakened abdominal muscles, which are worsened by the natural reduction in muscle mass and strength that goes with aging [7].

Statistical analyses within these studies likely highlight that age is a significant determinant of both the complexity and outcome of breast reconstruction surgeries [8]. This needs a comprehensive preoperative assessment focused on evaluating the vascular health and overall medical condition of older patients. Such assessments help tailor surgical approaches to accommodate age-specific needs, potentially opting for less invasive procedures when necessary to minimize risks and enhance recovery.

A subset of patients presented with comorbid conditions such as hypertension and type 2 diabetes. These factors, especially type 2 diabetes, are crucial as they can affect healing and increase the risk of surgical complications, including ischemia and necrosis. There is one partial flap necrosis having type 2 diabetes. Therefore, managing these conditions preoperatively is essential for minimizing risks.

Flap complications

The TRAM flap procedure involved transferring a section of the rectus abdominis muscle along with skin and subcutaneous fat to reconstruct the breast. The flap’s substantial blood supply from the rectus muscle ensured viability and robustness of the reconstructed breast. Our study reported lower incidence of flap ischemia and necrosis in TRAM flaps. Only one case of flap ischemia was seen, with no cases of partial or total necrosis. The TRAM flaps are known for robust vascular supply due to muscle inclusion, which generally mitigates ischemic complications.

On the other hand, our results suggest that higher incidence of both partial and total necrosis was seen, with six cases of ischemia/necrosis, including one total necrosis and two partial necrosis incidents in the DIEP flap group. Due to the absence of muscle inclusion reducing donor site issues, the reliance on perforator vessels poses a higher risk of vascular complications. Gill et al. (2004) emphasized the importance of surgical ability in DIEP procedures, noting that meticulous vascular connection is crucial to minimize necrosis risks, a complication more frequent in the DIEP cohort of the current study [9].

Donor Site Morbidity

Higher morbidity in abdominal wall is noted in TRAM flap due to the use of the rectus abdominis muscle, leading to issues such as abdominal wall weakness, hernias, and potentially more significant post-operative pain. Our study had 1 case of abdominal hernia in TRAM reconstruction group. In addition, all the TRAM cases showed significant difference in post-operative pain compared with DIEP reconstruction group. Nahabedian et al. (2004) reported similar findings, highlighting the prevalence of abdominal wall complications in TRAM procedures [1].

In contrast, DIEP flaps present fewer donor site issues. Less morbidity compared to TRAM flaps due to muscle preservation, resulting in better abdominal wall integrity and quicker recovery times. Similar findings are echoed in global studies (e.g., those by Macadam et al.), which highlight the lower donor site morbidity of DIEP flaps but point out the technical challenges in managing their vascular supply.

Aesthetic and quality of life Outcomes

In our result, the DIEP and TRAM group reported 77.8% and about 50% high satisfaction with their aesthetic outcomes, respectively, which showing a favorable belief of breast appearance post-reconstruction. The p-value is 0.06, indicating that the observed difference in satisfaction rates between the two groups is not statistically significant. However, the aesthetic superiority of the DIEP flap is consistently supported by literature. Allen et al. (1994) were pioneers in illustrating the advantages of the DIEP flap, focusing on its muscle-sparing capabilities [10]. This preservation is crucial as it minimizes donor site morbidity, a finding echoed by Blondeel et al. (1999), who noted that patients favored DIEP for its natural breast shape and enhanced symmetry [11].

The enhancement of quality of life and patient satisfaction post-DIEP flap reconstruction is significant. Macadam et al. (2016) proved that patients reported not only improved cosmetic satisfaction but also psychological and physical well-being due to reduced abdominal morbidity [12]. This was further supported by Momoh et al. (2012), who found higher overall satisfaction rates among DIEP recipients, attributing these outcomes to the technique’s ability to support abdominal wall strength and function. This aligns with the findings at Cho Ray Hospital, where DIEP flaps were preferred for their minimal impact on physical activities and lifestyle [13].

In our study, patients who received DIEP flap breast reconstruction rated their quality of life highly after surgery (average 94.5 points). Patients who received TRAM flap reconstruction highly rated their quality of life after surgery, however, due to unsatisfactory appearance of the mammary glands and complications of the donor area, the score was lower than that of patients in the first group (an average of 82 points). However, the results are not statistically significant (p=0.198)

The TRAM flap, although effective in achieving adequate breast volume, often compromises abdominal muscle integrity, leading to higher rates of bulging and hernia, as described by Garvey et al. (2006). In addition, the inclusion of muscle in TRAM flaps can sometimes affect the symmetry and contour of the These complications underscore the importance of muscle preservation, a key advantage of DIEP flaps, reducing long-term morbidity significantly [5].

The study conducted at Cho Ray Hospital shows important insights into the comparative effectiveness of TRAM and DIEP flaps for breast reconstruction, aligning with global research findings. The results show that DIEP flaps generally offer superior aesthetic outcomes and enhanced patient satisfaction due to their muscle-sparing nature, which minimizes donor site complications and preserves abdominal functionality. These advantages make DIEP flaps a preferred choice for many patients, contributing to higher quality of life and overall contentment with the surgical results.

Conversely, TRAM flaps are still a practical choice, particularly in situations where DIEP flaps may not be feasible. Despite their higher associated donor site morbidity, TRAM flaps provide reliable vascular supply and satisfactory reconstructive outcomes. The choice between these two techniques should be individualized, considering the patient’s specific anatomical, functional, and aesthetic needs, as well as the surgeon’s expertise and experience [14].

The decision to use either TRAM or DIEP flaps should be based on a thorough evaluation of patient-specific factors. As Van Landuyt et al. (2004) showed, preoperative assessments must consider the patient’s anatomy, lifestyle, and expectations to choose the most suitable reconstructive method [15].

There is a pressing need for continued advancements in surgical techniques to enhance outcomes further. The study echoes Allen (2016) and Chang (2018) in calling for ongoing training and skill development among surgical teams, particularly in mastering the intricate microvascular techniques necessary for successful DIEP reconstructions [16, 17]. Future research should also focus on innovative methods to reduce necrosis rates in DIEP flaps and decrease donor site morbidity in TRAM flaps, ensuring both techniques continue to evolve and improve patient outcomes.

Conclusion

Overall, our findings from this study reinforce the role of DIEP flap reconstruction as a leading possibility in breast reconstruction surgery, while also recognizing the continued relevance of TRAM flaps in certain clinical contexts. Future research should continue to explore innovations in technique and technology to improve patient outcomes and expand the applicability of these reconstructive options.