Aesth Plast Surg DOI 10.1007/s00266-014-0333-3

ORIGINAL ARTICLE

BREAST

Meta-analysis of the Safety and Factors Contributing to Complications of MS-TRAM, DIEP, and SIEA Flaps for Breast Reconstruction Xiao-Li Wang • Lin-Bo Liu • Feng-Min Song Qi-Ying Wang



Received: 22 August 2013 / Accepted: 18 April 2014 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014

Abstract Background Muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps have been increasingly adopted for breast reconstruction. However, their safety, patient satisfaction with them, and factors contributing to complications are not well understood. Methods PubMed, MEDLINE, EMBASE, and The Cochrane Library were searched to identify eligible studies for inclusion in our analysis. The complication rates of and patient satisfaction rates with the flaps were measured as the outcome, and factors contributing to complications and patient satisfaction were also studied. The data were extracted, and pooled relative risks (RRs) and 95 % confidence intervals (CIs) were calculated. Results Thirteen studies involving 1,843 patients met the inclusion criteria. The results of the meta-analysis showed that patients with MS-TRAM had a higher rate of abdominal hernias (RR 2.354, 95 % CI 1.154–4.802, P = 0.019) and a lower rate of fat necrosis (RR 0.502, 95 % CI 0.347–0.727, P = 0.000) than patients with DIEP. In addition, there was no significant difference between MS-TRAM and DIEP with respect to other complications (P [ 0.05), between MS-TRAM and DIEP with respect to patient satisfaction (P = 0.923), and between DIEP and SIEA with respect to complication rates (P = 0.377). The complication rates of MS-TRAM, DIEP, and SIEA were 25.6, 27.9, and 26.7 %, respectively. Diabetes mellitus (P = 0.078) influenced the complication rate of MSX.-L. Wang  L.-B. Liu  F.-M. Song  Q.-Y. Wang (&) Department of Plastic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China e-mail: [email protected]

TRAM, and obesity (P = 0.086) and diabetes mellitus (P = 0.110) were the potential factors correlated with complications with DIEP flaps. Conclusion There were no obvious differences in the overall incidence of complications between MS-TRAM and DIEP and between DIEP and SIEA. In addition, the patient satisfaction rates of MS-TRAM and DIEP were similar. However, MS-TRAM showed a higher rate of abdominal hernias and a lower rate of fat necrosis than DIEP. Obesity and diabetes mellitus were potential factors associated with the incidence of complications. Additional multicenter, large-sample-size, randomized controlled trials with long-term follow-up visits are necessary. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords MS-TRAM  DIEP  SIEA  Breast reconstruction  Meta-analysis

Introduction Breast cancer is one of the most common malignant diseases that threatens women’s’ health, and a lumpectomy is one of the most effective methods for treatment [1–3]. The relatively young age of onset, advances in breast cancer screening, and early detection in women at high risk of malignancy have led to an increased demand for breast reconstruction [4–6]. The National Institute for Health and Clinical Excellence (NICE) recommends that reconstruction should be offered to all patients with breast cancer, but the type of reconstruction to use is currently at the

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discretion of the surgeon and patient [7]. Abdominal tissue has proven to be a reliable source of high-quality soft tissue and is of adequate volume and quantity and its harvesting results in an inconspicuous scar. Autologous tissue for breast reconstruction is considered the gold standard because of its ability to maintain good long-term cosmetic appearance in terms of texture, consistency, ptosis, and fluctuation with body weight [8, 9]. With the emergence and development of hypogastric autograft use for breast reconstruction, the use of abdominal free-skin flaps has experienced continuous development. Of these free-flap methods, muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps are used most often [10–14]. TRAM has been the standard free-flap method used during breast reconstruction for longest time [15]. However, as the complete harvesting of rectus abdominis muscle for the TRAM flap was associated with frequent complications, muscle-sparing flaps, including MS-TRAM, were designed [16, 17]. In recent years, abdominal morbidity concerns have led to the popularization of the DIEP flap, which theoretically minimizes abdominal donor-site morbidity by avoiding the harvesting of the rectus abdominis muscle and anterior rectus fascia [18, 19]. The SIEA flap uses the lower abdominal skin and subcutaneous tissue for breast reconstruction without harvesting or incising the abdominal muscles or rectus fascia [20]. Thus, the SIEA flap method has great potential for decreasing donor-site morbidity because risk for postoperative motor weakness is eliminated [21, 22]. Currently, however, there is no consensus regarding the safety, patient satisfaction, and factors that influence complications of the different free-flap methods. Recently, a few case–control studies have assessed the safety, patient satisfaction, and factors contributing to complications of MS-TRAM, DIEP, and SIEA for breast reconstruction. However, the results that have been reported are inconsistent and include small sample sizes, low statistical power, and subjects from different ethnic backgrounds. This meta-analysis aimed to use the theories and methods of evidence-based medicine to evaluate studies on these three flaps and thus evaluate the safety, patient satisfaction, and factors that play a role in the complications of these free flaps to provide clinical evidence to use as support for the decisions of patients and plastic surgeons.

November 2013 for studies that examinee the safety, patient satisfaction and factors contributing to complications of MS-TRAM, DIEP and SIEA flaps used for breast construction. The medical subject headings used to retrieve articles were ‘‘breast reconstruction’’, ‘‘muscle-sparing transverse rectus abdominis myocutaneous’’ OR ‘‘MSTRAM’’, ‘‘deep inferior epigastric perforator’’ OR ‘‘DIEP’’, and ‘‘superficial inferior epigastric artery’’ OR ‘‘SIEA’’. We also manually searched the references in the retrieved articles for relevant publications. Study Selection The titles and abstracts were screened independently by two reviewers (XLW and FMS) and a study was included in the meta-analysis if it met the following criteria: (1) it was a randomized controlled trial or a retrospective study; (2) MSTRAM was compared with DIEP or SIEA; (3) it studied the safety, patient satisfaction, and factors influencing complications of the flaps. We did not exclude an article because of the language in which it was published. A study was excluded if (1) the participants were not human, (2) it did not have a control group, (3) there was insufficient information to support the integrity of the data upon extraction, (4) it was an abstract and the full text could not be obtained, (5) the same data could be acquired from another article, and (6) no comparisons were made among the three flaps. Data Extraction and Quality Assessment Two reviewers (XLW and FMS) independently extracted the data from the selected articles, including the first author’s name, year of publication, country where the study was conducted, language in which the article was published, age, follow-up time, method of treatment, and primary outcomes. Based on adequate sequence generation, allocation concealment, blinding, consideration of incomplete outcome data, the absence of selective reporting and baseline imbalance, sample size calculation, and the absence of funding bias, the risk of bias was evaluated in detail. Every quality component was judged as high, unclear, or low. The quality of the trials was assessed based on each component. When differences appeared, a third reviewer (QYW) participated in the discussion. Statistical Analysis

Methods Search Strategy We conducted a computer-aided search of PubMed, MEDLINE, EMBASE, and The Cochrane Library up to

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We treated the comparisons of the complication rates of MS-TRAM versus DIEP and DIEP versus SIEA as the primary end points and the comparison of the satisfaction rates of MS-TRAM versus DIEP as the secondary end point. In addition, the factors that influenced the complication rates and satisfaction rates were analyzed.

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Fig. 1 The process used to screen the studies

The relative risks (RR) and 95 % confidence intervals (CI) were calculated. Between-study heterogeneity was estimated using the v2-based Q statistic and I2 test. When I2 [ 50 % and P \ 0.1, heterogeneity was considered statistically significant, and a random-effects model was subsequently used to analyze the data. In contrast, a fixedeffects model was chosen. Egger’s test and Begg’s test were used to assess publication bias. P \ 0.05 was regarded as statistically significant. Sensitivity Analysis Sensitivity analysis was performed to detect the studies that obviously influenced the results. Meta-regression Analysis Meta-regression analysis was conducted to study the relationships of the covariates with the outcomes and to determine the sources of heterogeneity.

Results Study Identification and Selection Following the search strategy (Fig. 1), we initially acquired 571 studies. After discarding the duplicate studies and those that did not meet the criteria, there were 31 studies left after reading the titles and abstracts. After reading the full text, 13 studies [23–35] remained. Study Characteristics All 13 studies [23–35] were retrospective studies. In these studies, 1,169 patients had a MS-TRAM flap procedure, 639 patients had DIEP, and 35 patients had SIEA (Table 1). No study carried out allocation concealment, adequate sequence generation, and blinding of participants and personnel. All of the studies had complete data and were without selective reporting and other biases. Comparison of Complication Rates of MS-TRAM and DIEP

Assessment of the Quality of the Evidence The GRADE system was used to assess the quality of these outcomes.

Twelve studies [23–35], which involved 1,801 patients, compared MS-TRAM with DIEP with respect to complication rate. There were 1,169 patients who underwent

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Cheng [35]

Takeishi [34]

Chen [33]

Scheer [32]

Bonde [31]

Bajaj [30]

Chun [29]

Momoh [28]

Nelson [27]

Wu [26]

Nahabedian [25]

30

12

DIEP

SIEA

79

30

DIEP

41

DIEP

MS-TRAM

159

68

DIEP

MS-TRAM

40

DIEP

MS-TRAM

233

44

MS-TRAM

124

35

MS-TRAM

DIEP

DIEP

105

58

MS-TRAM

179

167

MS-TRAM

DIEP

35

DIEP

23

SIEA

59

24

DIEP

MS-TRAM

79

66

DIEP

MS-TRAM

65

DIEP

MS-TRAM

27

23

MS-TRAM

DIEP

Futter [24]

20

18

MS-TRAM

Blondeel [23]

N

Method

First author

Table 1 Details of the studies









51

48

49

49

51

51

50.1

50.1

44.7

47.8

47.6

48.7

50.3

50.0

51.4

51.2

51.4

49.1

49.6

46.8

49.8

44.0

46.8

Mean Age













28

26.9





27.0

25.4





27.6

27.3

29.0

28.6

28.6

27.0

25.3





23.6

25.6





BMI





4

14

















9

21

47

30



















4

5

Obesity









3

19

4

16

54

93

10

9

18

34

1

2

9

7

8





8

10

Smoker









1

4

















6

4

6

3







1

0









Diabetes mellitus













9

43









23

40

62

61

20

35















12

13

Radiotherapy





5 (12.2)

8 (9.9)





1 (1.5)

3 (7.5)

2 (4.5)

5 (2.1)

3 (8.6)

1 (1)

25 (19.8)

24 (11.4)



























Fat necrosis





2 (6.7)

5 (6.2)





6 (8.8)

6 (15)





0 (0)

0 (0)

0 (0)

3 (2.9)

0 (0)

7 (3.9)

0 (0)

1 (2)











0 (0)

1 (3.7)

0 (0)

1 (5)

Hernia

Complication (%)

3 (25)

1 (3.3)









2 (3)

3 (7.5)

1 (2.3)

13 (5.6)

4 (11.4)

15 (12)

4 (6.9)

3 (2.9)

5 (3.0)

17 (9.5)

0 (0)

2 (3)

6 (26)

6 (25)

15 (19)

1 (1.5)

3 (4.6)

7 (33)

9 (33)

0 (0)

2 (10)

Bulge





































9 (39.1)

4 (16.7)

12 (15)









2 (9)

6 (22)

Abdominal pain





















19 (54)

59 (48)













4 (17.4)

2 (8.3)

7 (8.9)









1 (4)

2 (7)

Low back pain









1 (2.4)

6 (3.8)





















1 (2.9)

8 (13.6)



















Hematoma









1 (2.4)

11 (6.9)













3 (5.2)

1 (1)





6 (17.1)

4 (6.8)



















Seroma









2 (4.9)

12(7.5)













3 (5.2)

4 (3.9)





4 (11.4)

3 (5.1)



















Infection

























54 (92.6)

84 (79.7)

80 (70.2)

98 (81.7)























Satisfaction rate

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MS-TRAM and 632 patients who underwent DIEP. Heterogeneity analysis showed that there was obvious statistical heterogeneity among these studies (I2 = 52.4 %, P = 0.017); thus, a random-effects model was chosen. The result showed that there was no significant difference

between MS-TRAM and DIEP with respect to complication rate after breast reconstruction (RR 1.042, 95 % CI 0.739–1.469, P = 0.814) (Fig. 2; Table 2). MS-TRAM was associated with a lower incidence of fat necrosis than was DIEP (random-effects pooled RR 0.502,

Fig. 2 Forest plot showing the comparison of complication rates of MS-TRAM versus DIEP

Table 2 Pooled analysis for comparisons SNP

N

Comparison

Patients (n) Group A

Complication rate of MS-TRAM versus DIEP

Test of association Group B

OR (95 % CI)

Test of heterogeneity P

P

2

I (%)

Publication bias P Egger’s test

Begg’s test

12

Total

253/3,707

131/1,688

1.042 (0.739–1.469)

0.814

0.017

52.4

0.046

0.040

7

Hernia

24/485

8/391

2.354 (1.154–4.802)

0.019

0.774

0

0.193

0.881

5

Fat necrosis

41/540

36/189

0.502 (0.347–0.727)

0.000

0.147

41.2

0.700

1.000

10

Bulge

82/849

30/508

1.439 (0.981–2.112)

0.063

0.329

12.4

0.213

0.325

2

Abdominal pain

18/88

6/43

1.401 (0.607–3.235)

0.429

0.305

4.8

NA

0.317

2

Low back pain

9/97

3/44

1.230 (0.350–4.325)

0.747

0.739

0

NA

0.317

3

Hematoma

16/307

10/124

0.631 (0.273–1.461)

0.283

0.144

48.5

0.839

0.602

3

Seroma

19/304

9/125

0.829 (0.367–1.870)

0.651

0.484

0

0.524

0.602

2

Infection

14/204

2/74

2.958 (0.717–12.201)

0.134

0.448

0

NA

0.317

Complication rate of DIEP versus SIEA

2

Total

35/232

15/69

0.457 (0.080–2.594)

0.377

0.102

62.5

NA

0.317

Satisfactory rate of MS-TRAM versus DIEP

2

Total

182/102

134/91

0.983 (0.691–1.397)

0.923

0.003

88.6

NA

0.317

NA no available

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Fig. 3 Forest plot showing the comparison of complication rates of DIEP versus SIEA

95 % CI 0.347–0.727, P = 0.000), but the incidence of hernia was significantly lower with DIEP flaps (randomeffects pooled RR 2.354, 95 % CI 1.154–4.802, P = 0.019). In addition, there was no obvious difference between MS-TRAM and DIEP with respect to the rates of bulging (P = 0.063), abdominal pain (P = 0.429), low back pain (P = 0.747), hematoma (P = 0.283), seroma (P = 0.651), and infection (P = 0.134) (Table 2). Comparison of Complication Rates of DIEP and SIEA There were two studies [26, 35], which included 267 patients who underwent DIEP and 84 patients who underwent SIEA, that compared the complication rates of DIEP and SIEA. Heterogeneity analysis showed that there was obvious statistical heterogeneity between these studies (I2 = 62.5 %, P = 0.105). The results showed that there was no significant difference between the complication rates of DIEP and SIEA after breast reconstruction (RR 0.457, 95 % CI 0.080–2.594, P = 0.377) (Fig. 3 and Table 2). Comparison of Satisfaction Rates of MS-TRAM and DIEP Two studies [28, 29], which involved 509 patients, compared the satisfaction rates of patients who had MS-TRAM and DIEP flap procedures. There were 287 patients who underwent MS-TRAM and 222 patients who underwent DIEP. As there was obvious statistical heterogeneity between these studies (I2 = 88.6 %, P = 0.003), a

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random-effects model was chosen for the meta-analysis. The results showed that there was no significant difference between MS-TRAM and DIEP with respect to patient satisfaction rate (OR 0.983, 95 % CI 0.691–1.397, P = 0.923) (Fig. 4 and Table 2). Factors that Influence Complication Rates A total of 12 studies [23–34] provided data on the complication rate of MS-TRAM and the factors that influenced it. Heterogeneity analysis showed obvious statistical heterogeneity among these studies (I2 = 95.0 %, P = 0.000). The results showed that the complication rate of MSTRAM procedures was 25.6 % (95 % CI 0.180–0.032, P = 0.000) (Fig. 5). Univariate meta-regression analysis found that diabetes mellitus (P = 0.078) was a potential factor that correlated with the complications of MS-TRAM used during breast reconstruction, but age (P = 0.448), BMI (P = 0.473), obesity (P = 0.712), radiotherapy (P = 0.758), and smoking (P = 0.807) had no correlation with the complications. All 13 studies [23–35] provided data on the complication rate of DIEP and the factors that influenced it. Heterogeneity analysis showed obvious statistical heterogeneity among these studies (I2 = 97.9 %, P = 0.000). The results showed that the complication rate of DIEP was 27.9 % (95 % CI 0.189–0.368, P = 0.000), as shown in Fig. 6. Univariate meta-regression analysis found that obesity (P = 0.098) and diabetes mellitus (P = 0.110) were potential factors that correlated with the complications of DIEP used during breast reconstruction, but age

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Fig. 4 Forest plot showing the comparison of satisfaction rates of MS-TRAM versus DIEP

Fig. 5 Forest plot showing the individual incidence of complication of MS-TRAM

(P = 0.405), radiotherapy (P = 0.388), and smoking (P = 0.844) did not correlate with the complications. Two studies [26, 35] provided data on the complication rate of the SIEA flap and the factors that influenced it. Heterogeneity analysis showed no obvious statistical heterogeneity

between these studies (I2 = 0 %, P = 0.755). The results showed that the complication rate of the SIEA flap for breast reconstruction was 26.7 % (95 % CI 0.195–0.339, P = 0.000), as shown in Fig. 7. Because there were only two studies, meta-regression analysis was not performed.

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Fig. 6 Forest plot showing individual incidence of complication of DIEP

Fig. 7 Forest plot showing individual incidence of complication of SIEA

Sensitivity Analysis

Publication Bias

The results of the sensitivity analysis showed that no study had an obvious influence on the outcomes of this metaanalysis.

According to Egger’s test and Begg’s test, we found a potential publication bias in the outcome of the comparison of the complication rates of MS-TRAM and DIEP (Egger’s

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Aesth Plast Surg Table 3 The quality of outcomes according to the grade system Study design

Risk of biasa

Inconsistency

Indirectness

Imprecision

Publication bias

Large effect

Dose response

Other effect

Quality of evidence

Fat necrosis

Retrospective

Seriousa

Seriousb

No

No

No

Largec

No

No

High

Hemia

Retrospective

Seriousa

Seriousb

No

No

No

Largec

No

No

High

Bulge

Retrospective

Serious

a

No

No

No

No

Largec

No

No

High

Abdominal pain

Retrospective

Seriousa

No

No

No

No

No

No

No

Low

Low back pain Infection

Retrospective

Seriousa

No

No

No

No

Very larged

No

No

Moderate

Retrospective

Seriousa

No

No

No

No

Very larged

No

No

Moderate

Hematoma

Retrospective

Serious

a

No

No

No

No

Very larged

No

No

Moderate

Seroma

Retrospective

Seriousa

No

No

No

No

Very larged

No

No

Moderate

B

Retrospective

Seriousa

No

No

No

No

Very larged

No

No

Moderate

C

Retrospective

Seriousa

No

No

No

No

No

No

No

Low

Outcome

A

A MS-TRAM versus DIEP on the rate of complication, B DIEP versus SIEA on the rate of complication, C MS-TRAM versus DIEP on the rate of satisfaction a b

All the studies are retrospective study without blind method and allocation concealment which resulted in very serious bias There are difference between outcomes of several studies

c

There are large effect in this outcome

d

There are very large effect in this outcome

test: P = 0.046, and Begg’s test: P = 0.040), the complication rate for MS-TRAM (Egger’s test: P = 0.000, and Begg’s test: P = 0.004), and the complication rate for DIEP (Egger’s test: P = 0.000, and Begg’s test: P = 0.013). A language bias inflated the estimates using a flawed methodological design in smaller studies, and a lack of publications reporting small trials with opposite results may be the cause. Quality of the Outcomes According to the GRADE System Following the GRADE system, the quality of the outcomes and their causes are shown in Table 3.

Discussion Autogenous breast reconstruction with tissue transfer is an ongoing process and is generally considered to be superior to implant-based breast reconstruction in creating a natural breast mound and maintenance of long-term aesthetic results [8, 36]. Currently, a number of reconstruction options are available for immediate or delayed postmastectomy breast reconstruction, including MS-TRAM, DIEP, and SIEA flaps [22, 37, 38]. With MS-TRAM most of the rectus abdominis muscle can be retained; thus, damage to the donor site is minimal and the blood supply to

the flap is sufficient [39]. DIEP can reduce the amount of rectus abdominis muscle used, but the incidence of complications is not decreased because damage may occur to the inferior epigastric artery and reduce the blood supply to the flap [40, 41]. SIEA can preserve the rectus abdominis muscle entirely, thus reducing damage to the deep structure and theoretically reducing the incidence of complications [42, 43]. Each alternative has advantages and disadvantages with respect to postoperative complications, donor site morbidity, and aesthetic appearance of the reconstructed breast. In addition, the risk of postoperative complications could be influenced by many factors. Kelley et al. [44] found that tamoxifen, a selective estrogen receptor modulator, may increase the risk of microvascular flap complications so they suggested that surgeons consider temporarily stopping the drug 28 days before microsurgical breast reconstruction. Moreover, other factors such as obesity, smoking, and diabetes mellitus may also increase the risk of postoperative complications. Our meta-analysis showed that there was no obvious difference in the overall incidence of complications of MSTRAM and DIEP. However, MS-TRAM showed a higher rate of abdominal hernias and a lower rate of fat necrosis than DIEP. There was no obvious difference in the complication rates of DIEP and SIEA. The incidence of complications with the MS-TRAM flap was 25.6 %, and the meta-regression analysis found that

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diabetes mellitus was potentially a factor that correlated with the complication rate. This correlation may occur because healing of the operative wound of patients with diabetes mellitus was slow and the infection rate was high. The incidence of complications with the DIEP flap was 27.9 %, and meta-regression analysis indicated that obesity, smoking, and diabetes mellitus were factors that potentially correlated with the complication rate. Large vessels perforating the rectus abdominis muscle were more prevalent in patients with a high body mass index; thus, the complication rate of obese patients who had a DIEP flap was higher. The complication rate with SIEA was 26.7 %, which indicated that SIEA was not superior to MS-TRAM and DIEP in lowering the complication rate. Different preventive measures for different high-risk patients can obviously reduce the occurrence of complications. For patients with diabetes mellitus, we think that proper blood glucose levels during the perioperative period are important and necessary. Meanwhile, smokers should decrease their amount of smoking and control their smoking frequency if undergoing breast reconstruction with the use of free flaps. A safer approach for obese patients is to optimize perfusion to the flap by incorporating multiple perforators through the use of a free MSTRAM flap, thus minimizing fat necrosis and other flaprelated complications. Although we attempted to minimize the likelihood of bias by developing a detailed protocol before initiating the study, some insurmountable limitations of this meta-analysis may affect the results and thus the conclusions. First, because of incomplete raw data or publication limitations, several relevant studies could not be included in this metaanalysis. Second, the numbers of subjects and studies included in the meta-analysis was small and may not be sufficient to provide accurate results. Third, because all the necessary information could not be obtained from most of the included studies, relevant stratification could not be performed for many studies. In conclusion, our meta-analysis showed that there was no obvious difference with respect to the complication rate between MS-TRAM and DIEP and between DIEP and SIEA. Similarly, no difference was found between MSTRAM and DIEP with respect to the patient satisfaction rate. However, MS-TRAM patients had a higher rate of abdominal hernias compared to DIEP patients, and the opposite was observed for fat necrosis. Obesity and diabetes mellitus were the potential factors that correlated with the complication rates. Additional multicenter, largesample, randomized controlled trials with long-term follow-up visits are necessary. Conflict of interest disclose.

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The authors have no conflicts of interest to

References 1. Ertan K, Linsler C, di Liberto A et al (2013) Axillary ultrasound for breast cancer staging: an attempt to identify clinical/histopathological factors impacting diagnostic performance. Breast Cancer 7:35–40 2. Win AK, Lindor NM, Jenkins MA (2013) Risk of breast cancer in Lynch syndrome: a systematic review. Breast Cancer Res 15:R27 3. Siegel R, Naishadham D, Jemal A et al (2012) Cancer statistics. CA Cancer J Clin 62(1):10–29 4. Abbott A, Reuth N, Pappas-Varco S, Kuntz K, Kerr E, Tuttle T (2011) Perceptions of contralateral breast cancer: an overestimation of risk. Ann Surg Oncol 18:3129–3136 5. Crosby MA, Garvey PB, Selber JC et al (2011) Reconstructive outcomes in patients undergoing contralateral prophylactic mastectomy. Plast Reconstr Surg 128:1025–1033 6. Han E, Johnson N, Glissmeyer M et al (2011) Increasing incidence of bilateral mastectomies: the patient perspective. Am J Surg 201:615–618 7. Atherton DD, Hills AJ, Moradi P, Muirhead N, Wood SH (2011) The economic viability of breast reconstruction in the UK: comparison of a single surgeon’s experience of implant; LD; TRAM and DIEP based reconstructions in 274 patients. J Plast Reconstr Aesthet Surg 64:710–715 8. Clough KB, O’Donoghue JM, Fitoussi AD, Vlastos G, Falcou MC (2001) Prospective evaluation of late cosmetic results following breast reconstruction: II. Tram flap reconstruction. Plast Reconstr Surg 107:1710–1716 9. Casey WJ 3rd, Rebecca AM, Silverman A et al (2013) Etiology of breast masses after autologous breast reconstruction. Ann Surg Oncol 20:607–614 10. Chaput B, Garrido I, Chavoin JP, Gangloff D, Grolleau JL (2013) Rib-sparing and internal mammary artery-preserving microsurgical breast reconstruction with the free DIEP flap. Plast Reconstr Surg 132:868e–870e 11. Lymperopoulos NS, Sofos S, Constantinides J, Koshy O, Graham K (2013) Blood loss and transfusion rates in DIEP flap breast reconstruction: introducing a new predictor. J Plast Reconstr Aesthet Surg 66:1659–1664 12. Davidge KM, Brown M, Morgan P, Semple JL (2013) Processes of care in autogenous breast reconstruction with pedicled TRAM flaps: expediting postoperative discharge in an ambulatory setting. Plast Reconstr Surg 132:339e–344e 13. Dobbs NB, Latifi HR (2013) Diffuse FDG uptake due to fat necrosis following transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. Clin Nucl Med 38:652–654 14. Hadad I, Ibrahim AM, Lin SJ, Lee BT (2013) Augmented SIEA flap for microvascular breast reconstruction after prior ligation of bilateral deep inferior epigastric arteries. J Plast Reconstr Aesthet Surg 66:845–847 15. Holmstro¨m H (1979) The free abdominoplasty flap and its use in breast reconstruction: an experimental study and clinical case report. Scand J Plast Reconstr Surg 13:423–427 16. Beier JP, Horch RE, Arkudas A et al (2013) Decision-making in DIEP and ms-TRAM flaps: the potential role for a combined laser Doppler spectrophotometry system. J Plast Reconstr Aesthet Surg 66:73–79 17. Chang DW (2012) Breast reconstruction with microvascular MSTRAM and DIEP flaps. Arch Plast Surg 39:3–10 18. Allen RJ, Treece P (1994) Deep inferior epigastric flap for breast reconstruction. Ann Plast Surg 32:32–38 19. Blondeel PN (1999) One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 52:104–111 20. Taylor GI, Daniel RK (1975) The anatomy of several free flap donor sites. Plast Reconst Surg 56:243–256

Aesth Plast Surg 21. Arnez ZM, Khan U, Pogorelec D et al (1999) Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 52:276–279 22. Chevray PM (2004) Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 114:1077–1083 23. Blondeel N, Vanderstraeten GG, Monstrey SJ et al (1997) The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 50:322–330 24. Futter CM, Webster MH, Hagen S et al (2000) A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 53:578–583 25. Nahabedian MY, Tsangaris T, Momen B (2005) Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference? Plast Reconstr Surg 115:436–444 26. Wu LC, Bajaj A, Chang DW et al (2008) Comparison of donorsite morbidity of SIEA, DIEP, and muscle-sparing TRAM flaps for breast reconstruction. Plast Reconstr Surg 122:702–709 27. Nelson JA, Guo Y, Sonnad SS et al (2010) A comparison between DIEP and muscle-sparing free TRAM flaps in breast reconstruction: a single surgeon’s recent experience. Plast Reconstr Surg 126:1428–1435 28. Momoh AO, Colakoglu S, Westvik TS et al (2012) Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 69:19–23 29. Chun YS, Sinha I, Turko A et al (2010) Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 126:1133–1141 30. Bajaj AK, Chevray PM, Chang DW (2006) Comparison of donorsite complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 117:737–746 31. Bonde CT, Christensen DE, Elberg JJ (2006) Ten years’ experience of free flaps for breast reconstruction in a Danish microsurgical centre: an audit. Scand J Plast Reconstr Surg Hand Surg 40:8–12 32. Scheer AS, Novak CB, Neligan PC et al (2006) Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap. Ann Plast Surg 56:355–358

33. Chen CM, Halvorson EG, Disa JJ et al (2007) Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg 120:1477–1482 34. Takeishi M, Fujimoto M, Ishida K et al (2008) Muscle sparing-2 transverse rectus abdominis musculocutaneous flap for breast reconstruction a comparison with deep inferior epigastric perforator flap. Microsurgery 28:650–655 35. Cheng MH, Lin JY, Ulusal BG et al (2006) Comparisons of resource costs and success rates between immediate and delayed breast reconstruction using DIEP or SIEA flaps under a wellcontrolled clinical trial. Plast Reconstr Surg 117:2139–2142 36. Slavin SA, Scnitt SJ, Duda RB et al (1998) Skin-sparing mastectomy and immediate reconstruction: oncologic risks and aesthetic results in patients with early stage breast cancer. Plast Reconstr Surg 102:49–62 37. Kroll SS, Gherardini G, Martin JE et al (1998) Fat necrosis in free and pedicled TRAM flaps. Plast Reconstr Surg 102:1052–1057 38. Qiu SS, Jurado M, Hontanilla B (2013) Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 132:1020e–1027e 39. Lee BT, Chen C, Nguyen MD et al (2010) A new classification system for muscle and nerve preservation in DIEP flap breast reconstruction. Microsurgery 30:85–90 40. Appleton SE, Ngan A, Kent B et al (2011) Risk factors influencing transfusion rates in DIEP flap breast reconstruction. Plast Reconstr Surg 127:1773–1782 41. Blondeel PN, Neligan P (2011) Are bilateral TRAM flaps as good as bilateral DIEP flaps? Plast Reconstr Surg 128:590–591 42. Spiegel AJ, Khan FN (2007) An intraoperative algorithm for use of the SIEA flap for breast reconstruction. Plast Reconstr Surg 120:1450–1459 43. Apostolides JG, Magarakis M, Rosson GD (2011) Preserving the internal mammary artery: end-to-side microvascular arterial anastomosis for DIEP and SIEA flap breast reconstruction. Plast Reconstr Surg 128:225e–232e 44. Kelley BP, Valero V, Yi M, Kronowitz SJ (2012) Tamoxifen increases the risk of microvascular flap complications in patients undergoing microvascular breast reconstruction. Plast Reconstr Surg 129:305–314

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Meta-analysis of the safety and factors contributing to complications of MS-TRAM, DIEP, and SIEA flaps for breast reconstruction.

Muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric art...
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