Introduction: The superiority of free flaps to pedicled flaps has been a topic of intense debate. The traditional figure of 5-10% free flap loss is often used to justify higher rates of partial flap loss, major fat necrosis, and abdominal wall complications with pedicled TRAM flaps. The purpose of this study was to clarify the rates of major complications in the largest reported series of consecutive patients treated with free tissue transfer. Methods: The charts of 766 consecutive patients who underwent autologous free tissue breast reconstruction from 1991 to 2001 were retrospectively reviewed. Major and minor complications were evaluated. Results: Unilateral reconstruction was performed in 575 patients while 191 underwent bilateral reconstruction (957 flaps). TRAM flaps were performed in 755 cases (79%) while the superior gluteal (9.6%), TFL (3.4%), DICA (1.1%), gracilis (0,4%), and latissimus (0.3%) were performed in the remaining patients. Major complications included: 6 total flap losses (0.6%), 13 partial flap losses (1.35%), 14 venous thrombosis (1.5%), 5 arterial thrombosis (0.5%), hematomas (3.3%), pulmonary edema requiring intubation (0.8%), life threatening sepsis (0.3%), and 1 case of intestinal compartment syndrome. There were no deaths related to breast reconstruction. Minor complications consisted of: infection (6.5%), hernia/abdominal laxity (3.1%), minor to moderate fat necrosis (17%), mild CHF (1.6%), DVT (0.3%), and brachial plexus palsy (temporary; 0.7%). Discussion: Breast reconstruction using free tissue transfer can be very reliable (99.4% success) with low rates of major complications and acceptable rates of minor complications. With experience, rates of total flap loss can approach those of pedicled flaps while the frequency of partial flap loss and major fat necrosis can be significantly improved. Alternative donor sites to the TRAM flap are important (21% in our series had other free flaps). Flap selection and technical highlights will be presented.
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