BACKGROUND: Lower abdominal tissue remains the gold standard for autologous tissue breast reconstruction. Lower abdominal flaps have evolved to reduce donor site morbidity, and have progressed from harvesting the entire rectus abdominis muscle (pedicled TRAM flap), to excising only a portion of muscle (free ms-TRAM flap), to only incising the muscle and fascia (DIEP flap), to using an alternative blood supply so that the rectus abdominis muscle and fascia are neither excised nor incised (SIEA flap).

PURPOSE: This is a comparative study of the donor site function and outcomes of patients who have undergone SIEA flap, DIEP flap, or free ms-TRAM flap breast reconstruction. We investigate the postoperative morbidity, and examine patient perceptions, of abdominal donor site aesthetics, pain, and function.

METHODS: A 12 item questionnaire was sent to elicit patient perceptions regarding abdominal donor site contour, pain, and function. A retrospective chart review was used to obtain demographic data and outcomes with regard to donor site and flap complications.

RESULTS: 179 patients from a 5 year period were included in the study. There were 126 unilateral breast reconstruction patients (24 SIEA, 23 DIEP, 79 ms-TRAM), and 53 bilateral reconstruction patients (6 SIEA/SIEA, 5 SIEA/DIEP, 7 SIEA/ms-TRAM, 8 DIEP/DIEP, 4 DIEP/ms-TRAM, 23 ms-TRAM/ms-TRAM). The survey response rate was 63% (112 respondents). There was no difference between responders and non-responders with regard to flap types, follow-up time, timing of surgery (immediate or delayed), BMI, smoking history, or diabetes.

Unilateral SIEA flap patients had statistically significantly better postoperative lifting function compared to unilateral ms-TRAM flap patients (p=0.02), and a nearly significantly shorter duration of abdominal pain (p=0.06). Furthermore, unilateral SIEA flap patients showed a trend toward less pain, and higher functioning in 7 of 8 survey items. There was no difference in patient perceptions of abdominal contour between these two groups.

In the bilateral reconstructions, patients with at least one SIEA flap had statistically better ability to get out of bed (sit-up motion) when compared to patients with bilateral ms-TRAM flap and/or DIEP flaps (p=0.02). Moreover, in all remaining 11 survey items, bilateral breast reconstruction patients with at least one SIEA flap trended to having better postoperative abdominal contour, less pain, and higher functioning than patients who had bilateral breast reconstruction with any combination of DIEP and/or ms-TRAM flaps.

There was no detectable difference between the unilateral SIEA flap and unilateral DIEP flap patients with regard to postoperative abdominal contour, pain, or abdominal function.

CONCLUSIONS: We conclude patients who have unilateral breast reconstruction with SIEA flaps have less donor site morbidity than similar patients who have reconstruction with a ms-TRAM flap. In addition, patients who undergo bilateral breast reconstruction with at least one SIEA flap have less donor site morbidity than patients who have any combination of DIEP and/or ms-TRAM flaps. We were unable to detect a difference between SIEA flap and DIEP flap patients' perceptions of abdominal donor site morbidity.