1. breast reconstruction: TRAM vs DIEP a difficult challange Petit JY Manconi A Division of Reconstructive Surgery EIO Milan

7. Technique

10. Ped TRAM flap modelling length of the vascular peduncle in free flaps can make it difficult

14. Evolution of TRAM indication at the IEO in 2005 30 % 6 %

15. Ped. TRAM immediate complications hematomas : (2%) transfusions: (4.5%) pulmonary emboly: (0.4%) mortality 0

16. Ped. TRAM Partial flap necrosis 12% sponta.heal. 31% revision. AL. 62% AG 7%

17. Flap Complications DIEP with preoperative angio-tc scan series (11 consecutive cases): Partial flap necrosis*: 0% Total flap necrosis: 0% *more than 5% Mono TRAM Bi TRAM DIEP Partial necrosis* 21% 5,79% 14,28% Flap Failure 0,30% 0% 4,17%

18. Free flaps : flap necrosis fat necrosis Free flap : 2.2% 12.9% DIEP 1 : 37.5% 62.5% DIEP 2 : 8.7% 17.4% Kroll SS Plast Reconstr Surg 2000 sep 106 (3) 576

21. PRE-OP DIEP POST-OP TRAM POST-OP TRAM POST-OP

22. Bulging or herniae? Physiological disturb Pain

23. Obesity Risk factor +++

24. Ped. TRAM BR Abdominal necrosis umbilicus supra pubic total : 8 %

25. Fistula with infected mesh behind the rectus fascia fistula

26. Abdominal strength after pedicled or free TRAM No statistical difference in the immediate follow up The difference between the two procedures is small as compared to the individual variations (other factors) More bulging in free flaps …. Edsander-Nord A Wickman M et al Plast Reconstr Surg 1998 Oct 102 (5) 1508

27. Angiogenic cytokines perioperative levels increased by extent of surgery Induces perioperative stimulation of residual cancer cells

29. conclusion when the conditions are favorable DIEP is the best choice Unfortunatly, it is too late for me to learn microsurgery ! Thanks for your attention