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J Reconstr Microsurg 2019; 35(01): 074-082
DOI: 10.1055/s-0038-1667046
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Immediate Unilateral Breast Reconstruction using Abdominally Based Flaps: Analysis of 3,310 Cases

Alvin C. Kwok   *
1   Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah
,
Andrew M. Simpson   *
1   Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah
,
Xiangyang Ye
2   Division of Epidemiology, University of Utah, School of Medicine, Salt Lake City, Utah
,
Eric Tatro
3   Texas Tech Health Science Center, Paul L. Foster School of Medicine, El Paso, Texas
,
Jayant P. Agarwal
1   Division of Plastic and Reconstructive Surgery, University of Utah, School of Medicine, Salt Lake City, Utah
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Publikationsverlauf

18. Januar 2018

22. Mai 2018

Publikationsdatum:
29. Juli 2018 (online)

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Abstract

Background The abdomen is the most common area from which tissue is harvested for autologous breast reconstruction. We sought to examine national data to determine the differences in total hospital charges, length of stay (LOS), and early postoperative complications following pedicled transverse rectus abdominis myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator (DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps.

Methods The 2009–2013 Nationwide Inpatient Sample Database was used to identify patients who underwent a unilateral mastectomy and only one type of abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the same hospital admission. Outcomes of interest included total charges, LOS, and complications including revision of vascular anastomosis and hematoma.

Results A total of 3,310 cases were identified, corresponding to 15,991 abdominally based unilateral immediate breast reconstructions after standard weighting was applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206 (38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and $26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p = 0.002). The rates for return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001).

Conclusions There is variation in the total charges, LOS, and early complications between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP, and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and experience more immediate complications compared with pTRAM. Well-designed prospective trials are required to better understand the findings from this study with the inclusion of other critical outcomes such as patient satisfaction, aesthetic results, and long-term outcomes such as abdominal wall morbidity.

Keywords

breast reconstruction - microsurgery - free flaps

* Alvin C. Kwok and Andrew M. Simpson contributed equally to the work and should be considered co-first authors.


 

  • References

  • 1 How common is breast cancer? Available at: https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html . Accessed November 21, 2017.
    PubMed
  • 2 Handel N, Silverstein MJ, Waisman E, Waisman JR. Reasons why mastectomy patients do not have breast reconstruction. Plast Reconstr Surg 1990; 86 (06) 1118-1122 , discussion 1123–1125
    CrossrefPubMedSuche in Google Scholar
  • 3 Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000; 106 (04) 769-776
    CrossrefPubMedSuche in Google Scholar
  • 4 Craft RO, Colakoglu S, Curtis MS. , et al. Patient satisfaction in unilateral and bilateral breast reconstruction [outcomes article]. Plast Reconstr Surg 2011; 127 (04) 1417-1424
    CrossrefPubMedSuche in Google Scholar
  • 5 Yueh JH, Slavin SA, Adesiyun T. , et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010; 125 (06) 1585-1595
    CrossrefPubMedSuche in Google Scholar
  • 6 Scheflan M, Hartrampf CR, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69 (05) 908-909
    PubMedSuche in Google Scholar
  • 7 Kroll SS, Evans GR, Reece GP. , et al. Comparison of resource costs between implant-based and TRAM flap breast reconstruction. Plast Reconstr Surg 1996; 97 (02) 364-372
    CrossrefPubMedSuche in Google Scholar
  • 8 Nahabedian MY, Momen B, Galdino G, Manson PN. Breast reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110 (02) 466-475 , discussion 476–477
    CrossrefPubMedSuche in Google Scholar
  • 9 Feingold RS. Improving surgeon confidence in the DIEP flap: a strategy for reducing operative time with minimally invasive donor site. Ann Plast Surg 2009; 62 (05) 533-537
    CrossrefPubMedSuche in Google Scholar
  • 10 Kroll SS, Reece GP, Miller MJ. , et al. Comparison of cost for DIEP and free TRAM flap breast reconstructions. Plast Reconstr Surg 2001; 107 (06) 1413-1416 , discussion 1417–1418
    CrossrefPubMedSuche in Google Scholar
  • 11 Lee BT, Agarwal JP, Ascherman JA. , et al. Evidence-based clinical practice guideline: autologous breast reconstruction with DIEP or pedicled TRAM abdominal flaps. Plast Reconstr Surg 2017; 140 (05) 651e-664e
    CrossrefPubMedSuche in Google Scholar
  • 12 Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010; 125 (05) 1335-1341
    CrossrefPubMedSuche in Google Scholar
  • 13 Blondeel N, Vanderstraeten GG, Monstrey SJ. , et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50 (05) 322-330
    CrossrefPubMedSuche in Google Scholar
  • 14 Blondeel PN, Neligan P. Are bilateral TRAM flaps as good as bilateral DIEP flaps?. Plast Reconstr Surg 2011; 128 (02) 590-591 , author reply 591–592
    CrossrefPubMedSuche in Google Scholar
  • 15 Knox AD, Ho AL, Leung L. , et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg 2016; 138 (01) 16-28
    CrossrefPubMedSuche in Google Scholar
  • 16 Nahabedian MY. Secondary operations of the anterior abdominal wall following microvascular breast reconstruction with the TRAM and DIEP flaps. Plast Reconstr Surg 2007; 120 (02) 365-372
    CrossrefPubMedSuche in Google Scholar
  • 17 Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: is there a difference?. Plast Reconstr Surg 2005; 115 (02) 436-444 , discussion 445–446
    CrossrefPubMedSuche in Google Scholar
  • 18 Selber JC, Fosnot J, Nelson J. , et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part II. Bilateral reconstruction. Plast Reconstr Surg 2010; 126 (05) 1438-1453
    CrossrefPubMedSuche in Google Scholar
  • 19 Selber JC, Nelson J, Fosnot J. , et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part I. Unilateral reconstruction. Plast Reconstr Surg 2010; 126 (04) 1142-1153
    CrossrefPubMedSuche in Google Scholar
  • 20 Thoma A, Veltri K, Khuthaila D, Rockwell G, Duku E. Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis. Plast Reconstr Surg 2004; 113 (06) 1650-1661
    CrossrefPubMedSuche in Google Scholar
  • 21 Chun YS, Sinha I, Turko A. , et al. Comparison of morbidity, functional outcome, and satisfaction following bilateral TRAM versus bilateral DIEP flap breast reconstruction. Plast Reconstr Surg 2010; 126 (04) 1133-1141
    CrossrefPubMedSuche in Google Scholar
  • 22 Garvey PB, Buchel EW, Pockaj BA. , et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plast Reconstr Surg 2006; 117 (06) 1711-1719 , discussion 1720–1721
    CrossrefPubMedSuche in Google Scholar
  • 23 Sarik JR, Bank J, Wu LC, Serletti JM. Superficial inferior epigastric artery: learning curve versus reality. Plast Reconstr Surg 2016; 137 (01) 1e-6e
    CrossrefPubMedSuche in Google Scholar
  • 24 HCUP-US NIS Overview. Available at: https://www.hcup-us.ahrq.gov/nisoverview.jsp . Accessed December 12, 2017.
    PubMed
  • 25 Slee VN. The International Classification of Diseases: ninth revision (ICD-9). Ann Intern Med 1978; 88 (03) 424-426
    PubMedSuche in Google Scholar
  • 26 Weighting Tutorial Series HCUP. Available at: https://www.hcup-us.ahrq.gov/tech_assist/tutorials.jsp . Accessed December 21, 2017.
    PubMed
  • 27 Schoenfeld AJ, Wahlquist TC. Mortality, complication risk, and total charges after the treatment of epidural abscess. Spine J 2015; 15 (02) 249-255
    CrossrefPubMedSuche in Google Scholar
  • 28 Lee MK, Yen SL, Allareddy V. Hospitalization outcomes of cleft lip repair in neonates across the United States. Cleft Palate Craniofac J 2018; 55 (04) 528-535
    CrossrefPubMedSuche in Google Scholar
  • 29 Wasif N, Etzioni DA, Habermann EB. , et al. Does improved mortality at low- and medium-volume hospitals lead to attenuation of the volume-outcome relationship for major visceral surgery?. J Am Coll Surg 2018 Doi: S1072-7515(18)30180-7
    PubMedSuche in Google Scholar
  • 30 Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992; 45 (06) 613-619
    CrossrefPubMedSuche in Google Scholar
  • 31 Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002; 109 (07) 2265-2274
    CrossrefPubMedSuche in Google Scholar
  • 32 Edsander-Nord A, Jurell G, Wickman M. Donor-site morbidity after pedicled or free TRAM flap surgery: a prospective and objective study. Plast Reconstr Surg 1998; 102 (05) 1508-1516
    CrossrefPubMedSuche in Google Scholar
  • 33 Grotting JC, Urist MM, Maddox WA, Vasconez LO. Conventional TRAM flap versus free microsurgical TRAM flap for immediate breast reconstruction. Plast Reconstr Surg 1989; 83 (05) 828-841 , discussion 842–844
    CrossrefPubMedSuche in Google Scholar
  • 34 Larson DL, Yousif NJ, Sinha RK, Latoni J, Korkos TG. A comparison of pedicled and free TRAM flaps for breast reconstruction in a single institution. Plast Reconstr Surg 1999; 104 (03) 674-680
    CrossrefPubMedSuche in Google Scholar
  • 35 Nahabedian MY, Dooley W, Singh N, Manson PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg 2002; 109 (01) 91-101
    CrossrefPubMedSuche in Google Scholar
  • 36 Serletti JM, Moran SL. Free versus the pedicled TRAM flap: a cost comparison and outcome analysis. Plast Reconstr Surg 1997; 100 (06) 1418-1424 , discussion 1425–1427
    CrossrefPubMedSuche in Google Scholar
  • 37 Momoh AO, Colakoglu S, Westvik TS. , et al. Analysis of complications and patient satisfaction in pedicled transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flap breast reconstruction. Ann Plast Surg 2012; 69 (01) 19-23
    CrossrefPubMedSuche in Google Scholar
  • 38 Siegel R, DeSantis C, Virgo K. , et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin 2012; 62 (04) 220-241
    CrossrefPubMedSuche in Google Scholar
  • 39 Albornoz CR, Cordeiro PG, Mehrara BJ. , et al. Economic implications of recent trends in U.S. immediate autologous breast reconstruction. Plast Reconstr Surg 2014; 133 (03) 463-470
    CrossrefPubMedSuche in Google Scholar
  • 40 Sailon AM, Schachar JS, Levine JP. Free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps for breast reconstruction: a systematic review of flap complication rates and donor-site morbidity. Ann Plast Surg 2009; 62 (05) 560-563
    CrossrefPubMedSuche in Google Scholar
  • 41 HCUP-US SID Overview. Available at: https://www.hcup-us.ahrq.gov/sidoverview.jsp . Accessed March 22, 2018
    PubMed
  • 42 Pien I, Caccavale S, Cheung MC. , et al. Evolving trends in autologous breast reconstruction: is the deep inferior epigastric artery perforator flap taking over?. Ann Plast Surg 2016; 76 (05) 489-493
    CrossrefPubMedSuche in Google Scholar
  • 43 DellaCroce FJ, Sullivan SK, Trahan C. Stacked deep inferior epigastric perforator flap breast reconstruction: a review of 110 flaps in 55 cases over 3 years. Plast Reconstr Surg 2011; 127 (03) 1093-1099
    CrossrefPubMedSuche in Google Scholar
  • 44 Henry SL, Chang CC, Misra A, Huang JJ, Cheng MH. Inclusion of tissue beyond a midline scar in the deep inferior epigastric perforator flap. Ann Plast Surg 2011; 67 (03) 251-254
    CrossrefPubMedSuche in Google Scholar
  • 45 Leonhardt H, Mai R, Pradel W. , et al. Free DIEP-flap reconstruction of tumour-related defects in head and neck. J Physiol Pharmacol 2008; 59 (Suppl. 05) 59-67
    PubMedSuche in Google Scholar
  • 46 Masià J, Sommario M, Cervelli D, Vega C, León X, Pons G. Extended deep inferior epigastric artery perforator flap for head and neck reconstruction: a clinical experience with 100 patients. Head Neck 2011; 33 (09) 1328-1334
    CrossrefPubMedSuche in Google Scholar
  • 47 Vanschoonbeek A, Fabre G, Nanhekhan L, Vandevoort M. Outcome after urgent microvascular revision of free DIEP, SIEA and SGAP flaps for autologous breast reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1598-1608
    CrossrefPubMedSuche in Google Scholar
  • 48 Visser NJ, Damen TH, Timman R, Hofer SO, Mureau MA. Surgical results, aesthetic outcome, and patient satisfaction after microsurgical autologous breast reconstruction following failed implant reconstruction. Plast Reconstr Surg 2010; 126 (01) 26-36
    PubMedSuche in Google Scholar
  • 49 Lie KH, Barker AS, Ashton MW. A classification system for partial and complete DIEP flap necrosis based on a review of 17,096 DIEP flaps in 693 articles including analysis of 152 total flap failures. Plast Reconstr Surg 2013; 132 (06) 1401-1408
    CrossrefPubMedSuche in Google Scholar
  • 50 Spiegel AJ, Khan FN. An intraoperative algorithm for use of the SIEA flap for breast reconstruction. Plast Reconstr Surg 2007; 120 (06) 1450-1459
    CrossrefPubMedSuche in Google Scholar
  • 51 Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975; 56 (03) 243-253
    CrossrefPubMedSuche in Google Scholar
  • 52 Arnez ZM, Khan U, Pogorelec D, Planinsek F. Breast reconstruction using the free superficial inferior epigastric artery (SIEA) flap. Br J Plast Surg 1999; 52 (04) 276-279
    CrossrefPubMedSuche in Google Scholar
  • 53 Chevray PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004; 114 (05) 1077-1083 , discussion 1084–1085
    PubMedSuche in Google Scholar
  • 54 Selber JC, Samra F, Bristol M. , et al. A head-to-head comparison between the muscle-sparing free TRAM and the SIEA flaps: is the rate of flap loss worth the gain in abdominal wall function?. Plast Reconstr Surg 2008; 122 (02) 348-355
    CrossrefPubMedSuche in Google Scholar
  • 55 Coroneos CJ, Heller AM, Voineskos SH, Avram R. SIEA versus DIEP arterial complications: a cohort study. Plast Reconstr Surg 2015; 135 (05) 802e-807e
    CrossrefPubMedSuche in Google Scholar
  • 56 Golpanian S, Gerth DJ, Tashiro J, Thaller SR. Free versus pedicled TRAM flaps: cost utilization and complications. Aesthetic Plast Surg 2016; 40 (06) 869-876
    CrossrefPubMedSuche in Google Scholar
  • 57 Bajaj AK, Chevray PM, Chang DW. Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 2006; 117 (03) 737-746 , discussion 747–750
    CrossrefPubMedSuche in Google Scholar
  • 58 Chen CM, Halvorson EG, Disa JJ. , et al. Immediate postoperative complications in DIEP versus free/muscle-sparing TRAM flaps. Plast Reconstr Surg 2007; 120 (06) 1477-1482
    CrossrefPubMedSuche in Google Scholar
  • 59 Scheer AS, Novak CB, Neligan PC, Lipa JE. Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap. Ann Plast Surg 2006; 56 (04) 355-358
    CrossrefPubMedSuche in Google Scholar
  • 60 Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA. A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions. Ann Plast Surg 2007; 59 (02) 137-142
    CrossrefPubMedSuche in Google Scholar
  • 61 Grover R, Padula WV, Van Vliet M, Ridgway EB. Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis. Plast Reconstr Surg 2013; 132 (05) 709e-723e
    CrossrefPubMedSuche in Google Scholar
  • 62 HCUP NIS Definitions. Total charges. Available at: https://www.hcup-us.ahrq.gov/db/vars/totchg/nisnote.jsp . Accessed March 22, 2018.
    PubMed
  • 63 Andrews RM. Statewide hospital discharge data: collection, use, limitations, and improvements. Health Serv Res 2015; 50 (Suppl. 01) 1273-1299
    CrossrefPubMedSuche in Google Scholar
  • 64 Wan DC, Tseng CY, Anderson-Dam J, Dalio AL, Crisera CA, Festekjian JH. Inclusion of mesh in donor-site repair of free TRAM and muscle-sparing free TRAM flaps yields rates of abdominal complications comparable to those of DIEP flap reconstruction. Plast Reconstr Surg 2010; 126 (02) 367-374
    CrossrefPubMedSuche in Google Scholar
  • 65 Schusterman MA, Kroll SS, Miller MJ. , et al. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center's experience with 211 consecutive cases. Ann Plast Surg 1994; 32 (03) 234-241 , discussion 241–242
    CrossrefPubMedSuche in Google Scholar
  • 66 Fischer JP, Nelson JA, Sieber B. , et al. Free tissue transfer in the obese patient: an outcome and cost analysis in 1258 consecutive abdominally based reconstructions. Plast Reconstr Surg 2013; 131 (05) 681e-692e
    CrossrefPubMedSuche in Google Scholar
  • 67 Zoghbi Y, Gerth DJ, Tashiro J, Golpanian S, Thaller SR. Deep inferior epigastric perforator versus free transverse rectus abdominis myocutaneous flap: complications and resource utilization. Ann Plast Surg 2017; 78 (05) 516-520
    CrossrefPubMedSuche in Google Scholar
  • 68 Chang DW, Wang B, Robb GL. , et al. Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction. Plast Reconstr Surg 2000; 105 (05) 1640-1648
    CrossrefPubMedSuche in Google Scholar
  • 69 Guerra AB, Metzinger SE, Bidros RS. , et al. Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps. Ann Plast Surg 2004; 52 (03) 246-252
    CrossrefPubMedSuche in Google Scholar
  • 70 Kroll SS, Netscher DT. Complications of TRAM flap breast reconstruction in obese patients. Plast Reconstr Surg 1989; 84 (06) 886-892
    CrossrefPubMedSuche in Google Scholar
  • 71 Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg 2011; 127 (03) 1086-1092
    CrossrefPubMedSuche in Google Scholar