Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: a cost-effectiveness analysis.

Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis. Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients. This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction.

The authors investigated hernia repair rates following pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, and deep inferior epigastric perforator (DIEP) flap breast reconstruction in English National Health Service hospitals. Women diagnosed with breast cancer who underwent pedicled TRAM, free TRAM, or DIEP flap breast reconstruction procedures in English National Health Service hospitals between April of 2006 and March of 2012 were identified using the Hospital Episode Statistics database. Women who underwent mastectomy without reconstruction acted as controls, and hernia repair rates were calculated for all four groups. Multiple Cox regression was performed to estimate the relative risk of hernia repair among the reconstruction groups, adjusted for age, obesity, previous abdominal surgery, reconstruction year, and bilateral flap harvest. Between 2006 and 2012, 7929 women had a DIEP or TRAM flap breast reconstruction. The overall hernia repair rate within 3 years was 2.45 percent after abdominal flap breast reconstruction, and 0.28 percent among the 15,679 women who had mastectomy only. Mean time to hernia repair following an abdominal flap harvest was 17.7 months. Compared with DIEP flaps, free and pedicled TRAM flap procedures were associated with adjusted hazard ratios of 1.81 (95 percent CI, 1.24 to 2.64) and 2.89 (95 percent CI, 1.91 to 4.37), respectively. The only independent risk factor for hernia repair was age older than 60 years (p = 0.039). Abdominally based autologous breast reconstruction carries a small risk of subsequent donor-site hernia repair. The rates herein can be used to inform patients and to assess quality of care across service providers. Therapeutic, III.

A series of 310 breasts reconstructed by a single surgeon using free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps was reviewed to see if there were any differences in the incidence of fat necrosis and/or partial flap loss between the two techniques. During the study period, 279 breasts were reconstructed with free TRAM flaps and 31 breasts were reconstructed with DIEP flaps. In the breasts reconstructed with free TRAM flaps, the incidence of partial flap loss was 2.2 percent and the incidence of fat necrosis was 12.9 percent. The DIEP flaps were divided into two groups. For the first eight flaps, patients were selected using the same criteria normally used to choose patients for free TRAM flaps. In this unselected early group, the incidence of partial flap loss was 37.5 percent and the incidence of fat necrosis was 62.5 percent. Because of the high incidence of partial flap loss and fat necrosis in the first eight flaps, subsequent selection was modified to limit the use of DIEP flaps to patients who had at least one sufficiently large perforator in each flap (a palpable pulse and a vein at least 1 mm in diameter) and who did not require more than 70 percent of the flap to create a breast of adequate size. In this later (selected) group, fat necrosis (17.4 percent) and partial flap loss (8.7 percent) were reduced to a level only moderately higher than that found in the free TRAM flap group. From these data, it can be concluded that the incidence of partial flap loss and fat necrosis is higher in DIEP flaps than in free TRAM flaps, probably because the blood flow to the former flap is less robust. This difficulty can be circumvented to some extent, however, by careful patient selection. Factors that should be considered include tobacco use, size of the perforators (especially the vein), and (in unilateral reconstructions) the amount of flap tissue across the midline needed to create an adequately sized breast. If these factors are properly considered when planning the operation, fat necrosis and partial flap loss can be reduced to an acceptable level. For selected patients, the DIEP flap is an excellent technique that can obtain a successful, autologous tissue breast reconstruction with minimal donor-site morbidity. For patients who are not good candidates for reconstruction with this flap, the free TRAM flap remains a good alternative.

Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

One presumed advantage of the free deep inferior epigastric perforator (DIEP) flap over the free muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flap is decreased donor-site morbidity. The purpose of this study was to compare the donor-site morbidity and functional outcomes in women who underwent free muscle-sparing TRAM flap or free DIEP flap breast reconstruction. All patients who underwent breast reconstruction using a free muscle-sparing TRAM flap or a free DIEP flap performed by the two senior authors at the M. D. Anderson Cancer Center between 1999 and 2003 were included in the study. The authors conducted a chart review to obtain demographic data and information regarding flap-related complications and donor-site complications. Each living patient was sent a 12-item questionnaire to elicit her perceptions about donor-site outcomes. One hundred sixty-four patient charts were reviewed (203 flaps). Muscle-sparing TRAM flaps were used in 124 patients (98 unilateral and 26 bilateral). DIEP flaps were used in 35 patients (27 unilateral and eight bilateral). In five bilateral breast reconstructions, a muscle-sparing TRAM flap was used for one side and a DIEP flap was used for the other side. There was no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM and free DIEP flaps. Eighty-nine of 159 patients (56 percent) responded to the questionnaire; results showed no significant difference in patient-perceived abdominal function after free muscle-sparing TRAM flaps and free DIEP flaps. In the authors' experience, there is no significant difference in flap-related complications or donor-site morbidity between the free muscle-sparing TRAM flap and the free DIEP flap. Thus, the authors advocate using the most expeditious and reliable flap based on the vascular anatomy of the DIEP system.

This is the first study to use a standardized ultrasound protocol to evaluate hernia and abdominal wall laxity following free transverse rectus abdominis myocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flap surgery. All patients who underwent free TRAM and DIEP flap surgery performed by the senior author between the years 1994 and 2003 were recruited for physical examination and ultrasound of the abdominal wall for the dynamic evaluation of hernia and abdominal wall laxity. A total of 25 of 28 patients were followed up (89 percent). Eleven were in the DIEP flap group (44 percent) and 14 were in the free TRAM flap group (56 percent). Age- and body habitus-matched female volunteers (n = 12) were also used in this study. The mean follow-up was 3.8 years (range, 0.8 to 8.2 years). Although the kappa coefficient was +1 for detection of hernia on physical examination between two independent examiners, the interobserver correlation was poor for detection of bulges (kappa coefficient, +0.53). Ultrasound showed that abdominal wall laxity was statistically highest in the upright position, followed by 30 degrees of truncal flexion, and lowest in the supine position. The amount of abdominal wall laxity detected by ultrasound was significantly higher in the free TRAM flap group than in the free DIEP flap group. Two hernias were detected in the TRAM flap group by ultrasound and one hernia was previously known in the DIEP flap group. This is the first study to establish a standardized ultrasound protocol as an adjunct diagnostic tool to clinical examination for the dynamic evaluation of postoperative hernia and abdominal wall laxity.

Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes. Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction. Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction. Therapeutic, II.

Although several studies have found obesity to increase the risk of postoperative morbidity in autologous breast reconstruction, there remains some controversy over the influence of obesity for muscle-conserving abdominal flaps, including muscle-sparing transverse rectus abdominis myocutaneous (msTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. This review evaluates the effects of obesity on complications in breast reconstruction using muscle-conserving abdominal flaps and compares them to those for conventional free transverse rectus abdominis myocutaneous (TRAM) flaps. A literature search was conducted using MEDLINE, Ovid, and Cochrane databases for studies reporting complication rates for obese and nonobese patients undergoing breast reconstruction using msTRAM, DIEP, and SIEA flaps and conventional free TRAM flaps. The pooled relative risks (RRs) of the obesity for flap-related and donor complications were estimated in the muscle-conserving flaps by meta-analytic methodology and the pooled complication rates in obese patients were compared between muscle-conserving flaps and conventional TRAM flaps. Here, only those studies following the World Health Organization definition of obesity (body mass index ≥ 30 kg/m) were included. A total of 17 articles were analyzed. Eight studies were used to compute the obesity-related risks of flap-related and donor complications for msTRAM, DIEP, and SIEA flaps. Obesity increased the risk of total flap loss [RR, 1.68; 95% confidence interval (CI), 0.85-3.33], partial flap loss (RR, 2.26; 95% CI, 1.01-5.02), abdominal bulge or hernia (RR, 1.72; 95% CI, 1.00-2.95), and overall abdominal complications (RR, 1.53; 95% CI, 1.10-2.14). The results of a pooled analysis with 15 studies are consistent with those of the meta-analysis. In comparison to free TRAM flaps, muscle-conserving abdominal flaps showed a lower pooled incidence of flap loss, fat necrosis, and abdominal bulge or hernia in obese patients. This review suggests that obesity increases the risk of both flap-related and donor-site complications in breast reconstruction using msTRAM, DIEP, and SIEA flaps. In comparison to conventional TRAM flaps, however, muscle-conserving abdominal flaps may have an advantage in reducing the morbidity in obese patients.

The deep inferior epigastric perforator (DIEP) flap has gained notoriety because of its proposed benefit in decreasing donor-site morbidity but has been associated with longer operative times, higher perfusion-related complications, and increased cost relative to muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flaps. The authors performed the first cost-utility analysis examining the cost effectiveness of DIEP flaps relative to muscle-sparing free TRAM flaps in women who underwent mastectomy. A comprehensive literature review was conducted using the MED- LINE, Embase, and Cochrane library databases to include studies directly comparing DIEP to muscle-sparing free TRAM flaps in matched patient cohorts. Eight studies were included, examining 740 DIEP flaps and 807 muscle-sparing free TRAM flaps. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from a previous cost-utility analysis. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis. The overall complication rates were 24.7 percent and 21.8 percent for DIEP and muscle-sparing free TRAM flaps, respectively. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $69.42 and a clinical benefit of 0.0035 quality-adjusted life-year when performing DIEP flap surgery relative to muscle-sparing free TRAM flap surgery, yielding an incremental cost-utility ratio of -$19,834.29. When using societal costs, the incremental cost-utility ratio increased to $87,800. DIEP flaps are cost effective relative to muscle-sparing free TRAM flaps when patients are carefully selected based on perforator anatomy and surgery is performed by experienced surgeons.

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.

The deep inferior epigastric perforator (DIEP) flap is a major advance in breast reconstruction, but many surgeons are reluctant to use it because of concerns about a higher flap loss rate when compared with free/muscle-sparing transverse rectus abdominis myocutaneous (TRAM) flaps. Previous studies, however, have not statistically analyzed the relationship of patient characteristics to outcome. This study evaluates the authors' institutional experience with immediate postoperative complications following DIEP and free/muscle-sparing TRAM flaps. Results of 200 consecutive free/muscle-sparing TRAM and DIEP flaps performed by two surgeons at a single institution between 2003 and 2005 were reviewed using a prospectively maintained database. The incidence of flap complications was compared. Patient demographics, procedure type, diagnosis, adjuvant treatment, and complications were recorded. Outcome variables included total and partial flap loss, infection, seroma, hematoma, wound-healing problems, fat necrosis, and mastectomy flap necrosis. One hundred forty-three patients were treated with 159 free/muscle-sparing TRAM flaps and 41 DIEP flaps. The demographics of the two groups were statistically similar. No statistically significant differences were noted in total or partial flap loss. In the authors' series, the use of the DIEP flap did not result in more postoperative flap-related complications when compared with the free/muscle-sparing TRAM flap. Furthermore, no patient characteristics were statistically associated with a more successful result. The authors conclude that in patients whose anatomy reveals perforators of adequate size, the DIEP flap is a safe and reliable procedure for breast reconstruction.

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required post-operative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: Abdominal based free flaps such as the Transverse Rectus Abdominis Myocutaneous (TRAM) flap and Deep Inferior Epigastric Perforator (DIEP) flap are essential tools in the reconstructive armamentarium post mastectomy. These reconstructions are often prolonged, complex and associated with complications. This study aims to compare the complication rate, particularly focusing on perioperative transfusions, between TRAM and DIEP flaps performed by the senior author in our tertiary referral centre. Methods: A retrospective review was conducted of one hundred and seven consecutive TRAM and DIEP flaps from 2000 to 2014. The two groups were analysed for demographics, preoperative risk factors and post-operative complications including blood transfusions, haematomas, flap losses, redo-anastomoses, flap infections, abdominal wound sequelae and non-surgical complications. Results: Sixty-three patients underwent 67 free/muscle sparing TRAM flaps and 35 patients underwent 40 DIEP flaps. There were no statistically significant differences in patient demographics or preoperative risk factors between the two groups. Five TRAM flap cases (7.9%) required transfusion whilst no DIEP flap cases required transfusion. This difference was not found to be statistically significant (p = 0.16). However, free/muscle-sparing TRAM flaps were found to have a significantly higher overall complication rate compared to DIEP flaps (23.8% vs. 5.7%, p = 0.02). Conclusion: The current study demonstrated no difference in perioperative transfusion requirement between TRAM and DIEP cases. There was however a significantly higher rate of overall complications associated with TRAM flaps warranting the authors to conclude that care be taken when opting for this reconstructive method.

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

Use of the transverse rectus abdominis myocutaneous (TRAM) flap for immediate breast reconstruction is controversial because of fear of flap loss and concern that a high complication rate could interfere with adjuvant therapy. One common complication of the TRAM, partial flap necrosis, can interfere with both institution of postoperative therapy and evaluation for recurrence. In an attempt to minimize this problem, we began using the free TRAM flap based on the inferior deep epigastric vessels. This study compares our experience with conventional superior-pedicled (cTRAM) flaps and free TRAM (fTRAM) flaps. A total of 68 breasts were reconstructed in 63 patients, of which 48 of 68 (71 percent) were conventional TRAM flaps and 20 of 68 (29 percent) were free TRAM flaps. Of the 48 conventional TRAM flaps, 26 (54 percent) were unipedicled and 22 (46 percent) were bipedicled. There were 39 of 48 (81 percent) conventional TRAM flaps and 17 of 20 (85 percent) free TRAM flaps with T1 or T2 lesions. Node-positive patients occurred in 14 of 48 (29 percent) conventional TRAM flaps and 2 of 20 (10 percent) free TRAM flaps. One-fourth of patients in both groups smoked cigarettes. Twenty-one of 48 patients (44 percent) with conventional TRAM flaps required postoperative chemotherapy, and 6 of 21 (29 percent) were delayed because of complications of the TRAM flap. Of the 7 of 20 (35 percent) free TRAM flap patients who required postoperative chemotherapy, only 1 of 7 (14 percent) was delayed because of TRAM flap complications. Partial flap necrosis occurred in 8 of 48 (17 percent) conventional TRAM flaps and none of the free TRAM flaps, and this was a statistically significant difference (p = 0.05). Fat necrosis occurred in 11 of 48 (23 percent) conventional TRAM flap patients and in 0 of 20 free TRAM flap patients (p = 0.015). Patients reconstructed with the free TRAM flap have had a lower incidence of partial flap necrosis and less of a delay in receiving adjuvant chemotherapy. The free TRAM flap is therefore recommended for selected patients in whom immediate reconstruction with autogenous tissue is being contemplated.