|
Source
|
| Plastic
& Reconstructive Surgery
Volume:
n/a
Number: n/a
March
2001 |
|
Comparison
of the Costs of DIEP and TRAM Flaps
Sir:
In a recent article by Kaplan and Allen ("Cost-Based Comparison
between Perforator Flaps and TRAM Flaps for Breast Reconstruction"
Plast. Reconstr. Surg. 105:943, 2000), the authors compared
the costs of their own breast reconstructions with DIEP flaps
in 1997 to the costs of breast reconstructions performed at
the M. D. Anderson Cancer Center during the period from 1986
to 1994. Based on this, the article concluded that DIEP flaps
cost less than TRAM flaps.
We wish to point out that comparing patient hospital stays
in 1997 to those from the period from 1986 to 1994 is a bit
like comparing apples to oranges. The earlier time period from
which we took our data comparing implant-based and TRAM flap
reconstructions was a kinder and gentler one, during which patients
went home when they felt ready.
Today, because of pressure from insurance companies, hospital
stays are shorter for all patients regardless of the technique
used for reconstruction. In one recent (not yet published) series
of patients from our institution, the average length of stay
for patients undergoing free TRAM flap breast reconstruction
during 1997-1998 was 5.21 days, whereas for patients undergoing
DIEP flap reconstruction it was 4.86 days. Although this is
a difference, it is not nearly as significant as that reported
by Drs. Kaplan and Allen. If we were to use their figures calculating
the cost of a hospital day at $393.00, the savings we would
achieve by switching exclusively to the use of DIEP flaps would
amount to only $138.00 per patient.
Another problem with this article is the comparison of operating
times for one surgeon with one technique to the times of another
surgeon using a different technique. Different surgeons work
at very different speeds, and the quality of the result can
vary considerably as well. To meaningfully compare the operating
times of the DIEP and TRAM flaps, one needs to use one surgeon
(or group of surgeons) performing both operations, which was
not what was done here.
We would agree with Dr. Allen that patients reconstructed with
DIEP flaps have less pain than those reconstructed with TRAM
flaps. We are not comfortable, however, sending patients home
before their flaps have been monitored for a full 3 days after
the surgery. For this reason we usually keep our DIEP flaps
patients in the hospital until at least the fourth postoperative
day.
We consider the DIEP flap an important advance in the reconstruction
not only of breasts but of many other defects as well. We are
all indebted to Dr. Allen for helping to bring to the perforator
flap concept the attention it deserves. It would be fortunate,
however, if insurance companies were to conclude from this article
that hospital stays for patients who undergo autologous tissue
breast reconstruction should be limited to only 3 days. We believe
that, except perhaps in the hands of the most experienced of
microsurgeons, sending patients home this early could increase
the risk of flap loss and cause harm to our patients. We believe
that patients should go home when they and their surgeons believe
that it is safe and not just when it is convenient for the insurance
company.
Stephen S. Kroll, M.D.
Michael J. Miller, M.D.
David C. Chung, M.D.
Charles Butler, M.D.
Gregory P. Reece, M.D.
Geoffrey L. Robb, M.D.
Howard N. Langstein, M.D.
1515 Holcombe Boulevard
Houston, Texas 77030
.............................................................................................................................
REPLY
Sir:
Thank you for the interesting comments offered by Stephen S.
Kroll et al. in their letter to the editor concerning our article
about the cost savings of the DIEP flap in breast reconstruction.
We are in full agreement with the overall conclusions of their
letter. Since 1992, when we discovered the clear superiority
of the perforator flap for breast reconstruction in terms of
decreased morbidity and cost savings for the patient, we have
not been able to justify the use of a myocutaneous flap in any
breast reconstruction. Thus, for ethical reasons, we were able
to undertake only one arm of our retrospective review examining
the financial cost of sacrificing versus preserving rectus abdominis
muscle in women seeking autologous tissue breast reconstruction.
Like the surgeons of M. D. Anderson, who have since converted
to the DIEP flap for 70 percent of their breast reconstructions,
we have found that use of a perforator flap in breast reconstructions
has resulted in shorter hospital stays and lower costs for the
patient.
We thank the surgeons of M. D. Anderson for pointing out that
this finding of shorter hospital stays could potentially be
misused by insurance companies to limit postoperative hospital
stay to a time period that is medically unsafe. Since the publication
of our article, we have also found that overly aggressive early
discharge might increase the risk of flap loss, and we have
since lengthened the postoperative hospital stay for our patients
to 4 days.
The bottom line, however, as the surgeons of M. D. Anderson
have agreed, is that patients reconstructed with DIEP flaps
experience significantly less pain. This decrease in postoperative
morbidity has resulted in shorter hospital stays and cost savings.
In the future, we hope that increasing numbers of surgeons might
be able to take these findings into consideration when planning
autologous tissue breast reconstruction for their own patients.
Robert J. Allen, M.D.
Constance Chen
Section of Plastic Surgery
Louisiana State University Medical Center
1542 Tulane Avenue
New Orleans, LA 70112-2822
