A Cost Based Comparison between Perforator Flaps and
TRAM Flaps for Breast Reconstruction
Robert J. Allen, M.D.
Robert J. Allen, M.D.
New Orleans, LA
More women than ever before are undergoing mastectomies
secondary to increased awareness and screening. This has
also caused a corresponding increase in the number of
breast reconstructions requested each year. The increased
demand for reconstruction has fueled recent advances in
new techniques. Aside from foreign-body reconstruction
such as implants, the methods now being employed are related
to autogenous donations and reconstruction. TRAM (transverse
rectus abdominis myocutaneous) flaps and perforator flaps
are currently being used for autogenous breast reconstruction.
This study will compare these two techniques on the basis
of cost and length of stay. A retrospective study of 49
patients undergoing a total of 64 perforator flap breast
reconstructions at Memorial Medical Center in New Orleans,
Louisiana during the 1997 calendar year were used for
this study. There were 59 DIEP (deep inferior epigastric
perforator) and 5 GAP (gluteal artery perforator) breast
reconstructions. All patients underwent some form of breast
reconstruction and differed only in respect to whether
a mastectomy was performed and whether the reconstruction
was unilateral or bilateral. Those patients that underwent
a mastectomy with immediate perforator flap reconstruction
(n=26) were then compared to patients undergoing mastectomy
with immediate TRAM flap reconstruction (n=154) at the
University of Texas M.D. Anderson Cancer Center. The data
from the Anderson Study was obtained from material published
in the journal, Plastic Reconstructive Surgery in 1996.1
Comparison of patients was limited to those who underwent
mastectomy with immediate breast reconstruction since
this was the design of the M.D. Anderson study. This allowed
a cost and length of stay comparison while keeping other
variables relatively similar. Patients in the perforator
flap series enjoyed a marginally shorter operating time
and a much shorter length of stay. On average, the operative
time for all perforator flap reconstructions was approximately
three hours shorter than all TRAM flaps. As for length
of stay, all perforator flap patients were discharged,
on average, three days after the initial reconstruction.
In contrast, all TRAM flap patients remained in the hospital
for an average of approximately seven days after the initial
reconstruction. The overall total, average cost for the
perforator flap reconstruction in this study is $9,625,
whereas the average cost of all TRAM flaps performed in
the M.D. Anderson study is $18,070. (P;ast. Reconstr.
Surg. 105:943, 2000)
With the recent revision of mammography screening guidelines,
more women are undergoing mastectomies than ever before.
After these procedures, women often choose to undergo
breast reconstruction partly for restoration of their
self-image as a woman. The need for such restoration
has fueled research and development of newer techniques.
Through its evolution, breast reconstruction has come
to include several modalities. Most familiar, are those
modalities dealing with silicone and presently, saline
implants. Saline implants are advantageous because they
are simple to insert and relatively safe. However, they
appear less natural than the normal breast and may result
in capsular contraction. After four years, the incidence
of capsular contraction is at least 30%, and increases
in subsequent years.1 Additionally, implants tend to
become more expensive than other techniques over several
years. This is usually due to the need for removal of
implants or capsulectomy secondary to contractures.2
Because of these disadvantages, other forms of reconstruction
were needed and have evolved over the last decade. This
is clearly advantageous for women because they are now
provided with choices in the type of reconstruction
they prefer. With the disadvantages stated above, research
and development has now given way to newer microvascular
techniques including transverse rectus abdominis myocutaneous
This class of autogenous breast reconstruction is advantageous
in areas where implant-based reconstruction is lacking.
This tissue by definition is not foreign, and therefore
does not cause a foreign-body reaction or capsular contracture.
Additionally, the reconstructed breast mound itself
is made of muscle, fat and skin; ingredients with a
consistency very similar to that of a natural breast.3
As with any procedure, there are disadvantages. Common
to all autogenous breast reconstruction is the much
longer initial surgical procedure. An added disadvantage
with TRAM flaps is the morbidity associated with abdominal
hernias and restricted range of motion.4
A newer procedure that is being done in increasing
numbers, is the perforator artery flaps. Koshima and
Soeda first described paraumbilical perforator flaps
in 1989.5 This technique involves the harvesting of
free flaps based on dissection of the myocutaneous perforators,
using fat and skin alone, while avoiding the use of
muscle which can result in functional deficits. These
perforator flaps can be based on the deep inferior epigastric
perforator (DIEP) or the superior gluteal artery perforator
(S-GAP) 6. Allen and Treece first introduced perforator
flaps for breast reconstruction.7 Over 500 perforator
flaps for breast reconstruction have been successfully
performed at the Louisiana State University Medical
Center (LSUMC) since 1992. In this series, there were
fewer donor site complications with the perforator flaps,
especially complications involving abdominal hernias
and muscle weakness when compared to the TRAM flaps.
In review, autogenous tissue reconstruction can be
grouped into two major categories: TRAM flaps and more
recently, perforator flaps. A corollary often cited
in the practice of surgery states that if there are
many procedures for the same purpose, then none are
very effective. This retrospective study will challenge
this corollary by examining the advantages of perforator
flaps when compared to TRAM flaps. These advantages
will be presented within the confines of cost, length
of stay and donor site morbidity. These variables are
often seen as disadvantages but this is limited to the
short term and not representative of the long-term advantages
of perforator flaps.
Patients and Methods
A retrospective study of 49 patients undergoing a total
of 64 perforator flap breast reconstructions at Memorial
Medical Center in New Orleans, Louisiana during the
1997 calendar year were used for this study. There were
59 DIEP and 5 GAP breast reconstructions. The breakdown
of the patients included in the study is as follows:
13 patients who previously underwent unilateral mastectomies
and were now receiving unilateral flap reconstructions;
21 patients who underwent mastectomies with immediate
unilateral flap reconstruction; 5 patients who underwent
bilateral mastectomies with immediate bilateral DIEP
reconstruction; 4 patients who had a previous mastectomy
but then underwent a mastectomy of the contralateral
breast with immediate bilateral reconstruction; and
6 patients who previously underwent bilateral mastectomies
and were now receiving bilateral flap reconstructions.
All but 10 of the patients had undergone follow-up nipple
reconstruction at the time of this study. Those patients
undergoing immediate reconstruction (n=26) were then
compared to patients undergoing TRAM flaps (n=154) at
the University of Texas M.D. Anderson Cancer Center.
The data from the Anderson Study was obtained from material
published in the journal, Plastic Reconstructive Surgery
in 1996.1 Patients in the two studies were compared
for cost of procedure, other costs of care and length
of stay. It is important to note that costs were compared;
not charges to the patient. Charges were not evaluated
because of varying hospital-charging practices.
One of the major costs analyzed for the study were
those pertaining to the cost of operative time. This
included the cost per hour of operating room time in
the initial procedure as well as any follow up procedures
secondary to nipple reconstruction or complications.
Costs also included the cost of the procedure itself
that was performed by the staff surgeons. This included
the cost of the plastic surgeon and oncologic surgeon,
if a mastectomy was performed, and one assistant plastic
surgeon. Any additional assistance was provided by Residents
from the Section of Plastic Surgery at LSUMC in New
Orleans. The cost of services provided by the Department
of Anesthesiology per hour of operating room time was
also included. One additional cost that was included
in this study but not the M.D. Anderson study was the
cost of operating room supplies.
The cost of operating room time was provided by the
Division of Perioperative Services at Memorial Medical
Center and was based on salaries, wages and benefits
of operating room staff, which excluded surgeons, anesthesiologists
and nurse anesthetists.
The cost of surgeons performing the perforator flap
reconstruction and the mastectomy, if one was needed,
was estimated using a method similar to that used in
the M.D. Anderson study.1 The cost of the surgeons performing
the breast reconstruction and mastectomy was estimated
in terms of cost per hour. This cost was determined
by dividing the average surgeons yearly salary
by the estimated number of hours worked. The result
was then multiplied by the number of hours of operative
time in the initial reconstruction to calculate the
surgeons cost for the procedure.
However, in the case of the oncologic surgeon performing
the mastectomy, the cost per hour was multiplied by
fewer hours. While the oncologic surgeon begins the
mastectomy when the plastic surgeons begin harvesting
the flap, they finish their procedure before the plastic
surgeon. The oncologic surgeon that performed all of
the mastectomies in our study would on average, finish
a mastectomy in one and a half-hours. Therefore, the
oncologic surgeons cost per hour was multiplied
by one-and-a-half hours.
Only the cost of one plastic surgeon was included in
all follow-up operations such as nipple reconstruction
and complications since only one surgeon is normally
needed. The cost of the primary and secondary (assistant)
plastic surgeons and the oncologic surgeon in this study
is estimated at $218.00 per hour for each surgeon. The
M.D. Anderson study determined the surgeons cost
to the patient as $156.00 per hour.2
The Department of Anesthesiology based the cost of
anesthesia personnel per hour of operating room time
and supplies on accounts payable. The cost of operating
room supplies was based on records kept by the Division
of Perioperative Services.
Another source of cost included in this study pertained
to the cost of the hospital stay after the initial procedure
and any additional days that were required secondary
to complications. No hospital days were required for
nipple reconstruction, as this was done on an outpatient
basis. The cost of a hospital bed, calculated by the
Finance Department at Memorial Medical Center, was based
on whether the bed was in the ICU, private or semi-private
room. The usual protocol for a patient undergoing a
perforator flap is transfer to the ICU after the initial
operation. The patient stays in the ICU overnight for
flap monitoring. The patient is then transferred on
post-op day one to a traditional room for what is usually
an uncomplicated recovery. Finally, the patient is routinely
discharged on post-op day three. Therefore, each patients
total cost included the cost of a one-night stay in
the ICU followed by two nights in a hospital room. Those
patients that did not follow this protocol exactly had
the appropriate variations incorporated into the total
cost of their reconstruction.
As for increased costs secondary to complications, this
study differed from the M.D. Anderson study in its calculation
of complication costs. The M.D. Anderson study corrected
the total cost by dividing by the success rate. This
increased the total cost to account for failures and
complications. Whereas, in this study, we added the
extra cost associated with complications directly to
the total cost per patient. These extra costs included
the surgeons cost per hour to rectify the complication,
operating room time, operating room supplies and hospital
stay, if any was necessary. We felt that direct inclusion
of the costs, rather than averaging complication costs
would prove to be an accurate assessment of the extra
cost to the patient.
It is important to note that the M.D. Anderson total
cost calculation is in 1993 dollars whereas the calculation
for perforator flap reconstruction is in 1997 dollars.
Therefore, using the Medical Care subindex from the
Bureau of Labor Statistics, 1993 Dollars have been converted
to 1997 Dollars for greater ease of comparison. The
total costs in 1993 Dollars were multiplied by 1.123,
the Medical Care subindex, which was calculated from
the Consumer Price Index that corrects for inflation
in the health care field.8 All of the aforementioned
costs were those variables included in the total calculation
of costs for breast reconstruction using the perforator
The cost variables mentioned above are discussed and
incorporated into Table 1. The cost of operating room
time, which is based on salaries, wages and benefits
of operating room personnel, is $176.00 per hour. The
differences in cost pertaining to hospital stay is differentiated
on the basis of whether the room was in the ICU, private
or semi-private room, which is $975.64, $393.80 and
$208.50 respectively. As mentioned previously, the Department
of Anesthesiology based the cost of anesthesia personnel
and supplies on the accounts payable.
Cost Components in 1997 dollars at Memorial Medical
Center, New Orleans, LA (LSU affiliate)
Component Dollar Value ($)
|Operating room (1 hour)
Hospital day ICU bed
Hospital day Private bed
Hospital day Semi-private
Staff surgeon (1 hour)
Anesthesia personnel (1 hour)
|ICU, intensive care unit.
Based on the hourly or daily rates above, the cost per
patient can be determined if the average number of hours
in the operating room and the average length of stay
is known. Table 2 relates the average time spent in
the operating room and length of stay for patients depending
on the type of reconstruction they underwent. While
all patients did undergo a perforator flap reconstruction,
the procedure performed did vary in regards to whether
the patient had undergone a previous mastectomy or not
and their need for a unilateral or bilateral flap. The
column in Table 2 labeled cumulative reconstruction
is the total time and length of stay after the initial
and follow-up reconstruction, which includes flap and
donor revisions, nipple reconstruction and any complications
which may have necessitated a return to the operating
room or further hospitalization with non-operative treatment.
Aside from hourly and daily fees, patients were also
subjected to costs secondary to surgical supplies and
cost to the staff surgeons. The cost of operating room
supplies was determined using information found in the
Division of Perioperative Services data bank. While
it would be cumbersome to list the cost of supplies
for each patient, these figures have been accurately
included when determining total cost per patient.
With all of the cost variables being illustrated in
the two tables above, the total cost of initial and
follow-up reconstruction, complications, operating room
supplies, operating room time and hospital stay can
be calculated. The total costs are demonstrated in the
far-left column of Table II.
With all of the facts and figures associated with perforator
artery flaps elucidated above, a comparison between
perforator flaps and TRAM flaps can now be pursued.
The first point of comparison is that involving mean
operative time and length of stay. Similar to the M.D.
Anderson study, our series used for comparison only
included patients that had a mastectomy with immediate
reconstruction. This comparison consisted of a series
of 26 perforator flap patients. Table III below highlights
the differences in initial and total reconstruction
time, as well as initial and total length of stay.
A TRAM flap requires that the surgeon mobilize the rectus
abdominis muscle for the breast reconstruction. As seen
in Table 3, this takes on average, a minimum of eight
hours, regardless of whether the reconstruction is unilateral
or bilateral. In addition to the marginally increased
operative time, resection of part of the rectus muscle
is responsible for the difference in trunk flexion capacity
between the DIEP flap and the TRAM flap.9 Unfortunately,
abdominal strength is reduced during rotation as well
as flexion. This is due to the bilateral displacement
and damage of the insertion of the oblique muscles.10
Therefore, the donor site morbidity plays a significant
role when choosing one technique over another. The donor
site moribidity, in terms of pain and abdominal wall
manipulation, may also contribute to the longer length
of stay in TRAM flap patients.
On average, the TRAM flap necessitates a hospital stay
of 6.78 days for the initial reconstruction alone, while
a perforator flap patient is routinely discharged on
post-op day three. In this series of 26 patients, one
patient had her hospital stay extended by three days
secondary to complications regarding a pre-existing
respiratory disorder. Only 3 patients had their stay
extended by one day to a total of four hospital days.
However, in almost all cases, which include 500 since
1992, the patient was only hospitalized for a total
of three days. These numbers demonstrate that under
the cautious care of a physician, a free flap patient
can be successfully discharged on post-op day three
if the flap color and temperature are within normal
limits. This was also found to be true in a 1996 study
which found flap monitoring to be most cost effective
during the first two post-operative days.11 With the
monitoring techniques now available, the hospital stay
for free flap patients can be shortened if, and only
if, the situation in each patients case allows.
The shortened hospital stay experienced in our study
is the single most influential factor that reduced the
cost of the perforator flap versus the TRAM flap.
After converting 1993 dollars to 1997 dollars, it is
clear by examining the figures in Table IV that the
cost between the two procedures is quite different.
The two main causes for the cost discrepancy is found
in the shorter length of stay and shortened operative
time associated with the perforator flap reconstruction.
Because of differences in cost calculation of operating
room cost between the two hospitals in the study, there
was a discrepancy in the operating room cost per hour
for the LSU hospital compared to the cost in the M.D.
Anderson study. However, even if the operating room
cost in the LSU hospital was equivalent to the M.D.
Anderson study and adjusted for inflation, the average
cost of all perforator flaps performed would be approximately
$13,000, which is still significantly less than the
total cost for TRAM flap breast reconstruction.
Overall, the advantages of the perforator artery flap
outweigh the disadvantages. When first used, the perforator
flap was thought to be more labor intensive and more
expensive than other forms of autogenous breast reconstruction.
The exact opposite is shown to be true in this study.
Once the advantages of shorter operating room time and
length of stay, as well as less donor site morbidity
and decreased cost are publicized throughout the medical
community, this technique will gain credibility and
greater use in breast reconstruction.
Robert J. Allen, M.D.
Section of Plastic Surgery
Louisiana State University Medical Center
1542 Tulane Avenue
New Orleans, LA 70112-2822
The authors would like to thank Clare Austin, Debbie
Hamilton, Sandy Tabary, Donna Carlino and Jean Kaplan
for their help in obtaining costs for the reconstructive
procedures discussed. Thanks are extended to Mrs. Ann
Seal and Mrs. Pam Houk in the Dept. of Perioperative
Services for their help in determining costs of operating
room time and follow-up care. Thanks as well to Sylvon
White in the Department of Medical Records for her help
in research of patient records.
Reprints should be addressed to: Robert J. Allen, MD
Chief, Section of Plastic Surgery
Louisiana State University Medical Center
1542 Tulane Avenue
New Orleans, Louisiana 70112-2822
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3. Kroll, S.S. Why autologous tissue? Clin. Plast. Surg.
4. Suominen, S., Asko-Seljavaara, S., von Smitten, K.,
et al. Sequelae in the abdominal wall after pedicaled
or free TRAM flap surgery. Ann. Plast. Surg. 36:629-36,
5. Koshima, I., Soeda, S. Inferior epigastric artery
skin flap without rectus abdominis muscle. Br. J. Plast.
Surg. 42:645-48, 1989.
6. Allen, R.J. The superior gluteal artery perforator
flap. Clin. Plast. Surg. 25:2, 1998.
7. Allen, R.J., Treece, P. Deep inferior epigastric
perforator flap for breast reconstruction. Ann. Plast.
8. Consumer Price Index. Bureau of Labor Statistics.
Online. Oct. 20, 1998.
9. Blondeel, Ph., Vanderstraeten, G.G., Monstrey, S.J.,
et al. The donor site morbidity of free DIEP flaps and
free TRAM flaps for breast reconstruction. Br J Plast
Surg. 50:322-330, 1997.
10. Blondeel, Ph., Boeckx, W.D., Vanderstraeten, G.G.,
et al. The fate of the oblique muscles after free TRAM
flap surgery. Br J Plast Surg. 50:315-321, 1997.
11. Kroll, S.S., Schusterman, M.A., Reece, G.P., et
al. Timing of pedicle thrombosis and flap loss after
free-tissue transfer. Plast. Reconstr. Surg. 98(7):1230-3,