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Source
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| David
L. Larson, M.D. Department of Plastic Surgery
Medical College of Wisconsin
Volume: n/a
Number: n/a
August 1998 |
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Index
Letter
A Comparison of Pedicled and Free
TRAM Flaps for Breast Reconstruction in a Single Institution
- Commentary by R.J. Allen, M.D.
A Comparison of Pedicled and Free
TRAM Flaps for Breast Reconstruction in a Single Institution
Dear Sir:
Thank you for the interesting comments offered by Stephen
S. Kroll, Michael J. Miller, David C. Chang, Charles
Butler, Gregory P. Reece, Geoffrey L. Robb, and Howard
N. Langstein, in their group 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 only able to underake
one arm of our retrospective review examining the financial
cost of sacrificing vs. preserving rectus abdominis
muscle in women seeking autologous tissue breast reconstruction.
Like the surgeons of MD Anderson, who have since converted
to the DIEP flap for 70% 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 MD Anderson for pointing out that this finding of
shorter hospital stay could potentially be misused by
insurance companies to limit post-operative stay to
a time period that is medically unsafe. Since the publication
of our article, we have also found that overly aggressive
early discharge may increase the risk of flap loss,
and we have since lengthened the post-operative hospital
stay for our patients to 4 days. The bottom line, however,
as the surgeons of MD Anderson have agreed, is that
patients reconstructed with DIEP flaps experience significantly
less pain. This decrease in post-operative 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.
Sincerely,
Robert J. Allen, M.D.
Jonathan Kaplan, M.D.
Constance Chen
A Comparison of Pedicled and Free
TRAM Flaps for
Breast Reconstruction in a Single Institution
The article concludes that the pedicle TRAM is better
than the free TRAM with regard to costs and clinical
advantages. Our comparison of the DIEP flap to the TRAM
flap found the DIEP technique of breast reconstruction
to cost significantly less, with shorter operating time
and length of stay than the TRAM flap.(1) In addition,
Steve Kroll's study of pain medication requirement revealed
significantly less pain medication in DIEP patients
compared to TRAM patients. I agree with Larson, et al
that the free TRAM is not significantly better than
the pedicle TRAM. However, in my opinion, the DIEP flap
is superior to both the pedicle and free TRAM flaps
and should be the procedure of choice for microsurgical
breast reconstruction.
R. J. Allen, M.D.
(1) Kaplan, JL and Allen, RJ. Cost-Based Comparison
between Perforator Flaps and TRAM flaps for Breast Reconstruction.
Plast. Reconstr. Surg. 105: 943,2000.
A Comparison of Pedicled and Free
TRAM Flaps for Breast Reconstruction in a Single Institution
David L. Larson, M.D., N. John Yousif, M.D., Raj K.Sinha,
M.D., Jorge Latoni, M.D. and Thomas G. Korkos, M.D.
Milwaukee, Wis.
Several reports concluded that free tissue transfer
of the transverse rectus abdominis muscle (TRAM) flap
for breast reconstruction is superior to pedicled transfer
of the flap. In an effort to compare the various parameters
of both techniques, the authors took advantage of a
unique experience at one hospital where one surgeon
(D.L.L.) used only the pedicled method and the other
(N.J.Y.) used only free tissue transfer. Additionally,
the authors compared the findings of the study with
the experieiices of other surgeons by surveying active
members of the American Association of Plastic Surgeons.
The records of 119 patients who underwent TRAM flap
reconstruction between January of 1988 and July of 1997
were interviewed. Of these, 33 patients received free
TRAM flaps, and 86 received pedicled TRAM flaps. To
provide an adequate number of patients for statistical
analysis, only those with unilateral, single-muscle
reconstructions were considered (immediate or delayed).
This provided 61 patients in the pedicied flap group
and 26 in the free tissue group. Parameters examined
included length of operation and of hospitalization,
amount of pain medication used, amount of blood lost
and received, and complications. A small subset of the
patients had hospital records available to compare hospital
charges; the comparison of pedicled and 12 free TRAM
flaps showed a mean difference of $15,637 (p < 0.001)
in favor of the pedicied flap.
On the basis of the findings from this study, it seems
that the pedicled TRAM flap has significant economic
and clinical advantages over the free TRAM flap. There
is less need for blood, a shorter operating time and
hospital stay, and a need for less pain medication.
However, both methods of transfer have indications and
contraindications in certain clinical settings. It will
always remain the responsibility of the surgeon to evaluate
all issues and select a method that is economically
responsible and within the abilities of the surgeon,
while producing a satisfactory outcome that best serves
the patient. The information provided in this report
should aid in accomplishing this goal.
(Plast. Reconstr. Surg. 104: 674. 1999.)
The transverse rectus abdominis musculocutaneous (TRAM)
flap, as described by Hartrampf et al., (1) is a standard
operation for breast reconstruction. The flap may be
transferred as either a free or pedicled flap. There
have been various reports on the superiority of one
method over the other based on morbidity, ease of surgery,
outcome, or cost. In today's health-care environment,
these issues are becoming increasingly important.
It seems that the potential for considerable bias exists
regarding the method of transferring the abdominal tissue
used for breast reconstruction. Ideally, a double-blinded
study would provide a definitive answer to the question
of which method is the superior technique. In the absence
of such a study, we took advantage of a unique experience
at one academic institution. One surgeon there used
only the pedicled technique (D.L.L.), and the other
used only free tissue transfer (N.J.Y.). The purpose
of the current study was not to prove the superiority
of one technique over the other but, rather, to examine
parameters common to both, thereby providing insight
on methods to reduce cost, increase efficiency, improve
outcomes, and enhance patient care. We also compared
our findings with the experiences of other surgeons
across the country by using a survey.
One area of particular interest to us was pain control.
There is little published about pain control in these
patients in the perioperative period. In informal conversations
with peers and a random survey of members of the American
Associition of Plastic Surgeons, we discovered that
some physicians rely solely on oral pain medication
in the postoperative period, whereas others use a patient-controlled
analgesia device (pump) or even an epidural block.
Materials and Methods
The records of all 119 patients who underwent breast
reconstruction with a TRAM flap at Froedtert Memorial
Lutheran Hospital in Milwaukee, Wis. between January
1, 1988, and June 30, 1997, were reviewed. All patients
were operated on by one of two surgeons. Of these, 86
patients received a pedicled flap (unilateral [61 patients],
bilateral [15 patients], or double-muscle [10 patients]),
and 33 patients had free tissue transfers (26 patients
had a unilateral transfer and seven a bilateral one).
To obtain a valid number in both the free and the pedicied
groups, a subset of patients was selected. This subset
consisted of those patients having unilateral, single-muscle,
immediate or delayed reconstruction. The parameters
examined included the following: (1) length of operation,
(2) days of hospitalization-including the day of surgery,
(3) estimated blood loss, (4) amount of blood received,
(5) postoperative pain (measured by equianalgesic doses
of morphine), and (6) complications. A small subset
of patients had hospital charge information available;
these charges were used to compare the costs of the
17 pedicled and 12 free TRAM flaps performed since 1996.
Postoperative pain was evaluated by converting the
total dose of pain medication received by a patient
to an "equianalgesic" total dose of intravenous
morphine using the method of Foley.(2) Any adverse occurrence
that required secondary surgery or admission, including
fat necrosis, was judged a complication.
For the most part, the choice of transfer technique
rested with the surgeon who first saw the patient. All
patients initially seen by the microsurgeon (N.J.Y.)
received a free tissue transfer for breast reconstruction.
Of the patients referred to the other senior author
(D.L.L.), four were referred for free tissue transfer.
The reason for these referrals was patient choice (n
= 2) and the need to use the entire abdomen to accomplish
the reconstruction (n = 2). No patients were referred
for free tissue transfer because of a significant history
of smoking, obesity, or diabetes (insulin-dependent).
Therefore, the groups were as similar as a nonrandomized
group of patients could be under the circumstances.
To determine some form of national standards related
to breast reconstruction using the TRAM flap, active
members of the American Association of Plastic Surgeons
were surveyed. The information regarding the practices
of the respondents that was elicited in this survey
included the following information: frequency of performance
of free versus pedicled TRAM flaps, average length of
operation, standard order for controlling postoperative
pain, average length of patient's hospital stay, and
average amount of blood received by the patient in the
perioperative period.
Results
Table I summarizes the findings of the study. The means
of the parameters were calculated. Group comparisons
were performed with p values calculated using one-way
analysis of variance for each variable in both the pedicled
and the free transfer groups.
 |
There were 61 patients (mean age, 44.57 years) in the
pedicied group and 26 in the free tissue transfer group
(mean age 47.84 years). Patients in the pedicled group
had an operation that lasted 4.77 hours and were hospitalized
for 4.7 days, whereas those in the free tissue transfer
group required 8.15 hours of surgery and remained in
the hospital for 7.65 days. A mean of 308 cc of blood
was lost by patients in the pedicled flap group, with
a mean of 61 cc of blood replaced; patients in the free
tissue transfer group lost 438 cc of blood on average,
and 1000 cc of blood were replaced. Both the hours of
surgery and days of hospitalization were significantly
different (p < 0.001). The usual postoperative pain
order for the pedicled flap group was 50 to 75 mg of
intramuscular Demerol (meperidine) each 3 to 4 hours
for I to 2 days and then, after a peros (regular) diet
was reestablished, Percocet (oxycodone and acetaminophen)
was given every 4 hours as required for 5 days. In the
free tissue transfer group, standard orders included
giving morphine for 1 to 2 days by a patient-controlled
pump and then, after a per os (regular) diet was reestablished,
Percocet was given each 4 hours as required for 10 days.
The amount of pain medication required during hospitalizationi
was measured in equidoses of morphine (mg); it was 72.42
mg in the pedicled flap group and 121.32 mg in the free
flap group (p < 0.0005). The complication rate was
similar in both groups; 18 of 61 patients (30 percent)
in the pedicle group and 10 of 26 patients (38 percent)
ii-i the free group had complications.
The results of the survey are shown in Table II. We
had a response rate of 49 percent (138 of 280). Although
it was a blinded survey and was only meant to provide
a "snapshot" of some parameters of the TRAM
flap operation that we reviewed in our study, the survey
did provide some useftil information. Of the 126 responders
who perform breast reconstruction tissue the TRAM flap
(12 responders do not perform the TRAM flap operation),
60 percent (75 of 126) always use the pedicle technique,
whereas only, 6 percent (7 of 126) only use free tissue
tranfer. The majority of respondents (61 percent; 77
of 126) peform one or two TRAM flap procedures per month;
a small number of respondents (17 of 126) perform as
many as four or more TRAM flap procedures monthly. The
average length of the operation was as low as 70 minutes
for one responder and over 8 hours for another, but
most operations lasted between these two extremes (46
surgeons, 2 to 4 hours; 65 surgeons, 4 to 6 hours; and
13 surgeons, 6 to 8 hours).
 |
The longer times (in the 6 to 8 hour range) were weighted
toward those respondents using free tissue transfer.
Two-thirds of surgeons did not give any blood (85 of
126) to patients in the operative or perioperative period,
whereas 16 percent of respondents (20 of 126) gave patients
1 U of blood and 15 percent (19 of 126) gave patients
an average of 2 U. Two surgeons routinely administered
3 U of blood. Many of the surgeons who routinely gave
blood noted that it was autologous. When asked for their
standard postoperative order for pain medication within
the first 2 or 3 days. 50 percent of surgeons (63 of
126) responded that they use a patient-controlled pump,
5 percent (six surgeons) use an epidural anesthetic,
3 percent (four surgeons) used only oral pain medication,
and the remainder (42 percent; 53 of 126) use intravenous
or intramuscular morphine or Demerol. The majority of
the surgeons who perform free tissue transfer use a
patient-controlled analgesia pump, whereas only 40 percent
of the surgeons performing pedicled flaps use the device.
Most responders had patients stay in the hospital for
3 (31 of 126), 4 (36 of 126), or 5 days (44 of 126),
including the day of surgery. The free flap patients
seemed to require longer hospital stays. The extremes
for hospital stays were 2 days (3 surgeons) and 7 days
(1 surgeon). The pain medication received upon discharge
was split among Vicodin (37 surgeons), Percocet (61
surgeons), and Tylenol 3 or Darvocet (28 surgeons).
These medications were needed for pain control for up
to 2 weeks in many patients.
Hospital charges were only available from 1996 to the
present; we used these charges to compare 17 pedicled
and 12 free TRAM flaps. The comparison showed a mean
difference of $15,637 (p < 0.001) in favor of the
pedicled flap.
Discussion
Since it was initially described by Hartrampf et al.(1)
in the early 1980s as a pedicled flap, the TRAM flap
has steadily gained popularity worldwide as the "gold
standard" for breast reconstruction. within a short
time, others expanded the method of transfer to the
free tissue technique.(3-6) By the late 1980s. substantial
debate existed regarding the merits of the "conventional"
TRAM flap and the "microsurgical" TRAM flap.(3-6)
As stated by Schusterman (4) and Grotting et al.,(3)
the advantages of free tissue transfer in the immediate
setting include the ready availability of the recipient
vessels for atastomosis, improved blood supply, with
a larger, more predictable vessel (which avoids or prevents
fat necrosis and partial skin loss), availability when
the upper abdomen is scarred, reduction of the incidence
of hernia, and retention of the entire inframammary
fold. Its disadvantages include longer operating time,
a need for special expertise, the "all or none"
phenomenon of microvascular surgery, (5-7) and some
technical problems in a patient receiving a delayed
reconstruction (e.g., need for vein grafts and occasional
need for dissection of internal mammary vessels). The
usual patient seen for breast reconstruction is a healthy,
young or middle-aged woman with a negative medical history
who has a medium build and an adequate abdominal pannus
to provide semmetry with the opposite breast; she is
a good candidate for either method of transfer.
Resource Cost Comparison
One area of comparison between the two TRAM techniques
in breast reconstruction is related to resource cost.
The most extensive study of this topic was reported
by physicians from the M. D. Anderson Cancer Center
Department of Reconstructive and Plastic Surgery.(8-9)
They found that autogenous tissue reconstruction with
the TRAM flap (primarily free tissue transfer) was at
least as cost effective, in terms of time and dollars,
as implant-based reconstruction. On the basis of these
studies, we may assume something that is counterintuitive:
all standard methods of breast reconstruction cost approximately
the same when considering resource consumption.
The financial records of the TRAM patients at our institution
were only available from 1996 to the present. Recognizing
that data exist only for 17 pedicled and 12 free TRAM
flaps, a significant difference of over $15,000 still
existed, which favored the pedicled procedure. Most
of these charges were related to the longer hospital
stay and, to a lesser degree, the longer operative time
required for free TRAM flaps.
Outcome Comparison
Recently, Edsander-Nord et al.(10) prospectively studied
23 patients with pedicled TRAM flaps and 19 with free
TRAM flaps for breast reconstruction. Using both a patient
questionnaire and an active isokinetic dynamometer system
to study maximal voluntary trunk flexion and extension
preoperatively and at 6 and 12 months postoperatively,
they determined that the method of transfer had no influence
on postoperative abdominal wall strength per se.
Pain Control Comparison
As shown from conversations with peers and the results
of our survey (Table II), a wide range of methods for
controlling postoperative pain in the TRAM-flap patient
seems to exist. As noted in the survey, some surgeons
use nothing more than oral pain medication supplemented
with parenteral or intravenous drugs, whereas others
use a patient-controlled analgesia pump or epidural
anesthesia. One would think that there should be more
agreement than this, despite the diversity of preferences!
The use of equianalgesic doses of drugs is common when
treating cancer pain to prevent undermedication when
switching from one route of administration to another.(2)
Because this is the standard in clinical oncology and
pain clinics, it seemed appropriate to apply this concept
to our postoperative TRAM patients to compare analgesic
requirements using a variety of analgesics.
Final Selection Is the Surgeon's Preference
The success of either TRAM operation can be improved
by appropriate patient selection, patient education,
and a noninvasive Doppler vascular study of the abdominal
wall to map out the location and integrity of the vessels.(11)
As Clark (l2) states in his discussion of the article
by Schusterman et al(4)
... most investigators use their best professional
judgment to choose possible confounding factors and
then fit a logistic regression equation where the outcome
variable is successful treatment or not and the predictor
variables include both which treatment the patient received
and the possible confounding variables. For this model
to work, the logistic regression equation must actually
correctly model the real world, and all important confounding
factors must be included in the model.
In other words, surgeons must use their clinical judgment
to provide patients with the best result possible within
their surgical capabilities.
Significance of This Study
We have taken advantage of a unique situation at one
hospital-one surgeon (D.L.L.) performing pedicle TRAM
flaps exclusively and another (N.J.Y.) using only free
tissue transfer. There were four referrals for free
tissue transfer (two by patient request and two because
the entire abdomen was needed); all of these patients
were otherwise healthy women. There was no statistically
significant difference between the two methods of transfer
with regard to complications. There was statistical
difference between patient age; patients in the free
tissue group were 3 years older. Significant differences
also existed in the length of the operation, number
of days in the hospital, and the amount of pain medication
required after surgery. Almost all patients received
a second surgery for nipple reconstruction, mound revision,
and/or obtaining symmetry with the opposite breast.
Because the breast mound provided by the free TRAM flap
has a richer blood supply, it can be sculpted with more
confidence and it has a more "finished" look
after the initial surgery. There were more mound "revisions"
as the second surgery after the pedicle procedure, but
the end results of both procedures were judged comparable.
Comments have been made in conversation and implied
in the literature that the use of the pedicled TRAM
flap "sacrifices" the abdominal wall. This
view is used as further justification for the use of
the free TRAM flap. For those who use a single-muscle
TRAM flap associated with minimal fascia harvest (2
to 3 cm) and leave the lateral third of the rectus muscle
(which has an intact blood and nerve supply (l3) ) when
using pedicied TRAM flaps, no advantage of one method
of transfer over the other seems to exist. (10)
It seems that the TRAM flap patient would benefit from
less pain medication delivered in a more economical
manner (intramuscularly or intravenously versus a patient-controlled
pump) given over a shorter time frame (1 or 2 days).
One factor that might have played a role in the reduced
analgesic requirements of the patients with pedicled
flaps in our review is the surgeon's (D.L.L.) empiric
use of 500 mg of intravenous methylprednisolone at the
time of flap elevation. Admittedly, little scientific
evidence exists for administering this drug,(14-16)
but it seems to provide the patient with a decrease
in the initial need for parental analgesia by, providing
a psychological "boost" and making the transition
to oral pain medication more seamless. If patients are
properly selected (eliminating patients with tuberculosis,
ocular herpes simplex, acute psychosis, or history,
of gastrointestinal bleed), the only disadvantage of
this single dose of steroid is the possibility of a
mild, self-limiting depression, which occasionally occurs
5 to 10 days postoperatively.
Our hospital found these data valuable in establishing
resource consumption, minimizing practice variations,
and improving surgical efficiency.
Conclusions
It seems that both methods of TRAM flap transfer for
breast reconstruction have inherent advantages and disadvantages.
Most of the literature to date has suggested that the
pedicled and free tissue transfers are equal in relation
to outcome, result, and cost. There is little question
that there are certain indications for free tissue transfer.
These include a significant history of smoking, obesity;
diabetes (instilin-dependent); preexisting, unfavorable
abdominal scars; or required use of the entire abdomen
for reconstruction. Regardless, the majority of women
requesting TRAM flap reconstruction of a breast do not
fall into these categories and can, in fact, receive
a pedicled flap. With this in mind, the surgeon should
tailor his or her choice for method of transfer to the
specific patient rather than use one method for all.
Our findings suggest that all TRAM patients could have
perioperative pain in the first or second day controlled
by a simple, parental analgesics, without the need for
an analgesia pump or epidural analgesia. Although little
has been written on the advantages of the pedicled TRAM
flap over free TRAM transfer, our experience indicated
that with the pedicled TRAM flap, there is less need
for blood and a statistically significant difference
when comparing the length of the operation and of hospital
stay. Each of these parameters would, of course, translate
into decreased hospital cost. This cost factor must
be considered in today's health-care environment, especially
because recent federal legislation requires insurers
to offer breast reconstruction to all mastectomy patients
but makes no mention of reimbursement being guaranteed
to the provider.
Regardless, it must remain the responsibility of the
surgeon to evaluate each patient's needs and select
a method that is economically responsible, within his
or her abilities, and that can produce a satisfactory
outcome that best serves the patient. It is hoped that
this information aids in that decision.
David L. Larson, M.D.
Department of Plastic Surgery
Medical College of Wisconsin
9200 West TVisconsin Ave.
Milwaukee, Wis. 53226
dlarson@mcu.edu
