A Cost Based Comparison between Perforator Flaps and TRAM Flaps for Breast Reconstruction

   Robert J. Allen, M.D. | May 2000 |

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 (TRAM) flaps.

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 surgeon’s 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 surgeon’s 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 surgeon’s 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 surgeon’s 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 patient’s 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 surgeon’s 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 flap technique.


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.

Table 1
Cost Components in 1997 dollars at Memorial Medical
Center, New Orleans, LA (LSU affiliate)
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 patient’s 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


  1. Kroll, S.S., Evans, G.R.D., Reece, G.P., et al. Comparison of resource costs between implant-based and TRAM flap breast reconstruction. Plast. Reconstr. Surg. 97:364, 1996.
  2. Handel, N., Jenson, J.A., Black, Q., et al. The fate of breast implants: A critical analysis of complications and outcomes. Plast. Reconstr. Surg. 96:1521, 1995.
  3. Kroll, S.S. Why autologous tissue? Clin. Plast. Surg. 25:2, 1998.
  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, 1996.
  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. Surg. 32:32,1994.
  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, 1996.

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