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.
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.
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.