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
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