Original Article

Immediate Unilateral Breast Reconstruction using

Abdominally Based Flaps: Analysis of 3,310 Cases
Alvin C. Kwok, MD, MPH1,
Andrew M. Simpson, MD1,
Xiangyang Ye, PhD2 Eric Tatro, BS3
Jayant P. Agarwal, MD1

1 Division of Plastic and Reconstructive Surgery, University of Utah, Address for correspondence Alvin C. Kwok, MD, MPH, Division of
School of Medicine, Salt Lake City, Utah Plastic and Reconstructive Surgery, University of Utah, School of
2 Division of Epidemiology, University of Utah, School of Medicine, Medicine, 30 N 1900 E, 3B400, Salt Lake City, UT 84132
Salt Lake City, Utah (e-mail: [email protected]).
3 Texas Tech Health Science Center, Paul L. Foster School of Medicine,
El Paso, Texas

J Reconstr Microsurg

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Abstract Background The abdomen is the most common area from which tissue is harvested
for autologous breast reconstruction. We sought to examine national data to deter-
mine the differences in total hospital charges, length of stay (LOS), and early post-
operative complications following pedicled transverse rectus abdominis
myocutaneous flap (pTRAM), free TRAM (fTRAM), deep-inferior epigastric perforator
(DIEP), and superficial inferior epigastric artery perforator (SIEA) flaps.
Methods The 2009–2013 Nationwide Inpatient Sample Database was used to
identify patients who underwent a unilateral mastectomy and only one type of
abdominally based autologous flap (pTRAM, fTRAM, DIEP, and SIEA) during the
same hospital admission. Outcomes of interest included total charges, LOS, and
complications including revision of vascular anastomosis and hematoma.
Results A total of 3,310 cases were identified, corresponding to 15,991 abdominally
based unilateral immediate breast reconstructions after standard weighting was
applied; 5,079 (31.8%) were pTRAM flaps, 4,461 (27.9%) were fTRAM flaps, 6,206
(38.8%) were DIEP flaps, and 245 (1.5%) were SIEA flaps. The mean total charges for
pTRAM, fTRAM, DIEP, and SIEA flaps were $17,765.5, $22,637.6, $25,814.6, and
$26,605.2, respectively (p < 0.0001). The mean LOS for pTRAM, fTRAM, DIEP, and SIEA
flaps were 96.5, 106.5, 106.7, and 108.9 hours, respectively (p ¼ 0.002). The rates for
return to the OR for the revision of a vascular anastomosis for pTRAM, fTRAM, DIEP, and
SIEA were 0.0%, 1.72%, 2.66%, and 5.64%, respectively (p < 0.0001).
Conclusions There is variation in the total charges, LOS, and early complications
between pTRAM, fTRAM, DIEP, and SIEA flap-based breast reconstruction. fTRAM, DIEP,
and SIEA flaps incur higher hospital total charges, have longer lengths of stay, and
Keywords experience more immediate complications compared with pTRAM. Well-designed
► breast reconstruction prospective trials are required to better understand the findings from this study
► microsurgery with the inclusion of other critical outcomes such as patient satisfaction, aesthetic
► free flaps results, and long-term outcomes such as abdominal wall morbidity.

Alvin C. Kwok and Andrew M. Simpson contributed equally to the
work and should be considered co-first authors.

received Copyright © by Thieme Medical DOI https://doi.org/

January 18, 2018 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0038-1667046.
accepted after revision New York, NY 10001, USA. ISSN 0743-684X.
May 22, 2018 Tel: +1(212) 584-4662.
Abdominally Based Breast Reconstruction Kwok et al.

Introduction A retrospective cross-sectional analysis was conducted on

the 5-year NIS data from 2009 to 2013. Patients who received
In the United States, 1 in 8 women will develop invasive breast unilateral mastectomy and were billed for a single abdomin-
cancer in their lifetimes. Approximately 252,710 new cases of ally based immediate autologous breast reconstruction
breast cancer were diagnosed in women in 2017 alone.1 While using ICD-9-CM (International Classification of Diseases,
breast-conserving therapy is an option for some women, many Ninth Revision, Clinical Modification) procedure codes
will undergo mastectomy for oncologic control. 85.72 (pTRAM), 85.73 (fTRAM), 85.74 (DIEP), and 85.75
Women who receive breast reconstruction experience (SIEA) were included in this study.25 Prior to 2009, HCUP
less psychological distress and achieve more satisfaction NIS did not separate flaps based on type and therefore were
with outcomes compared with those women who receive not eligible for subgroup analysis. Patients who underwent
mastectomy alone.2 Those who receive autologous breast delayed reconstruction, bilateral reconstruction, non-
reconstruction report increased satisfaction and quality of abdominally based flap or implant-based reconstruction
life when compared with alloplastic methods.3–5 were excluded. Bilateral cases were excluded to adequately
The evolution of breast reconstruction to include abdom- power each individual group for analysis. The total sample of
inally based options began in 1982 when Scheflan et al included patients was weighted according to HCUP NIS
first described the pedicled transverse rectus abdominis instructions. The NIS uses weighting to produce national
myocutaneous flap (pTRAM).6 Rapid adoption of the techni- level estimates based on the sample of data within the

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que led to further advancements, including muscle-sparing database. After weighting is applied, the NIS is considered
microvascularly transplanted free TRAM (fTRAM) and finally to be reflective of all inpatient discharges from community
free deep-inferior epigastric perforator (DIEP) and super- hospitals in the United States, excluding rehabilitation hos-
ficial inferior epigastric artery perforator (SIEA) flap recon- pitals and long-term acute-care hospitals.26 Weighting is
struction. The decision regarding which reconstructive routinely performed in analysis of NIS data.27–29
option to pursue depends not only on patient factors but The primary outcomes of interest were total charges, length
also on facility capabilities and surgeon comfort, given that of stay (LOS), and inpatient complications including return to
technical difficulty and postoperative care increases sub- the operating room for revision of vascular anastomosis,
stantially with microvascular techniques. dehiscence, flap ischemia/failure, and donor-site hematoma.
Given the breadth of options available, there is much The surgical groups were assessed individually, and not
debate in the literature comparing flap techniques. Propo- grouped by microvascular versus pedicled. Overall complica-
nents of muscle sparing and perforator flap options cite the tions without return to the operating room were an aggregate
preservation of the abdominal musculature and the rectus of complications available in NIS. Patient factors associated
sheath as justifying the added complexity and increased with poorer outcome were characterized, including age, race,
operative time.7,8 Critics of free flap options cite increased diabetes, hypertension, chronic kidney disease, liver disease,
risk of fat necrosis and flap failure, in addition to complexity peripheral vascular disease, smoking, and obesity. The mean
and operative time as reasons to continue performing Deyo modification of the Charlson Comorbidity Index was
pedicled reconstruction.9,10 Current clinical practice guide- calculated for each group. This index is a method of categoriz-
lines do not make formal recommendations for or against ing comorbidities of patients based on 17 categories from ICD
either method of reconstruction.11 coding that are then assigned weighting from 1 to 6.30
While there is an abundance of literature comparing the
fTRAM, msTRAM, and DIEP procedures,8,10,12–20 there is Statistical Analysis
limited evidence comparing these with pTRAM and SIEA Demographic characteristics and postoperative outcomes
reconstruction.15,21–23 There is scant literature describing were examined for statistical differences between the dif-
inpatient characteristics of patients undergoing these recon- ferent types of reconstruction. Measures of central tendency
structions. With this in mind, we sought to use a U.S.-based (mean, standard error) and 95% confidence intervals for
national inpatient database to query the different character- continuous variables were reported. Frequencies and pro-
istics of the inpatient care and total charges associated with portions were reported for categorical variables.
abdominally based breast reconstructive procedures. Comparison of statistically significant difference between
the recipient groups were evaluated using least square
means for continuous variables and Rao-Scott chi-square
Methods
test for categorical variables. Sample weight, strata, and
The Nationwide Inpatient Sample (NIS) is a component of the cluster were used to accommodate the complex survey
Healthcare Cost and Utilization Project (HCUP) and is the structure for all analysis. Results of missing groups in cate-
largest all-payer inpatient care database currently available gorical variables were reported but not used in the statistical
to the public in the United States. The NIS gathers information significance test. In the situation of a zero cell count in a
from the care of patients covered by Medicare, Medicare category for Rao-Scott chi-square test, a random patient in
Advantage, Medicaid, private insurance and from the unin- the corresponding group was selected to assign with an event
sured. The database contains information from a 20% stratified to meet the Rao-Scott chi-square test requirement. All sta-
sample of U.S. hospitals, totaling approximately 8 million tistical analysis was conducted using SAS software V9.4 (SAS
hospital stays from 1000 hospitals.24 Institute Inc, Cary, NC).

Journal of Reconstructive Microsurgery

 Abdominally Based Breast Reconstruction Kwok et al.

Results modified Charlson Comorbidity Index, a standardized mea-

sure of patient comorbidities, varied significantly between
There were 30,240,562 individual patient encounters in the the groups, with patients receiving pedicled TRAM (2.5)
HCUP NIS database from 2009 to 2013. Of these, 43,817 were scoring higher than fTRAM (2.4), DIEP (1.9), and SIEA (2.2).
inpatient stays following unilateral mastectomy. Of patients The regional distribution of reconstructive techniques is
who had mastectomy, 3,310 underwent unilateral immedi- demonstrated in ►Table 2. Reconstructions requiring micro-
ate abdominally based breast reconstruction. Ten patients surgical techniques are more commonly performed in teach-
were male and were excluded from the analysis. After ing hospitals (p < 0.0001) and the vast majority (98.0%) are
weighting the data according to standard NIS protocols, there performed in urban areas (p ¼ 0.0002). There was no sig-
were 15,991 individual cases for analysis (►Fig. 1). nificant difference between the groups in the size of the
The distribution of abdominally based reconstruction hospital performing the surgery or the household income of
techniques is outlined in ►Table 1. Of patients, 5,079 patients undergoing reconstruction.
(31.8%) underwent pedicled TRAM, 4,461 (27.9%) underwent The total charges of hospital admission increased signifi-
fTRAM, 6,206 (38.8%) underwent DIEP, and 245 (1.5%) under- cantly between TRAM ($17,765.5), fTRAM ($22,637.6), DIEP
went SIEA flap reconstruction. The mean age of the overall ($25,814.6), and SIEA flaps ($26,605.2) (p < 0.0001)
cohort was 52.4 years, with a small but significant elevation (►Table 3). Likewise, the LOS was prolonged in the micro-
in age in the pedicled TRAM cohort (53.2 years). Comorbid- surgical groups compared with pedicled TRAM (p ¼ 0.002).

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ities within the groups are detailed in ►Table 1. The Deyo- The rate of overall complications without return to the

Fig. 1 Case inclusion criteria for immediate unilateral breast reconstruction using abdominally based flaps in the 2009–2013 National Inpatient
Sample database.

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Abdominally Based Breast Reconstruction Kwok et al.

Table 1 Demographics of patients undergoing immediate abdominally based breast reconstruction

Overall, N (%) pTRAM, N (%) fTRAM, N (%) DIEP, N (%) SIEA, N (%) p-Value
Total cases 15,991 5,079 (31.8) 4,461 (27.9) 6,206 (38.8) 245 (1.5) <0.0001
Age, mean  Std Err (y) 52.4  0.2 53.2  0.3 52.9  0.3 51.4  0.2 51.5  1.0 <0.0001
Race
White 9,787 (61.2) 3,315 (65.3) 2,583 (57.9) 3,721 (60.0) 167 (68.1) <0.0001
Black 2,288 (14.3) 753 (14.8) 678 (15.2) 843 (13.6) 14 (5.7)
Hispanic 1,485 (9.3) 398 (7.8) 398 (8.9) 659 (10.6) 30 (12.3)
Other 2,432 (15.2) 614 (12.1) 802 (18.0) 982 (15.8) 34 (13.8)
Comorbidities
Diabetes 1,117 (7.0) 370 (7.3) 340 (7.6) 403 (6.5) 5 (1.8) 0.4054
Hypertension 4,520 (28.3) 1,568 (30.9) 1,370 (30.7) 1,512 (24.4) 70 (28.7) 0.0021
Congestive heart failure 52 (0.3) 23 (0.5) 0 (0) 29 (0.5) 0 (0) 0.1291

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Chronic lung disease 95 (0.6) 42 (0.8) 24 (0.5) 29 (0.5) 0 (0) 0.5257
Chronic kidney disease 72 (0.4) 19 (0.4) 29 (0.7) 24 (0.4) 0 (0) 0.3106
Liver disease 32 (0.2) 14 (0.3) 13 (0.3) 4 (0.1) 0 (0) 0.0321
PVD 20 (0.1) 10 (0.2) 0 (0) 10 (0.2) 0 (0) 0.0291
Smoker 2,409 (15.0) 751 (14.8) 749 (16.7) 872 (14.0) 37 (15.2) 0.5025
Obesity 1,217 (7.6) 283 (5.6) 439 (9.8) 480 (7.7) 14 (5.5) 0.0049
Modified Deyo 2.2 2.5 2.4 1.9 2.2 0.0002
Comorbidity Index

Abbreviations: DIEP, deep inferior epigastric perforator; fTRAM, free transverse rectus abdominis myocutaneous; PVD, peripheral vascular disease;
SIEA, superficial inferior epigastric artery; StdErr, standard error; TRAM, transverse rectus abdominis myocutaneous.

operating room increased significantly in the microsurgical and academic medical centers.24 NIS is an aggregate of State
cohort (p ¼ 0.0007). The rate of flap ischemia and failure did Inpatient Databases, which are collected from discharge
not differ significantly between the groups (p ¼ 0.1205). abstracts and collated into standardized format.41
Our data corroborate previous findings that the DIEP flap
is increasing in popularity compared with TRAM proce-
Discussion
dures.42 This is despite the evidence that the number of
While there are multiple studies comparing the pedicled to institutions performing autologous reconstruction is
free TRAM31–36 and TRAM and perforator flap techni- decreasing overall.39 Based on our findings, DIEP flaps are
ques,21,22,37 there is comparatively little information regard- the most commonly performed method of immediate breast
ing inpatient characteristics, complications, and charges reconstruction using autologous tissue from the abdomen
associated with each technique on a large scale. This study (38.8%), followed by pTRAM (31.7%), fTRAM (27.9%), and
evaluated information derived from HCUP NIS to compare finally SIEA, which comprises only 1.5% of reconstructions in
inpatient information and early outcomes for immediate our cohort (►Table 1).
breast reconstruction using abdominally based flaps.
Of more than 250,000 women diagnosed with breast Early Complications Experienced following Surgery
cancer in the United States per year, 36% with early stage Microvascular free tissue transfer is a reliable reconstruction
and 60% with late stage will undergo mastectomy.1,38 Pro- option with failure rates ranging from 1 to 10%.8,43–48
phylactic mastectomy rates continue to rise and while Systematic review of the literature has demonstrated fTRAM
implant-based techniques for reconstruction remain the failure rate of 1.59%.40 The rate of DIEP failure ranges from 0
most commonly used, autologous techniques account for to 10%,43,45,48 with most series noting failure in less than 3%
20% of reconstructions.39,40 of cases.46,47 In a systematic review of 17,096 DIEP flaps by
The National Inpatient Sample (NIS) is a stratified sample Lie et al, a failure rate of 1.12% was described.49 The rate of
of discharges from U.S. community hospitals, defined as “all SIEA flap failure is significantly higher, possibly owing to
non-Federal, short-term, general, and other specialty hospi- variable presence, smaller caliber, and steeper learning curve
tals, excluding hospital units of institutions.” Included required for mastery.50
among community hospitals are specialty hospitals such as We found that 5.64% of SIEA flaps required return to the
obstetrics-gynecology, ear-nose-throat, orthopedic, and operating room for anastomotic revision, higher than DIEP
pediatric institutions. Also included are public hospitals flaps (2.66%) and fTRAM (1.72%) (p < 0.0001) (►Table 3). Due

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 Abdominally Based Breast Reconstruction Kwok et al.

Table 2 Demographics of hospitals performing immediate abdominally based breast reconstruction

Overall, N (%) pTRAM, N (%) fTRAM, N (%) DIEP, N (%) SIEA, N (%) p-Value
Region
Northeast 4,626 (28.9) 1,819 (35.8) 1,323 (29.7) 1,409 (22.7) 74 (30.2) 0.0227
Midwest 3,054 (19.1) 888 (17.5) 1,013 (22.7) 1,067 (17.2) 86 (35.1)
South 5,797 (36.3) 1,746 (34.4) 1,329 (29.8) 2,678 (43.1) 44 (18.1)
West 2,515 (15.7) 626 (12.3) 795 (17.8) 1,052 (17.0) 41 (16.7)
Teaching hospital 12,615 (78.9) 3,572 (70.3) 3,426 (76.8) 5,376 (86.6) 240 (98.0) <0.0001
Hospital size
Small 1,878 (11.7) 659 (13.0) 565 (12.7) 645 (10.4) 9 (3.8) 0.1252
Medium 2,677 (16.7) 1,087 (21.4) 673 (15.1) 897 (14.5) 21 (8.5)
Large 11,347 (71.0) 3,295 (64.9) 3,195 (71.6) 4,641 (74.8) 215 (87.8)
Missing 89 (0.6) 37 (0.7) 29 (0.6) 23 (0.4) 0(0)

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Hospital location
Rural 226 (1.4) 112 (2.2) 77 (1.7) 19 (0.3) 18 (7.4) 0.0002
Urban 15,676 (98.0) 4,930 (97.1) 4,356 (97.6) 6,163 (99.3) 227 (92.6)
Missing 89 (0.6) 37 (0.7) 29 (0.6) 23 (0.4) 0 (0)
Household income
1st quartile 2,402 (15.0) 742 (14.6) 598 (13.4) 1,014 (16.3) 48 (19.6) 0.0584
2nd quartile 2,908 (18.2) 1,043 (20.5) 827 (18.5) 1,004 (16.2) 35 (14.2)
3rd quartile 4,218 (26.4) 1,401 (27.6) 1,218 (27.3) 1,537 (24.8) 62 (25.2)
4th quartile 6,098 (38.1) 1,749 (34.4) 1,677 (37.6) 2,585 (41.7) 87 (35.3)
Missing 365 (2.3) 144 (2.8) 141 (3.2) 66 (1.1) 14 (5.7)

Abbreviations: DIEP, deep inferior epigastric perforator; fTRAM, free transverse rectus abdominis myocutaneous; SIEA, superficial inferior epigastric
artery; TRAM, transverse rectus abdominis myocutaneous.

Table 3 Total charges, length of stay, and complications in patients undergoing immediate abdominally based unilateral breast
reconstruction

pTRAM (n ¼ 5,079) fTRAM (n ¼ 4,461) DIEP (n ¼ 6,206) SIEA (n ¼ 245) p-Value

Total charges (USD), 17,765.5 22,637.6 25,814.6 26,605.2 <0.0001
N (95% CI) (16,260.0–19,271.0) (19,850.9–25,424.2) (21,517.2–30,111.9) (23,134.5–30,075.9)
LOS (h), N (95% CI) 96.5 (91.8–101.2) 106.5 (101.7–111.2) 106.7 (103.7–109.7) 108.9 (95.6–122.1) 0.0020
Overall complications 123 (2.42) 191 (4.28) 376 (6.05) 14 (5.55) 0.0007
without return to
OR, N (%)
Flap ischemia/failure, 33 (0.65) 48 (1.07) 106 (1.71) 5 (2.04) 0.1205
N (%)
Dehiscence, N (%) 9 (0.19) 10 (0.23) 25 (0.41) 0 (0) 0.1298
Hematoma, N (%) 85 (1.68) 137 (3.08) 248 (4.00) 9 (3.51) 0.0125
Return to OR for 0 (0) 77 (1.72) 166 (2.66) 14 (5.64) <0.0001
revision of vascular
anastomosis, N (%)

Abbreviations: CI, confidence interval; DIEP, deep inferior epigastric perforator; fTRAM, free transverse rectus abdominis myocutaneous; LOS, length
of stay; OR, operating room; PVD, peripheral vascular disease; SIEA, superficial inferior epigastric artery; TRAM, transverse rectus abdominis
myocutaneous; USD, U.S. dollars.

to the limitations of the dataset, the cause of this increase to be absent in 30 to 51% of cases and was less than 1.5 mm in
cannot be established. In the initial descriptive anatomic diameter in a further 19%.52,53 In another series, thrombotic
studies by Taylor and Daniel, the artery was absent in 35% of events requiring revision was as high as 17.4%, and although
cadaveric specimens.51 In a clinical series, the SIEA was found with revision the failure rate was reduced to 2.9%, this

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Abdominally Based Breast Reconstruction Kwok et al.

contrasted with the fTRAM revision (6%) and failure rate subdivided, and therefore it is not possible to make any
(0.35%).54 In a recent series, the rate of revision for DIEP flaps inference on what impacts the relative increase or decrease
(3.38%) was significantly lower than SIEA flaps (11.76%); in total charges. While the number derived does not allow for
moreover, SIEA flaps failed completely in 62.5% of cases formal cost utility analysis, it does allow for comparison of
requiring revision, compared with 37.5% of DIEP revisions.47 total charges between different treatment options at the
Evaluation of SIEA flap complications have led some surgeons hospital level.27,62
to abandon the procedure altogether55; however, some have The present study demonstrates the mean total charges
continued the technique citing improved abdominal wall for pTRAM, fTRAM, DIEP, and SIEA flaps as $17,778, $22,608,
integrity and acceptable outcomes.54 The comparison a revi- $25,819, and $26,605, respectively (p < 0.0001). The
sion of vascular anastomosis is not extended to pTRAM, due to increase in charges associated with free techniques may
the pedicled nature of this flap. reflect surgical complexity and the trend toward increased
The rates of hematoma for pTRAM, fTRAM, SIEA, and DIEP operative time; however, as the charges are not itemized this
flaps in the present study were 1.68%, 3.06%, 3.51%, and is not a certainty. Factors including LOS, increased operative
3.99%, respectively (p ¼ 0.0129) (►Table 3). The finding of time, and increasing likelihood of a second operation could
increased hematoma rate in free flap options is consistent account for the incremental increase in charges between
with previous studies.15,56–59 It is important to consider that microsurgical techniques; however, due to the nature of the
the number of SIEA flaps performed in this sample is low dataset this is not certain.

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(n ¼ 245) in this dataset. Since 2013 (the end of the most
current available NIS data block), the number and surgeon
Limitations
experience with SIEA flaps could have grown significantly.
We therefore suggest caution when interpreting these out- The present study is not without limitations. NIS does not
comes in this context. Follow-up studies of more recent data distinguish between types of fTRAM flaps performed (muscle-
with evolving procedures, including SIEA flaps, should be of sparing variations, supercharging, etc.), nor does it capture
interest. As many centers are moving to expedited discharge other intraoperative procedures related to reconstruction,
after postoperative care of free flap patients, the total such as mesh placement.
hospital charges incurred following these procedures may There are inherent issues with interpretation of data from
be greatly reduced. large datasets. NIS is a stratified sample of 20% of hospitals in 48
states and represents the largest collection of all-payer inpa-
Length of Inpatient Stay and Total Charges of tient data available in the United States. It is intended to provide
Reconstruction national estimates of clinical and resource-use data for indivi-
Inpatient LOS following autologous immediate breast recon- dual inpatient stays during a 30-day period. Data are derived
struction varies in the literature. Although it is generally felt from standard discharge abstract information, in the form of
that microsurgical reconstruction leads to increased LOS,53 core data and data derived from ICD codes.24,26,62 Information
several studies have demonstrated decreased time in hospital is collected from various sources and could be from medical
following DIEP flap reconstruction when compared with coders, nurses, or physicians. While NIS accounts for missing
pTRAM flaps.10,22 The mean LOS for pTRAM was significantly variables and undergoes rigorous internal and external validity
lower than free flap options (p ¼ 0.002) (►Table 3). Despite testing and the stratified sample should account for variability,
clinical significance, the difference in LOS is only prolonged it is important to recognize the limitations of these datasets.63
12 hours for fTRAM or 14 hours for SIEA. Given the overall LOS, NIS captures total charges incurred during the entire inpatient
it is unclear whether this increase is clinically significant. The stay; however, the database does not distinguish based on
incremental increase in LOS for fTRAM, DIEP, and SIEA may procedural versus hospital stay. While HCUP NIS list total
reflect the small number of cases that require a second opera- charges for inpatient stay, it does not itemize the charges and
tion for revision of anastomosis. The difference in LOS between does not account for regional, institutional, or surgeon billing
free flaps (fTRAM, DIEP, and SIEA) is unlikely to be clinically variation. Professional fees, including surgeon billing, is not
relevant. It is important to note that the database does not captured.62 These factors could affect the overall cost utiliza-
distinguish between experienced versus inexperienced sur- tion of varying reconstructive techniques.
geons or hospitals, these factors may affect the LOS associated As the database only includes information from the initial
with breast reconstruction.53,60 inpatient stay, complications that arise or are managed in the
It has been previously shown that while DIEP flap recon- outpatient setting are not captured. This is important when
struction costs more than fTRAM reconstruction ($7026 USD considering issues such as delayed wound healing, fat necrosis,
vs. $6508 USD, respectively) these costs are mitigated when flap revisions, and abdominal wall morbidity. Knox et al
accounting for the increased quality-adjusted life years described a 5-fold increase in odds of hernia or abdominal
associated with DIEP flap reconstruction.20 This was further bulge in pTRAM patients compared with DIEP-based recon-
corroborated by Grover et al, who found that both pedicled struction; 50% of these patients went on to require a second
and microsurgical techniques were cost-effective.61 operation for repair of the defect.15 Other authors indicate that
NIS collects total charges at the end of patient admission. mesh used with TRAM flap techniques decreases the risk of
This value reflects hospital fees, and professional charges hernia and bulge to levels on par with fascial sparing techni-
(i.e., physician billing) are excluded. The value is not further ques.64 As these revision procedures would not be captured by

Journal of Reconstructive Microsurgery

 Abdominally Based Breast Reconstruction Kwok et al.

our current dataset, they are important considerations when 2 Handel N, Silverstein MJ, Waisman E, Waisman JR. Reasons why
making conclusions regarding increased charges associated mastectomy patients do not have breast reconstruction. Plast
with fascial sparing perforator techniques. Formal utility ana- Reconstr Surg 1990;86(06):1118–1122, discussion 1123–1125
3 Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determi-
lysis, either in the form of prospective cohorts or with all-payer
nants of patient satisfaction in postmastectomy breast recon-
claims data, is required to determine superiority of procedures struction. Plast Reconstr Surg 2000;106(04):769–776
from a cost-effectiveness standpoint. 4 Craft RO, Colakoglu S, Curtis MS, et al. Patient satisfaction in
While the revision rate for pTRAM is 0% in our study, it is unilateral and bilateral breast reconstruction [outcomes article].
important to note that this does not infer that failure rates for Plast Reconstr Surg 2011;127(04):1417–1424
5 Yueh JH, Slavin SA, Adesiyun T, et al. Patient satisfaction in
pedicled techniques is zero, or even less than microsurgical
postmastectomy breast reconstruction: a comparative evaluation
techniques. Flap ischemia was noted in 0.65% of pedicled TRAM
of DIEP, TRAM, latissimus flap, and implant techniques. Plast
flaps (►Table 3), with no statistical difference from micro- Reconstr Surg 2010;125(06):1585–1595
vascular techniques. Indeed, centers with a high volume of free 6 Scheflan M, Hartrampf CR, Black PW. Breast reconstruction with a
flap surgeries report success rates consistent with pedicled transverse abdominal island flap. Plast Reconstr Surg 1982;69
techniques.22,31,36,65 Different comorbidities, such as smoking (05):908–909
7 Kroll SS, Evans GR, Reece GP, et al. Comparison of resource costs
and obesity, may lead to surgical selection bias and thus affect
between implant-based and TRAM flap breast reconstruction.
outcomes. Several studies have shown that DIEP flaps are more Plast Reconstr Surg 1996;97(02):364–372
commonly performed on obese patients.66,67 Obesity has an

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8 Nahabedian MY, Momen B, Galdino G, Manson PN. Breast recon-
unclear effect on abdominal wall complications in both pTRAM struction with the free TRAM or DIEP flap: patient selection,
and free microvascular techniques, with contradictory infor- choice of flap, and outcome. Plast Reconstr Surg 2002;110(02):
mation in the literature.15,68–71 Lastly, our sample was limited 466–475, discussion 476–477
9 Feingold RS. Improving surgeon confidence in the DIEP flap: a
to unilateral reconstruction to allow for manageable compar-
strategy for reducing operative time with minimally invasive
ison between the procedures. These data may not be general- donor site. Ann Plast Surg 2009;62(05):533–537
izable to bilateral reconstruction, and further work in this area 10 Kroll SS, Reece GP, Miller MJ, et al. Comparison of cost for DIEP and
is needed. free TRAM flap breast reconstructions. Plast Reconstr Surg 2001;
This work does not intend, nor does it have the necessary 107(06):1413–1416, discussion 1417–1418
11 Lee BT, Agarwal JP, Ascherman JA, et al. Evidence-based clinical
components, to assign superiority of a given abdominally
practice guideline: autologous breast reconstruction with DIEP or
based flap for breast reconstruction. We have described early
pedicled TRAM abdominal flaps. Plast Reconstr Surg 2017;140
differences in complications, LOS, and charges associated (05):651e–664e
with various flaps. At the authors’ institution, pedicled TRAM 12 Baumann DP, Lin HY, Chevray PM. Perforator number predicts fat
flaps have largely been abandoned in favor of free tissue necrosis in a prospective analysis of breast reconstruction with
transfer. We believe that prospective, long-term examination free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 2010;125
(05):1335–1341
of patient-reported satisfaction, abdominal wall morbidity,
13 Blondeel N, Vanderstraeten GG, Monstrey SJ, et al. The donor site
and costs are indicated. This work highlights the importance morbidity of free DIEP flaps and free TRAM flaps for breast
of these outcomes. reconstruction. Br J Plast Surg 1997;50(05):322–330
14 Blondeel PN, Neligan P. Are bilateral TRAM flaps as good as bilateral
DIEP flaps? Plast Reconstr Surg 2011;128(02):590–591, author
Conclusion reply 591–592
15 Knox AD, Ho AL, Leung L, et al. Comparison of outcomes following
The present study adds to the body of literature confirming
autologous breast reconstruction using the DIEP and pedicled
that the DIEP flap is increasing in popularity among surgeons TRAM flaps: a 12-year clinical retrospective study and literature
in the United States, and it is now the most commonly used review. Plast Reconstr Surg 2016;138(01):16–28
abdominal flap for autologous breast reconstruction. SIEA 16 Nahabedian MY. Secondary operations of the anterior abdominal
flaps require anastomotic revision more than twice as often wall following microvascular breast reconstruction with the
as DIEP flaps. fTRAM, DIEP, and SIEA flaps incur higher hospital TRAM and DIEP flaps. Plast Reconstr Surg 2007;120(02):365–372
17 Nahabedian MY, Tsangaris T, Momen B. Breast reconstruction
charges in the initial stages of management compared with
with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap:
pTRAM, but this finding may be mitigated when long-term is there a difference? Plast Reconstr Surg 2005;115(02):436–444,
costs including abdominal wall morbidity are considered. discussion 445–446
Well-designed prospective trials are required to determine 18 Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing
long-term patient satisfaction and cost-effectiveness. the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: part II. Bilateral reconstruc-
tion. Plast Reconstr Surg 2010;126(05):1438–1453
Conflict of Interest 19 Selber JC, Nelson J, Fosnot J, et al. A prospective study comparing
None. the functional impact of SIEA, DIEP, and muscle-sparing free
TRAM flaps on the abdominal wall: part I. Unilateral reconstruc-
tion. Plast Reconstr Surg 2010;126(04):1142–1153
20 Thoma A, Veltri K, Khuthaila D, Rockwell G, Duku E. Comparison of
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