The Transition from Pedicle TRAM to Perforator Flap – What is the Cost of Opportunity?

Purpose: 

This study evaluates how the transition from pedicled transverse rectus abdominus myocutaneous (pTRAM) to deep inferior epigastric perforator (DIEP) flaps at an academic center has affected outcome and reimbursement.

Methods:

In 2006, our practice transitioned to almost exclusively DIEP flaps for breast reconstruction.  This study retrospectively compares pTRAM flaps performed from 2002-2006 (Group 1) to DIEP flaps from 2006-2010 (Group 2).  Operative time, complications and reimbursement were compared between the two groups.

Results: 

We performed 93 pTRAM flaps in 69 patients in Group 1 and 102 DIEP flaps in 69 patients in Group 2. Operative time was shorter in Group 1 for unilateral breast reconstruction (399 minutes vs 543 minutes, p = 0.0001), but no significant difference was noted for bilateral cases (547 minutes vs 658 minutes, p=0.1) (Fig.1). Fat necrosis requiring reoperation was more frequent in Group 1 (23.7% vs 5.9%, p=0.0004) (Fig. 2). There was a trend toward higher partial flap necrosis (20% vs 12%, p= 0.2) and abdominal hernia (8.8% vs 1.6%, p=0.2) but fewer hematomas (1.5% vs 10%, p=0.06) in Group 1 vs Group 2 (Fig. 2). Mean revenue per case for Group 1 was $3594 ($8.70 per minute) vs $4857 ($8.15 per minute) in Group 2. 

Conclusions: 

DIEP flaps appear to be as profitable as pTRAM flaps with lower morbidity. The transition from pTRAM to DIEP can be done successfully with appropriate resources and support.  The development of a perforator flap practice represents an opportunity cost in optimizing patient care, and should be an option to patients seeking breast reconstruction.