Free versus the pedicled TRAM flap: a cost comparison and outcome analysis

Proponents for the free TRAM flap have advocated enhanced tissue vascularity, easier inset, and limited abdominal dissection. Equal aesthetic results without increased morbidity and without the risks of microvascular surgery have been suggested by surgeons using the pedicled technique. The free TRAM flap has been criticized for its considerably higher costs. The purpose of this study was to provide a cost comparison and outcome analysis of the free versus the pedicled TRAM flap. All patients who had had a TRAM flap performed in the authors' teaching institutions between March of 1990 and April of 1995 were evaluated. Outpatient and hospital records, and hospital and surgeon billing records, were reviewed for patient demographics, TRAM technique, delayed versus immediate, operating room time, length of stay, hospital and surgeon reimbursement, and surgical complications and their costs. All patients were sent a questionnaire asking about time back to work, abdominal strength, fitness, symmetry, and satisfaction. During the 5-year period, 125 TRAM flaps were performed. Of these flaps, 72 were free flaps and 53 were pedicled. Seventy percent were immediate reconstructions regardless of the technique used. Four percent of the free and 17 percent of the pedicled TRAM flaps were bilateral. There were no significant differences between the two techniques with regard to patient age, weight, or percentage of smokers, diabetes, hypertension, or preoperative chemotherapy or radiotherapy. Average operating room time was 7 hours with both techniques either delayed or immediate. Average length of stay was 7 days with the free (immediate and delayed) and 8 days with the pedicled (immediate and delayed) technique, although the difference was not significant. Average hospital reimbursement was $5300 for both the free and pedicled TRAM patients. Average surgeon reimbursement was significantly different, with $5000 for the free and $3500 for the pedicled TRAM flap. There were no differences in the occurrence of hematoma, partial/total flap loss, wound infection, hernia/bulge, fat necrosis, deep vein thrombosis, and pulmonary embolus with regard to the technique used. The cost of the treatment of the complications was not significantly different between the two techniques. There was a significant difference in the complication rate for the free TRAM patients compared with those treated by a routine reconstructive microsurgeon versus a more occasional microsurgeon. Ninety percent of both the free and pedicled patients responded to the questionnaire. There were no statistical differences between the free flap and pedicled flap survey results. The free flap patients returned to work 9 weeks after surgery; the pedicled flap patients returned at 10 weeks. Abdominal strength and overall fitness ranged from 74 to 79 percent for both groups. Symmetry and overall satisfaction averaged 3.4 of 4 for all. Average follow-up for the survey respondents was 20 months. This study did not demonstrate any significant differences in outcome or complications between the free and pedicled TRAM flaps. A modest cost difference of $1500 occurred for the free TRAM patients. An experienced microsurgeon had significantly fewer complications with the free TRAM patients. The authors recommend that surgeons use the technique with which they are comfortable and obtain predictable results.