FREE VERSUS THE PEDICLED TRAM FLAP - A COST COMPARISON AND OUTCOME ANALYSIS

Proponents for the free TRAM flap have advocated enhanced tissue vascu larity, easier inset, and limited abdominal dissection. Equal aestheti c results without increased morbidity, and without the risks of microv ascular surgery have been suggested by surgeons using the pedicled tec hnique. The free TRAM flap has been criticized for its considerably hi gher costs. The purpose of this study was to provide a cost comparison and outcome analysis of the free versus the pedicled TRAM flap. All p atients who had had a TRAM flap performed in tile authors' teaching in stitutions between March of 1990 and April of 1995 were evaluated. Out patient and hospital records, and hospital and surgeon billing records , were reviewed for patient demographics, TRAM technique, delayed vers us immediate, operating room time, length of stay, hospital and surgeo n reimbursement, and surgical complications and their costs. All patie nts were sent a questionnaire asking about time back to work, abdomina l strength, fitness, symmetry, and satisfaction. During the 5-year per iod, 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 perc ent of the pedicled TRAM flaps were bilateral. There were no significa nt differences between the two techniques with regard to patient age, weight, or percentage of smokers, diabetes, hypertension, or preoperat ive chemotherapy or radiotherapy. Average operating room time was 7 ho urs with both techniques either delayed or immediate. Average length o f stay was 7 days with the free (immediate and delayed) and 8 days wit h tile pedicled (immediate and delayed) technique, although the differ ence was not significant. Average hospital reimbursement was $5300 for both the free and pedicled TRAM patients. Average surgeon reimburseme nt was significantly different, with $5000 for the free and $3500 for the pedicled TRAM flap. There were no differences in tile occurrence o f hematoma, partial/total flap loss, wound infection, hernia/bulge, fa t necrosis, deep vein thrombosis, and pulmonary embolus with regard to the technique used. The cost of the treatment of the complications wa s not significantly different between the two techniques, There was a significant difference in tile complication rate for the free TRAM pat ients compared with those treated by a routine reconstructive microsur geon versus a more occasional microsurgeon. Ninety percent of both the free and pedicled patients responded to tile questionnaire. There wer e no statistical differences between the free nap and pedicled flap su rvey results. The free nap patients returned to work 9 weeks after sur gery; tile pedicled Rap patients returned at 10 weeks. Abdominal stren gth and overall fitness ranged from 74 to 79 percent for both groups. Symmetry and overall satisfaction averaged 3.4 of 4 for all. Average f ollow-up for the survey respondents was 20 months. This study did riot demonstrate any significant differences in outcome or complications b etween 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 Gee TRAM patients. The authors recommend that surgeons use the technique with which they are comfortable and obtain predictable results.