title: Using propensity score analysis to compare major complications between DIEP and free muscle-sparing TRAM flap breast reconstructions.
abstract: BACKGROUND
  Previous studies comparing muscle-sparing transverse rectus abdominis myocutaneous (TRAM) versus deep inferior epigastric artery perforator (DIEP) free flaps have not considered procedure selection bias. Propensity score analysis provides a statistical approach to consider preoperative factors in flap selection, and was used to compare major complications (breast and abdominal) between these microsurgical breast reconstruction (free muscle-sparing TRAM versus DIEP).
  
  
  METHODS
  This study evaluated major breast and abdominal complications in 292 consecutive patients (428 free abdominal flaps). Propensity scores were calculated for patient differences affecting flap selection (DIEP versus free muscle-sparing TRAM). Multivariate logistic models using selected covariates separately analyzed breast and abdominal complications between flap methods.
  
  
  RESULTS
  There were 83 major complications (28 percent): breast, 20 percent; abdomen, 8 percent. Using propensity scores, the adjusted odds of abdominal complications were significantly higher in free muscle-sparing TRAM than in DIEP flaps (OR, 2.73; 95 percent CI, 1.01 to 7.07). With prior chemotherapy, body mass index significantly increased abdominal complications (OR, 1.16; 95 percent CI, 1.01 to 1.34). Using propensity scores, there was no significant association between reconstruction method and breast complications; diabetics had significantly increased breast complications (OR, 4.19; 95 percent CI, 1.14 to 15.98). Previous abdominal operations (OR, 1.77; 95 percent CI, 0.96 to 3.30) and immediate reconstruction (OR, 1.86; 95 percent CI, 0.94 to 3.71) approached significance.
  
  
  CONCLUSIONS
  Propensity score analysis indicated significantly higher abdominal complications in free muscle-sparing TRAM compared with DIEP flaps. This study highlights the importance of separately evaluating recipient breast and donor abdominal complications and use of propensity scores to minimize procedure selection bias.
  
  
  METHODS
  Therapeutic, III.
authors.affiliation: Toronto, Ontario, Canada From the Division of Plastic and Reconstructive Surgery, Department of Surgery and Surgical Oncology, University Health Network; and the Division of Plastic and Reconstructive Surgery and the Lawrence S. Bloomberg Faculty of Nursing, University of Toronto.
authors.forename: Toni
authors.initials: T
authors.lastname: Zhong
authors.forename: Christine B
authors.initials: CB
authors.lastname: Novak
authors.forename: Shaghayegh
authors.initials: S
authors.lastname: Bagher
authors.forename: Saskia W M C
authors.initials: SWMC
authors.lastname: Maass
authors.forename: Jing
authors.initials: J
authors.lastname: Zhang
authors.forename: Udi
authors.initials: U
authors.lastname: Arad
authors.forename: Anne C
authors.initials: AC
authors.lastname: O'Neill
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Metcalfe
authors.forename: Stefan O P
authors.initials: SOP
authors.lastname: Hofer
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000453:epidemiology / Q000601:surgery; D003920:Diabetes Mellitus / Q000453:epidemiology; D005260:Female; D058752:Free Tissue Flaps / Q000009:adverse effects*; D006801:Humans; D016015:Logistic Models; D016462:Mammaplasty / Q000009:adverse effects* / Q000379:methods* / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D057216:Propensity Score; D012907:Smoking / Q000453:epidemiology