title: Evolving Trends in Autologous Breast Reconstruction: Is the Deep Inferior Epigastric Artery Perforator Flap Taking Over?
abstract: BACKGROUND
  Enthusiasm for the deep inferior epigastric artery perforator (DIEP) flap for autologous breast reconstruction has grown in recent years. However, this flap is not performed at all centers or by all plastic surgeons for breast reconstruction, and it is unclear whether practice patterns have measurably changed. This study aimed to (1) evaluate changing trends in breast flap use in the United States in recent years and (2) identify how these trends have affected charges and costs associated with autologous breast reconstruction.
  
  
  METHODS
  Patients undergoing autologous breast reconstruction [latissimus dorsi (LD), pedicled transverse rectus abdominus myocutaneous (pTRAM), free TRAM (fTRAM), and DIEP] were identified using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database (2009-2011). A total of 19,182 hospital discharges were reviewed. Patient demographics, hospital teaching center status, payer status, length of stay, total charges, and total costs per discharge were reviewed. Statistical analysis was performed using linear regression, t test, and analysis of variance models.
  
  
  RESULTS
  Between 2009 and 2011, the total number of discharges did not change significantly. Patient age distribution was similar for all flap groups. For individual flaps, there was a significant increase in DIEP flaps (P = 0.03), with a decreasing trend for other abdominal-based flaps. The patients receiving DIEP flap breast reconstruction were covered by private insurance at a higher rate than all other flap procedures (P = 0.03), whereas other potential cost determinants did not differ significantly between the groups. The mean charge per flap was $40,704 for LD, $51,933 for pTRAM, $69,909 for fTRAM, and $82,320 for DIEP. The mean cost per flap was $12,017 for LD, $15,538 for pTRAM, $20,756 for fTRAM, and $23,616 for DIEP.
  
  
  CONCLUSIONS
  Between 2009 and 2011, the total amount of autologous breast reconstruction discharges was relatively stable, but the number of DIEP flaps increased significantly. Review of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample data shows that, compared with LD, pTRAM, and fTRAM flaps, the DIEP flap is associated with higher charges and costs.
authors.affiliation: From the Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC.
authors.forename: Irene
authors.initials: I
authors.lastname: Pien
authors.forename: Sophia
authors.initials: S
authors.lastname: Caccavale
authors.forename: Michael C
authors.initials: MC
authors.lastname: Cheung
authors.forename: Parag
authors.initials: P
authors.lastname: Butala
authors.forename: Duncan B
authors.initials: DB
authors.lastname: Hughes
authors.forename: Cassandra
authors.initials: C
authors.lastname: Ligh
authors.forename: Michael R
authors.initials: MR
authors.lastname: Zenn
authors.forename: Scott T
authors.initials: ST
authors.lastname: Hollenbeck
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D019074:Epigastric Arteries / Q000601:surgery*; D005260:Female; D017722:Hospital Charges / Q000706:statistics & numerical data / Q000639:trends; D017721:Hospital Costs / Q000706:statistics & numerical data / Q000639:trends; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D016014:Linear Models; D016462:Mammaplasty / Q000191:economics / Q000379:methods* / Q000639:trends; D008875:Middle Aged; D061525:Perforator Flap / Q000098:blood supply / Q000191:economics / Q000706:statistics & numerical data* / Q000639:trends*; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000706:statistics & numerical data / Q000639:trends*; D014481:United States; D055815:Young Adult