title: The cost effectiveness of the DIEP flap relative to the muscle-sparing TRAM flap in postmastectomy breast reconstruction.
abstract: BACKGROUND
  The deep inferior epigastric perforator (DIEP) flap has gained notoriety because of its proposed benefit in decreasing donor-site morbidity but has been associated with longer operative times, higher perfusion-related complications, and increased cost relative to muscle-sparing free transverse rectus abdominis myocutaneous (TRAM) flaps. The authors performed the first cost-utility analysis examining the cost effectiveness of DIEP flaps relative to muscle-sparing free TRAM flaps in women who underwent mastectomy.
  
  
  METHODS
  A comprehensive literature review was conducted using the MED- LINE, Embase, and Cochrane library databases to include studies directly comparing DIEP to muscle-sparing free TRAM flaps in matched patient cohorts. Eight studies were included, examining 740 DIEP flaps and 807 muscle-sparing free TRAM flaps. Costs were derived adopting both societal and third-party payer perspectives. Utilities were derived from a previous cost-utility analysis. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis.
  
  
  RESULTS
  The overall complication rates were 24.7 percent and 21.8 percent for DIEP and muscle-sparing free TRAM flaps, respectively. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $69.42 and a clinical benefit of 0.0035 quality-adjusted life-year when performing DIEP flap surgery relative to muscle-sparing free TRAM flap surgery, yielding an incremental cost-utility ratio of -$19,834.29. When using societal costs, the incremental cost-utility ratio increased to $87,800.
  
  
  CONCLUSIONS
  DIEP flaps are cost effective relative to muscle-sparing free TRAM flaps when patients are carefully selected based on perforator anatomy and surgery is performed by experienced surgeons.
authors: Hannover and Lebanon, N.H.; Chicago, Ill.; Washington, D.C.; and Baltimore, Md. From the Geisel School of Medicine at Dartmouth; the Division of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center; the Division of Plastic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine; the Department of Plastic Surgery, Georgetown Hospital; and the Department of Plastic Surgery, Johns Hopkins University School of Medicine.
authors: Naveen M
authors: NM
authors: Krishnan
authors: Chad
authors: C
authors: Purnell
authors: Maurice Y
authors: MY
authors: Nahabedian
authors: Gary L
authors: GL
authors: Freed
authors: John F
authors: JF
authors: Nigriny
authors: Joseph M
authors: JM
authors: Rosen
authors: Gedge D
authors: GD
authors: Rosson
mesh_terms: D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000191:economics* / Q000379:methods*; D008408:Mastectomy; D061525:Perforator Flap / Q000191:economics; D013524:Surgical Flaps / Q000191:economics*