title: Free Versus Pedicled TRAM Flaps: Cost Utilization and Complications.
abstract: BACKGROUND
  Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset. However, clinical success depends upon more sophisticated technical expertise and facilities. This study aims to characterize postoperative outcomes undergoing free versus pedicled TRAM (pTRAM) flap breast reconstruction.
  
  
  METHODS
  Nationwide inpatient sample database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were females undergoing pTRAM or fTRAM breast reconstruction; males were excluded. We examined demographics, hospital setting, insurance information, patient income, and comorbidities. Clinical endpoints included postoperative complications, length-of-stay (LOS), and total charges (TC). Bivariate/multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization.
  
  
  RESULTS
  Overall, 21,655 cases were captured. Seventy-percent were Caucasian, 95 % insured, and 72 % treated in an urban teaching hospital. There were 9 pTRAM and 6 fTRAM in-hospital mortalities. On bivariate analysis, the fTRAM cohort was more likely to be obese (OR 1.2), undergo revision (OR 5.9), require hemorrhage control (OR 5.7), suffer hematoma complications (OR 1.9), or wound infection (OR 1.8) (p < 0.003). The pTRAM cohort was more likely to suffer pneumonia (OR 1.6) and pulmonary embolism (OR 2.0) (p < 0.004). Reconstruction type did not affect risk of flap loss or seroma occurrence. TC were higher with fTRAM (p < 0.001). LOS was not affected by procedure type. On risk-adjusted multivariate analysis, fTRAM was an independent risk factor for increased LOS (OR 1.6), TC (OR 1.8), and postoperative complications (OR 1.3) (p < 0.001).
  
  
  CONCLUSIONS
  Free TRAM has an increased risk of postoperative complications and resource utilization versus pTRAM on the current largest risk-adjusted analysis. Further analyses are required to elucidate additional factors influencing outcomes following these procedures.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A3 online Instructions to Authors. www.springer.com/00266 .
authors.affiliation: Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA.
authors.forename: Samuel
authors.initials: S
authors.lastname: Golpanian
authors.affiliation: Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Gerth
authors.affiliation: Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA.
authors.forename: Jun
authors.initials: J
authors.lastname: Tashiro
authors.affiliation: Division of Plastic, Aesthetic & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL, 33136, USA. SThaller@med.miami.edu.
authors.forename: Seth R
authors.initials: SR
authors.lastname: Thaller
mesh_terms: D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000601:surgery; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D005260:Female; D058752:Free Tissue Flaps / Q000098:blood supply / Q000191:economics / Q000637:transplantation*; D006084:Graft Rejection / Q000191:economics; D006085:Graft Survival; D017048:Health Care Costs; D006801:Humans; D007902:Length of Stay / Q000191:economics; D016462:Mammaplasty / Q000009:adverse effects* / Q000191:economics / Q000379:methods; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D064827:Myocutaneous Flap / Q000098:blood supply / Q000637:transplantation; D011183:Postoperative Complications / Q000191:economics / Q000401:mortality / Q000601:surgery; D017568:Rectus Abdominis / Q000637:transplantation*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply / Q000191:economics / Q000637:transplantation*; D014481:United States
keywords: Autologous breast reconstruction; Complications; Cost utilization; Free TRAM; Length of stay; Pedicled TRAM