D. J. Gerth1, J. Tashiro1, S. R. Thaller1 1University Of Miami,DIvision Of Plastic Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA
Introduction: Conventionally, free transverse rectus abdominis myocutaneous (fTRAM) flap breast reconstruction has been associated with decreased donor site morbidity and improved flap inset, at the expense of higher requirements for technical expertise and advanced facilities. This study aims to characterize postoperative outcomes and their differences in patients undergoing free vs. pedicled TRAM (pTRAM) flap breast reconstruction.
Methods: The Nationwide Inpatient Sample (NIS) database (2008-2011) was reviewed for cases of fTRAM (ICD-9-CM 85.73) and pTRAM (85.72) breast reconstruction. Inclusion criteria were female patients undergoing pTRAM or fTRAM total breast reconstruction; males were excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, with clinical endpoints of postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay (LOS), and total charges (TC). Bivariate and Multivariate analyses were performed to identify independent risk factors associated with increased complications and resource utilization. Cases were weighted to project national estimates.
Results: Overall, 21,655 cases were captured. Of the entire cohort, 70% were Caucasian, 95% were insured, and 72% of patients were treated in an urban teaching hospital. Of the 11,331 pTRAM and 10,328 (48%) fTRAM cases, 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 complications from a hematoma (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. Type of reconstruction did not affect risk of flap loss or seroma. TC were higher in the fTRAM group (p<0.001), while LOS was not affected by procedure type. On a risk-adjusted multivariate analysis, fTRAM was found to be an independent risk factor for increased LOS (OR=1.6), TC (OR=1.8), and postoperative complication rate (OR=1.3), p<0.001.
Conclusion: Free TRAM breast reconstruction was found to have an increased risk of postoperative complications and resource utilization vs. pedicled TRAM on the largest risk-adjusted analysis to date. Further analyses are required to elucidate additional factors influencing outcomes following fTRAM and pTRAM reconstruction.