The Cost Effectiveness of the DIEP Flap Relative to the Muscle-Sparing TRAM Flap in Postmastectomy Breast Reconstruction

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 rectu...

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Veröffentlicht in:Plastic and reconstructive surgery (1963) 2015-04, Vol.135 (4), p.948-958
Hauptverfasser: Krishnan, Naveen M., Purnell, Chad, Nahabedian, Maurice Y., Freed, Gary L., Nigriny, John F., Rosen, Joseph M., Rosson, Gedge D.
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Sprache:eng
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Zusammenfassung: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. 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. 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. 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.
ISSN:0032-1052
1529-4242
DOI:10.1097/PRS.0000000000001125