Relatively little has been published to date comparing the resource costs of transverse rectus abdominis musculocutaneous (TRAM) flap and prosthetic breast reconstruction. The data that have been published reflect the experience at just one medical center with a previously known clear preference for autologous breast reconstruction. The goal of this study was to compare the resource costs of TRAM flap and prosthetic reconstruction in an institution where both procedures continue to be performed using modern techniques and at a relatively equivalent frequency. All available medical records were reviewed for patients who had completed their breast reconstruction between 1987 and 1997. Records of patients who had undergone TRAM flap or prosthetic reconstruction were reviewed to compare resource costs, including hospital stay, operating room time, anesthesia time, prosthetic devices, and physician's fees. Of 835 patients reviewed who had completed breast reconstruction, a total of 140 suitable patients were identified who had all the necessary financial information available. The patient population comprised 64 patients who received TRAM flaps and 76 patients who had undergone prosthetic reconstruction. The length of stay for the TRAM flap group, including all subsequent admissions for each patient, ranged from 2 to 24 days (mean, 6.25 days), and that for the prosthetic reconstruction group ranged from 0 to 20 days (mean, 4.36 days). Operating room time for the complete multistage reconstructive process for a TRAM flap ranged from 5 hours, 20 minutes to 12 hours, 25 minutes (mean, 7 hours, 34 minutes); with implant-based reconstruction, operating time ranged from 1 hour, 45 minutes to 8 hours, 56 minutes (mean, 4 hours, 6 minutes). With prostheses costing from $600 to $1200, a surgeon's fee of $160/hour, and an assistant's fee of $45/hour, the average cost of TRAM flap reconstructions was $19,607 (range, $11,948 to $49,402), compared with $15,497 for prosthetic reconstructions (range, $6422 to $40,015). The results were statistically significant (p < 0.001). Several factors weigh into the decision as to which reconstructive operation best suits the patient's needs. These factors include surgical risk, potential morbidity, and aesthetic results. On the basis of this review of autologous and prosthetic breast reconstruction in an institution where both are performed frequently, during a 10-year period with a mean time elapsed since reconstruction of 7.45 years, prosthetic reconstruction was significantly less expensive.
In an environment where health care resources are scarce, the cost of procedures and hospitalizations is of obvious concern to insurance companies, physicians, health care providers, and, ultimately, patients. 1-3 Cost and outcome studies represent a new discipline combining academic and business perspectives and are relatively new to the medical literature. 4-6 This science of cost and outcome studies becomes even more important when there are several options for treatment of a particular disease. In the field of breast reconstruction, there are a handful of studies comparing the costs of immediate versus delayed breast reconstruction 7,8 and free versus pedicled reconstruction. 9 There is only one study investigating the cost of implant-based versus autogenous breast reconstruction. 10
It was not until the late 1970s and early 1980s that breast reconstruction became increasingly popular. 11 This was due in part to the poor results seen with earlier methods of breast reconstruction, but with the introduction of the transverse rectus abdominis myocutaneous (TRAM) flap 12 and the latissimus flap and refinements in implant-based reconstruction, there have been dramatic improvements in breast reconstruction with a corresponding increase in its frequency. 13
Reconstructions using autogenous tissue have the potential to yield the highest quality aesthetic results. When done well, however, implant-based reconstruction can yield very good results with a lower morbidity to the patient, at least in terms of distant sites. 14 Implant-based reconstructions have the benefits of a shorter operative time, a shorter hospital stay, fewer surgical assistants, and a smaller investment by the patient and the surgeon. The resource costs were shown by Kroll 10 at M. D. Anderson Cancer Center to be higher initially for the TRAM flap patient. However, according to Kroll's experience, that cost difference changed by the fourth postoperative year, and implant-based reconstruction at that institution was projected to ultimately be more costly for the system than the TRAM flap.
At our institution, Georgetown University Medical Center, we perform a large number of breast reconstructions each year, using TRAM flaps and implants in relatively equal numbers. Unlike M. D. Anderson Cancer Center, our hospital has no clear predetermined preference for either procedure. Recommendations are made on an individual basis. We looked, therefore, at our experience with breast reconstruction during the past 10 years and compared the resource cost of the TRAM flap versus implant-based breast reconstruction at our institution, where both procedures are performed with equal frequency using modern techniques.