Division of Plastic and Reconstructive Surgery, University of Utah School of Medicine, Salt Lake City, Utah, United States.
Division of Epidemiology, University of Utah, Salt Lake City, Utah, United States.
J Reconstr Microsurg. 2019 Oct;35(8):594-601. doi: 10.1055/s-0039-1688719. Epub 2019 May 10.
Bilateral mastectomy rates are increasing in the United States. The abdomen is the most common harvest site for autologous reconstruction. Nationwide data were examined to determine differences in hospital charges, length of stay (LOS), and early postoperative complications following immediate bilateral pedicled transverse rectus abdominis myocutaneous (pTRAM), free TRAM (fTRAM), deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) perforator flaps and were compared with unilateral reconstruction.
Patients who underwent immediate bilateral breast reconstruction using a single method of abdominally based reconstruction were identified using the 2009 to 2014 Nationwide Inpatient Sample Database. Outcomes included total hospital charges, LOS, and immediate postoperative complications.
We identified 13,348 cases of bilateral mastectomy with a single type of immediate bilateral autologous flap reconstruction. The majority were bilateral DIEP flaps. Mean total cost for bilateral pTRAM, fTRAM, DIEP, and SIEA flaps was US $21,886.80, US $28,839.40, US $30,051.30, and US $33,784.90, respectively (< 0.0001). Mean LOS for bilateral pTRAM, fTRAM, DIEP, and SIEA was 4.3, 4.9, 4.5, and 5.4 days, respectively ( = 0.0002), and hematoma rates were 1.93, 2.61, 3.68, and 16.59%, respectively, ( = 0.0001), whereas return to the operating room for vascular anastomosis revision was 0, 1.63, 1.99, and 19.07%, respectively (< 0.0001). Cost is less for unilateral pTRAM, fTRAM, and DIEP flaps (< 0.0001). LOS is shorter for unilateral fTRAM versus bilateral (< 0.0001). No differences were appreciated between unilateral and bilateral hematoma and reoperation rates for any reconstruction (> 0.1).
Immediate complication rates were higher in bilateral free flaps compared with bilateral pedicled flaps. pTRAM and fTRAM flap reconstructions are still performed frequently with acceptable immediate results without considering long-term morbidity, aesthetics, and abdominal muscle function. Bilateral SIEA free flaps were associated with significantly higher total cost, LOS, and complication rates compared with other groups. Complications were similar between unilateral and bilateral reconstruction procedures. While cost is significantly greater for bilateral procedures compared with unilateral pTRAM, fTRAM, and DIEP flaps, it is not doubled.
在美国，双侧乳房切除术的比例正在增加。腹部是自体重建最常用的采集部位。本研究旨在通过全国性数据来确定即刻双侧带蒂横行腹直肌肌皮瓣（pTRAM）、游离 TRAM（fTRAM）、腹壁下动脉穿支皮瓣（DIEP）和腹壁浅动脉穿支皮瓣（SIEA）即刻重建后在医院收费、住院时间（LOS）和早期术后并发症方面的差异，并与单侧重建进行比较。
使用 2009 年至 2014 年全国住院患者样本数据库，确定采用单一腹部基础重建方法即刻行双侧乳房重建的患者。主要结局包括总住院费用、LOS 和即刻术后并发症。
我们共确定了 13348 例单侧乳房切除术和单一类型即刻双侧自体皮瓣重建的病例。其中大多数为双侧 DIEP 皮瓣。双侧 pTRAM、fTRAM、DIEP 和 SIEA 皮瓣的平均总费用分别为 21886.80 美元、28839.40 美元、30051.30 美元和 33784.90 美元（<0.0001）。双侧 pTRAM、fTRAM、DIEP 和 SIEA 的平均 LOS 分别为 4.3、4.9、4.5 和 5.4 天（=0.0002），血肿发生率分别为 1.93%、2.61%、3.68%和 16.59%（=0.0001），而血管吻合口修复的再次手术率分别为 0、1.63%、1.99%和 19.07%（<0.0001）。单侧 pTRAM、fTRAM 和 DIEP 皮瓣的费用较低（<0.0001）。单侧 fTRAM 比双侧 fTRAM 的 LOS 更短（<0.0001）。任何重建术的单侧和双侧血肿及再次手术率均无差异（>0.1）。
与带蒂皮瓣相比，游离皮瓣即刻并发症发生率更高。pTRAM 和 fTRAM 皮瓣重建术仍在广泛应用，且即刻效果可接受，而无需考虑长期发病率、美观度和腹肌功能。与其他组相比，双侧 SIEA 游离皮瓣的总费用、LOS 和并发症发生率显著更高。单侧和双侧重建术的并发症相似。尽管双侧手术的费用明显高于单侧 pTRAM、fTRAM 和 DIEP 皮瓣，但并未翻倍。
