Deep Inferior Epigastric Perforator Versus Free Transverse Rectus Abdominis Myocutaneous Flap Complications and Resource Utilization Yasmina Zoghbi, BS, David J. Gerth, MD, Jun Tashiro, MD, MPH, Samuel Golpanian, MD, and Seth R. Thaller, MD, DMD, FACS Introduction: Abdominal based breast reconstruction exists in a continuum from pedicled transverse rectus abdominis myocutaneous (TRAM) flap to deep infe- rior epigastric perforator (DIEP) free flap. DIEP flap has the advantage of com- plete rectus abdominis sparing during harvest, thus decreasing donor site morbidity. Aim of this study is to determine whether the surgical advantages of the DIEP flap impact postoperative outcomes versus the free TRAM flap (fTRAM). Methods: We reviewed the Nationwide Inpatient Sample database (2010–2011) for all cases of DIEP and fTRAM breast reconstruction. Inclusion criteria were: fe- male sex and patients undergoing DIEP or fTRAM total breast reconstruction. Male sex was excluded from the analysis. We examined demographic characteristics, hospital setting, insurance information, patient income, comorbidities, postopera- tive complications (including reoperation, hemorrhage, hematoma, seroma, myocar- dial infarction, pulmonary embolus, wound infection, and flap loss), length of stay, and total charges (TCs). Bivariate and multivariate analyses were performed to identify independent risk factors of increased length of stay and TCs. Results: Fifteen thousand eight hundred thirty-six cases were identified. Seventy percent were white, 97% were insured, and 83% of patients were treated in an ac- ademic teaching hospital setting. No mortalities were recorded. The DIEP cohort was more likely to be obese (P = 0.001). Free TRAM cohort was more likely to suffer pneumonia (P < 0.001; odds ratio [OR], 3.7), wound infection (P = 0.001; OR, 1.7), and wound dehiscence (P < 0.001; OR, 4.3). Type of reconstruction did not appear to affect risk of revision, hemorrhage, hematoma, seroma, or flap loss. Total charges were higher in the DIEP group (P < 0.001). Multivariate analysis demonstrated that fTRAM was an independent risk factor for increased length of stay (P < 0.001; OR, 1.6), and DIEP was an independent risk factor for in- creased TCs (P < 0.01; OR, 1.5). There was no significant difference in postoperative complications. Conclusions: The fTRAM cohort was more likely to develop surgical site com- plications and have an increased length of stay, but TCs were higher for the DIEP group. Key Words: breast reconstruction, health care cost, free tissue flaps, postoperative complications (Ann Plast Surg 2017;78: 516–520) A number of authors have proposed free autologous breast recon- struction as the standard of care to provide a cosmetically pleasing natural breast, by harvesting a reliable flap that minimizes abdominal wall (donor-site) morbidity. 1–3 The free tranverse rectus abdominis myocutaneous (fTRAM) flap was introduced in 1979, 4 and it had been the preferred method for abdominal based breast reconstruction until 1989 when Koshima and Soeda 5 described a technique that allowed sur- geons to harvest lower abdominal skin and fat while sparing the rectus abdominis muscle and anterior rectus fascia. This technique was popu- larized in 1994 6 and it involved the dissection of one or more perfora- tors originating from the deep inferior epigastric vessels. It is now known as the deep inferior epigastric perforator (DIEP) flap. 5 Both the TRAM and DIEP flaps result in a natural appearance, soft consistency, and durable aesthetically pleasing postmastectomy re- construction. 7 Both possess a direct reliable blood supply and have the additional advantage of potential restoration of cutaneous sensation to the breast. 8–10 In theory, by complete rectus abdominis muscle sparing, the DIEP flap shares the advantages of the fTRAM flap while minimiz- ing its disadvantages, which are primarily donor site complications. 11 However, determining whether or not the DIEP flaps are superior to fTRAM flaps remains unsettled. Published studies are inconclusive with respect to surgical technique and functional outcome measures. 11–15 The DIEP flap outcomes have been reported superior with regards to abdominal strength, bulge and contour, post-operative pain, and total charges (TC) for the procedures. 3,4,16–18 This is the first study to review the Nationwide Inpatient Sample (NIS) database, which provides the largest cohort comparing these two flaps. The goal of this study is to determine whether the surgical advan- tages of the DIEP flap impact postoperative outcomes versus the free TRAM flap. METHODS We reviewed the NIS database (2010–2011) for all cases of DIEP (International Classification of Disease, 10th Revision, Clinical Modifi- cation 85.74) and fTRAM (International Classification of Disease, 10th Revision, Clinical Modification 85.73) breast reconstruction. Inclusion criteria were: female sex and patients undergoing DIEP or fTRAM total breast reconstruction. Males were excluded from the analysis. We compared demographic characteristics, hospital setting, in- surance funding resource, patient income, comorbidities, postoperative complications (including reoperation, hemorrhage, hematoma, seroma, myocardial infarction, pulmonary embolus, wound infection, and flap loss), length of stay (LOS), and TCs. Bivariate and multivariate analyses were performed to identify independent risk factors of increased complications and resource utili- zation. Statistical significance was considered at P less than 0.05. Statis- tical analyses were performed using SPSS version 21.0 (IBM, Armonk, NY). RESULTS A summary of the demographic data can be found in Table 1. Fifteen thousand eight hundred thirty-six total cases were identified in the database. Of these, 61% (n = 9,699) were DIEP flap patients while 39% were fTRAM (n = 6,137). There was no difference in the age range of patients undergoing either flap procedure at time of admission. Me- dian age was 50 years old. There were no in-hospital mortalities noted throughout the entire study period. The majority of the cohort was white Received June 6, 2016, and accepted for publication, after revision August 30, 2016. From the Division of Plastic, Aesthetic, & Reconstructive Surgery, DeWitt Daughtry Family Department of Surgery, University of Miami Leonard Miller School of Medicine, Miami, FL. Conflicts of interest and sources of funding: none declared. D.J.G., J.T., and S.R.T. contributed to study conception and design. J.T. contributed to acquisition of data. J.T., D.J.G., and SG contributed to analysis and interpretation of data. Y.Z., D.J.G., and S.G. contributed to drafting of article. All authors contributed to critical revision of the article. Reprints: Seth R. Thaller, MD, DMD, FACS, Division of Plastic, Aesthetic, & Reconstructive Surgery, Clinical Research Building 4th Floor, 1120 NW 14th St, Miami, FL 33136. E-mail: SThaller@med.miami.edu. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/17/7805–0516 DOI: 10.1097/SAP.0000000000000936 MICROSURGERY 516 www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 78, Number 5, May 2017 Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.