Introduction: The deep inferior epigastric perforator flap is becoming a popular technique for post- mastectomy breast reconstruction. It is touted as a superior technique to the free TRAM flap in reducing abdominal donor site morbidity. The efficacy of both techniques has been recently documented.. A literature review has failed to identify a single article that deals specifically with the cost-effectiveness of the DIEP flap using proper health economic methodology. The purpose of this study is to compare the DIEP flap to the free TRAM flap using a Cost-Utility analysis, a variant of Cost-Effectiveness analysis.

Material and Methods: A decision Analytic Model and a Ministry of Health perspective were used for this study. Direct medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits (April 2002). Hospital costs were obtained from St.Joseph’s Hospital, a University Hospital in Hamilton , Ontario. Utilities were obtained from 33 plastic surgeons across Canada who were knowledgeable about the techniques and the associated complications. Utilities were converted into Quality Adjusted Life Years (QALYs). The probabilities of the various health states, (eg total flap failure, partial flap failure, abdominal hernia, abdominal bulging etc.) associated with the DIEP and free TRAM flaps were obtained by reviewing the recent literature. An Incremental Cost-Utility Ratio (ICUR ) was calculated on the assumption that the probabilities of health states and cost estimates reflected the two techniques. A sensitivity analysis was also performed by increasing the probabilities of key complications associated with the DIEP flap to see if the results are stable.

Results: The DIEP flap was more costly than the free TRAM flap but it provided more QALYs. The ICUR was $15,523.76/QALY. The sensitivity analysis has shown that the ICUR did not change substantially by increasing the probability of some of the key (plausible) complications of DIEP. Using the grades of recommendation for adoption of new medical interventions (Laupacis et al 1992), this study has shown that there is strong evidence of adoption of the DIEP flap.

Conclusions: This study has shown that the DIEP flap is cost-effective in the Canadian Health Care System. Due to the uncertainty and the biases surrounding the reported rate of complications , and the true estimates of costs associated with the two techniques however, there is a need to collect sampled data (costs and utilities) directly from patients in a Randomized Controlled Trial comparing the two techniques.