A Cost Comparison of Single Stage Direct-To-Implant and Two-Staged Tissue Expander-To-Implant Breast Reconstruction with Acellular Dermal Matrix Versus Abdominal Based Perforator Free Flap
Bao Ngoc N. Tran, MD1, Sherise Epstein, BS2, Bernard T. Lee, MD, MBA, MPH1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Harvard School of Public Health, Boston, MA, USA.
Background: Autologous and implant-based reconstruction are the two most popular techniques in breast reconstruction post mastectomy. The current standard of care for breast implant reconstruction after mastectomy is two-stage reconstruction with tissue expanders followed by implants (TE/I+ADM). Immediate single-stage direct-to-implant breast reconstruction with acellular dermal matrix (SSI+ADM) has gained much popularity recently. We performed comprehensive cost analysis to compare these two types of implant-based breast reconstruction with the most popular autologous reconstruction, deep inferior epigastric perforator flap (DIEP).
Methods: A comparative cost analysis of TE/I+ADM, SSI+ADM, and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of perioperative complications including cellulitis, seroma, hematoma, skin necrosis, capsular contracture, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010-2016.
Results: Average actual cost for successful TE/I+ADM, SSI+ADM, and DIEP flap were $13,304.55, $8,055.71, $10,237.13 respectively. The overall pooled complications for TE/I+ADM, SSI+ADM, and DIEP flap were 32%, 11%, and 27%. Incorporating pooled complication data from published literature resulted in an increase in cost to $13,842.78, $8,278.08, and $11,422.27 respectively for each group. The expected costs for successful TE/I+ADM, SSI+ADM, and DIEP flap were $9,029.80, $7,107.55, and $7,414.75, significantly lower than the actual costs.
Conclusions: SSI+ADM reconstruction was the most cost-effective method of reconstruction at baseline as well as with pooled complications. TE/I+ADM reconstruction incurred the highest perioperative complication cost. Long-term costs associated with implant-based reconstruction such as revision, implant rupture, implant replacement, and additional need for future MRI screenings should be considered when making decision about treatment plans. 
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