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A Cost-Effectiveness Analysis of Nipple-Areola Complex Reconstruction
Pooja S. Yesantharao, MS1, Chao Long, MD1, Pathik Aravind, MBBS1, Helen Xun, BS1, Justin M. Sacks, MD MBA2, Kristen P. Broderick, MD1.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Washington University in St. Louis School of Medicine, St. Louis, MO, USA.

BACKGROUND: The Women’s Health and Cancer Rights Act (WHCRA) mandates coverage for postmastectomy breast reconstruction. In women who have skin-sparing mastectomy, NAC reconstruction represents the final stage of definitive breast reconstruction. However, as it currently stands, WHCRA language on NAC reconstruction is vague, especially with regards to 3D NAC dermopigmentation. While some insurance plans cover 3D NAC dermopigmentation performed by both physicians and tattoo artists, other plans limit this procedure to physicians only, and others do not cover it at all. As 3D NAC dermopigmentation gains popularity, especially in patients who cannot or do not want to undergo an additional surgical procedure for NAC reconstruction, it is important to understand the cost-effectiveness of this procedure compared to flap-based NAC reconstruction. Such an analysis considering both patient outcomes and procedure costs can have important implications for reimbursement considerations, as well as for patient and provider decision-making, especially in the current cost-conscious healthcare climate.
METHODS: This was an Institutional Review Board-approved retrospective investigation of the cost-effectiveness of flap-based techniques versus 3D intradermal tattooing for post-mastectomy NAC reconstruction. Costs were estimated using Centers for Medicare and Medicaid Services data. Effectiveness was determined using BREAST-Q adjusted life years (BQALYs), using BREAST-Q data collected at 12 months post-reconstruction. Decision tree modeling with TreeAge software (Williamstown, MA) was used to study cost-effectiveness from the payer perspective.
RESULTS: Study data were derived from 128 NAC reconstruction patients between 2015-2019. 3D areolar dermopigmentation was associated with a 1.1 decrease in BQALYs per patient and a $2,476 decreased in costs when compared to flap-based reconstruction with a skin graft. Thus, in the base case, the ICER for 3D areolar dermopigmentation was $2,250 per BQALY, which was cost effective at a willingness to pay threshold of $50,000. 3D areolar dermopigmentation did not substantially decrease BQALYs but did substantially decrease costs, and was therefore cost-effective. When specifically investigating post-mastectomy radiation therapy patients (PMRT), 3D areolar dermopigmentation was found to be the dominant strategy compared to local flap reconstruction with skin grafting. Revision surgery and complication costs were greater for flap-based NAC reconstruction in PMRT patients.
CONCLUSIONS: 3D dermopigmentation may present a cost-effective approach to NAC reconstruction, especially in certain patient cohorts (i.e. PMRT patients). This conclusion was strengthened by the robustness of our model results upon probabilistic and deterministic sensitivity analyses. Understanding cost-effectiveness of NAC reconstruction techniques can improve the conversation between surgeons and patients during the clinical decision-making process.


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