A Comparison of Acellular Dermal Matrix to Autologous Dermal Flaps in Single-Stage, Implant-Based Immediate Breast Reconstruction: A Cost-Effectiveness Analysis

Hanover and Lebanon, N.H. From the Geisel School of Medicine at Dartmouth, Division of Plastic Surgery, Department of Surgery, Dartmouth Hitchcock Medical Center, and the Tuck School of Business at Dartmouth.
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 05/2013; 131(5):953-61. DOI: 10.1097/PRS.0b013e3182865a24
Source: PubMed

ABSTRACT : The use of acellular dermal matrix has allowed for single-stage immediate breast reconstruction after mastectomy at a significantly decreased cost compared with two-stage expander/implant reconstruction. The use of a pedicled autologous dermal flap in the same fashion as acellular dermal matrix in women with larger, ptotic breasts has also allowed for single-stage immediate breast reconstruction with similarly low complication rates and without the added procedural cost of using acellular dermal matrix. There have been no prior studies evaluating whether the added procedural cost for acellular dermal matrix is cost-effective relative to using an autologous dermal flap in single-stage immediate breast reconstruction following mastectomy.
: A comprehensive literature review was conducted to identify published complication rates for single-stage, implant-based immediate breast reconstruction using either acellular dermal matrix or an autologous dermal flap. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes and expert utility estimates to fit into a decision model to evaluate the cost-effectiveness of acellular dermal matrix.
: The decision model revealed a baseline cost difference of $261.72 and a 0.001 increase in the quality-adjusted life years when using acellular dermal matrix, yielding an incremental cost-utility ratio of $261,720 per quality-adjusted life year. Sensitivity analysis showed that acellular dermal matrix was not cost-effective when the complication rate for autologous dermal flaps was below 20 percent.
: The authors' study demonstrates that acellular dermal matrix is not a cost-effective technology in patients who can have an autologous dermal flap in single-stage immediate breast reconstruction.

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    ABSTRACT: Computed tomographic (CT)-angiography is a diagnostic tool increasingly used for preoperative vascular mapping in abdomen-based perforator flap breast reconstruction. This study compared the use of CT-angiography and the conventional practice of Doppler ultrasonography only in post mastectomy reconstruction using a cost-utility model. Following a comprehensive literature review, a decision analytic model was created using the three most clinically relevant health outcomes in free autologous breast reconstruction with CT-angiography versus Doppler ultrasonography only. Cost and utility estimates for each health outcome were used to derive the quality adjusted life years (QALY) and incremental cost utility ratio (ICUR). One-way sensitivity analysis was performed to scrutinize the robustness of our results. Six studies and 782 patients were identified. Cost-utility analysis revealed a baseline cost savings of $ 3,179, a gain in QALY of 0.25. This yielded an ICUR of -$12,716 implying a dominant choice favoring pre-operative CT-angiography. Sensitivity analysis revealed that CT-angiography was costlier when the operative time difference between the two techniques was less than 21.3 minutes. However, the clinical advantage of CT angiography over Doppler ultrasonography only showed that CT angiography would still remain the cost effective option even if it offered no additional operating time advantage. Our results show that CT-angiography is a cost effective technology for identifying lower abdominal perforators for autologous breast reconstruction. While the perfect study would be a randomized controlled trial of the two approaches with true cost accrual, our results represent the best available evidence.Level of Evidence: III.
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    ABSTRACT: Complete implant coverage by pectoralis major muscle in immediate breast reconstruction prevents implant exposure but restricts implant volume, increases the risk of a high-riding implant, and prevents natural ptosis. The authors hypothesized that extension of the subpectoral pocket with Vicryl mesh may produce more satisfactory results. The safety and efficiency of this technique were assessed by comparing complication rates and clinical results of the two reconstruction techniques: with and without mesh. The authors reviewed 161 immediate breast reconstructions in 139 patients from 2002 to 2010. A complete submuscular pocket was performed in 46 breasts and a partial submuscular pocket with Vicryl mesh extension was performed in 115 breasts. Complications, surgical revisions rates, implant size, and contralateral breast procedures were compared between the two groups. Early and late surgical revisions were similar between the mesh and nonmesh groups (11.6 percent versus 4.3 percent at 90 days, p = 0.09; and 34.3 percent versus 41.4 percent at 5 years, p = 0.41). There were fewer revisions for implant malposition in the mesh group (8.9 percent versus 21.7 percent, p = 0.05). Patients with mesh could have a larger implant in comparison with those without mesh (329 g versus 284 g, p = 0.01) and had fewer contralateral mastopexies (12 percent versus 30 percent, p = 0.01). Larger implants and perhaps better control of implant position were possible using the Vicryl mesh extension without increasing complications. Because the mesh technique also recreates a slightly ptotic breast, fewer contralateral mastopexies were needed. The Vicryl mesh extension is a low-cost alternative to biological matrices or tissue expanders. Therapeutic, III.
    Plastic &amp Reconstructive Surgery 03/2015; 135(3):498e-507e. DOI:10.1097/PRS.0000000000001027 · 3.33 Impact Factor
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    ABSTRACT: INTRODUCTION The global use of acellular dermal matrices as an adjunct to tissue expander or implant-based breast reconstruction, by surgeons wishing to cover and support the inferior pole, has increased in frequency in the last two decades. However despite the reported enhanced cosmetic outcomes, issues regarding their cost effectiveness have led to their infrequent use within the UK National Health Service and the need for an equally efficacious but cheaper alternative. PRESENTATION OF CASES We report two patients requiring bilateral revision breast surgery for severely asymmetrical, tender, ptotic breasts and cosmetically poor abdomens. Both were denied assisted acellular dermal matrix reconstructive surgery on the state NHS system and unable to afford the private costs. We therefore utilised free dermal fat grafts, harvested from concomitant abdominoplasties to extend the pectoralis major muscle and smooth surface irregularities. DISCUSSION Both patients achieved excellent cosmetic outcomes and aside from a small, spontaneously resolving abdominal site seroma in one patient, have remained free of any complications for over two years. This cost effective procedure is only feasible in patients with an adequate pannus who are amenable to the extra surgery and resultant scarring. CONCLUSION We herein report the use of free dermal fat graft in revision aesthetic and reconstructive surgery in a manner akin to recent acellular dermal matrix use. The comparable enhanced aesthetic outcomes, minimal complication rate and substantial cost savings merit dissemination to a global audience and encourage surgeons to consider this economic alternative.
    09/2014; 5(11). DOI:10.1016/j.ijscr.2014.08.026