The purpose of this study was to assess the cost-effectiveness of five standardized procedures for breast reconstruction to delineate the best reconstructive approach in postmastectomy patients in the settings of nonirradiated and irradiated chest walls.
A decision tree was used to model five breast reconstruction procedures from the provider perspective to evaluate cost-effectiveness. Procedures included autologous flaps with pedicled tissue, autologous flaps with free tissue, latissimus dorsi flaps with breast implants, expanders with implant exchange, and immediate implant placement. All methods were compared with a “do-nothing” alternative. Data for model parameters were collected through a systematic review, and patient health utilities were calculated from an ad hoc survey of reconstructive surgeons. Results were measured in cost (2011 U.S. dollars) per quality-adjusted life-year. Univariate sensitivity analyses and Bayesian multivariate probabilistic sensitivity analysis were conducted.
Pedicled autologous tissue and free autologous tissue reconstruction were cost-effective compared with the do-nothing alternative. Pedicled autologous tissue was the slightly more cost-effective of the two. The other procedures were not found to be cost-effective. The results were robust to a number of sensitivity analyses, although the margin between pedicled and free autologous tissue reconstruction is small and affected by some parameter values.
Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.
Hanover and Lebanon, N.H.; Aurora, Colo.; and Los Angeles, Calif.
From the Geisel School of Medicine at Dartmouth, Dartmouth College; the Center for Pharmaceutical Outcomes Research, University of Colorado Health Sciences Center; the Department of Plastic Surgery, Los Angeles County Hospital, University of Southern California; and the Department of Plastic Surgery, Dartmouth-Hitchcock Medical Center.
Received for publication December 19, 2012; accepted May 9, 2013.
The first two authors contributed equally to this article.
Disclosure: None of the authors has a financial interest in any of the products or devices mentioned in this article.
Ritwik Grover, M.D., 9500 Euclid Avenue, Cleveland, Ohio 44195, firstname.lastname@example.org