PURPOSE: Prepectoral breast reconstruction is increasingly prevalent due to numerous esthetic and patient-reported outcome benefits. However, the need for more mesh draws criticism regarding cost. There are limited studies comparing the economics of subpectoral versus prepectoral techniques. We aim to evaluate total patient cost differences between prepectoral and subpectoral breast reconstruction at our institution.
METHODS: We performed a retrospective review of patients undergoing immediate tissue expander-based reconstruction at our institution from 2016 to 2018. We excluded patients with <1-year follow-up, those who had concurrent gynecologic or nonreconstructive breast procedures, or those who did not receive postoperative antibiotics. In addition to clinical data, we recorded net patient charges for the initial surgery (reconstruction and mastectomy), implant exchange, and readmissions or reoperations for complications and revisions. Unilateral and bilateral cohorts were independently evaluated. Our primary outcome was the total charge for reconstruction (TCR).
RESULTS: There were 53 unilateral reconstructions (12 prepectoral and 41 subpectoral) and 69 bilateral reconstructions (16 prepectoral and 53 subpectoral). There were no significant demographic or treatment differences in terms of age, body mass index, smoking history, or chemotherapy and radiation exposure. Average follow-up was 25 months and 21 months for the prepectoral and subpectoral groups respectively. Among unilateral reconstructions, the TCR at follow-up was $194,000 for the prepectoral cohort and $168,000 for the subpectoral cohort (P = 0.07). The average cost of initial operation was $17,000 more for the prepectoral group (P < 0.01), and the average cost of implant exchange was $6,000 more in the subpectoral group (P = 0.03). There were no differences in cost for complications, readmissions, or revisions between cohorts. Six (50%) prepectoral patients and 9 (22%) subpectoral patients had ≥1 reoperation (P = 0.06). Four (33%) prepectoral patients and 9 (22%) subpectoral patients had ≥1 readmission (P = 0.42). Among bilateral reconstructions, the TCR at follow-up was $240,000 for the prepectoral cohort and $220,000 for the subpectoral cohort (P = 0.19) The average cost of initial operation was $27,000 more for the prepectoral group (P < 0.01), and the average cost of implant exchange was $11,000 more in the subpectoral group (P = 0.01). There were no differences in costs for complications, readmissions, or revisions between cohorts. Ten (63%) prepectoral patients and 31 (58%) subpectoral patients had ≥1 reoperation (P = 0.78). Two (13%) prepectoral patients and 17 (32%) subpectoral patients had ≥1 readmission (P = 0.12). Subpectoral patients trended toward more admissions for pain control following any surgical procedure at 25% versus 6% (P = 0.11).
CONCLUSIONS: The costs associated with prepectoral breast reconstruction were not statistically different from subpectoral breast reconstruction at our institution in patients with ≥1-year follow-up. Although trends toward higher costs of total reconstruction were seen in the prepectoral group, these are likely offset by quality of life measures, less invasive nature, and decreased long-term revisions for animation deformity and capsular contracture that have not yet been measured. Longer follow-up may allow a more detailed assessment of any difference in overall cost between these 2 techniques.