The economic viability of breast reconstruction in the UK: comparison of a single surgeon's experience of implant; LD; TRAM and DIEP based reconstructions in 274 patients.

A retrospective audit was performed of patients undergoing breast reconstruction under the care of the senior author from 2000 to 2007. We documented reconstruction type, length of stay and total number of revisions. Income to the trust based on the 2008/9 HRG codes along with any "top ups" was also recorded. This was compared to calculations of cost to the trust of performing each reconstruction. 274 patients had 278 primary reconstructions and a further 366 revisions. Only patients with a minimum one-year's follow-up were included (mean 3 years). This included 68 DIEPs'; 39 TRAMs'; 98 LDs'; and 73 implant reconstructions. The median length of stay for implant based reconstruction was 4 days; 9 for LD flaps; 11 for TRAMs' and 8 for DIEPs'. This was significantly shorter for the implant group compared to other reconstructions (P<0.001). The mean number of surgical revisions was 1.5 for implant reconstructions; 1.6 for LDs; 0.9 for TRAMs' and 0.8 for DIEPs'. There were significantly more revisions of implant reconstructions than DIEPs (P=0.037) and significantly more revisions of LDs compared to TRAM and DIEPs' (P=0.012 and 0.0023). In our study, the cost of an LD, TRAM or DIEP reconstruction including both primary surgery and any revisions was similar, and while at an average of three years, the implant reconstruction remains cheaper, that patient will still require more revisions, and if followed up enough will lose this small financial benefit. Furthermore, the difference is small (£8034 for implants vs. £10910 for DIEPs), and it could be argued this is justified by the increased patient satisfaction and cosmetic outcome. Finally we highlight several areas of financial inequality, including insufficient remuneration for providing individual operations, the lack of payment for performing more than one procedure at the same time and lack of payment for bilateral procedures.