Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, Missouri, USA.
Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Microsurgery. 2022 Jul;42(5):401-427. doi: 10.1002/micr.30882. Epub 2022 Mar 31.
BACKGROUND: Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. METHODS: Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. RESULTS: From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. CONCLUSIONS: All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.
背景：接受即刻乳房重建且不接受放疗的女性可选择多种重建方法，但这些方法与需要手术和修复的并发症相关的长期成本不确定。我们评估了 9 种局部乳腺癌即刻乳房重建方法的成本效益。
方法：对单侧/双侧乳房重建进行 10 年的 Markov 建模，从医疗保健/社会角度考虑。在 PubMed、Embase、Cochrane、Scopus 和 CINAHL 中进行检索，从 79 项前瞻性研究中的 13744 名患者中获取数据。需要手术的并发症（乳房切除术坏死、全/部分皮瓣坏死、血清肿、血肿、感染、伤口裂开、腹疝、植入物取出/移植）和修复（脂肪坏死、包膜挛缩、不对称、疤痕/多余组织、植入物破裂/取出、脂肪移植）每年评估一次。重建方法包括：直接到植入物（DTI）、组织扩张器到植入物（TEI）、背阔肌皮瓣到植入物（LDI）、背阔肌（LD）、带蒂横行腹直肌肌皮瓣（TRAM）、游离 TRAM、腹壁下动脉穿支皮瓣/腹壁浅动脉皮瓣（DIEP/SIEA）、股部和臀部分区皮瓣。结果是增量成本效益比（ICER）和净货币效益（NMB）。意愿支付阈值为 50000 美元和 100000 美元。
结果：从单侧重建的医疗保健角度来看，与 LD 相比，DTI 的 ICER 为-42109.35 美元/QALY，LDI 为-25300.83 美元/QALY，TEI 为-22036.02 美元/QALY，DIEP/SIEA 为 8307.65 美元/QALY，游离 TRAM 为 8677.26 美元/QALY，带蒂 TRAM 为 13021.44 美元/QALY，臀部分区皮瓣为 17698.99 美元/QALY，股部分区皮瓣为 23447.82 美元/QALY。DIEP/SIEA 的 NMB 为 404523.47 美元，游离 TRAM 为 403821.40 美元，臀部分区皮瓣为 392478.64 美元，股部分区皮瓣为 387691.70 美元，带蒂 TRAM 为 376901.83 美元，LD 为 370646.93 美元，DTI 为 339668.77 美元，LDI 为 334350.30 美元，TEI 为 329265.84 美元。
结论：从医疗保健/社会角度来看，即刻乳房重建的 9 种方法均被认为具有成本效益。LD 提供的成本最低，而 DIEP/SIEA 提供的效果和 NMB 最大。
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