Cost-effectiveness of indocyanine green angiography in postmastectomy breast reconstruction.

BACKGROUND: Mastectomy skin flap necrosis is a major complication of skin- or nipple-sparing mastectomy. Indocyanine green angiography (ICGA) is a novel technology that can identify flaps at risk of necrosis, but there is paucity of cost-effectiveness data particularly in the Australian context. We evaluated its cost-effectiveness in breast reconstruction surgery. METHODS: Single-institution retrospective study of 295 implant-based breast reconstructions using ICGA compared with 228 reconstructions without ICGA from 2015 to 2020. Costs were calculated using Medicare item numbers and micro-costing analysis. Break-even point analysis determined the number needed to break-even. Cost-utility analysis compared probabilities of ischaemic complications and utility estimates derived from surveys of surgeons to fit into a decision model. RESULTS: There were 295 breast reconstructions using ICGA with a total cost of AU$164,657. The average cost of treating an ischaemic complication was AU$21,375. Use of ICGA reduced the ischaemic complication rate from 14.9% to 8.8%. Ischaemic complications were prevented in 18 breasts resulting in gross cost savings of AU$384,745 and net savings of AU$220,088. Three hundred eighteen cases using ICGA are needed to break-even. The decision model demonstrated a baseline cost difference of AU$1,179, a quality-adjusted life-years (QALY) difference of 1.77, and an incremental cost-utility ratio (ICUR) of AU$656 per QALY favouring ICGA. CONCLUSIONS: Routine use of ICGA during implant-based breast reconstruction is a cost-effective intervention for the reduction of ischaemic complications in the Australian setting. ICGA use was associated with a gain of 1.77 additional years of perfect health at a cost of AU$656 more per year.

Patterns of ischaemia and reperfusion in nipple-sparing mastectomy reconstruction with indocyanine green angiography.

BACKGROUND: Intraoperative assessment of mastectomy flaps and nipple-areola complex (NAC) with indocyanine green angiography (ICGA) for decision-making in delayed breast reconstruction after nipple-sparing mastectomy (NSM) remains to be fully elucidated. We evaluated patterns of ischaemia and reperfusion in NSM with delayed breast reconstruction and their outcomes. METHOD: Single-institution retrospective study of delayed implant-based breast reconstructions following NSM due to poor perfusion analysis on ICGA. Intraoperative ICGA perfusion values and fluorescence patterns during the delayed and subsequent reconstruction operations were analysed. RESULTS: Fifty-six (45 patients) delayed breast reconstructions following NSM were performed. The median time to reconstruction was seven days (range, 4-21 days). A total of 112 fluorescence images were reviewed. Four patterns of ischaemia were identified during initial mastectomy (Type I, diffuse ischaemia; Type II, geographic ischaemia; Type III, incisional ischaemia; Type IV, NAC only ischaemia). All, but 1 breast, had adequate reperfusion during delayed reconstruction. Obesity (BMI ≥ 30) was associated with Type I ischaemia (p < 0.001). Mean ICGA absolute and relative perfusion values during initial mastectomy were significantly lower than the perfusion values during delayed reconstruction (absolute value 6.7 versus 40.2 units, p < 0.001; relative value 10% versus 44%, p < 0.001, respectively). There were no cases of partial-thickness or full-thickness necrosis. CONCLUSIONS: Delaying breast reconstruction for NSM with ischaemia predicted by ICGA may allow blood supply to the flap and NAC to improve, reducing the risk for necrosis. Distinct patterns of ischaemia and low perfusion values with ICGA may be used in the decision to delay reconstruction.