Splitting the Difference: Using Synthetic and Biologic Mesh to Decrease Cost in Prepectoral Immediate Implant Breast Reconstruction.

SUMMARY: Prepectoral breast reconstruction has minimized morbidity and dynamic deformities associated with submuscular implant-based breast reconstruction. However, reliance on implant coverage with acellular dermal matrix in immediate implant reconstruction remains limited by high material costs. The authors describe a technique in which anterior implant coverage in prepectoral reconstruction is split into acellular dermal matrix inferolaterally and synthetic, absorbable mesh superiorly. Use of acellular dermal matrix inferiorly provides coverage and reinforces the inframammary fold, whereas the absorbable mesh is trimmed and sutured to the acellular dermal matrix at the appropriate tension to support the implant and relieve pressure on mastectomy flaps. A retrospective review was performed on all consecutive prepectoral one-stage breast reconstructions using this technique at a single institution. Patient demographics, mastectomy and reconstruction characteristics, reconstructive outcomes, and cost of support materials were queried and analyzed. Eleven patients (21 breasts) underwent prepectoral immediate implant reconstruction with Vicryl and acellular dermal matrix anterior coverage. Average mastectomy weight was 775.8 g. Smooth, round cohesive implants were used in all cases and average implant size was 514.5 ml. Overall complication rates were low and included one minor infection (4.8 percent) and one case of minor mastectomy flap and partial nipple necrosis each (4.8 percent). Calculated cost savings of Vicryl and acellular dermal matrix anterior coverage was up to $3415 in unilateral and $6830 in bilateral cases. Prepectoral breast reconstruction using acellular dermal matrix inferiorly and Vicryl mesh superiorly is a safe technique that decreases material costs associated with support materials and allows the surgeon to precisely control the implant pocket and position. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Use of Absorbable Mesh in Implant-Based Breast Reconstruction: A 7-Year Review.

BACKGROUND: Breast reconstruction is most frequently performed using implants or expanders. Adjunctive materials such as acellular dermal matrix and synthetic meshes are used to support the implant or expander. A paucity of large studies exist on the use of synthetic mesh for breast reconstruction. METHODS: A retrospective chart review of all patients over the past 7 years who had implant reconstruction with synthetic absorbable mesh at the Massachusetts General Hospital was performed. Data were collected on demographic and surgical outcomes. Statistical analysis was performed. RESULTS: A total of 227 patients (376 mastectomies) were treated with direct-to-implant subpectoral reconstruction with absorbable mesh from 2011 to 2017. The infection rate was 2.1 percent. The rate of capsular contracture was 4.8 percent. Patients who had radiation therapy either preoperatively or postoperatively had a higher rate of complications, including capsular contracture. Cost savings for using mesh instead of acellular dermal matrix surpassed $1.2 million. CONCLUSION: Synthetic absorbable mesh is a safe alternative to acellular dermal matrix in prosthetic breast reconstruction and provides stable results along with significant cost savings. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Economic Analysis of Using Free Fat Graft or Acellular Dermis to Prevent Post-parotidectomy Frey Syndrome.

A decision tree was constructed to determine the incremental cost-effectiveness ratio (ICER) of grafting techniques used to prevent Frey Syndrome. The authors performed a sensitivity analysis to calculate what the probability of preventing Frey Syndrome would have to be and maximum costs associated with using grafting techniques to warrant their use as more "cost-effective" choice than using neither. Decision pathways utilized were uses of (1) free fat graft (FFG), (2) acellular dermis, and (3) no grafting. The probability of developing Frey syndrome and costs were extracted from previous studies to construct the decision tree. The primary effectiveness was the ICER of FFG or acellular dermis to prevent Frey syndrome. The initial outcomes included preventing Frey syndrome (effectiveness = 1) or developing Frey syndrome (effectiveness = 0). Compared with not using a graft, the ICER of using FFG and acellular dermis were $10,628 and $50,813, respectively. Frey syndrome was found in 2.6% of patients postoperatively in FFG group, 9.8% of patients in acellular dermis group, and 30.7% of patients who did not have a graft. The ICER shows absolute dominance of FFG with lower cost and high effectiveness over acellular dermis. This economic evaluation strongly supports the use of FFG over acellular dermis as cost-effective approach for prevention of postparotidectomy Frey syndrome.

Assessing value in breast reconstruction: A systematic review of cost-effectiveness studies.

INTRODUCTION: Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models. METHODS: A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017. RESULTS: After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer. CONCLUSIONS: Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

Cost analysis of postmastectomy reconstruction: A comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps.

BACKGROUND AND OBJECTIVES: Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. METHODS: A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. RESULTS: Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. CONCLUSIONS: DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.

A prospective, randomised, controlled, multicentre clinical trial examining healing rates, safety and cost to closure of an acellular reticular allogenic human dermis versus standard of care in the treatment of chronic diabetic foot ulcers.

Acellular dermal matrices can successfully heal wounds. This study's goal was to compare clinical outcomes of a novel, open-structure human reticular acellular dermis matrix (HR-ADM) to facilitate wound closure in non-healing diabetic foot ulcers (DFUs) versus DFUs treated with standard of care (SOC). Following a 2-week screening period in which DFUs were treated with offloading and moist wound care, patients were randomised to either SOC alone or HR-ADM plus SOC applied weekly for up to 12 weeks. At 6 weeks, the primary outcome time, 65% of the HR-ADM-treated DFUs healed (13/20) compared with 5% (1/20) of DFUs that received SOC alone. At 12 weeks, the proportions of DFUs healed were 80% and 20%, respectively. Mean time to heal within 12 weeks was 40 days for the HR-ADM group compared with 77 days for the SOC group. There was no incidence of increased adverse or serious adverse events between groups or any adverse events related to the graft. Mean and median graft costs to closure per healed wound in the HR-ADM group were $1475 and $963, respectively. Weekly application of HR-ADM is an effective intervention for promoting closure of non-healing DFUs.

[Application of combination of xenoskin with delayed microskin graft in extensively burned patients].

OBJECTIVE: To observe clinical effects of combination of acellular porcine skin with delayed microskin graft on extensively burned patients.
 Methods: Forty extensively burned patients were assigned into a treatment group and a control group. In the treatment group, 20 patients were covered with acellular porcine skin after escharectomy, and the delayed microskin grafting was performed 5 days later. In the control group, 20 patients were covered with allograft skin combined with microskin graft after escharectomy. The cure rate, the graft survival rate, wound healing time and cost per 1% wound were observed.
 Results: The cure rate for the 2 groups was the same (90%), and wound healing time was similar between the two groups (P>0.05). The graft survival rate in the treatment group was higher than that in the control group (P<0.05), and cost per 1% wound in the treatment group was less than that in the control group (P<0.05).
 Conclusion: The combination of acellular porcine skin with delayed microskin graft is an effective method to treat extensively burned patients, and it provides an ideal substitute for allograft skin combined with microskin graft.

Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis.

BACKGROUND: Biologic mesh choice in ventral hernia repair is challenging due to lack of prospective data. This study examines long-term, single-center biologic mesh outcomes. METHODS: Prospective operative outcomes data was queried for open ventral hernia repair with biologic mesh. Univariate and multivariate analysis were used to compare mesh outcomes. RESULTS: In the study, 223 patients underwent open ventral hernia repair with biologic mesh, including 40 with Alloderm, 23 AlloMax, 70 FlexHD, 68 Strattice, and 22 Xenmatrix. Overall, 9.8% had an American Society of Anesthesiology classification of 4, 54.6% with a classification of 3, and 35.6% with a classification of 1 or 2. Operative time averaged 241 minutes with estimated blood loss of 202 mL. Hernia defects averaged 257 ± 245 cm2 with mesh size 384 cm2. Biologic mesh was used as a fascial bridge in 19.6%, component separation was performed in 47.5%, and 82% had concomitant procedure. Inpatient mortality was 1.4%. Hernia recurrence varied significantly by mesh type: 35% Alloderm, 34.5% AlloMax, 37.1% FlexHD, 14.7% Strattice, and 59.1% Xenmatrix (P = .001). The mean follow-up was 18.2 months. After multivariate analysis comparing to Strattice, AlloMax had a 3.4 higher odds ratio for recurrence, FlexHD a 2.9 odds ratio, and Xenmatrix a 7.8 odds ratio. The rate of mesh infections requiring explantation was <1%. Total hospital charges averaged $131,004 ± $143,320. Mean charges varied significantly between meshes; Xenmatrix was the most expensive and AlloMax was the least expensive (P < .05). CONCLUSION: In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and Xenmatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.

A comparison of outcomes and cost in VHWG grade II hernias between Rives-Stoppa synthetic mesh hernia repair versus underlay biologic mesh repair.

BACKGROUND: The current literature is void of evidence-based guidelines regarding optimal choice of mesh. We aim to perform a comparative outcome analysis of synthetic mesh and acellular dermal matrix (ADM) in Ventral Hernia Working Grade (VHWG) grade II hernias with primary fascial closure. METHODS: A retrospective review of patients undergoing ventral hernia repair (VHR) by the senior author (S.J.K.) from 2007 to 2012 was performed. Patients undergoing VHR with primary fascial closure were risk stratified using the VHWG defined grading system. RESULTS: Seventy-two patients met the abovementioned inclusion criteria with 45 receiving synthetic mesh and 27 receiving ADM. The mean length of follow-up was 12.1 ± 9.1 months. Patients were, on average, 53.2 ± 11.6 years of age with a BMI of 33.9 ± 10.6 kg/m(2). The overall incidence of surgical site occurrence (SSO) in the cohort was 41.7 % and the incidence of hernia recurrence was 5.6 %. 30-day mortality was 1.2 %. Bivariate analysis demonstrated that obesity (P = 0.038) and number of comorbidities (P = 0.043) were associated with SSO. Bivariate analysis demonstrated that prior failed hernia, use of ADM, and operative time were associated with higher rates of hernia recurrence; however, adjusted multivariate regression found only prior failed hernia (OR = 4.1, P = 0.03) and biologic mesh (OR = 3.4, P = 0.046) to be independently associated with recurrent hernia. Comparison of mesh types revealed few differences in preoperative or operative characteristics between synthetic mesh and acellular dermal matrices (ADM). The rate of hernia recurrence was significantly higher with ADM (14.8 % vs. 0.0 %, P = 0.017). Patients receiving ADM repairs incurred significantly greater cost ($56,142.1 ± 54,775.5 vs. $30,599.8 ± 39,000.8, P < 0.001). CONCLUSIONS: These data suggest synthetic mesh is indicated in higher risk VHWG grade II repairs. In comparison to ADM, synthetic mesh was associated with significantly fewer hernia recurrences and lower cost utilization at 1-year. LEVEL OF EVIDENCE: Prognostic/risk category, level III.

An algorithmic approach for selective acellular dermal matrix use in immediate two-stage breast reconstruction: indications and outcomes.

BACKGROUND: Acellular dermal matrix use has gained widespread acceptance--despite higher material costs--because of its ease of use and potential for enhanced cosmesis. The authors developed a resource-sensitive algorithm for selective acellular dermal matrix use with indications and contraindications based on body mass index, breast size, radiation therapy, flap vascularity, and pectoralis anatomy. METHODS: The algorithm incorporates preoperative and intraoperative decision points. Complication rates and aesthetic scores were compared for procedures performed before and after adoption of the algorithm. Multiple logistic regression was used to determine the independent influence of the algorithm on postoperative outcomes. RESULTS: One hundred ninety-three breasts underwent reconstruction before and 179 underwent reconstruction after implementation of the algorithm. Overall complication rates did not differ between the cohorts (22.8 percent versus 20.7 percent; p=0.138). After adjusting for potential confounders, the algorithm did not significantly affect the incidence of infection, seroma, flap necrosis, explantation, or overall complications (all p>0.05). Aesthetic scores were not affected (2.75 of 4 versus 3.03 of 4; p=0.138). Acellular dermal matrix use decreased from 84 percent to 36 percent, resulting in a materials cost savings of $270,000 over the study period. CONCLUSIONS: This algorithm obviated placement of acellular dermal matrix in an estimated 48 percent of immediate tissue-expander reconstructions. Patients treated after adoption of this algorithm experienced similar complication rates and aesthetic outcomes as those who underwent reconstruction before. The authors' preliminary outcomes demonstrate that evidence-based measures can be taken to selectively use acellular dermal matrix without a concomitant worsening of patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The impact of conflicts of interest in plastic surgery: an analysis of acellular dermal matrix, implant-based breast reconstruction.

BACKGROUND: Although conflicts of interest in biomedical research have received significant attention, the impact of conflicts of interest on surgical outcomes has not been fully explored. METHODS: A systematic electronic search of the literature was performed for studies that evaluated surgical outcomes in acellular dermal matrix and non-acellular dermal matrix implant-based breast reconstruction. Surgical complications, including infection, seroma, hematoma, necrosis, and explantation, were used as outcome metrics and extracted from studies. Surgical outcomes were then pooled and compared between studies that disclosed conflicts of interest and those that did not disclose conflicts of interest. RESULTS: A total of 776 abstracts were identified, of which only 35 fulfilled the authors' inclusion criteria. Conflicts of interest were reported in 14 of these abstracts (40 percent). The pooled data from studies that reported no conflicts of interest and studies that reported conflicts of interest included a total of 8241 and 5384 breasts and 2852 and 1864 patients, respectively. Considered collectively, surgical complications were less common in studies that reported a conflict of interest than in studies that reported no conflicts of interest. When surgical outcome data were further stratified by acellular dermal matrix use, surgical complications were less common in studies with conflicts of interest when acellular dermal matrix was used. However, when acellular dermal matrix was not used, surgical complications were similar between authors that reported a conflict of interest and those that did not report a conflict of interest. CONCLUSIONS: Self-reported conflicts of interest are common in implant-based breast reconstruction research. Studies authored by groups with conflicts of interest are significantly associated with reporting lower surgical complications and therefore describing positive research findings, especially when industry-marketed products are being used in the study. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Multi Centre Canadian Acellular Dermal Matrix Trial (MCCAT): study protocol for a randomized controlled trial in implant-based breast reconstruction.

BACKGROUND: The two-stage tissue expander/implant (TE/I) reconstruction is currently the gold standard method of implant-based immediate breast reconstruction in North America. Recently, however, there have been numerous case series describing the use of one-stage direct to implant reconstruction with the aid of acellular dermal matrix (ADM). In order to rigorously investigate the novel application of ADM in one-stage implant reconstruction, we are currently conducting a multicentre randomized controlled trial (RCT) designed to evaluate the impact on patient satisfaction and quality of life (QOL) compared to the two-stage TE/I technique. METHODS/DESIGNS: The MCCAT study is a multicenter Canadian ADM trial designed as a two-arm parallel superiority trial that will compare ADM-facilitated one-stage implant reconstruction compared to two-stage TE/I reconstruction following skin-sparing mastectomy (SSM) or nipple-sparing mastectomy (NSM) at 2 weeks, 6 months, and 12 months. The source population will be members of the mastectomy cohort with stage T0 to TII disease, proficient in English, over the age of 18 years, and planning to undergo SSM or NSM with immediate implant breast reconstruction. Stratified randomization will maintain a balanced distribution of important prognostic factors (study site and unilateral versus bilateral procedures). The primary outcome is patient satisfaction and QOL as measured by the validated and procedure-specific BREAST-Q. Secondary outcomes include short- and long-term complications, long-term aesthetic outcomes using five standardized photographs graded by three independent blinded observers, and a cost effectiveness analysis. DISCUSSION: There is tremendous interest in using ADM in implant breast reconstruction, particularly in the setting of one-stage direct to implant reconstruction where it was previously not possible without the intermediary use of a temporary tissue expander (TE). This unique advantage has led many patients and surgeons alike to believe that one-stage ADM-assisted implant reconstruction should be the procedure of choice and should be offered to patients as the first-line treatment. We argue that it is crucial that this technique be scientifically evaluated in terms of patient selection, surgical technique, complications, aesthetic outcomes, cost-effectiveness, and most importantly patient-reported outcomes before it is promoted as the new gold standard in implant-based breast reconstruction. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00956384.

Economic analysis and review of the literature on implant-based breast reconstruction with and without the use of the acellular dermal matrix.

BACKGROUND: Use of the acellular dermal matrix (ADM) in two-stage implant-based breast reconstruction has been widely adopted. Despite an increasing focus on health care costs, few reports have addressed the financial implications of ADM use. This study sought to examine the costs of the two-stage technique with and without ADM, concentrating on the direct variable costs of patient care during the expansion process. METHODS: A retrospective review of a prospectively maintained database was conducted. Data were collected on 132 cases resulting in a second-stage exchange for a permanent implant. The findings showed that AlloDerm was used in 61 reconstructions and Strattice in 23 reconstructions. The primary outcome was the number of fills required to achieve the final expander fill volume. The cost of subsequent patient encounters for expansion was estimated using institutional cost data. RESULTS: The number of fills required to achieve the final volume was higher in the non-ADM group (6.5 ± 1.7) than in the ADM group (3.6 ± 1.4) (p < 0.0001). No significant difference was found in the small fill volumes (<350 ml; 5.3 vs. 3.7; p > 0.05). The difference was significant in the larger fill volumes (>500 ml; 8.3 vs. 3.7; p < 0.05). Relative to non-ADM reconstruction, with AlloDerm at current prices, the cost increase ranged from $2,727.75 for large reconstructions to $3,290.25 for small reconstructions ($2,167.75-$2,739.25 with Strattice). CONCLUSION: The use of ADM in two-stage reconstruction reduces the number of visits required for reconstructions with 350 ml or more. However, at current pricings, the direct cost of ADM use does not offset the cost savings from the reduced number of visits. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Use of Matriderm® 1mm in reconstructive surgery. Series of 31 cases]. / Utilisation de Matriderm® 1mm en chirurgie reconstructrice. Série de 31 cas.

INTRODUCTION: Dermal substitute are used for soft-tissue defect for their functional and aesthetic advantages. Matriderm® 1mm, single layer dermal matrix, composed of collagen and elastin covered by a split thickness skin graft simultaneously to its application, has been used most often in burned surgery. This prospective series evaluates the interest of this recent dermal matrix in reconstructive surgery. PATIENTS AND METHOD: Twenty-eight patients have been treated with the substitute in our department for reconstructive surgery indication between November 2008 and May 2012. Indications were tissue losses treatment after limb or trunk sarcoma resection, melanoma, extended baso- or spinocellular carcinoma, palmoplantar keratodermy, burn sequels, or traumatic tissue losses. Indications were preferentially deep tissue losses, functional areas and the face. RESULTS: Mean treated area has been 82.4 cm(2) (10 to 600 cm(2)). Mean taken rate has been 87±19% of the area and mean day of discharge has been 4.8 days and the mean cost per patient 906.5 euros. Negative wound therapy, until D3, was used 6 times. Three patients treated for limb sarcoma had radiotherapy performed on the grafted area. Aesthetic and functional results have been encouraging. CONCLUSIONS: Matriderm® 1mm, dermal substitute commonly used in acute burn treatment can be indicated in reconstructive surgery. This series show that it permits to obtain a good graft taken rate, a quick healing with a satisfying aesthetic and functional results and permit an early discharge. However, its indications are limited by its cost.

A European comparison of reimbursement in breast reconstruction.

AIMS: Case payment mechanisms have become the principal means of remunerating hospitals in most developed countries. The purpose of this study was to make an international comparison of reimbursement for breast reconstructive surgery. METHODS: We analysed remuneration for unilateral and bilateral female breast reconstruction (pedicled flaps, free flaps, alloplastic procedures) across five different European countries. National grouper software was used to identify Diagnosis Related Groups from which the proceeds were derived. RESULTS: The mean reimbursement was € 5593 for pedicled flaps, € 9149 for free flaps and € 4037 for implant-based reconstructions. The highest payments were in Sweden and the lowest in Italy. When adjusting payments by purchasing power parities, the relation among the countries did not change. The Austrian system makes a clear distinction between one-stage and two-stage delayed reconstructive interventions whereas reimbursement in other countries favoured a two-stage approach. Only one of five national reimbursement systems distinguishes between unilateral and bilateral reconstructions. CONCLUSIONS: Across a spectrum of European countries, reimbursement for breast reconstruction was based on similar procedure-specific systems, although there was a wide variation in tariffs and consideration of other factors such as underlying diagnosis. As delivery of healthcare becomes more rationalised, there is a need for individualised reimbursement which correlates directly with activity. Drawing on the experience of different healthcare systems may lead to development of a more robust and fair system of reimbursement.

Cost minimisation analysis of using acellular dermal matrix (Strattice™) for breast reconstruction compared with standard techniques.

BACKGROUND: We performed a cost analysis (using UK 2011/12 NHS tariffs as a proxy for cost) comparing immediate breast reconstruction using the new one-stage technique of acellular dermal matrix (Strattice™) with implant versus the standard alternative techniques of tissue expander (TE)/implant as a two-stage procedure and latissimus dorsi (LD) flap reconstruction. METHODS: Clinical report data were collected for operative time, length of stay, outpatient procedures, and number of elective and emergency admissions in our first consecutive 24 patients undergoing one-stage Strattice reconstruction. Total cost to the NHS based on tariff, assuming top-up payments to cover Strattice acquisition costs, was assessed and compared to the two historical control groups matched on key variables. RESULTS: Eleven patients having unilateral Strattice reconstruction were compared to 10 having TE/implant reconstruction and 10 having LD flap and implant reconstruction. Thirteen patients having bilateral Strattice reconstruction were compared to 12 having bilateral TE/implant reconstruction. Total costs were: unilateral Strattice, £3685; unilateral TE, £4985; unilateral LD and implant, £6321; bilateral TE, £5478; and bilateral Strattice, £6771. CONCLUSIONS: The cost analysis shows a financial advantage of using acellular dermal matrix (Strattice) in unilateral breast reconstruction versus alternative procedures. The reimbursement system in England (Payment by Results) is based on disease-related groups similar to that of many countries across Europe and tariffs are based on reported hospital costs, making this analysis of relevance in other countries.

Acellular dermal matrices in secondary aesthetic breast surgery: indications, techniques, and outcomes.

Acellular dermal matrices are integrally involved in the majority of expander-implant reconstructions and complex hernia repairs today, and they are now making their way into secondary aesthetic breast surgery. The number of revisional breast surgery cases has continued to increase as the materials and repair techniques have improved. The aesthetic outcome bar is constantly being raised, and the complexity of patient deformities often requires additional tissues to achieve a successful repair. The most common complications in breast augmentation are reviewed, along with indications and some current repair techniques, general principles, and specific caveats to help plastic surgeons deal with these complex and challenging patient problems utilizing acellular dermal matrices.

The use of acellular dermal matrices in revisional breast reconstruction.

BACKGROUND: The use of acellular dermal matrices in breast surgery has become popular in the last two decades, with a corresponding increase in experience and literature. The authors reviewed the literature and summarize key technical points regarding use of acellular dermal matrices in reconstructive breast surgery. METHODS: Current applications have emphasized both primary and secondary breast reconstruction. Newer approaches focus on breast revisional surgery, especially when matrix material is used to correct deformities commonly arising after breast implant placement. In these situations, matrices have widened the indications and improved results by providing additional support to the lower pole, extending the pectoralis major muscle, and smoothing surface irregularities. Increased use of these products has also spurred our understanding of their biological properties of cell infiltration, tolerance, and inflammation. RESULTS: Acquired deformities, such as symmastia, rippling, malposition, and lower pole bottoming out, that were previously difficult to treat are significantly improved by placement of acellular dermal matrix in the affected area. Although most of the available studies demonstrate short-term results (1 to 2 years of follow-up), our technical ability to treat complications after breast augmentation and mastopexy has expanded. Use of onlay grafts of matrix in areas of capsulectomy and capsulorrhaphy, placement of grafts of varying thickness for thinned tissues, and the wide variety of shapes and sizes of product available are reducing unfavorable aesthetic results. CONCLUSIONS: Increased complications, including seroma formation, infection, wound dehiscence, and implant exposure, remain challenging problems. Long-term studies will be needed to prove the durability of acellular dermal matrices in breast revisional surgery.

Cost analysis of implant-based breast reconstruction with acellular dermal matrix.

A comparative cost analysis of breast reconstruction using acellular dermal matrix (ADM) and traditional tissue expander-/implant-based techniques was carried out. Medicare reimbursement costs were calculated for tissue expander/implant alone (TE/I), TE/I with ADM (TE/I + ADM), and single-stage implant (SSI) with ADM (SSI + ADM). The most expensive procedure at baseline was TE/I + ADM ($11,255.78), followed by TE/I alone ($10,934.18), and SSI + ADM ($5,423.02). Incorporating the probability of complications as derived from the published literature into the cost analysis resulted in an increase in the excess cost of ADM-based procedures (TE/I + ADM, $11,829.02; TE/I, $11,238.60; SSI + ADM, $5,909.83). Although SSI + ADM have the lowest cost, not all patients are suitable candidates for this type of procedure. With increasing focus on healthcare expenditure, it is important that plastic surgeons are aware of the cost implications of using ADM products.