title: Medium-term cost analysis of breast reconstructions in a single Dutch centre: a comparison of implants, implants preceded by tissue expansion, LD transpositions and DIEP flaps.
abstract: BACKGROUND
  Free flap breast reconstruction (BR) is generally believed to be more expensive than implant BR, but costs were previously shown to level out over time due to complications and re-operations. The aim of this study was to assess the economic implications of four BR techniques: silicone prosthesis (SP), implant preceded by tissue expansion (TE/SP), latissimus dorsi transposition with or without implant (LD ± SP) and deep inferior epigastric perforator (DIEP) flap.
  
  
  METHODS
  A prospective historic cohort study was performed to evaluate intramural medical costs in 427 patients, who had undergone BR between 2002 and 2009. Short- and medium-term complications were incorporated. In addition, 58 patients, who had recently undergone BR, participated in a questionnaire study to prospectively evaluate extramural medical and non-medical costs. Estimates of mean short- and medium-term costs are presented per patient.
  
  
  RESULTS
  Intramural medical costs for BR and short-term complications for unilateral DIEP flaps (€ 12,848) and TE/SP reconstructions (€ 12,400) were significantly higher than those for LD ± SP reconstructions (€ 5804), which, in turn, were more expensive than SP reconstructions (€ 4731). In bilateral cases, costs of TE/SP (€ 12,723) and LD ± SP (€ 10,760) reconstructions were comparable, while DIEP flaps (€ 15,747) were significantly more expensive and SP reconstructions were significantly cheaper (€ 6784). Overall, the medium-term costs for complications and additional operations were not significantly different (€ 3017-€ 4503). Extramural medical costs and non-medical costs were approximately € 9300 per stage, regardless of technique.
  
  
  CONCLUSIONS
  Differences in short-term costs between techniques did not level out during follow-up and SP reconstructions remained least expensive. Single-stage SP reconstructions, however, are not suitable for all patients due to high complication rates. Definite implant placement is therefore increasingly preceded by tissue expansion at more comparable costs to autologous BR. Incorporation of non-medical costs into the cost analysis would render two-stage procedures more costly than autologous BR. To achieve the optimal result, careful patient selection is critical. Only in select cases where two options are equally applicable, cost comparison becomes a valid argument for treatment selection.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Erasmus Medical Centre, P.O. Box 2040, NL-3000 CA Rotterdam, The Netherlands. t.damen@erasmusmc.nl
authors.forename: T H C
authors.initials: TH
authors.lastname: Damen
authors.forename: W
authors.initials: W
authors.lastname: Wei
authors.forename: M A M
authors.initials: MA
authors.lastname: Mureau
authors.forename: R
authors.initials: R
authors.lastname: Tjong-Joe-Wai
authors.forename: S O P
authors.initials: SO
authors.lastname: Hofer
authors.forename: M L
authors.initials: ML
authors.lastname: Essink-Bot
authors.forename: S E R
authors.initials: SE
authors.lastname: Hovius
authors.forename: S
authors.initials: S
authors.lastname: Polinder
mesh_terms: D000328:Adult; D000368:Aged; D018427:Breast Implants / Q000191:economics*; D003365:Costs and Cost Analysis; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization / Q000191:economics; D006801:Humans; D016462:Mammaplasty / Q000191:economics* / Q000379:methods*; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000637:transplantation; D009426:Netherlands; D011183:Postoperative Complications / Q000191:economics; D011446:Prospective Studies; D012086:Reoperation / Q000191:economics; D016879:Salvage Therapy / Q000191:economics; D013524:Surgical Flaps / Q000191:economics*; D015626:Tissue Expansion / Q000191:economics*; D055815:Young Adult