title: A comparison of free autologous breast reconstruction with and without the use of laser-assisted indocyanine green angiography: a cost-effectiveness analysis.
abstract: BACKGROUND
  Laser-assisted indocyanine green angiography is a U.S. Food and Drug Administration-approved technology used to assess tissue viability and perfusion. Its use in plastic and reconstructive surgery to assess flap perfusion in autologous breast reconstruction is relatively new. There have been no previous studies evaluating the cost-effectiveness of this new technology compared with the current practice of clinical judgment in evaluating tissue perfusion and viability in free autologous breast reconstruction in patients who have undergone mastectomy.
  
  
  METHODS
  A comprehensive literature review was performed to identify the complication rate of the most common complications with and without laser-assisted indocyanine green angiography in free autologous breast reconstruction after mastectomy. These probabilities were combined with Medicare Current Procedural Terminology provider reimbursement codes (cost) and utility estimates for common complications from a survey of 10 plastic surgeons to fit into a decision model to evaluate the cost-effectiveness of laser-assisted indocyanine green angiography.
  
  
  RESULTS
  The decision model revealed a baseline cost difference of $773.66 and a 0.22 difference in the quality-adjusted life-years, yielding an incremental cost-utility ratio of $3516.64 per quality-adjusted life year favoring laser-assisted indocyanine green angiography. Sensitivity analysis showed that using laser-assisted indocyanine green angiography was more cost-effective when the complication rate without using laser-assisted indocyanine green angiography (clinical judgment alone) was 4 percent or higher.
  
  
  CONCLUSIONS
  The authors' study demonstrates that laser-assisted indocyanine green angiography is a cost-effective technology under the most stringent acceptable thresholds when used in immediate free autologous breast reconstruction.
authors: Lebanon and Hanover, N.H. From the Division of Plastic Surgery, Department of Surgery, Dartmouth Hitchcock Medical Center; the Geisel School of Medicine at Dartmouth; and the Tuck School of Business at Dartmouth.
authors: Abhishek
authors: A
authors: Chatterjee
authors: Naveen M
authors: NM
authors: Krishnan
authors: Michael M
authors: MM
authors: Van Vliet
authors: Stephen G
authors: SG
authors: Powell
authors: Joseph M
authors: JM
authors: Rosen
authors: Emily B
authors: EB
authors: Ridgway
mesh_terms: D000792:Angiography / Q000191:economics* / Q000379:methods*; D004396:Coloring Agents; D003362:Cost-Benefit Analysis; D005260:Female; D058752:Free Tissue Flaps / Q000098:blood supply / Q000191:economics; D019538:Health Care Surveys; D006801:Humans; D007208:Indocyanine Green; D016462:Mammaplasty / Q000009:adverse effects / Q000191:economics* / Q000379:methods*; D011183:Postoperative Complications / Q000191:economics / Q000517:prevention & control
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green
references: Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: The gray area defined. Plast Reconstr Surg. 2012;129:1043–1048
references: Newman MI, Samson MC, Tamburrino JF, Swartz KA. Intraoperative laser-assisted indocyanine green angiography for the evaluation of mastectomy flaps in immediate breast reconstruction. J Reconstr Microsurg. 2010;26:487–492
references: Phillips BT, Lanier ST, Conkling N, et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: Results of a prospective trial. Plast Reconstr Surg. 2012;129:778e–788e
references: Liu DZ, Mathes DW, Zenn MR, Neligan PC. The application of indocyanine green fluorescence angiography in plastic surgery. J Reconstr Microsurg. 2011;27:355–364
references: Komorowska-Timek E, Gurtner GC. Intraoperative perfusion mapping with laser-assisted indocyanine green imaging can predict and prevent complications in immediate breast reconstruction. Plast Reconstr Surg. 2010;125:1065–1073
references: Thoma A, Khuthaila D, Rockwell G, Veltri K. Cost-utility analysis comparing free and pedicled TRAM flap for breast reconstruction. Microsurgery. 2003;23:287–295
references: Thoma A, Veltri K, Khuthaila D, Rockwell G, Duku E. Comparison of the deep inferior epigastric perforator flap and free transverse rectus abdominis myocutaneous flap in postmastectomy reconstruction: A cost-effectiveness analysis. Plast Reconstr Surg. 2004;113:1650–1661
references: Elliott FL, Eskenazi L, Beegle PH, et al. Immediate TRAM flap breast reconstruction: 128 consecutive cases. Plast Reconstr Surg. 1993;92:217–227
references: Kroll SS. Fat necrosis in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106:576–583
references: Hamdi M, Weiler-Mithoff EM, Webster MH. Deep inferior epigastric perforator flap in breast reconstruction: Experience with the first 50 flaps. Plast Reconstr Surg. 1999;103:86–95
references: Blondeel PN, Arnstein M, Verstraete K, et al. Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2000;106:1295–1299
references: Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg. 1994;32:32–38
references: Gherardini G, Arnander C, Gylbert L, et al. Pedicled compared with free transverse rectus abdominis myocutaneous flaps in breast reconstruction. Scand J Plast Reconstr Surg Hand Surg. 1994;28:69–73
references: Suominen S, Asko-Seljavaara S, von Smitten K, Ahovuo J, Sainio P, Alaranta H. Sequelae in the abdominal wall after pedicled or free TRAM flap surgery. Ann Plast Surg. 1996;36:629–636
references: Scheer AS, Novak CB, Neligan PC, Lipa JE. Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap. Ann Plast Surg. 2006;56:355–358
references: Newman MI, Samson MC. The application of laser-assisted indocyanine green fluorescent dye angiography in microsurgical breast reconstruction. J Reconstr Microsurg. 2009;25:21–26
references: Pestana IA, Coan B, Erdmann D, Marcus J, Levin LS, Zenn MR. Early experience with fluorescent angiography in free-tissue transfer reconstruction. Plast Reconstr Surg. 2009;123:1239–1244
references: Francisco BS, Kerr-Valentic MA, Agarwal JP. Laser-assisted indocyanine green angiography and DIEP breast reconstruction. Plast Reconstr Surg. 2010;125:116e–118e
references: Holm C, Mayr M, Höfter E, Raab N, Ninkovic M. Interindividual variability of the SIEA Angiosome: Effects on operative strategies in breast reconstruction. Plast Reconstr Surg. 2008;122:1612–1620
references: Holm C, Mayr M, Höfter E, Ninkovic M. Perfusion zones of the DIEP flap revisited: A clinical study. Plast Reconstr Surg. 2006;117:37–43
references: Mohebali J, Gottlieb LJ, Agarwal JP. Further validation for use of the retrograde limb of the internal mammary vein in deep inferior epigastric perforator flap breast reconstruction using laser-assisted indocyanine green angiography. J Reconstr Microsurg. 2010;26:131–135
references: Atisha DM, Comizio RC, Telischak KM, Higgins JH, Collins ED. Interval inset of TRAM flaps in immediate breast reconstruction: A technical refinement. Ann Plast Surg. 2010;65:524–527
references: Laupacis A, Feeny D, Detsky AS, Tugwell PX. How attractive does a new technology have to be to warrant adoption and utilization? Tentative guidelines for using clinical and economic evaluations. CMAJ. 1992;146:473–481
references: Vernon JA, Payette M, Chatterjee A. Social welfare and adolescent vaccination programs in the United States: The economic opportunities for a systematic expansion. Soc Work Public Health. 2009;24:414–445
references: Grosse SD. Assessing cost-effectiveness in healthcare: History of the $50,000 per QALY threshold. Expert Rev Pharmacoecon Outcomes Res. 2008;8:165–178
references: Alderman AK, Jagsi R. Discussion: Immediate post-mastectomy breast reconstruction followed by radiotherapy: Risk factors for complications. Breast Cancer Res Treat. 2010;121:635–637
references: Fox IJ, Wood EH. Applications of dilution curves recorded from the right side of the heart or venous circulation with the aid of a new indicator dye. Proc Staff Meet Mayo Clin. 1957;32:541–550
references: Eren S, Rübben A, Krein R, Larkin G, Hettich R. Assessment of microcirculation of an axial skin flap using indocyanine green fluorescence angiography. Plast Reconstr Surg. 1995;96:1636–1649
references: Still J, Law E, Dawson J, Bracci S, Island T, Holtz J. Evaluation of the circulation of reconstructive flaps using laser-induced fluorescence of indocyanine green. Ann Plast Surg. 1999;42:266–274
references: Chatterjee A, Payette MJ, Demas CP, Finlayson SR. Opportunity cost: A systematic application to surgery. Surgery. 2009;146:18–22
references: Chatterjee A, Chen L, Goldenberg EA, Bae HT, Finlayson SR. Opportunity cost in the evaluation of surgical innovations: A case study of laparoscopic versus open colectomy. Surg Endosc. 2010;24:1075–1079