title: Whom should we SPY? A cost analysis of laser-assisted indocyanine green angiography in prevention of mastectomy skin flap necrosis during prosthesis-based breast reconstruction.
abstract: BACKGROUND
  Skin flap necrosis is the most common complication following prosthesis-based breast reconstruction. Many studies have reported on the efficacy of laser-assisted indocyanine green angiography (SPY Elite System) in detecting flap necrosis. A cost-effectiveness analysis of laser-assisted indocyanine green angiography is lacking.
  
  
  METHODS
  The authors performed a retrospective review of all consecutive immediate postmastectomy prosthesis-based reconstructions at the Brigham and Women's Hospital over a 7-year 10-month period. The rate of mastectomy skin flap necrosis and related implant loss was determined for the entire cohort and for the subgroups of patients at increased risk for developing this complication: smokers, obese patients, and patients with large breasts. Cost of treating implant loss and skin flap necrosis was calculated based on the average treatment courses and costs at the authors' institution. The cost of the SPY was obtained from LifeCell Corp.
  
  
  RESULTS
  From January of 2004 through October of 2011, 79 of 710 prosthesis-based breast reconstructions (11.1 percent) developed mastectomy skin flap necrosis requiring excision and reclosure. Performing laser-assisted indocyanine green angiography on the entire cohort would result in an additional cost of $1537.30 per case of flap necrosis prevented. If laser-assisted indocyanine green angiography was performed on only these high-risk subgroups, the cost savings per case of flap necrosis prevented is $2098.80 for smokers, $5162.30 for patients with a body mass index greater than 30, and $1892.70 for patients with mastectomy weight greater than 800 g.
  
  
  CONCLUSIONS
  Laser-assisted indocyanine green angiography is not cost-effective as a preventative measure for flap necrosis if used indiscriminately on all patients undergoing prosthesis-based breast reconstructions, but it is cost-effective for high-risk patients, such as smokers, obese patients, and patients with large breasts.
authors.affiliation: Boston and Burlington, Mass. From the Tufts University School of Medicine; the Harvard Plastic Surgery Program, and the Department of Plastic Surgery; and the Department of Plastic Surgery, Lahey Hospital and Medical Center.
authors.forename: Arjun
authors.initials: A
authors.lastname: Kanuri
authors.forename: Allen S
authors.initials: AS
authors.lastname: Liu
authors.forename: Lifei
authors.initials: L
authors.lastname: Guo
mesh_terms: D000792:Angiography / Q000191:economics / Q000379:methods; D019928:Breast Implantation / Q000191:economics; D004396:Coloring Agents; D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D005260:Female; D006801:Humans; D007208:Indocyanine Green; D007834:Lasers; D008408:Mastectomy; D012189:Retrospective Studies; D018570:Risk Assessment; D012867:Skin / Q000098:blood supply / Q000473:pathology*; D013524:Surgical Flaps / Q000098:blood supply / Q000473:pathology*
chemical_list: D004396:Coloring Agents; D007208:Indocyanine Green