title: Propensity-matched, longitudinal outcomes analysis of complications and cost: comparing abdominal free flaps and implant-based breast reconstruction.
abstract: BACKGROUND
  Choosing a breast reconstructive modality after mastectomy is an important step in the reconstructive process. The authors hypothesized that autologous tissue is associated with a greater success rate and cost efficacy over time, relative to implant reconstruction.
  
  
  METHODS
  A retrospective review was performed of patients undergoing free tissue (FF) transfer and expander implant (E/I) reconstruction between 2005 and 2011. Variables evaluated included comorbidities, surgical timing, complications, overall outcomes, unplanned reoperations, and costs. A propensity-matching technique was used to account for the nonrandomized selection of modality.
  
  
  RESULTS
  A total of 310 propensity-matched patients underwent 499 reconstructions. No statistically significant differences in preoperative variables were noted between propensity-matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. The E/I reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs 1.2%, p < 0.001). Expander implant reconstructions were associated with higher rates of seroma (p = 0.009) and lower rates of medical complications (p = 0.02), but overall significantly higher rates of unplanned operations (15.5% vs 5.8%, p = 0.002). The total cost of reconstruction did not differ significantly between groups ($23,120.49 ± $6,969.56 vs $22,739.91 ± $9,727.79, p = 0.060), but E/I reconstruction was associated with higher total cost for secondary procedures ($10,157.89 ± $8,741.77 vs $3,200.71 ± $4,780.64, p < 0.0001) and a higher cost of unplanned revisions over time (p < 0.05).
  
  
  CONCLUSIONS
  Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost. Although autologous reconstruction is not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA. Electronic address: John.Fischer2@uphs.upenn.edu.
authors.forename: John P
authors.initials: JP
authors.lastname: Fischer
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Ari M
authors.initials: AM
authors.lastname: Wes
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Jonas A
authors.initials: JA
authors.lastname: Nelson
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Marten
authors.initials: M
authors.lastname: Basta
authors.affiliation: Division of Finance, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Jeffrey I
authors.initials: JI
authors.lastname: Rohrbach
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Liza C
authors.initials: LC
authors.lastname: Wu
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Serletti
authors.affiliation: Division of Plastic Surgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Kovach
mesh_terms: D018427:Breast Implants / Q000191:economics*; D001943:Breast Neoplasms / Q000191:economics* / Q000601:surgery*; D003365:Costs and Cost Analysis; D005260:Female; D058752:Free Tissue Flaps / Q000191:economics*; D006801:Humans; D008137:Longitudinal Studies; D016462:Mammaplasty / Q000191:economics* / Q000379:methods*; D008875:Middle Aged; D011183:Postoperative Complications / Q000191:economics*; D057216:Propensity Score; D012189:Retrospective Studies; D016896:Treatment Outcome