title: The use of mesh versus primary fascial closure of the abdominal donor site when using a transverse rectus abdominis myocutaneous flap for breast reconstruction: a cost-utility analysis.
abstract: BACKGROUND
  During breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap, the use of mesh for abdominal donor-site closure provides for a technology that potentially offers clinical benefit yet incurs an added cost. The authors' goal was to determine whether it is cost effective to use mesh during abdominal donor-site closure when performing a TRAM flap for breast reconstruction.
  
  
  METHODS
  A literature review was conducted to identify and collect published hernia and bulge rates at abdominal TRAM flap donor sites closed either primarily or with mesh. A decision tree analysis was performed. Outcome probabilities, costs of complications, and expert utility estimates were populated into the decision tree model to evaluate the cost-utility of using mesh in TRAM abdominal donor-site closure. One-way sensitivity analyses were performed to verify the robustness of the results.
  
  
  RESULTS
  The authors' literature review resulted in 10 articles describing 1195 patients who had TRAM abdominal donor-site closure primarily and 696 patients who had donor-site closure performed with mesh. Pooled hernia/bulge complication rates for these two groups were 7.87 percent and 4.45 percent, respectively. The use of mesh was more clinically effective based on total quality-adjusted life-years gained of 30.53 compared with 30.41 when performing primary fascial closure alone. The incremental additional cost incurred by the mesh arm when running the decision tree model was $693.14. This difference in cost, divided by the difference in clinical efficacy (0.12), results in an incremental cost-utility ratio value of $5776.17 per quality-adjusted life-year gained when using mesh, making it cost effective (when using a willingness-to-pay threshold of $50,000). One-way sensitivity analysis revealed the following: (1) using mesh was a cost effective option, provided that the price of mesh was less than or equal to $5970; (2) mesh was cost effective when its use led to a hernia/bulge rate less than or equal to 7.25 percent; and (3) primary facial closure was cost effective when its use led to a hernia/bulge rate less than or equal to 4.75 percent.
  
  
  CONCLUSIONS
  The use of mesh when repairing the abdominal donor site during a pedicled or free TRAM flap breast reconstruction is cost effective compared with primary fascial closure alone.
authors.affiliation: Lebanon, N.H. From the Dartmouth-Hitchcock Medical Center.
authors.forename: Abhishek
authors.initials: A
authors.lastname: Chatterjee
authors.forename: Dipak B
authors.initials: DB
authors.lastname: Ramkumar
authors.forename: Tamara B
authors.initials: TB
authors.lastname: Dawli
authors.forename: John F
authors.initials: JF
authors.lastname: Nigriny
authors.forename: Mitchell A
authors.initials: MA
authors.lastname: Stotland
authors.forename: Emily B
authors.initials: EB
authors.lastname: Ridgway
mesh_terms: D003362:Cost-Benefit Analysis / Q000379:methods*; D000071938:Fasciotomy; D005260:Female; D006801:Humans; D016462:Mammaplasty / Q000191:economics* / Q000379:methods; D064827:Myocutaneous Flap; D017568:Rectus Abdominis / Q000637:transplantation*; D014945:Wound Healing