title: The Use of Integra Dermal Regeneration Template Versus Flaps for Reconstruction of Full-Thickness Scalp Defects Involving the Calvaria: A Cost-Benefit Analysis.
abstract: BACKGROUND
  INTEGRA®Dermal Regeneration Template is a well-known and widely used acellular dermal matrix. Although it helps to solve many challenging problems in reconstructive surgery, the product cost may make it an expensive alternative compared to other reconstruction procedures. This retrospective study aims at comparing INTEGRA-based treatment to flap surgery in terms of cost and benefit.
  
  
  METHODS
  We considered only patients treated for scalp defects with bone exposure in order to obtain two groups as homogeneous as possible. We identified two groups of patients: 17 patients treated with INTEGRA and 18 patients treated with flaps. All patients were admitted in our institution between 2004 and 2010, and presented a defect of the scalp following trauma or surgery for cancer, causing a loss of the soft tissues of the scalp with bone exposure without pericranium. To calculate the cost in constant euros of each treatment, three parameters were evaluated for each patient: cost of the surgical procedure (number of doctors and nurses involved, surgery duration, anesthesia, material used for surgery), hospitalization cost (hospitalization duration, dressings, drugs, topical agents), and outpatient cost (number of dressing changes, personnel cost, dressings type, anti-infective agents). The statistical test used in this study was the Wilcoxon Mann-Whitney (α = 0.05).
  
  
  RESULTS
  No significant difference was characterized between the two groups for gender, age, presence of diabetes, mean defect size, and number of surgical procedures. All patients healed with good quality and durable closure. The median total cost per patient was €11,121 (interquartile range (IQR) 8327-15,571) for the INTEGRA group and €7259 (IQR 1852-24,443) for the flap group (p = 0.34). A subgroup of patients (six patients in the INTEGRA group and five patients in the flap group) showing defects larger than 100 cm2were considered in a second analysis. Median total cost was €11,825 (IQR 10,695-15,751) for the INTEGRA group and €23,244 (IQR 17,348-26,942) for the flap group.
  
  
  CONCLUSIONS
  Both treatments led to a good healing of the lesions with formation of soft and resistant tissue. No significant difference was characterized between the two groups for days of hospitalization and costs. In cases of patients with defects larger than 100 cm2for whom major surgery is needed, the treatment with INTEGRA seemed to be less expensive than the treatment with free flaps or pedicle flaps.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the A5 online Instructions to Authors. www.springer.com/00266 .
authors.affiliation: Struttura Operativa Complessa di Chirurgia Plastica e Centro Ustioni, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy. mauro.schiavon@asuiud.sanita.fvg.it.
authors.forename: M
authors.identifier: http://orcid.org/0000-0003-0154-7086
authors.initials: M
authors.lastname: Schiavon
authors.affiliation: Struttura Operativa Complessa di Chirurgia Plastica e Centro Ustioni, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Francescon
authors.affiliation: Istituto di Igiene ed Epidemiologia Clinica, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: D
authors.initials: D
authors.lastname: Drigo
authors.affiliation: Struttura Operativa Complessa di Chirurgia Plastica e Centro Ustioni, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Salloum
authors.affiliation: Struttura Operativa Complessa di Chirurgia Plastica e Centro Ustioni, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: R
authors.initials: R
authors.lastname: Baraziol
authors.affiliation: Struttura Operativa Complessa di Chirurgia Plastica e Centro Ustioni, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: J
authors.initials: J
authors.lastname: Tesei
authors.affiliation: Struttura Operativa Complessa di Chirurgia Plastica e Centro Ustioni, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Fraccalanza
authors.affiliation: Istituto di Igiene ed Epidemiologia Clinica, Azienda Ospedaliero-Universitaria S. Maria della Misericordia, Udine, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Barbone
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002809:Chondroitin Sulfates / Q000191:economics*; D015331:Cohort Studies; D003094:Collagen / Q000191:economics*; D003362:Cost-Benefit Analysis; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000191:economics* / Q000637:transplantation*; D017721:Hospital Costs; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000503:physiopathology / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012535:Scalp / Q000293:injuries / Q000601:surgery*; D016038:Skin Transplantation / Q000191:economics / Q000379:methods*; D012886:Skull / Q000293:injuries / Q000601:surgery; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology
chemical_list: C114835:integra artificial skin; D002809:Chondroitin Sulfates; D003094:Collagen
keywords: Cost benefit; Dermal Matrix; Integra; Scalp reconstruction