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Evolution of Breast Reconstruction Paradigm with Increased Incidence of Prophylactic Mastectomy
Aisling M. Fitzpatrick, B.P.H.E, Lin Lin Gao, MD, Barbara L. Smith, MD, PhD, William G. Austen, Jr., MD, Eric C. Liao, MD, PhD.
Massachusetts General Hospital, Boston, MA, USA.

Purpose: The emerging national trend toward increased incidence of prophylactic mastectomy has generated an increased demand for bilateral breast reconstruction. This study presents a comprehensive analysis describing the shift in reconstructive methods meeting the combined demands of increased bilateral reconstruction, increased case volume, and efforts to decrease associated morbidity. A preliminary cost analysis was performed to determine how changes in the reconstructive paradigm impact cost of care. Since breast reconstruction constitutes a major clinical program in most plastic and reconstructive surgery units, current and future practice patterns are at the forefront of cost analysis at institutional and national policy levels.
Methods: A single institution case series of 3,171 consecutive mastectomy cases over a 10 year period: 1999-2004 (period A), and 2005-2010 (period B) was collected. Only the primary type of breast reconstruction was considered, which is the reconstruction performed at the time of immediate breast reconstruction following mastectomy. Hospital costs were obtained for a sample of patients from each procedure group. Groups were compared using two-tailed t-tests for continuous variables.
Results: The incidence of bilateral mastectomy increased 2.6 fold in period B, and the mean patient age at diagnosis decreased by 7 years (p <0.001). The total volume of reconstruction cases increased between periods A and B, from 589 cases to 1,137 cases, a significant increase of 193%. In period B, the percentage of autologous reconstruction dropped sharply (60% decreased to 26%), while implant-based reconstruction became dominant (40% increased to 74%). Notable reconstructive paradigm shift include increased application of single-stage acellular dermal matrix implant reconstruction, selective application of DIEP flap for bilateral autologous reconstruction, and continued preference of pedicled TRAM procedures for unilateral autologous reconstruction (p <0.001). Single-stage reconstruction with acellular dermal matrix and silicone implant was the most cost-efficient procedure type, and deep inferior epigastric perforator flap was the most cost-intense procedure type. Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%).
Conclusions: Changes in reconstructive methods toward decreasing morbidity were correlated with increased incidence of prophylactic mastectomy in younger patient demographic, with shift toward implant reconstruction. In a practice environment where several reconstructive options are available, selection of the reconstructive method should be tailored to an individual’s anatomy, clinical considerations and preferences of the patient. This study describes the manner in which changing oncologic and patient demographic trends are associated with evolution of reconstructive procedures performed. These changes are subject to the practice environment, hospital resources, and skill set of the surgical group, among other factors. We believe our experience is typical of most urban academic centers, and posit that this report of observed shift in reconstructive paradigm and associated costs may be informative to other centers. This project provides the foundation for the detailed cost analysis necessary to elucidate the effects of changing oncologic and reconstructive trends and their costs on local and national health care systems.


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