Complication Reporting and Cost Analysis in 75 Consecutive Cases of Single-Stage Implant Reconstruction with AlloDerm: Single Surgeon Series
Amy S. Colwell.
Mass General Hospital, Boston, MA, USA.
Goals/Purpose: Immediate implant reconstruction with AlloDerm optimizes aesthetics by preserving the mastectomy skin envelope. In addition, single-stage reconstruction avoids the monetary and time costs of a second-stage tissue expander-implant exchange. However, the cost of AlloDerm has prevented some surgeons from using this dermal matrix, and recent reports have suggested AlloDerm is an independent risk factor for infection in tissue expander-implant procedures. The author reports indications for single-stage implant reconstruction with AlloDerm, early complication profile, and general cost analysis between one-stage implant reconstruction with AlloDerm and two-stage tissue expander-implant reconstruction without AlloDerm.
Methods/Techniques: Single surgeon retrospective review was performed for immediate implant reconstruction with AlloDerm over 18 months. Complications were defined as infection requiring IV antibiotics, skin necrosis requiring operative revision, seroma, implant loss, wound dehiscence/exposure, hematoma, malposition, and contracture. The author’s first 6 month experience was compared with the subsequent 12 months to assess complication rates. The preliminary financial analysis compiled hospital, anesthesia, and surgeon charges for 5 bilateral immediate implant reconstructions with AlloDerm compared to 5 bilateral immediate tissue expander reconstructions followed by tissue expander-implant exchange.
Results/Complications: Forty-six patients 33-71 years old (average 51) had unilateral (17) or bilateral (29) implant reconstructions with AlloDerm (total 75 reconstructions) following mastectomy (Figure 1: Bilateral immediate implant reconstruction). Twenty-six reconstructions were nipple-sparing and 49 were skin-sparing mastectomies. Nine patients had pre-operative radiation and 2 patients had post-operative radiation. Indications for single stage reconstruction included small to moderate sized breasts, patient desire to be a similar or smaller breast size, and a healthy skin envelope. Implant size ranged from 125-800cc (average 350cc) and 97% were silicone compared to 3% saline. Total complications included 2 infections (2.7%), 2 hematomas (2.7%), one skin necrosis requiring implant removal (1.3%), one late malposition (1.3%), and one grade 2 contracture (1.3%). No seromas, wound dehiscence, or exposure were observed. There was no significant difference in the total rate of complications with early experience (<6 months) (6.3%) compared to later experience (7.0%). The average combined professional charges for one-stage reconstruction were $11,550 lower than for two-stage reconstruction (p<0.02). However, the hospital charges were an average of $10,610 higher for one-stage compared with two-stage reconstruction (p<0.01), so there was no significant total charge difference (p=0.8).
Conclusions: Immediate implant reconstruction with AlloDerm offers a safe, aesthetically pleasing reconstruction with a low rate of complications. The monetary cost of AlloDerm and the extra OR time for single-stage reconstruction is offset by the 2 surgeries required for two stage reconstruction, and the patient avoids office visits for fills and a second surgery. In patients with an adequate skin envelope and who are happy with their current breast size, this may be the procedure of choice.
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