Who Should We SPY: A Cost Analysis of Laser-Assisted Indocyanine Green Angiography in Prevention of Mastectomy Skin Flap Necrosis During Prosthesis-Based Breast Reconstruction
Arjun Kanuri, B.S.1, Allen S. Liu, MD2, Lifei Guo, MD, PhD, FACS3.
1Tufts University School of Medicine, Boston, MA, USA, 2UCLA Medical Center, Los Angeles, CA, USA, 3Lahey Hospital and Medical Center, Burlington, MA, USA.
PURPOSE: Skin flap necrosis is the most common complication following prosthesis-based breast reconstruction. Many studies have reported on the efficacy of laser-assisted indocyanine green angiography (LA-IGA, of SPY Elite System, LifeCell, Branchburg, NJ) in detecting flap necrosis. A cost-effectiveness analysis of LA-IGA is lacking.
METHODS: The authors performed a retrospective review of
all consecutive immediate post-mastectomy prosthesis-based reconstructions at the Brigham and Women’s Hospital over a seven year and ten month period. The rate of mastectomy skin flap necrosis and
related implant loss was determined for the entire cohort, as well as for the subgroups of patients at increased risk for developing this complication: smokers, obese patients, and patients with large breasts. Cost of treating implant loss and mastectomy skin flap necrosis by excision and re-closure was calculated based on the average treatment courses and costs at our institution. The cost of each individual use of LA-IGA was obtained from LifeCell.
RESULTS: From January 2004 through October 2011, 79 out
of 710 (11.1%) prosthesis-based breast reconstructions developed mastectomy skin flap necrosis requiring excision and re-closure. Taking into account the costs saved from preventing skin flap necrosis and subsequent implant loss, performing LA-IGA on the entire cohort would result in an additional cost of $1,537.3 per case of flap necrosis prevented. We used smoking status, BMI>30, and mastectomy weight>800g as cutoffs to classify patients as high risk. In our cohort, flap necrosis occurred at a significantly higher rate in smokers (37.5%, p<0.0001) and women with mastectomy weight >800g (18.9%, p=0.0128). Although not statistically significant, flap necrosis also occurred at a higher rate in obese patients with BMI >30 (14.8%, p=0.267). If LA-IGA was performed on only these high-risk subgroups, the cost savings per case of flap necrosis prevented is $2,098.8 for smokers, $5,162.3 for patients with BMI >30, and $1,892.7 for patients with mastectomy weight >800g.
CONCLUSION: LA-IGA is not cost-effective as a preventative measure for mastectomy necrosis if used indiscriminately on all patients undergoing prosthesis-based breast reconstructions. LA-IGA is cost effective for high-risk patients, such as smokers, obese patients, and patients with large breasts.
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