Is Single-stage Prosthetic Reconstruction Cost Effective?

A Cost-Utility Analysis for the Use of Direct-to-Implant Breast Reconstruction Relative to Expander-Implant Reconstruction in Postmastectomy Patients

Naveen M. Krishnan, M.D., M.Phil.; John P. Fischer, M.D.; Marten N. Basta, B.S.; Maurice Y. Nahabedian, M.D.


Plast Reconstr Surg. 2016;138(3):537-547. 

In This Article

Abstract and Introduction


Background: Prosthetic breast reconstruction is most commonly performed using the two-stage (expander-implant) technique. However, with the advent of skin-sparing mastectomy and the use of acellular dermal matrices, one-stage prosthetic reconstruction has become more feasible. Prior studies have suggested that one-stage reconstruction has economic advantages relative to two-stage reconstruction despite a higher revision rate. This is the first cost-utility analysis to compare the cost and quality of life of both procedures to guide patient care.

Methods: A comprehensive literature review was conducted using the MEDLINE, EMBASE, and Cochrane databases to include studies directly comparing matched patient cohorts undergoing single-stage or staged prosthetic reconstruction. Six studies were selected examining 791 direct-to-implant reconstructions and 1142 expander-implant reconstructions. Costs were derived adopting both patient and third-party payer perspectives. Utilities were derived by surveying an expert panel. Probabilities of clinically relevant complications were combined with cost and utility estimates to fit into a decision tree analysis.

Results: The overall complication rate was 35 percent for single-stage reconstruction and 34 percent for expander-implant reconstruction. The authors' baseline analysis using Medicare reimbursement revealed a cost decrease of $525.25 and a clinical benefit of 0.89 quality-adjusted life-year when performing single-stage reconstructions, yielding a negative incremental cost-utility ratio. When using national billing, the incremental cost-utility further decreased, indicating that direct-to-implant breast reconstruction was the dominant strategy. Sensitivity analysis confirmed the robustness of the authors' conclusions.

Conclusions: Direct-to-implant breast reconstruction is the dominant strategy when used appropriately. Surgeons are encouraged to consider single-stage reconstruction when feasible in properly selected patients.


Current statistics from the American Society of Plastic Surgeons demonstrate that two-stage expander-implant breast reconstruction is the most frequent modality in the setting of prosthetic breast reconstruction.[1] In the past decade, advancements in technology (e.g., acellular dermal matrix, prosthetic devices), improved mastectomy techniques, and greater clinical experience have enabled plastic surgeons to perform single-stage immediate breast reconstruction more predictably, reproducibly, and without significant complications.[2–4] Previous single-stage reconstructions were associated with a higher incidence of adverse events and reoperations because of mastectomy skin necrosis, device malposition, and asymmetry, all of which increased overall cost.[5–7]

A number of studies have looked at the cost or clinical outcomes for either method of reconstruction in isolated patient cohorts.[2–4] Few studies have compared the cost or clinical outcomes of single-stage reconstructions relative to expander-implant reconstruction in similar patient populations.[8–14] In a recent study from Boston, de Blacam et al. demonstrated that single-stage immediate prosthetic breast reconstruction using acellular dermal matrix reduced the number of postoperative clinic visits and reduced the need for a second procedure, both of which effectively reduced overall cost.[10] In another recent study, Susarla et al. compared the two reconstructive approaches in a single cohort and found a significant increase in revision operations in single-stage procedures relative to two-stage procedures and lower satisfaction with office and medical staff yet higher sexual satisfaction.[14] No study has truly evaluated the cost effectiveness of either technique using cost-utility analysis, the most rigorous type of comparative economic analysis, which compares the cost, outcomes, and quality of life for patients undergoing either method of reconstruction in terms applicable to patients, surgeons, hospital administrators, and health care policy makers.

Given that reported outcomes are mixed, it remains unclear whether one- or two-stage prosthetic reconstruction is the more cost-effective option. The purpose of this study was to conduct a cost-utility analysis that compared the cost, clinical outcomes, and quality of life associated with each reconstructive modality to guide reconstructive surgeons in providing cost-efficient care.