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The use of mesh versus primary fascial closure of the abdominal donor site when using a transverse rectus abdominis myocutaneous flap for breast reconstruction: a cost-utility analysis.

Abstract：

BACKGROUND:During breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap, the use of mesh for abdominal donor-site closure provides for a technology that potentially offers clinical benefit yet incurs an added cost. The authors' goal was to determine whether it is cost effective to use mesh during abdominal donor-site closure when performing a TRAM flap for breast reconstruction. METHODS:A literature review was conducted to identify and collect published hernia and bulge rates at abdominal TRAM flap donor sites closed either primarily or with mesh. A decision tree analysis was performed. Outcome probabilities, costs of complications, and expert utility estimates were populated into the decision tree model to evaluate the cost-utility of using mesh in TRAM abdominal donor-site closure. One-way sensitivity analyses were performed to verify the robustness of the results. RESULTS:The authors' literature review resulted in 10 articles describing 1195 patients who had TRAM abdominal donor-site closure primarily and 696 patients who had donor-site closure performed with mesh. Pooled hernia/bulge complication rates for these two groups were 7.87 percent and 4.45 percent, respectively. The use of mesh was more clinically effective based on total quality-adjusted life-years gained of 30.53 compared with 30.41 when performing primary fascial closure alone. The incremental additional cost incurred by the mesh arm when running the decision tree model was $693.14. This difference in cost, divided by the difference in clinical efficacy (0.12), results in an incremental cost-utility ratio value of $5776.17 per quality-adjusted life-year gained when using mesh, making it cost effective (when using a willingness-to-pay threshold of $50,000). One-way sensitivity analysis revealed the following: (1) using mesh was a cost effective option, provided that the price of mesh was less than or equal to $5970; (2) mesh was cost effective when its use led to a hernia/bulge rate less than or equal to 7.25 percent; and (3) primary facial closure was cost effective when its use led to a hernia/bulge rate less than or equal to 4.75 percent. CONCLUSION:The use of mesh when repairing the abdominal donor site during a pedicled or free TRAM flap breast reconstruction is cost effective compared with primary fascial closure alone.

journal_name

Plast Reconstr Surg

journal_title

Plastic and reconstructive surgery

authors

Chatterjee A,Ramkumar DB,Dawli TB,Nigriny JF,Stotland MA,Ridgway EB

doi

10.1097/PRS.0000000000000957

subject

Has Abstract

pub_date

2015-03-01 00:00:00

pages

682-689

issue

eissn

0032-1052

issn

1529-4242

pii

00006534-201503000-00009

journal_volume

135

pub_type

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The use of mesh versus primary fascial closure of the abdominal donor site when using a transverse rectus abdominis myocutaneous flap for breast reconstruction: a cost-utility analysis.