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Is It Really Better? A Comparison Of Healthcare Utilization And Aesthetic Revisions In Direct-to-implant Versus Tissue Expander-based Breast Reconstruction
Michael Tecce, DO, Jessica R. Cunning, MBA, Arturo J. Rios-Diaz, MD, Cutler Whitely, BS, Rotem Kimia, BA, Robyn B. Broach, PhD, Joseph M. Serletti, MD, Merisa Piper, MD, Joshua Fosnot, MD.
University of Pennsylvania, Philadelphia, PA, USA.

Purpose: Tissue expander (TE) placement followed by implant exchange is the standard two-staged procedure for implant-based reconstruction. However, direct-to-implant (DTI) is an attractive alternative with the potential of decreasing postoperative care and follow-up time. We aimed to compare healthcare utilization by implant-based reconstruction technique and to ascertain if aesthetic revisions differ between those undergoing two-staged reconstruction versus those undergoing DTI.
Methods: Adult women over 18 years old undergoing DTI or TE placement for immediate breast reconstruction were identified between 2015-2019. Patients with less than 6 months of follow-up were excluded. Patient characteristics, clinical outcomes, aesthetic revisions, and postoperative healthcare utilization, as defined by the total number of postoperative visits, were compared using Chi-square and Kruskal-Wallis tests.
Results: One hundred and twenty-two patients met inclusion criteria, and 45.9% underwent DTI reconstruction. Patients were a median age of 50 years old (interquartile range [IQR] 43-56) and mainly Caucasian (89.3%). Those undergoing two-staged reconstruction with TE were more likely to be publicly insured (25.8% vs. 5.4%, p<0.01) and less likely to have a chemotherapy history compared to DTI patients (21.2% vs. 39.3%, p<0.01). Cohorts did not differ in age, race, BMI, comorbidities, or indication for surgery (p>0.05). After adjusting for visits related to TE filling, the median total number of outpatient visits was comparable (DTI 9 [IQR 5.5-12] vs. TE 7 [5-11.5], p=0.48; Figure). Surgical site occurrences, implant loss, ED visits, and readmissions were also similar between groups (p>0.05). Overall, 39 implant-based reconstruction patients underwent a total of 47 aesthetic revisions, corresponding to 20 DTI patients with 23 revisions and 19 TE patients with 24 revisions (p>0.05). The breakdown of revision rates and types between DTI and TE patients are shown in the Table. When analyzing the time to first revision after placement of the permanent implant in both groups, there is a trend towards significance of DTI patients undergoing their first aesthetic revision months earlier than TE patients (median 6.4 months [IQR 5.5 11.1] vs. 10.5 months [7.2 17.7], p=0.06).
Conclusions: DTI reconstruction does not appear to result in decreased postoperative care utilization when compared to TE for implant-based reconstruction. Both groups have comparable rates of surgical site occurrences, implant loss, readmissions, and ED visits. Furthermore, approximately one-third of all implant-based reconstruction patients undergo aesthetic revisions, with fat grafting being the most common procedure. While the rates and types of revision do not differ based on one- or two-staged reconstruction, a trend shows that DTI patients undergo their first revision sooner than TE patients. Further investigation will look into patient reported quality of life outcomes between two-staged and direct-to-implant reconstruction.


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