Direct-to-implant reconstruction as a cost-efficient option in patients aged 65 years and older

Direct-to-implant (DTI) is a single-stage breast reconstruction technique. Data support its use in older patients, but most studies have focused on surgical outcomes rather than resource use. We compared costs, resource use, and outcomes between single-stage DTI and two-stage tissue expander (TE) reconstruction in patients aged ≥65 years.

A single-center retrospective review included patients ≥65 years who underwent implant-based breast reconstruction (2009-2023). Patients were matched 1:2 (DTI:TE) using Mahalanobis distance on age, body mass index, and history of smoking, radiation, chemotherapy, diabetes, and hypertension. Total cost was the sum of hospital costs spanning the index operation to one year after the final planned reconstruction, including costs for operative time, surgical materials, length of stay, emergency room visits, readmissions, and reoperations. Outcomes were analyzed using cluster-robust gamma regression with a log link and logistic regression adjusting for implant plane, laterality, and baseline characteristics.

The matched cohort included 30 DTI and 58 TE patients. DTI was associated with lower costs ($12,379 ± $5749 vs. $16,653 ± $6859; p=0.003) and shorter operative time (201 ± 100 vs. 353 ± 115 min; p<0.001). After adjustment, DTI continued to be associated with 15% lower costs (p=0.03), driven by a 36% shorter operating room time (p<0.001). The odds of any complication did not differ (p=0.22) CONCLUSION: DTI reconstruction was associated with lower costs and shorter operative time without increased risk of complications, supporting DTI as a reasonable lower-resource option for older patients.