Introduction Refined mastectomy techniques, the advent of new technologies and materials such as acellular dermal matrix (ADM), cohesive gel silicone implants, and intraoperative tissue perfusion analysis, have fueled a resurgence in prepectoral breast reconstruction. This article aims to compare an immediate direct-to-implant prepectoral ADM-sparing approach with the traditional subpectoral 2-stage immediate reconstruction. A cost analysis within a Canadian-run single-payer system is also presented. Methods A retrospective 2-group comparative chart review study was performed (June 2015–January 2017) to identify all patients who underwent prepectoral direct-to-implant breast reconstruction using an ADM-sparing technique. The comparison group consisted of patients having undergone traditional 2-stage subpectoral reconstruction with ADM. All countable variables were included in the cost analysis, which was performed in Canadian dollars. Results A total of 77 patients (116 reconstructed breasts) were included. Both the prepectoral and subpectoral groups were comparable in size, demographics including age, diabetic and smoking status, and receiving neoadjuvant chemotherapy and postmastectomy radiotherapy. Patients having undergone direct-to-implant prepectoral reconstruction benefited from fewer follow-up visits (3.8 vs 5.4, respectively) and from less complications (24.7% vs 35.6%, respectively) including animation deformity. In addition, direct-to-implant prepectoral reconstruction costs 25% less than the 2-stage subpectoral reconstruction when all associated costs were considered. Conclusion Prepectoral implant placement avoids many of the disadvantages of the traditional 2 stage subpectoral reconstruction, including pectoralis muscle dissection, animation deformity, and multiple surgeries. As the first comparative cost analysis study on the subject, our ADM-sparing direct-to-implant prepectoral reconstruction method costs 25% less than the traditional 2-stage subpectoral reconstruction with a comparable complication profile.

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Background: There is currently no consensus on the utility of preoperative computed tomography (CT) in nonsyndromic craniosynostosis. This systematic review and meta-analysis examines the evidence available on the necessity of preoperative CT for the treatment of nonsyndromic craniosynostosis. Methods: A comprehensive literature review of the National Library of Medicine (PubMed) database was performed. The following variables were analyzed: concordance of findings between clinical examinations and CT, incidental findings reported on imaging, and the effect of imaging on subsequent management. Concordance between clinical examination/CT and the presence of incidental findings were collected and displayed as descriptive data. The effect of imaging on subsequent diagnosis/management was analyzed by meta-analysis. Results: Eleven studies met the inclusion criteria for a total of 728 patients. Overall, physical examination concordance with CT diagnosis was 97.9% (371/379). Overall, incidental findings led to additional imaging/workup in 1.79% of cases (5/278). The results of the meta-analysis revealed that, in the absence of alternative imaging modalities, CT scans significantly altered diagnosis or led to additional investigations in 12 cases (4.8%, 95% confidence interval = 3%–8%). Preoperative CT scans led to additional investigations in 5 cases and detected incomplete/wrong diagnoses in 7 cases. Conclusions: The results of the present meta-analysis support the use of preoperative CT scans for nonsyndromic craniosynostosis in the absence of alternative imaging modalities. The results also suggest that in properly selected patients, alternative imaging modalities may be appropriate, potentially obviating the need for CT scans.