Patterns and costs of breast reconstruction in Chinese plastic surgery department: a study from national quality control databases (2022–2023)

Introduction

Breast cancer is the most common malignancy among women worldwide, accounting for 11.6% of all cancers in 2022 (1), and it also ranks first among Chinese women (2), with over 357,200 new cases annually (3). Surgery remains the primary treatment for early-stage breast cancer, and breast reconstruction after mastectomy is a critical component of recovery, improving both physical appearance and psychological well-being (4-8). Globally, reconstruction rates have risen markedly, driven by increased awareness and supportive policies such as the Women’s Health and Cancer Rights Act in the United States (US) (9,10). and the National Health Insurance Service in South Korea (11). In China, however, the increase has been more gradual, with reconstruction rates in high-volume hospitals rising from 4.5% in 2012 to 10.7% in 2017 (12,13). While reflecting socioeconomic improvements, surgical training, and patient demand, these rates remain far below international standards.

Unlike the legislative mandates in the US and South Korea (9-11), the potential for growth in China is closely tied to the evolution of its healthcare insurance system. While over 95% of the population is covered by basic medical insurance, reimbursement has traditionally excluded breast reconstruction, particularly implants and acellular dermal matrix (ADM), categorizing them as cosmetic procedures. This explains the high self-pay rate of 61.71% observed in our findings. Recent reforms, however, mark a turning point: under the new China Healthcare Security Diagnosis-Related Groups (CHS-DRG) framework, mastectomy with immediate reconstruction has been included as a single payment episode (e.g., code JA19 in Beijing). This shift signals that reconstruction is being recognized as part of comprehensive cancer care, paving the way for broader coverage and future growth.

Despite its clinical and policy significance, breast reconstruction in China has not been systematically assessed at the national level. This evidence gap hinders progress in three critical domains: benchmarking clinical quality, guiding healthcare resource allocation, and informing evidence-based policies to reduce patients’ financial burden. Previous knowledge has largely relied on fragmented single-center studies or regional surveys that lacked national representativeness, making it difficult to evaluate nationwide patterns, disparities, and economic implications.

In response, three major nationwide databases have recently been established to strengthen medical quality monitoring and provide reliable data for health services research: the National Clinical Improvement System (NCIS), the National Medical Quality Control Platform of Plastic and Aesthetic Medicine (QCP-PAM), and the Hospital Quality Monitoring System (HQMS) (14). NCIS provides a macro-level clinical overview across departments, QCP-PAM focuses on specialty-specific practices within plastic and aesthetic surgery, and HQMS contributes granular hospital-level information on surgical volume, reconstruction type, hospitalization costs, and complications. While collectively enabling—for the first time—a nationwide evaluation of breast reconstruction, these systems also present limitations, including variability in institutional reporting and incomplete geographic coverage in HQMS’s inaugural year. Findings derived from these sources therefore need to be interpreted with awareness of these constraints.

Against this background, the present study is the first to leverage the combined strengths of NCIS, QCP-PAM, and HQMS to perform a nationwide assessment of breast reconstruction in China. Specifically, we aimed to quantify surgical volumes and patterns, evaluate economic burden through hospitalization costs and self-pay ratios, and identify regional disparities across China’s provincial-level administrative divisions (PLADs). By analyzing both clinical indicators and socioeconomic correlates, this study seeks to establish a national baseline for breast reconstruction, thereby providing evidence to support clinical improvement, optimize healthcare resource allocation, and inform policy strategies that promote equitable access to reconstructive care for breast cancer patients across China. We present this article in accordance with the RECORD reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-246/rc).

Methods

Data sources

The Quality Control Center of Plastic and Aesthetic Major (QCC-PAM) was founded in 2018, with approval from the Medical Quality Evaluation Division of the National Health Commission. It is dedicated to regulating industry practices and enhancing service quality and safety, and to guiding the healthy and orderly development of the plastic and aesthetic medicine industry. Under the guidance of QCC-PAM, we utilized data from the NCIS, the QCP-PAM, and the HQMS to perform an analysis of female patients who underwent mastectomy with breast reconstruction. More information of the establishment, organization, and funding of the registry can be found in the paper of Zheng et al. (14) and the annual report (15).

These three data sources serve distinct yet complementary functions. NCIS is a macro-level clinical surveillance system that captures a large number of breast reconstruction procedures performed mainly in breast surgery departments, providing broad national coverage. QCP-PAM is a specialty-specific platform focusing exclusively on plastic and aesthetic surgery departments, thus offering detailed insights into specialty practice patterns. HQMS, established in 2023, is an administrative database that extracts structured front-page data from hospital medical records. It provides provincial-level information on surgical volume, reconstruction type (autologous vs. implant-based), hospitalization cost, and self-pay ratio. Collectively, these sources enable a comprehensive evaluation of the status and cost of breast reconstruction in China, from both clinical and economic perspectives.

Variables and indicators

Data from NCIS and QCP-PAM covered the years 2022–2023, and included annual surgical volume, perioperative antibiotic usage rate, and surgical site infection (SSI) rate for phase I breast reconstruction. HQMS, established in 2023, provided provincial-level information on surgical volume, reconstruction type (autologous vs. implant-based), average hospitalization cost, self-pay ratio, blood transfusion, and complications. For HQMS, 15 PLADs with complete records in 2023 were included in the analysis.

Socioeconomic indicators—per capita gross domestic product (GDP) and urbanization rate—were obtained from the National Bureau of Statistics of China. For international comparison, the composition of breast reconstruction in the US was sourced from the American Society of Plastic Surgeons (ASPS) (16).

The data were analyzed by first conducting descriptive statistics to summarize national and provincial distributions, followed by cross-database comparisons to assess consistency in reconstruction patterns. In addition, Pearson’s correlation analysis was performed to examine associations between socioeconomic indicators (per capita GDP and urbanization rate) and reconstruction-related outcomes such as hospitalization cost and self-pay ratio. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Statistical analysis

Continuous variables were reported as means, and categorical variables as frequencies and percentages. Cross-database comparisons were performed to examine consistency in reported figures. Pearson’s correlation analysis was used to assess associations between socioeconomic indicators (per capita GDP, urbanization rate) and breast reconstruction outcomes, including average hospitalization cost and self-pay ratio. All calculations were conducted using Microsoft Excel 2019.

Results

General situation of breast reconstruction

According to data from NCIS, 30,530 breast cancer surgery cases were conducted, and phase I breast reconstruction accounted for 6.4% (n=1,969) in 2022. The total number of phase I breast reconstructions after breast cancer surgery in 2023 was 1,844, with 1,832 in public and 12 in private hospitals, representing a decrease of 125 cases compared to 2022 (Table 1). In contrast, data from QCP-PAM indicated 924 cases in 2023, including 871 in public and 53 in private medical institutions, reflecting an increase of 487 cases compared to 2022 (Table 2).

According to NCIS, 1,573 patients (85.30%) received perioperative antibiotics, including 1,568 (85.59%) in public hospitals and 5 (41.67%) in private hospitals (Figure 1A). Similarly, QCP-PAM data revealed that 808 out of 924 patients (87.45%) received perioperative antibiotics (758 (87.03%) in public and 50 (94.34%) in private medical institutions (Figure 1B).

Figure 1 Perioperative antibiotic usage rate, and single site infection rate for postoperative breast reconstruction after breast cancer in NCIS (A) and QCP-PAM (B) (2022–2023). NCIS, National Clinical Improvement System; QCP-PAM, National Medical Quality Control Platform of Plastic and Aesthetic Medicine.

According to NCIS data, 41 patients (2.22%) developed SSIs, all reported by public hospitals (2.24% in public hospitals). Similarly, QCP-PAM data indicated that 33 patients (3.57%) experienced SSIs, all reported by public medical institutions (3.79%). According to the HQMS, the following complications were recorded: hematoma (2 cases), flap necrosis (1 case), implant removal (4 cases), SSI (38 cases, including 19 cases of incision infection, 9 cases of implant infection, and 10 cases of expander infection). All infected implants and expanders were removed. Additionally, expander rupture was reported in 3 cases, all of which required removal. The rate of SSI was 7.76%.

Breast reconstruction data at provincial level according to HQMS

A total of 490 breast reconstruction surgeries were identified in 15 out of 31 provincial-level administrative regions (Table 3, Figure 2). The data reveal significant regional disparities in economic factors, medical practices, and patient expenses. Regions with more abundant medical resources, such as Beijing (167 surgeries), and Shanghai (101 surgeries), reported the highest number of surgeries. Notably, Jiangxi and Guizhou demonstrated a 100% autologous reconstruction rate (Figure 3).

Figure 2 Bubble map of average reconstruction hospitalization cost and self-pay ratio across Chinese PLADs. The radius of each bubble is proportional to the total hospitalization cost. PLADs, China’s provincial-level administrative divisions.

Figure 3 Bubble map of total surgical volume and autologous/implant reconstruction percentage across Chinese PLADs. The radius of each bubble is proportional to total surgical volume. PLADs, China’s provincial-level administrative divisions.

The average hospitalization cost for breast reconstruction surgery was CNY 53,695.47 (Table 3, Figure 2). Notably, hospitalization costs were significantly higher in Beijing (CNY 89,401.38) and Liaoning (CNY 65,616.11). In contrast, regions such as Xinjiang reported lower hospitalization costs (CNY 19,207.23). The average self-pay rate was 61.71%. Self-pay rates reached 100% in Zhejiang, Guangdong, Shandong, and Jilin, while significantly lower rates were observed in Shanghai (7.78%) and Guizhou (31.11%). Pearson’s correlation analysis revealed a moderate positive correlation between per capita GDP and average hospitalization cost (r=0.45, P<0.05). Additionally, there was a moderate negative correlation between per capita GDP and self-pay ratio (r=−0.60, P<0.01). The negative correlation between urbanization rate and self-pay ratio was also moderate and statistically significant (r=−0.50, P<0.05).

Implant-based reconstruction data on provincial-level according to HQMS

A total of 278 (56.73%) implant-based reconstruction surgeries were performed in 11 provincial-level administrative regions (Figure 3). Beijing had the highest number of surgeries (n=83), followed by Shanghai (n=55) (Table S1). The surgery volumes of direct-to-implant reconstruction and expander-based reconstruction are similar, with 151 direct-to-implant and 127 expander-based procedures.

Shanghai had a high usage rate of direct-to-implants (81.82%), and Fujian had 100% (Table S1). Guangdong had the highest expander usage rate of 78.57%, while Liaoning had 72.73%, and Zhejiang had 66.67%. ADM was used in 62.59% of implant-based surgeries, indicating its widespread use in implant-based reconstruction. Beijing and Shanghai had very high ADM usage rates, at 100% and 69.09%, respectively. Guangdong and Sichuan did not use ADM in breast reconstruction.

Autologous reconstruction data on provincial-level according to HQMS

A total of 212 autologous reconstruction surgeries were performed in plastic surgery departments across 15 out of 31 PLADs, accounting for 43.27% of the total breast reconstruction surgeries (Figure 3). Deep inferior epigastric perforator (DIEP) surgery (50%) is the most common autologous procedure. In regions such as Guizhou and Liaoning (100.00%), DIEP is particularly prominent. Nationally, latissimus dorsi (LD) (35.85%) is the second most commonly used autologous technique. The highest proportions of LD surgeries are seen in Shandong, Hunan, and Xinjiang (100.00%) (Table S2).

Transverse rectus abdominis myocutaneous (TRAM) surgery (7.08%) involves the transfer of abdominal tissue is most commonly performed in Fujian (50.00%), but is less frequently used in most other regions (Table S2). Free Pectoralis Major surgery is very rare, comprising only 2.36% of the total autologous surgeries, and is only performed in Beijing (4.76%) and Fujian (12.50%). Superficial inferior epigastric artery flap (SIEA) surgery is also rare, performed only in Hubei (10%). Gluteal artery perforator flap (GAP) surgery is more commonly used in Zhejiang, accounting for 57.14%.

Comparison between China and US breast reconstruction trends

In China, autologous reconstruction is the most commonly used method, accounting for 43% of procedures (Figure 4A). It is followed by “direct-to-implant” (31.26%) and “tissue expander (TE) and implant” (25.88%). Other methods, such as DIEP (21.95%), LD (14.91%), TRAM (2.90%), and “other flap” (3.11%), make up smaller portions of the distribution.

Figure 4 Composition of breast reconstruction methods of 2023 in China (A) and the United States (B). DIEP, deep inferior epigastric perforator; LD, Latissimus dorsi; TE, tissue expander; TRAM, transverse rectus abdominis myocutaneous.

In contrast, in the US, “TE and implant” is the dominant method, used in 54.50% of breast reconstructions (Figure 4B). “Direct-to-implant” is the second most common at 23.18%, followed closely by “auto” reconstruction at 22%. Other methods, such as DIEP (13.12%), LD (3.41%), TRAM (2.19%), and “other flap” (3.60%) represent a smaller share. These statistics highlight a tendency in the US toward implant-based reconstruction, while China shows a higher reliance on autologous methods.

Discussion

Breast reconstruction surgery is an integral part of recovery for mastectomy patients, greatly improving both physical appearance and psychological well-being. Globally, reconstruction rates and the proportion of implant-based procedures have increased, given their significant benefits and cost-effectiveness (4,17). However, our findings highlight that reconstruction remains underutilized in China: NCIS recorded 30,530 breast cancer surgery cases in 2022, of which phase I breast reconstruction accounted for only 6.4% (n=1,969). This rate is markedly lower than the 40–65% reported in the US (ASPS 2023). Such disparities underscore both the growth potential and the systemic barriers within China’s healthcare system.

Within China, significant provincial differences were observed, with some regions facing higher financial burdens and fewer surgical options. Our results align with a questionnaire-based study that reported a 60% implant-based reconstruction rate in 2017, similar to our findings (18). We also found an autologous reconstruction rate of 43.27%, comparable to international patterns where autologous procedures accounted for less than 40%. Notably, the use of mesh (including ADM) has expanded rapidly—from only 0.91% of implant-based reconstructions in 2012 to 62.59% in our data—reflecting the adoption of new technologies that improve aesthetic outcomes and safety. These trends are consistent with recent international advances, such as fat grafting for volume retention (8), a comparative study on heterologous reconstruction after radiotherapy (5), evolving practices in pre-pectoral breast reconstruction (7), and the emerging role of sensory neurotization in implant-based reconstruction (6). Together, these findings indicate that China is beginning to adopt global innovations, yet significant gaps remain in accessibility, affordability, and equitable distribution of reconstructive services.

An essential strength of this study lies in the integration of three complementary national databases, whose divergences in reported figures reflect their distinct roles. NCIS, as a macro-level clinical surveillance system, captures most reconstructions performed in breast surgery departments, explaining its larger volume. QCP-PAM, in contrast, is a specialty-specific platform focusing exclusively on plastic and aesthetic surgery departments, accounting for its smaller size and higher proportion of private hospital cases. These differences in reporting standards and coverage scope partly explain the inconsistencies observed between NCIS and QCP-PAM reconstruction patterns. HQMS, as an automated system for extracting administrative, procedural, and financial data, offers unique provincial-level details on costs, self-pay rates, and technique choices, though its modest case number reflects its recent establishment in 2023. Collectively, these sources provide a triangulated perspective, while the observed discrepancies underscore the importance of cautious interpretation and highlight the need for cross-database validation to enhance reliability.

A key counter-intuitive finding was that private hospitals showed both higher prophylactic antibiotic use and higher SSI rates. Rather than undermining the efficacy of antibiotic prophylaxis, this paradox may reflect unobserved confounding factors, such as differences in patient mix, surgical complexity, or infection control practices. This finding should be interpreted with caution and highlights the need for further investigation in future studies.

Drawing on the current situation in China and experiences from other countries, the study calls for continued policy interventions and healthcare system reforms to further reduce these disparities. It aims to ensure that all breast cancer patients, regardless of their economic status or geographic location, have equal access to breast reconstruction surgery (19). Several key areas require attention to further enhance access to breast reconstruction for all patients (20). Firstly, expanding coverage policies like CHS-DRG, especially for low-income and minority populations, is crucial to ensuring equitable access to breast reconstruction procedures. Secondly, efforts should be made to improve healthcare infrastructure in underserved areas to ensure that geographic location does not limit a patient’s access to reconstructive surgery. Lastly, continued technological advancements in breast reconstruction are essential for improving outcomes, making surgeries safer and more effective, and enhancing the overall patient experience.

This study has several important limitations. First, data from QCP-PAM only covered procedures performed in plastic surgery departments, whereas the majority of reconstructions in China are conducted by breast surgery departments. This restricts the representativeness of the findings and means that the results cannot fully reflect the national landscape of breast reconstruction. Second, the sample size, particularly from HQMS (490 cases across 15 PLADs), was modest, which limits the robustness of nationwide inferences. Third, the short history of these databases (HQMS launched in 2023, NCIS/QCP-PAM beginning in 2022) prevented longitudinal analyses of how reconstruction rates, outcomes, or costs have evolved over time. Finally, the extremely low case volume in private hospitals (e.g., fewer than 20 cases in NCIS 2023) led to large fluctuations in indicators such as perioperative antibiotic usage and infection rates, undermining the reliability of subgroup analyses for private institutions. These limitations should be considered when interpreting the study’s results, though the data nonetheless provide the first authoritative national baseline for breast reconstruction in China.

Conclusions

This study provides the first nationwide assessment of breast reconstruction in China using three national databases. We found a low reconstruction rate of 6.4% in 2022, far below international benchmarks, and significant provincial disparities in financial burden and surgical access. Autologous and implant-based patterns were broadly consistent with global trends, while mesh/ADM use has expanded rapidly, reflecting the adoption of new technologies. By integrating NCIS, QCP-PAM, and HQMS, this study establishes a national baseline for surgical patterns, costs, and outcomes, underscoring the need for expanded insurance coverage, improved healthcare infrastructure, and systematic quality monitoring to ensure equitable access to breast reconstruction.

Acknowledgments

We acknowledge the Quality Control Center of Plastic and Aesthetic Major for providing national data.

Footnote

Reporting Checklist: The authors have completed the RECORD reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-246/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-246/prf

Funding: This study was supported by the National High Level Hospital Clinical Research Funding (No. 2022-PUMCH-B-042, to X.W.; and No. 2025-PUMCH-A-193, to F.D.), Peking Union Medical College Education Foundation and China Medical Board Open Competition Grants (No. 25-588, to X.L.; and No. 23-518, to F.D.).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-246/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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