Rise in Microsurgical Free-Flap Breast Reconstruction in Academic Medical Practices

Autor: David T. Cooke, Chanukya R. Dasari, Michael S. Wong, David H. Wisner, Christopher K. Gold, Sven Gunther
Rok vydání: 2015
Předmět:
Zdroj: Dasari, CR; Gunther, S; Wisner, DH; Cooke, DT; Gold, CK; & Wong, MS. (2015). Rise in microsurgical free-flap breast reconstruction in academic medical practices. Annals of Plastic Surgery, 74, S62-S65. doi: 10.1097/SAP.0000000000000483. UC Davis: Retrieved from: http://www.escholarship.org/uc/item/31p5x9zg
Annals of plastic surgery, vol 74 Suppl 1, iss Supplement 1
Annals of plastic surgery, vol 74 Suppl 1, iss &NA
ISSN: 0148-7043
DOI: 10.1097/sap.0000000000000483
Popis: R ESEARCH A RTICLE Rise in Microsurgical Free-Flap Breast Reconstruction in Academic Medical Practices Chanukya R. Dasari, MD,* Sven Gunther, MS,* David H. Wisner, MD,* David T. Cooke, MD,* Christopher K. Gold, MD,† and Michael S. Wong, MD* Background: Previous studies have examined national trends in breast recon- struction, using various data sets demonstrating increases in implant-based recon- struction and decreases in autologous reconstruction. However, academic breast reconstruction practices have never been specifically characterized. The University Health Consortium—Association of American Medical Colleges Faculty Practice Solutions Center database contains comprehensive, factual billing and coding data from 90 academic medical centers in the United States, and has been used to characterize practice patterns of various academic surgical specialties. Objective: To describe breast reconstruction trends unique to academic surgical practices, using the Faculty Practice Solutions Center database. Methods: Annual data for defined breast reconstruction procedures (current procedural terminology codes: 19340, 19342, 19357, 19361, 19364, 19366, 19367, 19369, and 19380) performed by university plastic surgeons during calendar years 2007 to 2013 were included in the study. Results: From 2007 to 2013, a 2-fold increase in the number of breast reconstruc- tion procedures was observed (from a mean of 45.3 to 94.2 procedures per surgeon). During this period, implant-based reconstructions and autologous reconstructions rose in tandem (28.9–44.6 and 11.4–19.3, respectively), with a preserved 2.5:1 ratio between the 2 categories each year. When compared to reconstructions overall, the proportion of both implant reconstruction and autologous reconstruction procedures declined, since revision and other types of reconstructions increased (11% of all reconstructions in 2007 vs 32% in 2013). With regard to autologous reconstruction, microsurgical free flaps (mostly comprised of deep inferior epigastric artery perforator flaps) have supplanted latissimus flaps as the favored modality and comprised 13% to 14% of breast reconstruction cases overall from 2011 to 2013. Conclusion: In contrast to national trends, university-based plastic surgeons are performing a growing number of microsurgical free flaps as the preferred method for autologous breast reconstruction. Whereas implant-based reconstructions still predominate in academic practices, the trend of increasing preference toward implant-based reconstructions has slowed in recent years and revision reconstructions are on the rise. Key Words: microsurgery, free flap, DIEP, perforator, autologous, breast reconstruction, academic surgery OBJECTIVE (Ann Plast Surg 2015;74: S62–S65) BACKGROUND Recent papers on breast reconstruction practices highlight the national trend toward implant-based reconstructions. In the Nationwide Inpatient Sample (NIS), implant-based reconstructions rose by 11% Received July 24, 2014, and accepted for publication, after revision, December 31, 2014. From the *Division of Plastic Surgery, University of California Davis, Sacramento, CA; and †Division of Plastic Surgery, Travis Air Force Base, Fairfield, CA. Conflicts of interest and sources of funding: none declared. Reprints: Michael S. Wong, MD, Division of Plastic Surgery, Department of Surgery, University of California Davis Medical Center, 2221 Stockton Blvd, Suite 2123, Sacramento, CA 95817. E-mail: michael.wong@ucdmc.ucdavis.edu. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7401–S062 DOI: 10.1097/SAP.0000000000000483 S62 annually from 1998 to 2008, whereas autologous reconstructions de- creased by 5% per year. 1 Immediate reconstructions, mostly implant based, also increased by 5% yearly, with a near-doubling reported in a Surveillance, Epidemiology, End-Results database analysis. 2 Associ- ated with this trend, a growing incidence of elective mastectomy and contralateral prophylactic surgery in lieu of breast conservation has been described in several large studies. 3,4 Implant-based reconstructions are often an attractive option for patients and practitioners. Primary implant reconstructions are gener- ally less technically challenging, requiring less intraoperative time, with more favorable insurance reimbursement when compared to autologous reconstructions. 1 More rapid postoperative recovery and avoidance of donor site morbidity are also reasons that may help explain the greater number of practices offering only implant-based reconstruction versus the full spectrum of autologous reconstructions and microvascular free flaps. 5 However, breast implants have negative implications. Over time, implant-based reconstructions can develop capsular contracture, rip- pling, implant migration, asymmetry, and implant rupture. 6 In contrast, autologous reconstructions age more naturally with the patient and may even look better over time. Recent investigations into patient education protocols have demonstrated a greater proportion of patients with a stated preference for autologous repairs in clinical settings. 7 For revision reconstructions of previous implant-based repairs, various modalities are used including autologous tissue transfer, fat grafting, implant exchange, and placement of acellular dermal matrix. The use of microvascular techniques and specifically, deep inferior epigastric artery perforator (DIEP) flaps for revision reconstruction is also well documented. 8,9 In various contexts, microsurgical free flaps are associated with high patient satisfaction and favorable aesthetic outcomes. 10–12 The effect has been that practices offering free flap expertise have evolved into referral hubs for all types of breast therapy. 13 Characterizing these practices can help us understand the recent impact of changing patients' preferences for primary reconstruc- tion and emerging strategies for revision reconstruction. www.annalsplasticsurgery.com The objective of this paper was to analyze breast reconstruction practices of academic plastic surgeons using the Faculty Practice Solu- tions Center (FPSC) database. The University Health Consortium— Association of American Medical Colleges maintains the FPSC database, which contains comprehensive coding and billing data from 90 aca- demic medical centers (comprising more than two thirds of qualifying institutions), encompassing all procedures performed at these facilities for all payer types in both inpatient and outpatient settings by individual specialty. Roughly 300 plastic surgeons (full-time, part-time, and ad- junct faculty) are represented. Previously, the FPSC database has been used to characterize practice patterns of other surgical specialties. 14,15 MATERIALS AND METHODS Annual data for defined breast procedures [current procedural terminology codes: 19316, 19318, 19324, 19325, 19328, 19330, 19369, 19370, 19371, 19380, and 19399] performed by university Annals of Plastic Surgery • Volume 74, Supplement 1, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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