Saturday, May 17, 2008

Questions about breast reconstruction

I got a late question in the "mailbag" from a Plastic Surgery resident asking

"When I was applying to programs last year and traversing the country visiting programs, there were a few trends which enticed applicants, probably none more that microvascular breast reconstruction. I was curious whether you think this trend will persist, or do you think increased insurance skepticism and comparability of implant based reconstruction and rotational flap reconstruction will leave this procedure for the uber rich willing to pay the difference?"

One thing to understand with questions like this is that while quality in healthcare is applauded, it is not paid for in a vacuum. With rare exception, reimbursement for insurance will continue to be depressed as we creak towards some kind of "federal medicare for all". As the feds and 3rd party payers look at things, quality is measured in things like length of stay and total cost rather then measuring quality in terms of "Does this type of reconstruction look more like a breast?".

Microsurgical expertise is gradually being concentrated in fewer and fewer hands as it has become a financially unsustainable procedure for most surgeons. (you can witness the same phenomena in pediatric plastic surgery & increasingly, hand surgery btw) I don't think there exists a large population of "uber rich" to sustain the field in a robust fashion, and there really is no plausible stimulus pending (50% increase in RVU's for instance) for rekindling interest in free flap surgery when other options exist.



Anonymous said...

You might think the results of free flap surgery is comparable to TRAM surgery, but as a woman who has had the latter, believe me, you're wrong.

Allowing the removal of my abdominal muscle was the worst mistake of my life. I am physically active, 40 years old, and feel extremely compromised from the surgery. I am an equestrian and my balance and strength has never been the same.

My alternative was an implant which I was told would not match the other breast and would need to be replaced at least once during my life.

So how are those alternatives as good as the free tram would have been?

Dr. Rob Oliver said...

A "free TRAM" has the same abdominal weakness produced as a traditional TRAM flap. In many clinical series, this weakness has been fairly minimal and well tolerated.

The new types of "perforator" flaps (eg. DIEP, GAP, or SIEP flaps) spare the muscle entirely and would offer some advantage in re. to abdominal weakness (in theory).

It's debateable whether any aesthetic advantage exists with free flaps. I certainly don't think they offer any advantage unless you're having bilateral DIEP flaps as I think bilateral TRAM harvests are too morbid for most people.

Plastic Surgery Information said...