The Use of Unlisted Billing Codes for Microsurgical Breast Reconstruction and Implications for Code Consolidation.

BACKGROUND: Private insurers have considered consolidating the billing codes presently available for microvascular breast reconstruction. There is a need to understand how these different codes are currently distributed and used to help inform how coding consolidation may impact patients and providers. METHODS: Using the Massachusetts All-Payer Claims Database between 2016 and 2020, patients who underwent microsurgical breast reconstruction following mastectomy for cancer-related indications were identified. Multivariable logistic regression was used to test whether an S2068 claim was associated with insurance type and median household income by patient ZIP code. The ratio of S2068 to CPT19364 claims for privately insured patients was calculated for providers practicing in each county. Total payments for professional fees were compared between billing codes. RESULTS: There were 272 claims for S2068 and 209 claims for CPT19364. An S2068 claim was associated with age < 45 years (OR: 1.89, 95% CI: 1.11-3.20, p = 0.019), more affluent ZIP codes (OR: 1.11, 95% CI: 1.03-1.19, p = 0.004), and private insurance (OR: 16.13, 95% CI: 7.81-33.33, p < 0.001). Median total payments from private insurers were 101% higher for S2068 than for CPT19364. In all but two counties (Worcester and Hampshire), the S-code was used more frequently than CPT19364 for their privately insured patients. CONCLUSION: Coding practices for microsurgical breast reconstruction lacked uniformity in Massachusetts, and payments differed greatly between S2068 and CPT19364. Patients from more affluent towns were more likely to have S-code claims. Coding consolidation could impact access, as the majority of providers in Massachusetts might need to adapt their practices if the S-code were discontinued.

Optimal Timing of Delayed Microvascular Breast Reconstruction after Radiation Therapy.

BACKGROUND: The purpose of this study was to determine the optimal timing of delayed microvascular breast reconstruction after completion of postmastectomy radiation therapy (PMRT). The authors evaluated whether the timing of reconstruction after PMRT completion affects the development of major postoperative complications. We hypothesize that delayed microvascular breast reconstruction can be safely performed within 12 months of PMRT completion. METHODS: A retrospective chart review of microvascular, autologous breast reconstructions at Brigham and Women's Hospital from 2007 to 2019 was performed. Logistic regression analysis and marginal estimation methods were used to estimate the probability of any major complication (flap compromise requiring operative intervention, hematoma formation requiring evacuation, infection requiring readmission, and flap necrosis requiring operative debridement) occurring in 2-month intervals after PMRT. Patients were classified as having undergone reconstruction 0 to 12 months after PMRT (group 1), 12 to 18 months after PMRT (group 2), or 18 to 50 months after PMRT (group 3). RESULTS: A total of 303 patients were identified. All patients received postmastectomy radiation (n = 143 group 1, n = 57 group 2, n = 103 group 3). Mean follow-up time was 71.4 ± 38 months. Patients in group 1 were significantly younger and more likely to have undergone neoadjuvant chemotherapy (p < 0.05). Major complications occurred in 10% of patients. There was no significant difference in the development of major complications between the three groups (p = 0.57). Although not statistically significant, the probability of any major complication peaked 2 to 6 months after PMRT completion. CONCLUSION: There was no significant difference in major complications among patients who underwent delayed, microvascular breast reconstruction within versus beyond 1 year of PMRT completion. These findings suggest that delayed microvascular breast reconstruction can be safely performed beginning 6 months after PMRT completion.

National Patterns of Breast Reconstruction and Nipple-Sparing Mastectomy for Breast Cancer, 2005-2015.

BACKGROUND: The purpose of this study was to explore national patterns in the uptake of breast reconstruction and nipple-sparing mastectomy (NSM). METHODS: We used the National Cancer Database to identify all women who underwent mastectomy for stage 0-III breast cancer between 2005-2015. Multivariable logistic regression was used to determine factors associated with receipt of reconstruction, with subset analyses performed to determine trends and predictors of NSM in those who underwent mastectomy with reconstruction. RESULTS: Our cohort consisted of 395,815 women, 238,568 (60.3%) who underwent mastectomy alone and 157,247 (39.7%) who underwent mastectomy followed by reconstruction. The use of breast reconstruction increased from 22.3% of mastectomy cases in 2005 to 49.7% of mastectomy cases in 2015 (odds ratio [OR] 9.7, 95% confidence interval [CI] 7.3-12.8). Among those receiving reconstruction, the use of NSM increased from 1.7% in 2005 to 14.3% in 2015 (OR 9.4, 95% CI 7.1-12.5), with increased utilization among those with early-stage and locally advanced disease, such that by 2015, NSM was performed in 15.3% of mastectomies with reconstruction for DCIS, 14.3% of mastectomies with reconstruction for stage I-II breast cancer, and 10.7% of mastectomies with reconstruction for stage III breast cancer. Factors strongly predicting receipt of NSM included age < 45 years, smaller clinical tumor size, clinically node negative disease, use of neoadjuvant therapy, and facility type. CONCLUSIONS: There has been a dramatic increase in the use of breast reconstruction and NSM between 2005-2015. Further prospective studies evaluating oncologic outcomes of NSM in locally advanced breast cancer are warranted.

Management of Rhinophyma: Outcomes Study of the Subunit Method.

BACKGROUND: Rhinophyma causes a nasal deformity and functional airway obstruction. Partial excision (eg, tangential) with secondary healing commonly removes hypertrophic soft tissues but does not improve nasal support. The subunit method for rhinophyma uses 6 nasal flaps to provide exposure for removal of rhinophymatous tissue and enhance structure. The purpose of this study was to evaluate outcomes of subunit method. METHODS: Medical records of patients with rhinophyma treated with the subunit method between 2013 and 2016 were analyzed. The technique comprises degloving the distal half of the nose by elevating 6 subunit-based flaps; debulking phymatous tissues to perichondrium; enhancing nasal support with sutures/cartilage grafts; trimming excess skin; and redraping the soft tissues. Patient age, gender, need for cartilage grafts or skin grafts, revisions, and follow-up were assessed. RESULTS: The study comprised 8 patients (6 male). Mean age was 63 years (range 34-72). All individuals had interdomal sutures for tip enhancement and 4 patients underwent cartilage grafts (alar batten) to correct external valve collapse. One patient had 2 subunits (alar) replaced with skin graft. Average follow-up was 1.6 years (range 0.2-3.7). Six patients underwent revisional procedures primarily to modify the scar between the dorsum and tip subunits. CONCLUSION: The subunit method addresses the 3 fundamental problems of the rhinophymatous nose: hypertrophic sebaceous tissues, excess skin, and destruction of support. Most patients may benefit from a minor revisional procedure to optimize the result. Individuals should be counseled that operation will likely require 2 stages.

The impact of anemia on microsurgical breast reconstruction complications and outcomes.

INTRODUCTION: Appropriate and adequate blood flow and oxygen delivery to a free flap is paramount to viability and success. We present a comprehensive examination of perioperative anemia, determining its prevalence and effect on complications and outcomes in autologous breast reconstruction. METHODS: We analyzed all autologous free flap breast reconstruction at the Hospital of the University of Pennsylvania from 2005 to 2011 with regards to anemia (hemoglobin (Hgb) <12 g dL(-1) ). Anemic patients were compared to those with Hgb > 12 g dL(-1) at preoperative and postoperative timepoints. Complications were analyzed relative to HgB levels and the incidence of anemia. Subgroups were analyzed based on worsening degrees of anemia. RESULTS: Overall, 839 patients were included in the analysis with an 18.3% incidence of preoperative anemia. No significant differences were noted in outcomes of these patients relative to their anemic state, although a higher percent did receive a blood transfusion (18% of anemic patients vs. 6% of nonanemic patients, P < 0.0001). There was a significant incidence of postoperative anemia (93.4%). A subgroup analysis demonstrated that worsening postoperative anemia was significantly related to preoperative HgB (P < 0.0001), bilateral cases (P < 0.0001), immediate reconstructions (P < 0.0001), increased estimated blood loss (P = 0.0001), and higher rates of intraoperative fluid administration (P = 0.025). A higher incidence of medical complications was observed in cohorts with HgB < 10 (P = 0.018). CONCLUSIONS: Anemia affects a significant portion of breast reconstruction patients. While preoperative anemia is not associated with increased risk of flap related complications, postoperative anemia may be associated with an increased risk of medical complications.

Gestational Pseudoangiomatous Stromal Hyperplasia Presenting as Gigantomastia: A Case Report of a Rare Breast Entity with Clinical Recommendations by a Multidisciplinary Team.

Introduction: Pseudoangiomatous stromal hyperplasia (PASH) presenting as gigantomastia is rare in pregnancy but can result in severe clinical consequences for both mother and fetus. Case Presentation. A 43-year-old female with a history of biopsy-proven bilateral PASH presented at 22 3/7 weeks gestation with massive bilateral breast enlargement that was symptomatic. After multidisciplinary care, she underwent bilateral mastectomies and delivered at term with no additional complications. Conclusion: Pregnant women who undergo mastectomies for PASH-induced gigantomastia during their second trimesters will likely recover quickly, and fetal risks are low. Given the rarity of this breast entity, management guidelines are sparse. Our case report is an effort to comprehensively review this condition and share the clinical recommendations made by our institution's multidisciplinary team.

Impact of Prepectoral vs. Subpectoral Tissue Expander Placement on Post-mastectomy Radiation Therapy Delivery: A Retrospective Cohort Study.

Background: Implant-based reconstruction is the most common method of postmastectomy reconstruction. Many patients require postmastectomy radiation (PMRT). Tissue expanders (TEs), typically inserted as a first stage, have historically been placed subpectorally. More recently, prepectoral reconstruction has gained popularity, but its impact on PMRT is unknown. Prior studies focus on complication rates and aesthetic outcomes. This study examines whether there is a difference in radiation dosimetry among patients undergoing prepectoral versus subpectoral TE reconstruction. Methods: Electronic medical records and radiation plans of 50 patients (25 prepectoral, 25 subpectoral) who underwent mastectomy with immediate TE reconstruction at our institution or affiliate site were reviewed. Pectoralis major muscle and chest wall structures were contoured and mean percentage volumes of these structures receiving less than 95%, 100%, and more than 105% target radiation dose were calculated, as were heart and ipsilateral lung doses. Welch two sample t test, Fisher exact test, and Pearson chi-squared tests were performed. Results: The groups had comparable patient and tumor characteristics and underwent similar ablative and reconstructive procedures and radiation dosimetry. Subpectoral patients had larger mean areas receiving less than 95% target dose ("cold spots"); prepectoral patients had larger mean areas receiving greater than 105% ("hot spots") and 100% target doses. There were no differences in chest wall, heart, and lung doses. Conclusions: Our results demonstrate an increased mean percentage area of pectoralis cold spots with subpectoral reconstruction and increased area of hot spots and 100% dose delivery to the pectoralis in prepectoral patients. Larger studies should analyze long-term effects of prepectoral reconstruction on radiation dosing and recurrence rates.

Left Internal Mammary Vein Size and Its Impact on Microsurgical Breast Reconstruction.

The internal mammary vessels are the preferred recipient during free-flap breast reconstruction (FFBR). Previous studies have demonstrated that the left internal mammary vein (IMV) is consistently smaller than the right, but with unclear clinical implications. This study explores the impact of IMV size difference on FFBR complication rates. Methods: Abdominal-based FFBRs were retrospectively reviewed. Venous coupler size was considered a proxy for IMV diameter. Outcomes of three patient cohorts (all, unilateral, and bilateral reconstructions) were analyzed with univariate and multivariate analysis. Results: Our cohort consisted of 582 patients who underwent 874 abdominal-based FFBR, with a similar number of unilateral (n = 290) and bilateral (n = 292), and right (n = 424) and left (n = 450) reconstructions. Mean follow-up was over 4-years. For all reconstructions, the left IMV (2.7 ± 0.4 mm) was smaller than the right (3.0 ± 0.4 mm) (P < 0.0001). Complication rates between left- and right-sided FFBR were similar, but with a trend toward increased fat necrosis on the left (n = 17, 3.8% versus n = 8, 1.9%). Further subgroup analysis showed significantly higher fat necrosis in unilateral left-sided FFBR (n = 12 versus n = 2, P = 0.02), with left-sided FFBR being an independent risk factor for fat necrosis on multivariate analysis. Conclusions: The left-side IMV is significantly smaller than the right IMV. In bilateral reconstructions, the smaller size of the left IMV did not result in a greater risk of complications; however, in unilateral FFBR, fat necrosis was significantly higher on the left side.

Safety of DIEP Flap Reconstruction in Patients with Factor V Leiden: A Retrospective Cohort Study.

Background: Factor V Leiden (FVL) is the most common inherited thrombophilia in White people. Thrombotic complications resulting from free flap breast reconstruction in FVL patients have been studied to a limited degree. We evaluated whether patients heterozygous for a FVL mutation undergoing deep inferior epigastric perforator flap reconstruction had increased risk of micro- or macrovascular thrombotic complications compared with patients without a diagnosed thrombophilia. Methods: We performed a retrospective cohort study of deep inferior epigastric perforator flap reconstructions at Brigham and Women's Hospital (1/2015-12/2020) comparing patients diagnosed as FVL heterozygotes compared with matched controls without a diagnosed thrombophilia. Patients were matched using coarsened exact matching algorithm based on clinical characteristics. The primary outcomes were micro- (return to OR for flap compromise, flap loss) and macrovascular (venous thromboembolism) complications. Results: A total of 506 patients (812 flaps) were included in this study. Eleven patients (17 flaps) were FVL heterozygotes. After matching, 10 patients (16 flaps) with FVL were matched to 55 patients (94 flaps). The return to OR for flap compromise was 0% in the FVL cohort compared with 5% (n = 5/94, 3/94 flaps lost, P = 1.00) in the matched controls (1.9%, n = 15/795 in unmatched controls, 0.6%, n = 5/795 loss rate). There were zero venous thromboembolism events among FVL patients compared with 2% of controls (n = 1/55). Conclusions: FVL heterozygosity did not increase the risk of micro- or macrovascular complications in patients undergoing deep inferior epigastric perforator flap breast reconstruction. This study supports the safety of microvascular reconstruction in this group of patients when appropriate venous thromboembolism prophylaxis is given.

Reduction Mammaplasty in a Patient with Kniest Dysplasia: Case Report and Literature Review.

Collagen plays a fundamental role in wound healing and consequently defective collagen can impair normal wound healing processes. Kniest dysplasia (KD) is a collagenopathy that results from a pathogenic mutation in a gene that codes for type II collagen. Clinical manifestations of the dysplasia include short-trunk dwarfism, kyphoscoliosis, hand arthropathy, cleft palate, hearing loss, and ocular abnormalities. We present the case of a 21-year-old woman who desired reduction mammaplasty. A review of the literature was performed, and there were no published reports of any plastic surgery procedures in patients with KD. The patient proceeded with surgery and healed without any complications. Given that wound healing appears normal in this patient population, it is reasonable to consider elective plastic surgical procedures in patients with KD.

Intra-abdominal Deep Inferior Epigastric Vessel Course Does Not Preclude Successful DIEP Flap Breast Reconstruction.

We present 2 patients in whom the course of the deep inferior epigastric vessels was intra-abdominal during deep inferior epigastric perforator (DIEP) flap breast reconstruction. Preoperative computed tomography angiography gave no indication of an unusual pedicle location. In both cases, pedicle dissection was completed safely without bowel injury, and reconstruction was completed successfully. Reconstructive surgeons need not abandon DIEP flap reconstruction upon discovering that the deep inferior epigastric vessels are intra-abdominal. Unfortunately, computed tomography angiography imaging does not identify this variant preoperatively. The risk of postoperative ileus after intra-abdominal pedicle dissection may be higher than the risk after dissection of retrorectus deep inferior epigastric pedicles, and thus it is reasonable to consider the use of prophylactic mesh in these cases.

Genetic Testing for Breast Cancer Susceptibility Should Be Offered before Unilateral Abdominally Based Free Flap Breast Reconstruction.

BACKGROUND: Pathogenic mutations have been identified in approximately 10 percent of patients who present with breast cancer. Notably, failure to identify deleterious genetic mutations has particular implications for patients undergoing abdominally based breast reconstruction, as the donor site can be used only once. The authors sought to determine: (1) how many patients underwent genetic testing before unilateral abdominally based free flap breast reconstruction; (2) how often deleterious mutations were detected after abdominally based free flap breast reconstruction; and (3) the cost-effectiveness of expanding genetic testing in this patient population. METHODS: The authors retrospectively identified all patients who underwent unilateral abdominally based free flap breast reconstruction at Brigham and Women's Hospital/Dana-Farber Cancer Institute between 2007 and 2016. Chart review was performed to collect relevant demographic and clinical data. Relevant hospital financial data were obtained. RESULTS: Of the 713 who underwent free flap breast reconstruction, 160 patients met inclusion criteria, and mean follow-up was 5.8 years. Three patients (1.9 percent of 160) underwent contralateral surgery after completing reconstruction, two of whom had BRCA2 and one with ATM mutation. One hundred eleven patients met National Comprehensive Cancer Network guidelines for genetic testing, but of those only 55.9 percent (62 patients) were tested. Financial data revealed that testing every patient in the cohort would result in a net savings of $262,000. CONCLUSIONS: During a relatively short follow-up period, a small percentage of patients were diagnosed with pathogenic mutations and underwent contralateral mastectomy and reconstruction. However, because of the costliness of surgery and the decreased cost of genetic testing, it is cost-effective to test every patient before unilateral abdominally based free flap breast reconstruction.

Complications and Patient-Reported Outcomes after Abdominally Based Breast Reconstruction: Results of the Mastectomy Reconstruction Outcomes Consortium Study.

BACKGROUND: Abdominal flap reconstruction is the most popular form of autologous breast reconstruction. The current study compared complications and patient-reported outcomes after pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator (DIEP), and superficial inferior epigastric artery (SIEA) flaps. METHODS: Patients undergoing abdominally based breast reconstruction at 11 centers were prospectively evaluated for abdominal donor-site and breast complications. Patient-reported outcomes were measured by the BREAST-Q and Patient-Reported Outcomes Measurement Information System surveys. Mixed-effects regression models were used to assess the effects of procedure type on outcomes. RESULTS: Seven hundred twenty patients had 1-year follow-up and 587 had 2-year follow-up. Two years after reconstruction, SIEA compared with DIEP flaps were associated with a higher rate of donor-site complications (OR, 2.7; p = 0.001); however, SIEA flaps were associated with higher BREAST-Q abdominal physical well-being scores compared with DIEP flaps at 1 year (mean difference, 4.72, on a scale from 0 to 100; p = 0.053). This difference was not significant at 2 years. Abdominal physical well-being scores at 2 years postoperatively were lower in the pedicled TRAM flap group by 7.2 points (p = 0.006) compared with DIEP flaps and by 7.8 points (p = 0.03) compared with SIEA flaps, and in the free TRAM flap group, scores were lower by 4.9 points (p = 0.04) compared with DIEP flaps. Bilateral reconstruction had significantly lower abdominal physical well-being scores compared with unilateral reconstruction. CONCLUSIONS: Although all abdominally based flaps are viable breast reconstruction options, DIEP and SIEA flaps are associated with higher abdominal physical well-being than pedicled and free TRAM flaps. Although SIEA flaps offer the advantage of not violating the fascia, higher rates of donor-site complications may diminish patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Outcomes of immediate versus delayed breast reconstruction: Results of a multicenter prospective study.

BACKGROUND: Previous studies suggest that immediate reconstruction following mastectomy produces superior results over delayed procedures. However, for medical or oncological reasons, some patients may be poor candidates for immediate reconstruction. We compared complications and patient-reported outcomes between immediate and delayed breast reconstructions in a prospective, multicenter study. METHODS: 1957 patients (1806 immediate, 151 delayed) met eligibility criteria. Demographic data, major complications, infections, and reconstructive failure rates were evaluated. Patient-reported outcomes were assessed with BREAST-Q, PROMIS, and EORTC QLQ-BR23 surveys, pre- and two years post-operatively. Subscale scores were compared across cohorts using mixed-effects regression models, controlling for patient characteristics and hospitals. FINDINGS: Complete data were available in 1639 immediate and 147 delayed reconstruction patients. There were significant baseline differences between immediate and delayed cohorts in age, BMI, prevalence of diabetes, lymph node management, use of radiation, and chemotherapy. Controlling for clinical covariates, the delayed group had lower odds of any (OR 0.38, p < 0.001) and major (OR 0.52, p = 0.016) complications, compared with immediate patients. Furthermore, delayed reconstruction was associated with a significantly lower failure rates (6% vs. 1.3%, p = 0.032). However, multivariate analyses found no significant differences in patient satisfaction or in psychosocial, sexual, or physical well-being at two years. CONCLUSIONS: Compared with immediate techniques, delayed reconstruction following mastectomy was associated with lower rates of overall and major complication, while providing equivalent patient satisfaction and quality of life benefits. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delaying reconstruction does not appear to compromise clinical or patient-reported outcomes.

Bilateral Free Flap Breast Reconstruction Outcomes: Do Abdominal Scars Affect Bilateral Flaps?

BACKGROUND: The incidence of bilateral mastectomies is increasing along with the rates of breast reconstructions. A substantial number of patients will present with abdominal scars after Cesarean section, laparoscopy, laparotomy, and so on. The aim of this study was to evaluate the impact of prior abdominal scars on complication rates in abdominal bilateral free flap breast reconstruction. METHODS: All consecutive patients with autologous free flap breast reconstruction between 2007 and 2014 were eligible. The relevant demographic and clinical data were prospectively collected into a study-specific database. Complications and reoperations were prospectively registered after postoperative outpatient visits. RESULTS: Overall, 493 patients underwent abdominally based breast reconstruction during the study period: unilateral (n = 250; 50.7%) or bilateral (n = 243; 49.3%). In the bilateral group, the abdominal scar locations were Pfannenstiel (n = 73; 30.1%), midline (n = 16; 6.6%), lower oblique (n = 17; 7.0%), upper oblique (n = 5; 2.1%), and laparoscopic (n = 69; 28.4%). Four (1.7%) flap failures (including 1 converted to a pedicled transverse rectus abdominis flap) were registered, all occurring in patients from the scar group: 3 with Pfannenstiel incision and 1 patient with prior laparoscopy. Pfannenstiel scar was associated with higher risk of hematoma at the recipient site when compared with no scar group (13.7% versus 2.2%; P = 0.006). Partial flap necrosis, infection, and seroma occurred in 14 (5.9%), 8 (3.4%), and 5 (2.1%) patients, respectively, and no differences between the scar groups were identified. CONCLUSION: Surgical outcomes of bilateral reconstructions in patients with abdominal scars are generally comparable with ones in patients without prior surgery; however, some problems have been identified. These procedures might have some intraoperative considerations and often require increased operative times. Apart from the traditional preoperative computed tomography angiography, intraoperative imaging (e.g., fluorescence angiography) may be advocated in patients with abdominal scars.

Why we are here: early reflections on the role of reconstructive plastic surgery in the 2013 Boston marathon bombings.

The 2013 Boston Marathon bombings resulted in a large and unexpected influx of patients requiring acute multidisciplinary surgical care. The authors describe the surgical management experience of these patients at Brigham & Women's Hospital and Brigham & Women's Faulkner Hospital, with a particular focus on the important role played by reconstructive plastic surgery. The authors suggest that this experience illustrates the value of reconstructive plastic surgery in the treatment of these patients specifically and of trauma patients in general, and argue for the increasing importance of promoting our identity as a specialty.