Trends in Physician Payments for Breast Reconstruction.

BACKGROUND: Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction. METHODS: The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models. RESULTS: There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders). CONCLUSIONS: The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

Evolving Approaches to Tissue Expander Design and Application.

Prosthetic reconstruction utilizing a 2-stage saline tissue expander-to-implant procedure is the most common technique for breast reconstruction in the United States. For nearly the past 50 years, 2-stage breast reconstruction using saline tissue expanders has been the standard of care. However, in December 2016, a carbon dioxide-filled, remote-controlled tissue expander received U.S. Food and Drug Administration clearance. This tissue expander, known as the AeroForm Tissue Expander System (AirXpanders, Inc., Palo Alto, Calif.), is a novel, patient-controlled, needle-free expander operated by a wireless remote control device, which allows patients the comfort and convenience of home expansion, precluding the need for percutaneous saline injections. A multicenter, randomized, prospective clinical trial has revealed statistically significant shorter times to full expansion as well as shorter overall reconstructive times. It is the first tissue expander device designed successfully with an alternative filling medium to saline, namely carbon dioxide. This CO2-filled expander thus provides several potential advantages over previous expander designs, including patient-controlled expansion, obviation of saline injections, and shorter expansion times.

Future Perspectives of Pre-expanded Perforator Flaps.

Although clinical application of a pre-expanded perforator flap is primarily focused on face and neck reconstructions, such a flap has also been used to reconstruct defects in the trunk, extremities, or hands. With better understanding of the improved blood supply to the flap and the mechanism on the prefabrication of blood supply within the flap, the pre-expanded perforator flap will definitely play a more important role in reconstructive surgery and can be used in selected patients by many plastic surgeons worldwide with good reconstructive and cosmetic outcomes.

[Transfer of autologous fat and plasma : The future of anti-aging medicine?]. / Autologer Fett- und Bluttransfer : Die Zukunft der Anti-aging-Medizin?

BACKGROUND: Aging is a complex process driven by endogenous and exogenous stimuli. The distinct cellular and noncellular components of skin and adjacent connective tissue are constantly and irreversibly degraded during aging. OBJECTIVES: The aim was to provide an overview of the biology of skin aging and the therapeutic options for rejuvenation. METHODS: A review of the current literature and a demonstration of autologous fat transfer and platelet-rich plasma (PRP) are presented from a clinical perspective. RESULTS: The aging process affects cellular components and the extracellular matrix (ECM); thus, the first stage is the degradation of the ECM. The loss of skin elasticity is induced by a breakdown of fibers such as collagen, elastin, or reticulin, whereas the degradation of proteoglycans results in decreased turgor and skin hydration. Synthetic filling agents primarily compensate for volume loss, but do not rejuvenate biologically. In contrast, the transfer of autologous fat and PRP is based on activating stem cell populations and growth factors, in addition to providing volume to target regions. CONCLUSIONS: A profound comprehension of the cellular and molecular mechanisms of aging is important in anti-aging medicine. The transfer of autologous fat and PRP offers interesting alternatives in the sense of more biological skin rejuvenation.

Cost and outcome analysis of breast reconstruction paradigm shift.

Increased bilateral mastectomy for breast cancer treatment has generated an increased demand for bilateral breast reconstruction. This study examines changing patterns of reconstruction over the last decade to accommodate increased case volume and decreased morbidity associated with reconstruction. A single institution series of 3171 consecutive breast reconstruction cases of more than 10 years was divided into 2 periods, that is, 1999 to 2004 and 2005 to 2010. Bilateral breast reconstruction case volume increased 260% from 1999 to 2004 (n = 237) to 2005 to 2010 (n = 634). Mean patient age at diagnosis decreased by 7 years (P < 0.001). In 2005 to 2010, autologous reconstruction decreased from 60% to 26%, implant-based reconstruction increased from 40% to 74%. There was a noted increase in single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (P < 0.001). Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%) in the later period. A younger patient demographic and increased case volume were accommodated through increased single-staged and prosthesis-based procedures.

[The reconstructive sequence in the 21st century. A reconstructive clockwork]. / Die rekonstruktive Sequenz des 21. Jahrhunderts. Ein rekonstruktives Uhrwerk.

Mathes and Nahai introduced the conventional reconstructive ladder in 1982 to address tissue defects starting with primary and secondary closure of wounds followed by autologous skin grafting. Regional and local pedicled flaps, tissue expansion and free tissue transfer were further steps. Despite enormous achievements and refinements in these techniques, clinical situations and problems occur beyond the scope of these conventional reconstructive measures. Composite tissue allotransplantation (CTA) of partial faces or of unilateral or bilateral forearms and upper arms, are a novel part of transplantation medicine. The initially reported clinical results are encouraging, especially in light of the initial clinical reports of organ transplantation. However, short and long term problems such as potential tumor induction by immunosuppression and chronic rejection must be taken into consideration. Given the fact that patients receiving CTA have already undergone various reconstructive procedures before, patients often gain tremendous improvement in the quality of life. Robots such as the Da Vinci system for surgeons and the Penelope assistant robot have found their way into the surgical routine. While even microsurgical anastomosis has been accomplished using the Da Vinci system, the total amount of time and resources spent is beyond being practical at present. Regeneration and tissue engineering are of distinct interest in reconstructive surgery. Adipose-derived stem cell transfer is able not only to improve contour defects by volume effects, but also to improve the quality of the overlying skin. Therefore we would propose that these novel techniques, CTA, robotics, regeneration and tissue engineering should be considered as potential future integral cogs in the reconstructive mechanism for the 21st century with the patient being at the centre of the reconstructive efforts.

Primary and secondary tissue expansion gives high quality skin and subcutaneous coverage in children with a large myelomeningocele and kyphosis.

When operating on a child with a large myelomeningocele and kyphosis, coverage with skin of high quality and a supporting layer of subcutaneous tissue can be difficult. The dermal circulation in the newborn is finite and an extensive mobilisation of the skin is a risky venture. Between 1988 and 2003 five children with large thoraco-lumbal myelomeningocele and kyphosis underwent subcutaneous insertion of silicon tissue expanders due to skin cover difficulties. In three children the skin surface was allowed to granulate over the myelomeningocele. In the other two children closure of the myelomeningocele was attempted but failed leading to secondary epithelialisation. Four of the children had two tissue expanders inserted at the age of 8-12 months; two of them before delayed operation for the myelomeningocele and two before elective spinal column surgery. The fifth child was nine years old when two tissue expanders were inserted before delayed myelomeningocele repair. Saline was injected into the expanders every 3-7 days during six to eight weeks. The expansion treatment was well tolerated. The result was an excellent skin and subcutaneous coverage in four of the children. For the fifth child who was the oldest and obese, one filling port was damaged during one of the injections, leading to insufficient tissue expansion. An extensive skin mobilisation was required and the result was not optimal. Tissue expansion is a simple, but a less known technique for acquiring good skin and subcutaneous coverage in children with large myelomeningocele and kyphosis. The expansion can be done either before delayed myelomeningocele repair or after failed primary operation thus eliminating the need for extensive musculo-cutaneous flaps.

Tissue expansion: past, present, and future.

The history of tissue expansion, technique, indications, and complications are reviewed. A detailed review of delayed tissue expansion's histologic, biochemical, biomechanical, and physiologic changes in the skin is given. There is a net gain in epidermal tissue during delayed expansion. Recent experimental and clinical experience suggests that expansion for 1 to 2 weeks is just as effective as longer delayed expansion for 6 to 8 weeks. A new deviation from standard technique, intraoperative tissue expansion, may have significant implications for dermatologic surgery. Intraoperative tissue expansion is explored in relation to other commonly used techniques of intraoperative load cycling.

Tissue expansion in perspective.

Tissue expansion is a recent advance in skin cover technique. Its empirical use has enabled many previously difficult reconstructions to be completed without recourse to distant flaps. Its high complication rate and lack of basic scientific understanding at present restrict its use to selected cases, but the quality of repairs possible by this method encourage further serious scientific study.