Staged breast reconstruction utilizing primary nipple repositioning surgery prior to nipple-sparing mastectomy.

Staged nipple-sparing mastectomy (NSM) following mastopexy or breast reduction has become increasingly utilized in patients with large or ptotic breasts. The safety and efficacy of this approach has been demonstrated in recent years. However, the optimal timing between stages has not been established. The authors provide their experience with this staged approach with emphasis on timing between stages. An institutional review board approved this retrospective study. Data of all patients at a single institution who underwent staged NSM following mastopexy or reduction mammaplasty for therapeutic or prophylactic oncologic surgical management from 2016 to 2020 were reviewed. Timing between stages as well as surgical, oncologic, aesthetic, and patient-reported outcomes were evaluated. Nineteen patients (38 breasts) underwent staged NSM following planned mastopexy/breast reduction. The mean time interval between stages was 25 weeks. No patients developed nipple areolar complex necrosis. Infection and hematoma were seen in one breast (2.6%) and seroma in two (5.3%) after NSM. Delayed wound healing was seen in eight breasts (21.1%) after first stage mastopexy/reduction and in 12 breasts (31.6%) after NSM. Skin flap necrosis was noted in two breasts (5.3%) after NSM. No patients developed oncological recurrence. Mean patient-reported post-operative satisfaction and well-being scores were 63 and 67 out of 100, respectively. The authors describe their experience with staged NSM following nipple repositioning procedures. Their results suggest that this procedure can be performed safely with cosmetically favorable results if surgeons wait an average of 25 weeks between first and second stage procedures.

Strategic Approaches to Intraflap Anastomosis: Navigating Conjoined DIEP Flap Reconstruction-A Comprehensive Roadmap.

Background: For patients desiring autologous breast reconstruction without adequate abdominal tissue volume, the deep inferior epigastric perforator (DIEP) flap may be stacked or combined with other flaps for bilateral reconstruction. Various combinations of anastomoses have been described in the literature. We sought to describe a framework for intraflap anastomoses. Methods: A retrospective review of 17 patients who underwent conjoined DIEP flaps with intraflap anastomoses with a single surgeon was performed. Patient demographics, comorbidities, operative details, and complications were reviewed. A framework scheme was developed for the type of intraflap anastomosis performed. Results: Between 2016 and 2020, 17 patients underwent conjoined DIEP flaps for unilateral breast reconstruction. Fourteen patients had delayed reconstruction. Eleven patients underwent an intraflap anastomosis in which a medial perforator on the left hemiabdomen flap was anastomosed with a distal lateral row perforator in the right hemiabdomen flap (type A). Four patients underwent an intraflap anastomosis in which a left lateral perforator was anastomosed to a right distal lateral row perforator (type B). Two patients underwent an intraflap anastomosis in which the left superficial inferior epigastric vessel was anastomosed to a right lateral row perforator (type C). Complications included reoperation (11.8%), partial flap loss (5.9%), seroma (23.5%), and hematoma (11.8%). Conclusions: We report a detailed framework for intraflap anastomoses of conjoined DIEP flap reconstruction including superficial inferior epigastric artery/superficial inferior epigastric vessel options. Knowledge of this comprehensive framework will allow surgeons to identify the type of intraflap anastomoses required for the anatomy they encounter and will standardize reporting of surgical technique in the literature.

Feasibility for Immediate Targeted Muscle Reinnervation Based on Lower Extremity Amputations Trends.

Targeted muscle reinnervation has been adopted as a strategy for the management and prevention of phantom limb pain and symptomatic neuroma formation for patients undergoing lower extremity amputation. The procedure is often performed by surgeons different from those performing the amputation, creating scheduling dilemmas. The purpose of this study was to analyze historic trends in lower extremity amputation scheduling in a single hospital system to evaluate if offering routine immediate targeted muscle reinnervation is practical. Methods: De-identified data over a five-year period for all patients undergoing lower extremity amputation were collected. The data gathered included the specialty performing the amputation, weekly distribution of cases, start time, and end time, among others. Results: A total of 1549 lower extremity amputations were performed. There was no statistically significant difference in average number of below-the-knee amputations (172.8) and above-the-knee amputations (137.4) per year. Top specialties performing amputations were vascular surgery (47.8%), orthopedic surgery (34.5%), and general surgery (13.85%). No significant difference was noted in the average number of amputations across the week, per year. Most cases started between 6 am and 6 pm (96.4%). The average length of stay after surgery was 8.26 days. Conclusions: In a large, nontrauma hospital system, most lower extremity amputations are performed during typical working hours and are evenly distributed throughout the week. Understanding peak timing of amputations may allow for targeted muscle reinnervation to be performed concurrently with amputation procedure. Data presented will be a first step to optimizing amputation scheduling for patients in a large nontrauma health system.

Does Surgeon Specialty Make a Difference in Ventral Hernia Repair With the Component Separation Technique?

Background Abdominal wall reconstruction (AWR) has evolved with the continued advent of new techniques such as component separation (CS). General (GS) and plastics surgeons (PS) are trained to perform this procedure. Differences in patient population and clinical outcomes between specialties are unknown. Methods Using a national database, patients who underwent incisional/ventral hernia repair managed with CS were grouped according to the primary specialty. Patient demographics, perioperative details, and postoperative complications were compared, and the risk factors associated with clinical outcomes were analyzed.  Results A total of 4,088 patients were identified. PS operated more often in the inpatient setting, and patients had a higher prevalence of hypertension and clean-contaminated wounds. Hypertension and being operated by a PS were associated with an increased risk of needing a blood transfusion after CST. Conclusion CS surgical outcomes are similar and comparable specialties. Primary specialty does not affect postoperative complications or 30-day mortality after CS.

Deep venous thrombosis in a 41-year-old female with May-Thurner syndrome following abdominoplasty and medial thigh lift.

Deep venous thrombosis (DVT) is a feared occurrence following body contouring surgery as it can result in pulmonary embolism. Acute presentation can range from lower extremity edema and pain to being totally asymptomatic. Surgical literature reports reveal many risk factors for developing DVT, and surgeons must risk stratify their patients to best prevent this outcome. However, there are conditions which place patients at risk that are difficult to account for when making such decisions as they can be undiagnosed and are not a part of standard screening protocols. We present a case of DVT in a 41-year-old female with undiagnosed May-Thurner syndrome following abdominoplasty and medial thigh lift for massive weight loss. The authors discuss the current literature as well as challenges faced by surgeons who strive to appropriately risk stratify their cosmetic surgery patients to avoid complications such as venous thromboembolism.

Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes.

BACKGROUND: Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute. METHODS: A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups. RESULTS: A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001). CONCLUSIONS: More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

Refining the Rib-sparing Approach in Microsurgical Breast Reconstruction: Keys to Success.

BACKGROUND: Free tissue transfer using microsurgical techniques is a popular option for breast reconstruction, and the internal mammary vessels remain the most popular recipient vessels for the anastomosis. Traditionally, ribs were resected for better access to these vessels in the intercostal space. However, rib resection has the potential for complications and adds a surgical step. Here, the authors evaluate and compare both techniques in a retrospective study as well as offer technical pearls. METHODS: The 400 most recent consecutive patients who underwent microsurgical breast reconstruction by a single surgeon were retrospectively reviewed. 54 patients underwent the traditional rib-resecting approach. 346 patients underwent the rib-sparing approach, which was the preferred approach of the senior author, when possible. Patients requiring the rib-resecting approach were distributed evenly throughout the series. Primary outcomes were any immediate post-operative complications. RESULTS: Between the two clinical groups, there was no difference between demographic or clinical details, the flap type, history of previous radiation, or timing of reconstruction. Complications of any kind as well as the subset of complications were significantly more frequent in the rib resection than in the rib-sparing group. Specifically, the rate of reanastomosis was higher in the rib resection group [10.6 vs 2.7%, p < 0.001] as was the frequency of return to the OR in the immediate post-operative setting [3.0 vs 0.3%, p < 0.001]. There is a 4.50 odds ratio of having a complication in a rib resection case versus rib sparing [CI: 1.97-10.30, p < 0.001]. All cases were initiated with the intent to perform a rib-sparing approach if possible, and they were converted to a rib-resection approach as needed. CONCLUSION: In the largest reported series to date, the rib-sparing approach is demonstrated to be both safe and efficacious in microsurgical breast reconstruction.

Static Suspension of the Paralyzed Face Utilizing the Midfacial Corridor: Anatomic Evaluation and Surgical Technique.

BACKGROUND: Fascia lata and tendon grafts are frequently utilized to support the paralyzed midface and to extend muscular reach in McLaughin style, orthodromic temporalis transfers. The grafts are frequently placed in a deep subcutaneous positioning that can lead to the development of a, bowstring deformity in the cheek. This paper describes insertion of tendon grafts into the midfacial corridor collectively formed by the buccal, submasseteric and superficial temporal spaces. METHODS: Over a seven-year period, all patients that underwent insertion of facia lata and tendon grafts in the midfacial corridor were included. Demographic information, perioperative variables and clinical outcomes were collected and analyzed. RESULTS: A total of 22 patients were included with a mean age of 64.3 years (33-86). There were multiple etiologies for the facial weakness including acoustic neuroma (9.1%), Bell's palsy (13.6%), facial nerve schwannoma (9.1%), temporal bone fracture (4.6%) and malignancy (22.7%). Midfacial corridor grafts were utilized in combination with nerve transfers (V-VII and XII-VII) in nine patients, McLaughin style temporalis transfers in 12 and as a standalone procedure in one individual. During the study period, no patients exhibited a tethering, or concave deformity in the midface. Additionally, no impingement, difficulties with mastication, parotitis or hematoma were encountered. One patient developed a postoperative infection, that was successfully managed. CONCLUSION: Placement of tendon or fascia grafts for static support or tunneling of an orthodromic temporalis transfer through the midfacial corridor can be performed rapidly while providing midfacial support and avoiding the creation of visible cutaneous deformities.

Primary and Revision Rhinoplasty: A Single Surgeon Experience and Patient Satisfaction.

There is minimal information describing the common characteristics among patients seeking primary/revision rhinoplasty. Success is traditionally interpreted from the surgeon's viewpoint, without considering the patient's perspective. The study's aims were to (1) identify/compare anatomic and functional characteristics commonly found in patients seeking primary and revision rhinoplasties; (2) assess patient satisfaction using a survey; and (3) explore whether graft choice (auricular cartilage versus rib cartilage) affects patient satisfaction and outcome in revision rhinoplasty. METHODS: A retrospective review of all rhinoplasties by a single surgeon from June 2016 to January 2020 was performed, focusing on preoperative anatomic/functional characteristics and operative interventions performed. A survey was then used to assess patient satisfaction. Finally, survey outcomes were compared between patients who received auricular and rib cartilage grafts in revision rhinoplasty. RESULTS: A total of 102 rhinoplasties (53 primary and 49 revisions) were included. Primary rhinoplasties were noted to have more patients with "big" noses (P = 0.015) or humps (P < 0.010). Patients undergoing revision rhinoplasties more commonly exhibited middle vault collapse (P = 0.022). The survey response rate was 60%. Revision rhinoplasty patients had a higher incidence of dissatisfaction with their outcome. CONCLUSIONS: Several features among patients seeking revision rhinoplasties could have been created in the primary operation. The rhinoplasty surgeon should be careful to not introduce new issues or create worse deformities than those seen following the initial operation. Survey-based outcome analysis demonstrated that revision rhinoplasty patients are more likely to have a greater rate of dissatisfaction following their operation.

Dual Innervation of Free Functional Muscle Flaps in Facial Paralysis.

Dual innervation in free muscle flap facial reanimation has been used to create a functional synergy between the powerful commissure excursion that can be achieved with the masseter nerve and the spontaneity that can be derived from a cross-face nerve graft. The gracilis has been the most frequently used muscle flap, and multiple combinations of neurorrhaphies have been described, including the masseter to the obturator (end-to-end) combined with a cross-face nerve graft to the obturator (end-to-side) and vice versa. Single and staged approaches have been reported. Minimally, dual innervation is as effective as using the motor nerve to masseter alone.

Comparing plastic surgery and otolaryngology surgical outcomes and cartilage graft preferences in pediatric rhinoplasty: A retrospective cohort study analyzing 1839 patients.

ABSTRACT: Rhinoplasty in children has raised concerns about its safety in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. We analyzed post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists.Data was collected through the Pediatric National Surgical Improvement Program from 2012 to 2017. Current Procedure Terminology codes were used for data extraction. Patients were grouped according to type of rhinoplasty procedures (primary, secondary, and cleft rhinoplasty). A comparison between plastic surgeons and otolaryngologists was made in each group in terms of postoperative complications. Additionally, a sub-group analysis based on cartilage graft preferences was performed.During the study period, a total of 1839 patients underwent rhinoplasty procedures; plastic surgeons performed 1438 (78.2%) cases and otolaryngologists performed 401 (21.8%) cases. After analyzing each group, no significant differences were noted in terms of wound dehiscence, surgical site infection, readmission, or reoperation. Subgroup analysis revealed that plastic surgeons prefer using rib and ear cartilage, while otolaryngologists prefer septal and ear cartilage.The analysis of 1839 pediatric patients undergoing three types of rhinoplasty procedures showed similar postoperative outcomes, but different cartilage graft utilization between plastic surgeons and otolaryngologists.

Breast Implant Utilization Trends in USA versus Europe and the Impact of BIA-ALCL Publications.

BACKGROUND: The goals of this study were to analyze and compare breast implant preferences between US and European surgeons in terms of size, shape, and surface texturing. Furthermore, we set out to investigate the impact of BIA-ALCL scientific publications on surgeon practice patterns. METHODS: Breast implant sales data from the USA and Europe dating from June 2013 to September 2018 were provided by one of the world's leading breast implant manufactures (Mentor Worldwide LLC). Change-point analysis was used to identify when significant changes in sales trends occurred. These changes were compared with dates of government announcements and publications of landmark scientific articles regarding BIA-ALCL. RESULTS: Our data demonstrate that US surgeons tend to prefer larger, smooth round implants compared with European surgeons, who prefer smaller, textured round implants. Despite these differences, medium-sized implants were still the most common size used between both regions. Sales trends illustrate an increase in smooth implants and a decrease in textured implants for both regions. Significant changes in trends align with publication dates of announcements and landmark scientific articles. CONCLUSIONS: We demonstrate definitive differences in implant preferences between the USA and Europe. We encourage physicians to continue their pursuit of publishing because it seems these publications affect medical device selection.

Safety of Routine Pedicle Division during Delayed Breast Augmentation following Free Flap Breast Reconstruction.

BACKGROUND: Autologous free flap breast reconstruction is a common reconstructive procedure, with the ability to produce a natural breast shape and a long history of success. Despite its benefits, there are special situations in which patients lack sufficient donor-site tissue to achieve adequate breast size and projection. With this study, the authors describe their institutional experience of delayed implant augmentation after autologous breast reconstruction with a particular focus on pedicle division as a technique to improve aesthetic results. METHODS: A retrospective chart review of patients that underwent free flap autologous breast reconstruction with delayed implant augmentation was conducted over a 13-year period. Flaps were divided into a control group without pedicle division and a divided pedicle group. Groups were compared in terms of demographics, clinical and surgical characteristics, implant details, and postoperative implant and flap complications. RESULTS: No significant differences in terms of age, body mass index, comorbidities, radiation therapy, or surgical indications were noted. The most common reason for delayed implant augmentation after autologous breast reconstruction was change in breast size and breast asymmetry. In terms of implant and flap complications, we found no significant differences between the control and divided pedicle groups after delayed implant augmentation. CONCLUSIONS: From the authors' institutional experience, pedicle division in delayed breast augmentation with implants after free flap breast reconstruction can be safety performed in selected cases. This technique can be a powerful tool for plastic surgeons to improve the final aesthetic appearance of the reconstructed breast. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficacy of Closed Incision Negative Pressure Wound Therapy on Abdominal Donor Site After Free Flap Breast Reconstruction.

INTRODUCTION: Negative pressure wound therapy (NPWT) has been used to treat acute and chronic wounds in a variety of scenarios. Specifically, in autologous breast reconstruction, studies investigating the use of closed incision NPWT (ciNPWT) in breast surgery are lacking. OBJECTIVE: The aim of this study was to analyze the use of ciNPWT at the abdominal donor site following deep inferior epigastric perforator (DIEP) flap breast reconstruction. MATERIALS AND METHODS: A retrospective cohort study was conducted over a 15-month period including patients who underwent abdominally based microsurgical breast reconstruction. Patients were divided into 2 groups: (1) a control group that underwent standard abdominal donor site closure and (2) an experimental group that underwent standard abdominal donor site closure plus ciNPWT. Groups were compared in terms of demographic characteristics, perioperative variables, and abdominal donor site complications. RESULTS: A total of 42 patients were identified. Of these, 18 were included in the control group and 24 in the ciNPWT group. No cases of seroma, abdominal bulge, or abdominal hernia were reported. Wound dehiscence developed in 2 patients (11.1%) in the control group and in 3 patients (12.5%) in the experimental group (P = 1.000). One patient (5.6%) in the control group had an infection of the donor site compared with none in the ciNPWT group (P = .429). Interestingly, 3 patients developed hyperpigmentation where the ciNPWT plastic drape was placed. CONCLUSIONS: The use of ciNPWT on the abdominal donor site following DIEP flap breast reconstruction did not lower the incidence of wound dehiscence and wound infection. Different approaches are needed to decrease the incidence of donor site complications in abdominally based postmastectomy breast reconstruction.

Reoperative Cervical Endocrine Surgery: Appropriate Valuation for the Time and Effort?

BACKGROUND: Controversies currently exist regarding the best way to appropriately quantify complexity and to benchmark reimbursement for surgeons. This study aims to analyze surgeon reimbursement in primary and redo-thyroidectomy and parathyroidectomy using operative time as a surrogate for complexity. METHODS: A retrospective analysis using the National Surgical Quality Improvement Program database was performed to identify patients who underwent primary and redo-thyroidectomy and parathyroidectomy. Calculations of median operative time work relative value units per minute and dollars per minute were compared between primary and redo procedures. RESULTS: Thyroidectomy cases represented 53.5% (22,521 cases), and the other 46.5% (19,596 cases) were parathyroidectomy cases. The median dollars per minute in primary thyroidectomy was $4.97 and for redo-thyroidectomy was $8.12 (P < 0.0001). By the same token, dollars per minute were higher in the redo cases with $15.40 when compared with primary parathyroidectomy cases with $13.14 dollars per minute (P < 0.0001). CONCLUSIONS: By Current Procedural Terminology codes, surgeons appear to be appropriately reimbursed for redo-thyroid and parathyroid procedures indexed to first time parathyroidectomy based on the compensated operative time of these procedures calculated using a nationally representative sample.

Parastomal Hernia Repair Using a Silo Biologic Mesh.

BACKGROUND: A parastomal hernia (PSH) is an enlargement of the stoma's original opening through the abdominal wall's musculature around a colostomy, ileostomy, or urostomy. Its incidence can be up to 48%. The described methods for its repair have high recurrence rate.This article presents a 3-dimensional silo technique for PSH repair (PSH-R). The aims of this technique are to enhance the structural strength of the tunnel wall, to reinforce both the sidewalls and the fascia above and below the muscular opening, and to maintain a stable stoma opening. METHODS: All consecutive patients undergoing PSH-R with the silo technique between January 2009 and May 2018 by 2 plastic surgeons were included. The outcome parameters of interest were hernia recurrence and wound-related complications. RESULTS: This study reports 22 patients (9 male, 13 female) with a mean age of 66.7 years and an average body mass index of 29.2. The variety of ostomy types included 10 colostomies, 7 ileostomies, and 5 urostomies. Postoperatively, there were 3 surgical site infections, 1 seroma, and 2 wound healing delays. Six patients were readmitted, 3 of those because of small bowel obstruction. These 3 cases all required reoperation, in addition to 1 operative revision for stoma retraction. During our average follow-up of 19.9 months, 3 cases of PSH recurrence were diagnosed for a recurrence rate of 13.6%. CONCLUSIONS: This silo technique is associated with favorable complication and low recurrence rates compared with the available techniques in surgical literature. In our practice, it has established itself as a new and safe technique for complex or recurrent PSHs and should be considered in a surgeon's armamentarium. This technique has become our standard for treatment of recurrent PSHs.

How to Maximize Aesthetics in Autologous Breast Reconstruction.

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.

Incidental Findings in CT and MR Angiography for Preoperative Planning in DIEP Flap Breast Reconstruction.

BACKGROUND: Autologous breast reconstruction with deep inferior epigastric perforator flaps is considered a standard of care in the treatment after mastectomy, yet vascular anatomy is highly variable and perforator selection remains challenging. The use of preoperative imaging can influence surgical planning and assist intraoperative decision-making. However, this imaging can inevitably uncover incidental findings. The purpose of this study was to analyze incidental findings, evaluate correlation with patient factors, and examine effects on overall care. METHODS: A retrospective review was performed on 350 consecutive patients who received magnetic resonance angiography (MRA) or computed tomographic angiography (CTA) as a preoperative evaluation for deep inferior epigastric perforator flap breast reconstructions done between August 2015 and June 2019. Radiology reports were analyzed for incidental findings. Patient charts were reviewed for patient history, genetic history, cancer treatment, and type of reconstruction. RESULTS: Of the 350 patients meeting the criteria, 56.9% were noted to have incidental findings on preoperative imaging, 12.9% received additional imaging, and 4.0% underwent additional interventions. There was no difference in the percentage of patients with incidental findings between immediate and delayed reconstructions or between CTA and MRA. Five patients were found to have malignancies. CONCLUSIONS: Preoperative CTA and MRA is a valuable tool to optimize outcomes and efficiency in breast reconstruction with abdominal perforator flaps. However, this imaging can also be beneficial to the overall wellness of the patient. With the high prevalence of incidental findings on preoperative imaging, it is important to counsel patients and adjust surgical plans, if necessary.

Is Our Effort Appropriately Valued? An Analysis of Work Relative Value Units in Immediate Breast Reconstruction.

BACKGROUND: The work relative value units system was developed as a quantifier of physician labor, technical skill, and training time required to complete surgical procedures. Thus, more complex surgical procedures that require greater technical skills and are more time consuming should yield a greater compensation. It is known that prosthetic breast reconstruction reimburses more per hour than autologous breast reconstruction. However, there are limited data comparing work relative value units and operative times in breast reconstruction procedures. Therefore, this study aims to compare mean operative times and work relative value units per minute across three different modalities of breast reconstruction. METHODS: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing implant-, pedicle-, and free flap-based reconstruction over a 6-year period. Calculation and comparison of median operative times, work relative value units, and dollars per minute was performed. RESULTS: A total of 3135 patients were included in the analysis: 2249 (71.7 percent) underwent immediate implant-based reconstruction, 745 (23.8 percent) underwent immediate free flap-based breast reconstruction, and 141 (4.5 percent) underwent immediate pedicle flap-based reconstruction. Patients were distributed in unilateral and bilateral cases. Consistently, median operative time was greater for free flap breast reconstruction, followed by pedicle flap- and implant-based reconstruction (p < 0.0001). However, work relative value units per minute and dollars per minute were found to be higher for prosthetic reconstruction in all comparisons (p < 0.0001). CONCLUSION: In the authors' analysis, more complex and time-consuming procedures resulted in a lower reimbursement in dollars and work relative value units per minute for the procedure.