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1.
Plast Reconstr Surg ; 147(3): 505-513, 2021 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-33587555

RESUMEN

BACKGROUND: Commercial payments for implant-based breast reconstruction have increased within the past decade, whereas reimbursements have stagnated for microsurgical techniques. The physician payment-to-work relative value unit ratio allows for standardization when comparing procedures of differing complexity. This study aimed to characterize payment per work relative value unit for common breast and nonbreast microsurgical procedures. METHODS: The Massachusetts All-Payer Claims Database was queried from 2010 to 2014 for Current Procedural Terminology (CPT) codes related to microsurgical and breast reconstruction. International Classification of Diseases codes were further used to categorize procedures by anatomical region, including head and neck, breast, trunk, and extremities. Physician payments, both commercial and governmental, were aggregated by anatomical region and CPT code. Payment distributions were described with means and medians and compared using statistical tests. RESULTS: Among 3435 commercial claims, distributions of physician payments per work relative value unit for microsurgical and common breast procedures differed only for breast free flaps billed through S codes (p < 0.001). Microsurgical breast procedures (CPT code 19364) had significantly greater median payments per work relative value unit compared to microsurgery of the head and neck, trunk, and upper extremities (p = 0.004). Payment per work relative value unit for common breast and nonbreast microsurgical procedures did not differ significantly among governmental claims (p = 0.103). CONCLUSIONS: Adjustment of physician payments by work relative value units did not show significant variability across common breast procedures, except for S codes, suggesting that payments are mostly driven by differences in work relative value units and individual contractual negotiations. Lower payments per work relative value unit for other regions compared to breast suggests an opportunity for negotiation with commercial payers.

3.
Artículo en Inglés | MEDLINE | ID: mdl-33151192

RESUMEN

Oral cancer treatment involving the maxilla and/or mandible often results in esthetic and functional deficits that can diminish the patient's quality of life. As a result, expeditious reconstruction of the defect and dental rehabilitation is desirable. Dental rehabilitation shortly after reconstruction with an osteocutaneous free flap and resection prosthesis is a persistent challenge for patients with oncologic defects where immediate dental rehabilitation is not a possibility. Additionally, conventional prosthesis fabrication techniques are impractical or impossible due to postoperative anatomical changes and limitations in clinical armamentarium. To address these limitations, a technique and a novel implant-supported prosthetic workflow for the oncologic patient were developed to provide interim dental rehabilitation for such clinical situations. This article describes the prosthesis fabrication technique, reports short-term outcomes, and evaluates patient-reported quality-of-life outcomes using the FACE-Q Head and Neck Cancer Module.


Asunto(s)
Implantes Dentales , Colgajos Tisulares Libres , Reconstrucción Mandibular , Implantación Dental Endoósea , Prótesis Dental de Soporte Implantado , Peroné/cirugía , Humanos , Calidad de Vida
4.
Plast Reconstr Surg ; 146(5): 964-975, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-33141527

RESUMEN

BACKGROUND: Despite the rise in rates of contralateral prophylactic mastectomy, few studies have used patient-reported outcomes to assess satisfaction between unilateral and bilateral breast reconstruction with autologous tissue. The purpose of this study was to investigate patient satisfaction and quality of life following autologous reconstruction to determine whether differences exist between unilateral and bilateral reconstructions to better guide clinical decision-making. METHODS: The current study examined prospectively collected BREAST-Q results following abdominal free flap breast reconstruction procedures performed at a tertiary academic medical center from 2009 to 2017. The reconstruction module of the BREAST-Q was used to assess outcomes between laterality groups (unilateral versus bilateral) at 1 year, 2 years, 3 years, and more than 3 years. RESULTS: Overall, 405 patients who underwent autologous breast reconstruction completed the BREAST-Q. Cross-sectional analysis at 1 year, 2 years, and 3 years revealed similar satisfaction scores between groups; however, bilateral reconstruction patients demonstrated higher satisfaction scores at more than 3 years (p = 0.04). Bilateral reconstruction patients reported lower scores of abdominal well-being at 1 year, 2 years, and more than 3 years (p = 0.01, p = 0.03, and p = 0.01, respectively). CONCLUSIONS: These results suggest that satisfaction with breasts does not differ with the laterality of the autologous reconstruction up to 3 years postoperatively but may diverge thereafter. Bilateral reconstruction patients, however, have lower satisfaction with the abdominal donor site. These data can be used in preoperative counseling, informed consent, and expectations management in patients considering contralateral prophylactic mastectomy.

5.
Plast Reconstr Surg ; 146(6): 721e-730e, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33234949

RESUMEN

BACKGROUND: Implementation of payment reform for breast reconstruction following mastectomy demands a comprehensive understanding of costs related to the complex process of reconstruction. Bundled payments for services to women with breast cancer may profoundly impact reimbursement and access to breast reconstruction. The authors' objectives were to determine the contribution of cancer therapies, comorbidities, revisions, and complications to costs following immediate reconstruction and the optimal duration of episodes to incentivize cost containment for bundled payment models. METHODS: The cohort was composed of women who underwent immediate breast reconstruction between 2009 and 2016 from the MarketScan Commercial Claims and Encounters database. Continuous enrollment for 3 months before and 24 months after reconstruction was required. Total costs were calculated within predefined episodes (30 days, 90 days, 1 year, and 2 years). Multivariable models assessed predictors of costs. RESULTS: Among 15,377 women in the analytic cohort, 11,592 (75 percent) underwent tissue expander, 1279 (8 percent) underwent direct-to-implant, and 2506 (16 percent) underwent autologous reconstruction. Adjuvant therapies increased costs at 1 year [tissue expander, $39,978 (p < 0.001); direct-to-implant, $34,365 (p < 0.001); and autologous, $29,226 (p < 0.001)]. At 1 year, most patients had undergone tissue expander exchange (76 percent) and revisions (81 percent), and a majority of complications had occurred (87 percent). Comorbidities, revisions, and complications increased costs for all episode scenarios. CONCLUSIONS: Episode-based bundling should consider separate bundles for medical and surgical care with adjustment for procedure type, cancer therapies, and comorbidities to limit the adverse impact on access to reconstruction. The authors' findings suggest that a 1-year time horizon may optimally capture reconstruction events and complications.

6.
Plast Reconstr Surg ; 146(6): 768e-776e, 2020 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-33234971

RESUMEN

BACKGROUND: Despite reports demonstrating feasibility of immediate dental implant placement in mandibular reconstruction with free fibula flaps for benign disease, this practice is not routinely used in the oncologic setting. The authors aim to demonstrate the safety of immediate dental implant placement for oncologic mandible reconstruction. METHODS: In 2017, the authors' center began immediate dental implant placement in free fibula flaps for oncologic patients undergoing mandibulectomy reconstruction. Immediate dental implant placement patients were compared to a historical cohort also reconstructed with computer-aided design and manufacturing technology beginning in 2011 (n = 34) as a noninferiority study design. Primary outcomes of interest included 90-day complications, time to radiotherapy, and time to and number of patients achieving dental restoration. RESULTS: Sixty-one patients underwent free fibula flaps following mandibulectomy using computer-aided design and manufacturing. Seventy-two dental implants were placed in the immediate dental implant placement cohort (n = 27). No differences were noted in major or minor 90-day complications between groups (p > 0.05). Radiotherapy was required in 55 percent in the immediate dental implant placement cohort versus 62 percent in the historical cohort, with no significant difference in time to radiotherapy (67.6 days versus 62.2 days, respectively). One dental implant was removed for nonosseointegration noted during vestibuloplasty. Fourteen (51.8 percent) immediate dental implant patients had complete dental restoration at 90 days compared with none in the historical cohort (p < 0.05). CONCLUSIONS: Immediate dental implant placement is a safe procedure with an unchanged short-term complication profile and no delay in radiotherapy initiation. Patients undergoing immediate dental implant placement are more likely to complete full dental rehabilitation. Long-term and health-related quality-of-life outcomes remain to be determined. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

8.
Plast Reconstr Surg Glob Open ; 8(8): e2988, 2020 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-32983763

RESUMEN

Chronic complications following anterior cranial fossa tumor extirpation, such as cerebrospinal fluid leak, meningitis, mucocele, pneumocephalus, and abscess, negatively impact patient quality of life. Robust vascularized tissue is generally required to adequately reconstruct and obliterate this complex geometric space. The aim of this study was to describe outcomes and advantages of the omental flap for these defects. Following institutional review board approval, a prospective, reconstructive database was reviewed from 2011 to 2020. Four patients with chronic anterior skull base complications treated with omental flap reconstruction were identified, with chart reviews performed. Median time from the index operation until the complication ultimately required a free omental transfer was 7.3 years. All patients underwent adjuvant radiation with the indications for surgery, including cerebral abscess, recurrent meningitis, osteomyelitis, and pneumocephalus. All free flaps survived without any need for revision. There were no donor site complications. One patient had delayed healing at an adjacent nasal wound that healed secondarily. At a median follow-up of 19.4 months, none of the patients had recurrent infections. The omental free flap has a number of properties, which make it ideally suitable for anterior skull base defects. Its malleable nature combined with the presence of multiple vascular arcades enable flexibility in flap design to contour to the crevices of 3-dimensional skull base defects. Although other free flaps are available to the plastic surgeon, the versatility and reliability of the omentum make it a first-line consideration for anterior skull base reconstruction.

9.
J Reconstr Microsurg ; 2020 Aug 30.
Artículo en Inglés | MEDLINE | ID: mdl-32862417

RESUMEN

Successful microvascular reconstruction of head and neck defects requires the ability to safely identify, isolate, and utilize recipient vessels. To date, however, a comprehensive review of the anatomy and techniques relevant to the available anatomic regions has not been undertaken. This review covers the relevant clinical anatomy of the anterior triangle, posterior triangle, submandibular region, intraoral region, preauricular region, chest, and arm, taking particular care to highlight the structures that are crucial to identify while performing each dissection. Finally, a step-by-step technique for safely dissecting the recipient vessels at each site is provided.

10.
Ann Surg ; 2020 Jul 16.
Artículo en Inglés | MEDLINE | ID: mdl-32694446

RESUMEN

OBJECTIVE: This study sought to estimate the incidence and incidence rate of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) at a high-volume single institution, which enables vigorous long-term follow-up and implant tracking for more accurate estimates. SUMMARY BACKGROUND DATA: The reported incidence of BIA-ALCL is highly variable, ranging from 1 in 355 to 1 in 30,000 patients, demonstrating a need for more accurate estimates. METHODS: All patients who underwent implant-based breast reconstruction from 1991 to 2017 were retrospectively identified. The incidence and incidence rate of BIA-ALCL were estimated per patient and per implant. A time-to-event analysis was performed using the Kaplan-Meier estimator and life table. RESULTS: During the 26-year study period, 9373 patients underwent reconstruction with 16,065 implants, of which 9589 (59.7%) were textured. Eleven patients were diagnosed with BIA-ALCL, all of whom had a history of textured implants. The overall incidence of BIA-ALCL was 1.79 per 1000 patients (1 in 559) with textured implants and 1.15 per 1000 textured implants (1 in 871), with a median time to diagnosis of 10.3 years (range, 6.4-15.5 yrs). Time-to-event analysis demonstrated a BIA-ALCL cumulative incidence of 0 at up to 6 years, increasing to 4.4 per 1000 patients at 10 to 12 years and 9.4 per 1000 patients at 14 to 16 years, although a sensitivity analysis showed loss to follow-up may have skewed these estimates. CONCLUSIONS: BIA-ALCL incidence and incidence rates may be higher than previous epidemiological estimates, with incidence increasing over time, particularly in patients exposed to textured implants for longer than 10 years.

11.
Plast Reconstr Surg ; 146(3): 637-648, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32459736

RESUMEN

BACKGROUND: Maxillofacial reconstruction with vascularized bone restores facial contour and provides structural support and a foundation for dental rehabilitation. Routine implant placement in such cases, however, remains uncommon. This study aims to determine dental implant survival in patients undergoing vascularized maxillary or mandibular reconstruction through a systematic review of the literature. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature was queried for implant placement in reconstructed jaws using Medical Subject Headings terms on PubMed, Embase, and Cochrane platforms. Weighted implant survivals were calculated for the entire cohort and subcohorts stratified by radiotherapy. Meta-analyses were performed to estimate effect of radiation on implant osseointegration. RESULTS: Of 3965 publications identified, 42 were reviewed, including 1084 patients with 3636 dental implants. Weighted implant survival was 92.2 percent at a median follow-up of 36 months. Survival was 97.0 percent in 269 implants placed immediately in 60 patients versus 89.9 percent in 1897 delayed implants placed in 597 patients, with follow-up of 14 and 40 months, respectively. Dental implants without radiotherapy exposure had better survival than those exposed to radiation (95.3 versus 84.6 percent; p < 0.01) at a median follow-up of 36 months. Meta-analyses showed that radiation significantly increased the risk of implant failure (risk ratio, 4.74; p < 0.01) and suggested that implants placed before radiotherapy trended toward better survival (88.9 percent versus 83.4 percent, p = 0.07; risk ratio, 0.52; p = 0.14). CONCLUSIONS: Overall implant survival was 92.2 percent; however, radiotherapy adversely impacted outcomes. Implants placed before radiotherapy may demonstrate superior survival than implants placed after.


Asunto(s)
Trasplante Óseo/métodos , Implantación Dental Endoósea , Reconstrucción Mandibular/métodos , Oseointegración/fisiología , Colgajos Quirúrgicos/irrigación sanguínea , Humanos , Procedimientos Quirúrgicos Reconstructivos
14.
Plast Reconstr Surg ; 145(2): 333-339, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985616

RESUMEN

BACKGROUND: Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction. METHODS: The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality. RESULTS: Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001). CONCLUSIONS: Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.


Asunto(s)
Reembolso de Seguro de Salud/economía , Mamoplastia/economía , Microcirugia/economía , Adulto , Implantación de Mama/economía , Implantación de Mama/estadística & datos numéricos , Implantes de Mama/economía , Implantes de Mama/estadística & datos numéricos , Neoplasias de la Mama/economía , Neoplasias de la Mama/cirugía , Femenino , Colgajos Tisulares Libres/economía , Humanos , Mamoplastia/estadística & datos numéricos , Massachusetts , Mastectomía/economía , Mastectomía/métodos , Medicaid/economía , Medicaid/estadística & datos numéricos , Microcirugia/estadística & datos numéricos , Microvasos , Persona de Mediana Edad , Reoperación/economía , Reoperación/estadística & datos numéricos , Trasplante Autólogo/economía , Estados Unidos
15.
Plast Reconstr Surg ; 145(2): 284e-294e, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985618

RESUMEN

The American Society of Plastic Surgeons commissioned the Autologous Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing autologous breast reconstruction and other breast reconstruction surgery. Four outcome measures and one process measure were identified. Outcomes include patient satisfaction with information for all breast reconstruction, a subscale of the BREAST-Q, and the length of stay, operative time, and rate of blood transfusion for autologous blood transfusion. The process measure looks at coordination of care around managing the breast reconstruction patient's care, with the physician coordinating the ongoing care, be it an oncologist, radiologist, other specialist, or primary care physician. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, continuing medical education, maintenance of certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality-reporting programs.


Asunto(s)
Mamoplastia/métodos , Mastectomía/métodos , Garantía de la Calidad de Atención de Salud/métodos , Medicina Basada en la Evidencia , Femenino , Humanos , Mamoplastia/normas , Satisfacción del Paciente
16.
Clin Implant Dent Relat Res ; 22(1): 91-95, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31777154

RESUMEN

OBJECTIVES: The current pilot study aims to report short-term experience as it relates to acute radiotherapy treatment outcomes comparing patients with immediate dental implants in fibula free flap reconstructions to a historical cohort of patients with fibula free flap reconstructions without dental implants. MATERIALS AND METHODS: A retrospective review of patients who underwent segmental mandibulectomy, reconstruction with fibula free flaps, and adjuvant radiotherapy with (n = 10) and without immediate dental implants (n = 10) at a tertiary cancer center from 2015 to 2018 was performed (IRB #17-271). Incidence of postoperative complications, time to initiation of radiation therapy, development of acute toxicity, and patient reported outcome data were recorded. The radiation plans were evaluated to identify the mean and maximum doses received by the mandible and oral cavity as well as the locations of radiation global hot spots. RESULTS: There was a similar number of postoperative complications in both cohorts, with three events in the case group and two events in the control group. Patients with dental implants reported less trismus than control patients. Evaluation of the radiation treatment plans revealed similar median radiation global hot spots in both groups. CONCLUSIONS: The current study suggests that the presence of dental implants does not increase the risk of complications following surgery or during radiation treatment. Implants do not alter radiation dosimetry but do appear to positively impact early patient quality of life. Although longer follow-up is needed, based on this preliminary experience, cancer patients should be offered this type of reconstruction without fear of impacting radiation timing or delivery.


Asunto(s)
Implantes Dentales , Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Neoplasias Mandibulares , Procedimientos Quirúrgicos Reconstructivos , Trasplante Óseo , Humanos , Mandíbula , Proyectos Piloto , Calidad de Vida , Estudios Retrospectivos , Resultado del Tratamiento
17.
Ann Surg Oncol ; 27(6): 1877-1888, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31811437

RESUMEN

BACKGROUND: Obesity is a significant public health concern and clear risk factor for complications following breast reconstruction. To date, few have assessed patient-reported outcomes (PROs) focused on this key determinant. OBJECTIVE: Our study aimed to investigate the impact of obesity (body mass index ≥ 30) on postoperative satisfaction and physical function utilizing the BREAST-Q in a cohort of autologous breast reconstruction patients. METHODS: An Institutional Review Board-approved prospective investigation was conducted to evaluate PROs in patients undergoing autologous breast reconstruction from 2009 to 2017 at a tertiary academic medical center. The BREAST-Q reconstruction module was used to assess outcomes between cohorts preoperatively and at 6 months, 1 year, 2 years, and 3 years after reconstruction. RESULTS: Overall, 404 patients underwent autologous breast reconstruction with abdominal free-tissue transfer (244 non-obese, 160 obese) and completed the BREAST-Q. Although obese patients demonstrated lower satisfaction with breasts preoperatively (p = 0.04), no significant differences were noted postoperatively (p = 0.58). However, physical well-being of the abdomen was lower in the obese cohort compared with their non-obese counterparts at long-term follow-up (3 years; p = 0.04). CONCLUSION: Obesity significantly impacts autologous breast reconstruction patients. Although obese patients are more likely to present with dissatisfaction with breasts preoperatively, they exhibit comparable PROs overall compared with their non-obese counterparts, despite increased complications.

18.
Plast Reconstr Surg Glob Open ; 7(10): e2475, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31772898

RESUMEN

Reconstruction of segmental maxillary or mandibular defects with osteocutaneous free flaps can be reliably accomplished; however, buccal or lingual rotation of the fibula during rigid fixation can render immediate endosseous implant position unusable for functional dental rehabilitation. To address this issue, a custom inset guide is introduced which utilizes surface topography of the immediately placed dental implant abutments and the patient's dentition to orient the fibula segments during inset. Use of this technique facilitates successful endosseous implant position to optimize postoperative functional rehabilitation.

19.
Plast Reconstr Surg Glob Open ; 7(6): e2299, 2019 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-31624690

RESUMEN

Background: Alternatives to postoperative, narcotic pain management following implant-based, postmastectomy breast reconstruction (IBR) must be a focus for plastic surgeons and anesthesiologists, especially with the current opioid epidemic. Paravertebral blocks (PVBs) are a regional technique that has demonstrated efficacy in patients undergoing a variety of breast cancer-related surgeries. However, a specific understanding of PVB's efficacy in pain management in patients who undergo IBR is lacking. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library electronic database was conducted to examine PVB administration in mastectomy patients undergoing IBR. Data were abstracted regarding: authors, publication year, study design, patient demographics, tumor laterality, tumor stage, type, and timing of reconstruction. The primary outcome was PVB efficacy, represented as patient-reported pain scores. Secondary outcomes of interest include narcotic consumption, postoperative nausea and vomiting, antiemetic use, and length of stay. Results: The search resulted in 1,516 unique articles. After title and abstract screening, 29 articles met the inclusion criteria for full-text review. Only 7 studies were included. Of those, 2 studies were randomized control trials and 5 were retrospective cohort studies. Heterogeneity of included studies precluded a meta-analysis. Overall, PVB patients had improved pain control, and less opioid consumption. Conclusion: PVBs are a regional anesthesia technique which may aid in pain management in the breast reconstructive setting. Evidence suggests that PVBs aid in controlling acute postoperative pain, reduce opioid consumption, and improve patient length of stay. However, some conflicting findings demonstrate a need for continued research in this area of pain control.

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