The Cost of Ambulatory Breast Reduction: Hospital Reimbursement Versus Surgeon Payments.

Introduction: Reduction mammoplasty (RM) is one of the most common operations performed in plastic surgery. While US national surgical expenditures have risen in recent years, studies have reported decreasing reimbursement rates for plastic surgeons. The purpose of this study is to characterize the trends in charges and payments for a common plastic surgery operation, ambulatory RM, for facilities and physicians. Methods: A Medicare patient records database was used to capture hospital, surgeon, and anesthesiologist charges and payments for ambulatory RM from 2005 to 2014. Values were adjusted for inflation. A ratio of hospital to surgeon charges and payments were calculated: charge multiplier (CM) and payment multiplier (PM), respectively. Charges, payments, Charlson comorbidity index, CM, and PM values were analyzed for trends. Results: This study included 1001 patients. During the study period, the facility charge for RM per patient increased from $8477 to $11,102 (31% increase; p < .0005), and the surgeon charge increased from $7088 to $7199 (2% increase; p = .0009). Facility payments increased from $3661 to $3930 (7% increase; p < .0005), and surgeon payments decreased from $1178 to $1002 (15% decrease; p < .0005). CM increased from 1.2 to 1.54, and PM increased from 3.11 to 3.92. Conclusions: Charges and payments to facilities for ambulatory RM increased disproportionately to that of surgeons, likely due in part to rising administrative costs in health care delivery. This may disincentivize plastic surgeons from offering RM at hospital-based surgical centers, limiting patient access to this operation.

Introduction: La mammoplastie de réduction (MR) est l'une des interventions les plus courantes pratiquées en chirurgie plastique. Alors que les dépenses chirurgicales aux États-Unis ont augmenté au niveau national au cours des dernières années, les études ont signalé une diminution des taux de remboursement pour les chirurgiens plasticiens. L'objectif de cette étude est de définir les tendances dans les frais et paiements pour une intervention courante de chirurgie plastique, une MR ambulatoire, pour les établissements et pour les médecins. Méthodes: Une base de données des dossiers de patients Medicare a été utilisée pour collecter les frais pour les hôpitaux, les chirurgiens et les anesthésiologistes ainsi que les paiements pour MR ambulatoires de 2005 à 2014. Les valeurs ont été ajustées pour tenir compte de l'inflation. Des ratios des frais hôpital/chirurgien et des paiements ont été calculés : respectivement, un facteur de multiplication des frais (MF) et des paiements (MP). Les tendances de la valeur des frais, des paiements, de l'indice de comorbidité de Charlson, du MF et du MP ont été analysées. Résultats: Cette étude a inclus 1001 patients. Au cours de la période de l'étude, les frais pour MR par patient à la charge de l'établissement ont augmenté de 8 477 $ à 11 102 $, soit une augmentation de 31 % (P < 0,0005) et les frais du chirurgien sont passés de 7 088 $ à 7 199 $, soit une augmentation de 2 % (P = 0,0009). Les paiements de l'établissement ont augmenté de 3 661 $ à 3 930 $, soit une augmentation de 7 % (P < 0,0005) et les paiements du chirurgien ont diminué de 1 178 $ à 1 002 $, soit une diminution de 15 % (P < 0,0005). Le facteur MF est passé de 1,2 à 1,54 et le facteur MP est passé de 3,11 à 3,92. Conclusions: Les frais et paiements aux établissements pour MR ambulatoire ont augmenté de manière disproportionnée par rapport à ceux des chirurgiens, probablement en partie à cause de l'augmentation des coûts administratifs croissants de l'administration des soins. Cela pourrait inciter les chirurgiens plasticiens à ne plus offrir de MR dans les centres chirurgicaux hospitaliers et pourrait donc limiter l'accès des patients à cette opération.

Determinants of pressure injury development in patients with COVID-19.

OBJECTIVE: Pressure injuries (PIs) often develop in critically ill patients due to immobility, and underlying comorbidities that decrease tissue perfusion and wound healing capacity. This study sought to provide epidemiological data on determinants and current managements practices of PI in patients with COVID-19. METHOD: A US national insurance-based database consisting of patients with coronavirus or COVID-19 diagnoses was used for data collection. Patients were filtered by International Classification of Diseases (ICD) codes corresponding to coronavirus or COVID-19 diagnosis between 2019-2020. Diagnosis of PI following COVID-19 diagnosis was queried. Demographic data and comorbidity information was compared. Logistic regression analysis was used to determine predictors for both PI development and likelihood of operative debridement. RESULTS: A total of 1,477,851 patients with COVID-19 were identified. Of these, 15,613 (1.06%) subsequently developed a PI, and 8074 (51.7%) of these patients had an intensive care unit (ICU) admission. The average and median time between diagnosis of COVID-19 and PI was 39.4 and 26 days, respectively. PI was more likely to occur in patients with COVID-19 with: diabetes (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.29-1.49; p<0.001); coronary artery disease (OR: 1.11, 95% CI: 1.04-1.18, p=0.002), hypertension (OR: 1.43, 95% CI: 1.26-1.64; p<0.001); chronic kidney disease (OR: 1.18, 95% CI: 1.10-1.26; p<0.001); depression (OR: 1.45, 95% CI 1.36-1.54; p<0.001); and long-term non-steroidal anti-inflammatory drug use (OR: 1.21, 95% CI: 1.05-1.40; p=0.007). They were also more likely in critically ill patients admitted to the ICU (OR: 1.40, 95% CI: 1.31-1.48; p<0.001); and patients requiring vasopressors (OR:1.25, 95% CI: 1.13-1.38; p<0.001), intubation (OR: 1.21, 95% CI 1.07-1.39; p=0.004), or with a diagnosis of sepsis (OR: 2.38, 95% CI 2.22-2.55; p<0.001). ICU admission, sepsis, buttock and lower back PI along with increasing Charlson Comorbidity Index (CCI) (OR: 1.04, 95% CI 1.00-1.08; p=0.043) was associated with surgical debridement. The vast majority of patients with COVID-19 did not undergo operative debridement or wound coverage. CONCLUSION: PIs are widely prevalent in patients with COVID-19, especially in those who are critically ill, yet the vast majority do not undergo operative procedures. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Case-matched Comparison of Implant-based Breast Reconstruction with and without Acellular Dermal Matrix.

Background: Acellular dermal matrix (ADM) is commonly used in implant-based breast reconstruction due to improved soft-tissue support and control of the implant pocket and decreased capsular contracture. However, concerns about complications have prompted the FDA to request more clinical data. This large-scale study aims to examine perioperative outcomes of ADM use in breast reconstruction. Methods: This study utilized a national insurance-based database to identify patients who underwent mastectomy between 2011 and 2019, with and without ADM. The groups were matched for age, region, and comorbidities. Complications within 90 days were compared using univariate and multivariate analyses. Results: A total of 49,366 patients were identified with 26,266 patients in the ADM group and 23,100 in the non-ADM group. Infection rates (4.7% ADM versus 4.4% no ADM) and seroma rates (3.9% ADM versus 4% no ADM) were similar. However, the ADM group had a 1% higher rate of implant removal (4.9% ADM versus 3.9% no ADM, P < 0.001). In direct-to-implant procedures, ADM use was associated with higher explantation rates (8.2% versus 6.3%, P = 0.002). Multivariate analysis identified tobacco use, hypertension, depression, obesity, ADM usage, and direct-to-implant surgery as risk factors for implant removal. Conclusions: This study found comparable infection and seroma rates in implant-based breast reconstruction with and without ADM. ADM use was associated with a 1% higher risk of implant removal, with risk factors including tobacco use, obesity, hypertension, depression, and direct-to-implant procedures. Multicenter studies and registry data on prepectoral breast reconstruction are warranted to help interpret these findings.

Gender-Affirming Surgery Improves Mental Health Outcomes and Decreases Anti-Depressant Use in Patients with Gender Dysphoria.

BACKGROUND: Patients with gender dysphoria face significant health disparities and barriers to care. Transition-related care includes hormonal therapy, mental healthcare, and gender-affirming surgeries. Studies have described favorable surgical outcomes and patient satisfaction, however, the degree to which these procedures impact mental health conditions is not fully understood. The purpose of this study was to evaluate the effect of gender-affirming plastic surgery on mental health and substance abuse in the transgender population. METHODS: A national insurance claims-based database was used for data collection. Patients with a diagnosis of gender dysphoria were propensity score-matched for the likelihood of undergoing gender-affirming surgery (no surgery being the control cohort), based on comorbidities, age, and sex. Primary outcomes included post-operative antidepressant use and the prevalence of mental health conditions. RESULTS: A total of 3,134 patients with gender dysphoria were included in each cohort. Patients in the surgery group had overall lower rates of mental health conditions, substance abuse, and SSRI/SNRI use. There was an absolute decrease of 8.8% in SSRI or SNRI prescription after gender-affirming plastic surgery (p<0.001), and significant decreases in post-operative depression (7.7%), anxiety (1.6%), suicidal ideation (5.2%) and attempts (2.3%), alcohol abuse (2.1%), and drug abuse (1.9%). CONCLUSION: Gender-affirming surgery in appropriately selected gender dysphoric patients is associated with decreased postoperative rates of SSRI or SNRI use and improved mental health.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds.

BACKGROUND: Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. METHODS: Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. RESULTS: Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. CONCLUSIONS: Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Optimizing perioperative outcomes in autologous breast reconstruction.

Perioperative optimization in surgery is paramount to the success of an operation. This especially applies to autologous breast reconstruction where small details can make the difference between success and failure. In this article, the authors discuss a wide array of aspects of perioperative care in autologous reconstruction and best practices. Stratification of surgical candidates, including types of autologous breast reconstruction are discussed. The informed consent process, including benefits, alternatives, and risks specific to autologous breast reconstruction is delineated. The importance of operative efficiency and benefits of pre-operative imaging are discussed. The importance and benefits of patient education is examined. Also examined at length are pre-habilitation and its effects on patient recovery, antibiotic prophylaxis including duration and organism coverage, venous thromboembolism risk stratification and prophylaxis, anesthetic and analgesic interventions including multiple types of regional blocks are broken down. Flap monitoring methods and the importance of clinical exam are emphasized, and the potential risks of blood transfusion in free flap patients are examined. Post-operative interventions and determining readiness for discharge are also reviewed. The review of these components of perioperative care allows the reader to gain comprehensive insight into autologous breast reconstruction best practices and the important role perioperative care plays in this patient population.

Use of Sentinel Lymph Node Incision for Second Stage Implant-Based Breast Reconstruction After Radiation.

BACKGROUND: Staged expander to implant breast reconstruction is associated with a high complication rate when the patient has had postmastectomy radiation. With an increasing number of American women undergoing implant-based breast reconstruction after postmastectomy radiation, surgeons may find themselves operating in a radiated field with synthetic devices. We report the performance characteristics of a novel surgical modification to the second stage expander to implant exchange after adjuvant radiation using a transaxillary approach through a prior sentinel lymph node incision, a site remote from the breast implant pocket. METHODS: We performed a retrospective review of a prospectively maintained database to evaluate the surgical outcomes of serial patients undergoing second staged expander to implant exchange through the sentinel lymph node incision 6 months or more after completing whole breast radiation. A case matched cohort to age, body mass index, and comorbid status was used to compare outcomes between patients in the group of interest versus a traditional skin sparing incision on the anterior breast mound through the radiated skin envelope. All patients included demonstrated grade 1 or 2 skin changes on the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring Schema for the skin organ system. RESULTS: Nineteen breasts were reconstructed for 18 women after immediate tissue expander placement and adjuvant whole breast radiation were included in our group of interest. Forty-one case-matched second controls were identified for the comparison group. There were no intraoperative complications. Two postoperative complications were reported for the sentinel lymph node approach group (10.5%) with an average of 9 months of follow-up: 1 operative exploration for hematoma and 1 minor wound requiring recloser in the office. The case matched cohort demonstrated significantly more minor postoperative complications (P = 0.037) with a total complications rate of 41.4%. There were 31.7% of the patients that experienced a minor complication alone, whereas 9.7% of the case-matched cohort experienced a major complication. CONCLUSIONS: These data support the use of the existing axillary sentinel lymph node access incision for second stage placement of a gel implant after immediate expander and adjuvant radiation therapy. The sentinel lymph node incision approach facilitates layered closure over the breast pocket at a site remote from irradiated tissue, reducing the incidence of postoperative minor complications. Forthcoming long-term data will determine if differences in reported capsular contracture rates can be achieved with a remote transaxillary approach to second stage implant reconstruction after radiation.

Reducing Infection Rates in Implant-Based Breast Reconstruction: Impact of an Evidence-based Protocol.

BACKGROUND: Infection is the most significant complication in implant-based breast reconstruction, potentially leading to reconstructive failure. We hypothesized that implementation of an evidence-based protocol marked by preoperative decolonization and sterility optimization would result in a decline in postoperative infection rates. METHODS: Informed by a literature review, we developed an evidence-based, perioperative infection prevention protocol implemented in 2015. Surgical outcomes were compared between patients who had undergone implant-based breast reconstruction before and after protocol implementation. A Fisher exact test was used to compare infection rates before and after protocol implementation. A logistic regression analysis was modeled to evaluate the impact of the protocol on infection rate while controlling for nonmodifiable risk factors. RESULTS: Three hundred fifty-eight breasts underwent reconstruction before protocol implementation and 135 afterward. Patients were similar in terms of demographics and surgical characteristics. There was a significantly reduced incidence of clinically relevant infection after protocol implementation (9.5%-2.9%, P = 0.013). Logistic regression analysis confirmed that the protocol was independently associated with a decrease in infection risk (odds ratio, 0.244; P = 0.021). After protocol implementation, no gram-positive bacteria were isolated among cultures obtained from infected periprosthetic fluid. Radiation and drain duration greater than 21 days were independently associated with greater risk for infection. CONCLUSIONS: Our evidence-based protocol was associated with a significant decline in infection rates among implant-based breast reconstruction patients and was particularly effective for gram-positive infections. We will continue to use this protocol in our practice and will consider future directions for addressing gram-negative infections as well.

Advanced Imaging Techniques for Investigation of Acellular Dermal Matrix Biointegration.

BACKGROUND: Biointegration, a concept involving a dynamic interplay among three processes-inflammation, cellular infiltration, and angiogenesis-is key to understanding the interaction between acellular dermal matrices and the host. The current standard for evaluating acellular dermal matrix biointegration involves histologic analysis at fixed time points; however, the authors' approach uses advanced imaging techniques to serially assess biointegration in real time. METHODS: The authors have adapted two advanced imaging techniques-two-photon microscopy and photoacoustic microscopy-to investigate biointegration in a murine deepithelialized dorsal skin-fold window chamber model, specifically engineered to recapitulate the host microenvironment of acellular dermal matrix-assisted breast reconstruction. Four mice per group were assessed. Two-photon imaging of dual-transgenic mice allows for detection of fluorescently labeled perivascular cells, and macrophage lineage cells. Photoacoustic microscopy noninvasively assesses oxygen and hemoglobin concentration in living tissues, generating high-resolution, three-dimensional mapping of the nascent acellular dermal matrix-associated microvasculature and metabolic consumption of oxygen. These outcomes were corroborated by confirmatory histologic analysis at the terminal time point. RESULTS: The acellular dermal matrix/host interface is characterized by robust inflammation (0 to 3 days), increased oxygen consumption and neoangiogenesis in the matrix border zone (10 to 14 days), and vascular and inflammatory cell penetration into the center of the matrix (>21 days). CONCLUSION: The data broaden the core knowledge of acellular dermal matrix biology, and serve as a potential template for elucidating the key differences among various commercially available and developmental products to guide the reconstructive surgeon to better select a reconstructive adjunct that meets their specific needs.

Techniques to refine the upper outer breast aesthetic subunit in alloplastic breast reconstruction: The lateral capsular flap.

BACKGROUND: Lateral displacement of breast implants and axillary fullness are common causes of patient dissatisfaction and reoperation following prosthetic breast reconstruction. Suture plication of the capsule and acellular dermal matrix slings have been described to address lateral implant malposition, but with unacceptably high rates of recurrence and additional cost, respectively. OBJECTIVE: To describe a novel technique using a lateral capsular flap to provide durable correction of implant malposition and, at the same time, redefinition of the lateral breast border, thereby restoring balance to the breast aesthetic subunits. METHODS: Sixteen patients presented with lateral malposition of tissue expanders or breast implants during staged implant-based breast reconstruction, four of whom had additional unwanted axillary soft tissue fullness. An anteriorly based lateral capsular flap was performed for each breast to reconstruct the lateral border of the breast, return the implant to its appropriate position and address axillary fullness when indicated. RESULTS: Lateral capsular flaps were performed for 16 patients (20 breasts) resulting in durable medial repositioning of the implant for a minimum of six months follow-up (range six to 60 months). Eight patients presented after implant placement with subsequent malposition while the remainder presented after tissue expander placement alone. For the eight patients with axillary fullness, elevation of the capsular flap allowed access to axillary contents for excision (four cases) or incorporation of axillary fat into the flap to prevent lateral implant palpability. No major complications, infectious complications or wound healing complications were reported. All patients showed satisfactory results, and reported high cosmetic and functional satisfaction with the appearance of their reconstructed breasts and axillary comfort. CONCLUSIONS: In the authors' experience, the lateral capsular flap represents a simple, safe and reliable technique to correct breast implant lateral malposition, reconstruct the lateral breast border, and address unwanted axillary fullness in primary or revision implant-based breast reconstruction with improved cosmetic appearance and balance of the breast.

HISTORIQUE: Le déplacement latéral des implants mammaires et de la plénitude axillaire sont des causes courantes d'insatisfaction des patientes et de réopération après une reconstruction mammaire prosthétique. La plication de la suture de la capsule et les attelles de la matrice dermique acellulaire corrigent la malposition latérale des implants, mais s'associent à un taux inacceptable de récurrence et à des coûts supplémentaires, respectivement. OBJECTIF: Décrire une technique novatrice au moyen d'un lambeau capsulaire latéral afin de corriger durablement la malposition de l'implant tout en redéfinissant la limite latérale du sein, afin de restaurer l'équilibre des sous-unités esthétiques du sein. MÉTHODOLOGIE: Seize patientes ont consulté en raison d'une malposition latérale des expanseurs tissulaires ou des implants mammaires pendant la reconstruction mammaire graduelle par implants, dont quatre présentaient une plénitude indésirable des tissus mous axillaires. Elles ont reçu un lambeau capsulaire latéral antérieur pour chaque sein afin de reconstruire la bordure latérale du sein, de remettre l'implant en position et de corriger la plénitude axillaire, au besoin. RÉSULTATS: Les 16 patientes (20 seins) ont reçu des lambeaux capsulaires latéraux pour assurer le repositionnement médian durable de l'implant pendant un suivi d'au moins six mois (plage de six à 60 mois). Huit patientes ont consulté après l'installation d'implants qui s'étaient déplacés et les autres se sont présentées après l'installation d'expanseurs tissulaires seulement. Chez les huit patientes qui présentaient une plénitude axillaire, l'élévation du lambeau capsulaire a permis d'accéder au contenu axillaire pour l'exciser (quatre cas) ou incorporer la graisse axillaire dans le lambeau afin d'éviter de palper l'implant latéral. Elles n'ont souffert d'aucune complication majeure, complication infectieuse, ni complication de la cicatrisation des plaies. Toutes les patientes ont obtenu des résultats satisfaisants et se sont dites très satisfaites de leurs seins reconstruits et du confort axillaire sur le plan esthétique et fonctionnel. CONCLUSIONS: Selon l'expérience des auteurs, le lambeau capsulaire latéral est une technique simple, sécuritaire et fiable pour corriger la malposition latérale des implants mammaires, reconstruire la bordure mammaire latérale et corriger une plénitude axillaire indésirable lors de la reconstruction primaire ou révisée des implants mammaires, ce qui améliore l'esthétisme et l'équilibre du sein.

Evaluation of Sidestream Darkfield Microscopy for Real-Time Imaging Acellular Dermal Matrix Revascularization.

BACKGROUND: Acellular dermal matrices (ADMs) serve as a regenerative framework for host cell integration and collagen deposition to augment the soft tissue envelope in ADM-assisted breast reconstruction-a process dependent on vascular ingrowth. To date noninvasive intra-operative imaging techniques have been inadequate to evaluate the revascularization of ADM. METHODS: We investigated the safety, feasibility, and efficacy of sidestream darkfield (SDF) microscopy to assess the status of ADM microvascular architecture in 8 patients at the time of tissue expander to permanent implant exchange during 2-stage ADM-assisted breast reconstruction. The SDF microscopy is a handheld device, which can be used intraoperatively for the real-time assessment of ADM blood flow, vessel density, vessel size, and branching pattern. The SDF microscopy was used to assess the microvascular architecture in the center and border zone of the ADM and to compare the native, non-ADM-associated capsule in each patient as a within-subject control. RESULTS: No incidences of periprosthetic infection, explantation, or adverse events were reported after SDF image acquisition. Native capsules demonstrate a complex, layered architecture with an average vessel area density of 14.9 mm/mm and total vessel length density of 12.3 mm/mm. In contrast to native periprosthetic capsules, ADM-associated capsules are not uniformly vascularized structures and demonstrate 2 zones of microvascular architecture. The ADM and native capsule border zone demonstrates palisading peripheral vascular arcades with continuous antegrade flow. The central zone of the ADM demonstrates punctate perforating vascular plexi with intermittent, sluggish flow, and intervening 2- to 3-cm watershed zones. CONCLUSIONS: Sidestream darkfield microscopy allows for real-time intraoperative assessment of ADM revascularization and serves as a potential methodology to compare revascularization parameters among commercially available ADMs. Thr SDF microscopy demonstrates that the periprosthetic capsule in ADM-assisted implant-based breast reconstruction is not a uniformly vascularized structure.