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Autologous Breast Reconstruction: Practice Patterns of U.S. Plastic Surgeons
Anita R. Kulkarni, MD1; Erika D. Sears, MD1; Dunya M. Atisha, MD2; Amy K. Alderman, MD, MPH3
1Section of Plastic Surgery, University of Michigan; 2Section of Plastic Surgery, Duke University; 3Private practice, Atlanta GA

PURPOSE:
Autologous breast reconstruction has shown superior long-term outcomes compared to implant-based procedures. Yet, concern exists that plastic surgeons are performing fewer autologous, and especially microsurgical, reconstructions due to low reimbursement for these labor-intensive procedures. Our purpose was to describe the proportion of U.S. plastic surgeons performing autologous and microsurgical breast reconstruction, and to evaluate motivating factors and perceived barriers to performing these procedures.
METHODS:
A survey was mailed to a national sample of randomly selected members of the American Society of Plastic Surgeons (N =325, Response Rate = 76%). The primary dependent variables were a) surgeon volume of autologous breast reconstructions (none, low < 25%, moderate 25-50%, and high >50%) and b) use of microsurgery for breast reconstruction (yes/no). Surgeon and practice characteristics were assessed including demographics (age, gender, race), completion of microsurgical fellowship, years in practice, size of practice, cancer center affiliation, and participation in resident or fellow teaching. Two multiple logistic regression models were created to evaluate factors associated with a) performing >50% autologous breast reconstructions, and b) performing microsurgical breast reconstruction, controlling for the surgeon and practice characteristics that had statistically significant bivariate associations with the dependent variables. Motivating factors and perceived barriers related to performing microsurgical reconstruction were also assessed.
RESULTS:
Less than one-fifth of plastic surgeons perform autologous procedures for more than 50% of their breast cancer patients, and only one-quarter perform any microsurgical breast reconstruction. Surgeon involvement with resident or fellow education is an independent predictor of a high-volume autologous breast reconstruction practice (odds ratio [OR] 2.82, 95% CI 1.41-5.67), as is having a surgeon with a microsurgical fellowship (OR 2.19, CI 1.08-4.44). Other factors, such as surgeon age, gender, race, years in practice, size of practice, and cancer center affiliation are not independently associated with high-volume autologous providers in bivariate comparisons. Factors significantly associated with performing microsurgical breast reconstruction include having a surgeon with a microsurgery fellowship (OR 2.15, CI 1.04-4.44) and surgeon involvement with resident or fellow education (OR 7.25, CI 3.62-14.48). Surgeons who perform microsurgical breast reconstruction (n=58) report superior outcomes as the primary motivating factor (85%). Surgeons who do not perform microsurgical breast reconstruction (n=251) report time commitment (68%) and low reimbursement (63%) as the primary barriers. High-volume autologous providers and providers of microsurgical breast reconstruction are significantly less likely to report that their practices are limited by insurance reimbursement compared to low-volume autologous and non-microsurgical providers.
CONCLUSION:
The proportion of U.S. plastic surgeons with a high volume autologous breast reconstruction practice is low, and even fewer perform microsurgical procedures. Involvement with resident education appears to facilitate both the use of autologous and microsurgical breast reconstruction; while time constraints and reimbursement appear to be the primary deterrents for low-volume surgeons. Future efforts need to focus on improving the feasibility and accessibility of complex breast reconstruction by plastic surgeons before oncoplastic breast surgeons fill this unmet need.


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