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Background: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction., Method: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types., Results: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice., Conclusion: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction., (© 2024 Wiley Periodicals LLC.)

Background: This study investigated breast cancer-related lymphedema (BCRL) and its correlation with the incidence of cellulitis and mortality in the National Health Insurance (NHI) database in Taiwan., Methods: Between 2004 and 2014, the NHI database of patients with breast cancer who underwent surgical procedures, adjuvant therapies, BCRL, cellulitis, and mortality were retrospectively reviewed. Cox regression was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for incidence of BCRL and cellulitis in different treatment groups. The associations of BCRL with the incidence of cellulitis and mortality were further analyzed using the Kaplan-Meier curve., Results: Among 100 301 patients, 5464 (5.4%) developed BCRL with a median onset of 1.3 years. At a mean follow-up of 4.77 years, the incidence of cellulitis in the BCRL group (12.7%, 694/5464 patients) was significantly higher than in the no-BCRL group (2.73%, 2589/94 837 patients) (HR: 3.74; 95% CI: 3.43-4.08; p < 0.0001). At a mean follow-up of 5.77 years, the mortality rate in the cellulitis group (34.21%, 1123/3283 patients) was significantly greater than in the no-cellulitis group (16.29%, 15 804/97 018 patients) (HR: 1.17; 95% CI: 1.1-1.24; p < 0.0001)., Conclusions: BCRL had a significantly higher incidence of cellulitis and mortality., (© 2022 Wiley Periodicals LLC.)

Background: This study was to investigate the lymphoscintigraphy findings for the diagnosis and severity in unilateral gynecological cancer-related lymphedema (GCRL) and to correlate lymphoscintigraphy stages with the clinical findings., Methods: Patients with unilateral GCRL who underwent lymphoscintigraphy were staged using the presence of ileo-inguinal lymph nodes, distal-lymphatic ducts, and dermal backflow findings. Taiwan Lymphoscintigraphy Staging (TLS) was divided into three patterns and seven stages: normal drainage (L-0); partial obstruction (P-1, P-2, and P-3); and total obstruction (T4, T-5, and T-6). Correlations between clinical lymphedema severity and TLS were evaluated using analysis of variance and multivariable linear regression analyses., Results: A total of 141 patients with unilateral GCRL were divided as follows: 6 (4.3%) in normal drainage, 56 (39.7%) in partial-obstruction, and 79 (56%) in total obstruction. Cellulitis episodes, circumferential difference, and computed tomography (CT) volumetric difference were shown to be statistically different between TLS stages (P < .001 for all). Total obstruction stages were the most significant factors associated with the severity of circumferential difference (β = 19.72, 25.54, 32.42, respectively; P < .05) and CT volumetric difference (β = 36.04, 45.12, 52.78, respectively; P < .01)., Conclusions: Total lymphatic obstruction was present in 56% of unilateral GCGL. Lymphoscintigraphy stages were statistically correlated with episodes of cellulitis, circumferential difference and CT volumetric difference in unilateral GCRL., (© 2019 Wiley Periodicals, Inc.)

Backgroud: The optimal approaches for concurrent vascular lesions with limb lymphedema are not well established. The purpose of the study was to investigate the outcome of the surgical management of lymphedema with concomitant vascular lesions., Methods: Between August 2010 and November 2015, 15 consecutive patients with extremity lymphedema and concomitant vascular lesions treated with vascularized lymph node flaps were reviewed. The patients had vascular interventions discovered during workup for lymphedema surgery. Outcomes were assessed using circumferential difference (CD) and circumferential reduction rate (CRR) at 12-month and final follow-up visits., Results: Vascular lesions (n = 15) included proximal arterial occlusion ( n = 1), vascular malformation ( n = 2), and proximal venous compression/stenosis ( n = 12). Concomitant vascular lesions had an incidence of 15.8% in patients that underwent vascularized lymph node transfers (VLNTs). We had 100% VLNT survival rate and average number of episodes of cellulitis after VLNTs decreased significantly ( p < 0.05). The CRR for the below knee/elbow measurement at 12-months follow-up was significantly higher for patients that underwent vascular intervention for venous lesions before VLNT instead of concurrently or after (23.7% vs 12.2%, P = 0.23). Final mean CRR was 23.7% and 12.2% respectively., Conclusion: Preoperative workup of concomitant vascular lesions is important for lymphedema management. We suggest appropriate vascular intervention should be done prior to VLNT to maximize the short-term and long-term outcomes., (© 2018 Wiley Periodicals, Inc.)

Background: Nipple-sparing mastectomy poses challenges in providing esthetically-pleasing immediate autologous breast reconstruction. This study was to investigate the outcomes of nipple-sparing mastectomy with breast reconstruction using free abdominal flaps between two different recipient sites., Methods: Between 2010 and 2016, 79 patients who underwent nipple-sparing mastectomy with autologous breast reconstruction using thoracodorsal (TD) vessels in 30 cases or internal mammary (IM) vessels in 49 cases were investigated. Demographics, intraoperative findings, complications, and quality of life using Breast-Q questionnaire were compared between two groups., Results: All flap survived. There was no statistical difference in age, BMI, ischemia time, and flap-used percentage. The TD artery had a statistically smaller diameter 1.8 ± 0.4 mm than the IM artery 2.7 ± 0.43 mm (p = 0.02). At a mean follow-up of 44.4 ± 35.2 months, there was no statistical difference in total complication rates between TD and IM groups (23.3% and 36.7%, respectively, p > 0.05). The "psychosocial well-being" of Breast-Q in TD group 83.9 ± 14.6 was statistically greater than IM group 72.8 ± 17.6 (p = 0.04)., Conclusions: Nipple-sparing mastectomy with immediate breast reconstruction using TD vessels with a low lateral scar is a safe procedure that provides an inconspicuous scar with better cosmesis and minimal complication rate., (© 2018 Wiley Periodicals, Inc.)

Background: The Hirsch index (h-index) is widely recognized as a reliable measure of academic productivity. While previous studies have applied the h-index to surgical disciplines, none have analyzed microsurgery faculty. This manuscript aims to examine the h-index of microsurgery fellowship faculty to categorize its applicability to microsurgeons as a determinant of academic output., Methods: Faculty demographics and institution characteristics were obtained from the American Society of Reconstructive Microsurgery (ASRM) and official program websites. Faculty h-indices were calculated using the Scopus database (Elsevier, USA). Data was assessed using bivariate analysis and multiple linear regression models to determine the relationship between independent variables and total publications, career h-index and 5-year h-index (h5-index) of each faculty., Results: A total of 139 faculties from 22 programs met inclusion criteria. The median faculty age was 44 (IQR 13) and 84.9% of faculty were male. Faculty size, number of years of fellowship existence, number of fellows, FACS memberships, number of free flaps annually, and academic appointment title were significantly associated with the total publications, h-index, and h5-index. Multivariable analysis based on the significant independent variables demonstrated that geographical region and faculty ranks were significantly associated with the h5-index., Conclusions: Variables associated with seniority (age, years of practice after fellowship, and academic appointment) were positively correlated with the h-index. Given the increased use of bibliometrics in academic medicine, these results show that h-index is a viable tool that can be used to assess research productivity among academic microsurgeons., (© 2016 Wiley Periodicals, Inc.)

Background: CT-angiography (CTA) has been introduced as a means of evaluating arterial anatomy and vascular integrity prior to free autologous breast reconstruction. There is limited published data, however, regarding the incidence, indications, and impact of preoperative CTA (pCTA) on procedural and flap outcomes., Methods: Retrospective review was performed of all autologous microsurgical breast reconstruction procedures at a single academic center between January 2004 and July 2014. Univariate analysis of patient, procedural, and flap characteristics was performed and a logistic regression model was configured to assess for factors associated with ischemia-related complications., Results: There were 1,110 microsurgical flap reconstructions performed in 778 patients by 3 surgeons at our institution during the study period. Overall, 11.4% of patients underwent pCTA; frequency increased from 0 to 35.7%. Patients who underwent pCTA had significantly higher body mass index (P = 0.041), and more coronary artery disease (P = 0.022), prior abdominal surgery (P = 0.004), and bilateral reconstruction (P = 0.015). No statistically significant difference between groups was found with respect to flap characteristics or operative time. Multivariate analysis revealed that although pCTA was associated with a lower incidence of ischemia-related complications (complete or partial flap loss or fat necrosis) (OR, 0.57, 95% CI, 0.32 to 1.02), this did not reach statistical significance (P = 0.058)., Conclusions: Use of pCTA has increased dramatically at our institution since it was first incorporated into the reconstructive surgical planning process in 2008. Given the expense, radiation exposure, and borderline impact on ischemia-related flap complications, surgeons should selectively consider pCTA as an adjunct to their surgical planning algorithm. © 2015 Wiley Periodicals, Inc. Microsurgery 36:623-627, 2016., (© 2016 Wiley Periodicals, Inc.)