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The Influence of Sociodemographic Factors on the Method of Breast Reconstruction, Including Microsurgery: A United States Population Based Study
Claudia R. Albornoz, MD MSc, Peter B. Bach, MD MAPP, Andrea L. Pusic, MD MHS, Colleen M. McCarthy, MD MS, Babak J. Mehrara, MD, Joseph J. Disa, MD, Peter G. Cordeiro, MD, Evan Matros, MD MMSc.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

PURPOSE:
Microsurgical breast reconstruction has gained popularity because of its association with decreased abdominal morbidity and high levels of satisfaction, yet the number of these procedures performed annually in the US remains unknown. Sociodemographic variables have been shown to impact whether a patient receives breast reconstruction; however, there is little information about their influence on the method of reconstruction. The purpose of this study was to ascertain the importance of microsurgical flaps within the reconstructive armamentarium and to evaluate the relationship between sociodemographic factors and breast reconstruction technique.
METHODS:
Since specific ICD-9 procedure codes detailing microsurgical breast reconstruction only became available in 2008, a population based, cross sectional study of breast reconstructions was performed using the Nationwide Inpatient Sample database for this year. National estimates of breast reconstructive procedures including microsurgery were obtained. The impact of variables on method of reconstruction (autologous vs implant reconstruction, microsurgical vs pedicled flaps) was analyzed using logistic regression.
RESULTS:
The immediate reconstruction rate was 37.8%. Approximately 1,900 microsurgical cases were performed in the US representing only 5.5% of all breast reconstructions. Half of microsurgical breast procedures were perforator flaps such as DIEP, SIEA, and SGAP, while the remainder was microsurgical TRAMs. Multivariable analysis showed that women 50-59 years old, teaching hospitals, patients with private insurance and delayed timing were more likely to have autologous than implant reconstruction. Implants were associated with young patients, Whites, Asians, higher income, and all regions except the Northeast. The likelihood to have a microsurgical versus a pedicle flap was greater in teaching hospitals, patients with private insurance and delayed reconstructions.
CONCLUSION:
Microsurgical techniques are currently used in only a minority of breast reconstructions. Since this is the first national estimate of microsurgical breast reconstruction, longitudinal information on trends is unavailable. Sociodemographic and hospital variables influence the likelihood to have a breast reconstruction as well as the method of reconstruction. Ideally the reconstructive technique should be chosen based on anatomic considerations and preference, not sociodemographic characteristics. Knowledge about reconstructive decision making can help identify targets for future educational and legislative initiatives which promote patient equality.


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