Hospital and patient characteristics affect breast reconstruction methods

Rate of microsurgical reconstructions remains low, nationwide study finds

April 30, 2012
American Society of Plastic Surgeons (ASPS)

Only a small minority of breast reconstructions in the United States are performed using the most advanced microsurgical techniques, according to a report in the May issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS).

A number of patient- and hospital-related factors affect the methods used for breast reconstruction, concludes the new research, led by Dr. C.R. Albornoz of Memorial-Sloan-Kettering Cancer Center, New York. "The presence of disparities in care suggests that current decision making for breast reconstruction is not based solely on patient preference or anatomic features," the researchers write.

Nationwide data show variations in breast reconstruction

Dr. Albornoz and colleagues used a large hospital database to analyze information on nearly 16,000 women undergoing mastectomy at U.S. hospitals during 2008. Approximately 6,000 patients underwent immediate breast reconstruction. The overall reconstruction rate was about 38%, compared to a 24% rate reported in a study using the same database from 1999 to 2003. Another 1,300 women underwent delayed reconstruction.

Breast implants were the most common method of reconstruction, used in 60.5% of patients. Another 34% of reconstructions were done with conventional plastic surgery skin flaps. The remaining 5.5% were performed using advanced microsurgical flap techniques.

Both conventional and microsurgical flap techniques use the woman's own tissues to reconstruct the beast (autologous reconstruction). The newer microsurgical techniques provide excellent results while avoiding some of the side effects and discomfort of conventional flap techniques.

Age, race and other factors affect choice of technique

Younger women were more likely to undergo reconstruction with implants. Implants were also more likely to be used for Caucasian or Asian patients, compared to African-American or Hispanic women. Implant reconstruction was also more likely performed on women with higher incomes, and in U.S. regions other than the Northeast.

In contrast, women in their 50s were more likely to undergo breast reconstruction using their own tissues. Autologous reconstruction was also more common for women treated at teaching hospitals (i.e., hospitals with surgical training programs) and women with private insurance (as opposed to Medicare or Medicaid).

Microsurgical breast reconstruction was more likely to be used at teaching hospitals and in women with private insurance. Microsurgical techniques were also more frequently used for delayed versus immediate reconstructions.

Microsurgical techniques have shown some important advantages over other alternatives for breast reconstruction. Performed by specially trained surgeons with the use of an operating microscope, these techniques provide new options for using the patient's own tissues for reconstruction. The new study suggests while the overall rate of breast reconstruction has increased, microsurgical techniques still account for a small proportion of reconstructions. The effect of teaching hospital status reflects the fact that only a relatively small percentage of surgeons and hospitals are currently capable of offering microsurgical breast reconstruction.

The study also identifies some patient- and hospital-related factors affecting the choice of reconstructive techniques-including significant effects of race/ethnicity. The findings suggest that important reconstructive decisions may be influenced by extraneous factors-such as the patient's demographic characteristics or the hospital where she is treated. "Armed with this knowledge, initiatives which minimize disparities can be made so that the technique of breast reconstruction is based solely on anatomic considerations and [patient] preference," Dr. Albornoz and coauthors conclude.