by Anu Bajaj, MD
“Implants are a cop out.” My father has made that statement on several occasions during the past few years whenever we have discussed breast reconstruction. And he said it again this past Monday as he was assisting on our weekly bilateral DIEP flap.
As I read this month’s issue of PRS, several articles intrigued me, but two in particular hit a personal note – this month’s article that discussed the cost-effectiveness of implants vs. autologous perforator flaps for breast reconstruction and the article discussing the cost-effectiveness of DIEP flaps vs. muscle-sparing TRAM flaps. These articles follow several articles that have appeared in PRS during the previous months regarding the benefits of autologous tissue based breast reconstruction — one looked at patient satisfaction in women undergoing autologous breast reconstruction (PRS January 2015) and another that looked at post-operative pain in women who have DIEP flaps compared with implants (PRS February 2015). It also comes at a time when I have spent the past year negotiating carve-outs with several payers for perforator flap breast reconstruction. During this process, I have had to present my data and outcomes to these payers and explain to them why women should have a choice when they have breast reconstruction.
As my practice has grown over the past eight years, I have developed a small niche in autologous tissue based breast reconstruction, specifically DIEP and muscle-sparing TRAM flaps, primarily because I live in a community where most of the other plastic surgeons focus on implant-based breast reconstruction. I joined my father in practice in 2007; at that time, his breast reconstructive practice included implant-based breast reconstruction, latissimus flaps, and pedicled TRAMs. After our first few years of working together and assisting me on many DIEP flaps, he made a comment to a general surgeon that he was impressed with how quickly these patients recovered and how well they did post-operatively, something that “he rarely saw” with his pedicled TRAM flaps.
In this month’s article on cost-effectiveness, the authors (Matros et al.) state that “autologous reconstructions have generally been considered by most plastic surgeons to be superior to implants because they adhere to the reconstructive axiom of replacing like with like”; I think that my father would agree with this statement since he has never been a huge supporter of breast implants primarily because of the long-term issues associated with them – rupture, capsular contracture, unnatural appearance, etc.
While it took me some time to understand the methods and logistics that take place behind a cost-effectiveness analysis, this month’s article strives to explain to payers why autologous perforator flap reconstruction is a cost effective option from the patient’s perspective. Intuitively, I have always believed that autologous perforator flap breast reconstruction provided a better quality of life for my patients. Similarly, I have observed that my DIEP flap patients have less post-operative pain, a smoother post-operative recovery, and return to work sooner than my tissue expander patients. I have told numerous patients that I routinely observe, “My patients who have a DIEP flaps have are able to bounce back to their regular lives more quickly than my tissue expander patients.” Last week, I had a patient who was two weeks s/p bilateral DIEP who asked if she could return to work because she was going stir crazy at home – and this isn’t unusual. I have had many patients following a DIEP flap who request clearance to return to work on a part-time or limited basis at 2-3 weeks post-op.
I also agree with the authors conclusion that the long-term cost-effectiveness is likely to be underestimated because quality of life will continue to improve for women with autologous tissue breast reconstruction while this is usually not the case for implant-based breast reconstruction. The article did support the fact that autologous tissue reconstruction becomes more cost-effective in younger patients as well.
One has to then ask despite these advantages, why is implant-based reconstruction the predominant form of breast reconstruction? Is it because of the time required? Insurance reimbursements? Patient perceptions? For most women, it seems counterintuitive – a more complex procedure that requires surgery on two different anatomic areas of your body is “easier” from a pain control and comfort standpoint and provides a better quality of life than a procedure with no additional incisions (other than your mastectomy incision). So, it isn’t surprising that many of them or their family members are initially skeptical. Payers are skeptical because of the higher associated initial costs. This inherent skepticism is then compounded by the fact that perforator flap breast reconstruction isn’t available at all centers.
Showing that autologous tissue reconstruction is a cost effective option to payers is an important first step. Using this data as well as other outcomes data about less post-operative pain and better patient satisfaction, we can start to negotiate with insurance carriers to improve our reimbursements; furthermore, these changes may encourage more surgeons to perform these procedures and offer them to their patients. As a surgeon who is committed to the benefits of autologous tissue reconstruction, I believe that women should be able to choose the method of reconstruction that is best suited to their lifestyle, but if few plastic surgeons offer one option, then women do not have the full-spectrum of choices.