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Is Our Effort Appropriately Valued? An Analysis of Work Relative Value Units in Immediate Breast Reconstruction

Supplemental Digital Content is available in the text. Background: The work relative value units system was developed as a quantifier of physician labor, technical skill, and training time required to complete surgical procedures. Thus, more complex surgical procedures that require greater technical skills and are more time consuming should yield a greater compensation. It is known that prosthetic breast reconstruction reimburses more per hour than autologous breast reconstruction. However, there are limited data comparing work relative value units and operative times in breast reconstruction procedures. Therefore, this study aims to compare mean operative times and work relative value units per minute across three different modalities of breast reconstruction. Methods: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing implant-, pedicle-, and free flap–based reconstruction over a 6-year period. Calculation and comparison of median operative times, work relative value units, and dollars per minute was performed. Results: A total of 3135 patients were included in the analysis: 2249 (71.7 percent) underwent immediate implant-based reconstruction, 745 (23.8 percent) underwent immediate free flap–based breast reconstruction, and 141 (4.5 percent) underwent immediate pedicle flap–based reconstruction. Patients were distributed in unilateral and bilateral cases. Consistently, median operative time was greater for free flap breast reconstruction, followed by pedicle flap– and implant-based reconstruction (p < 0.0001). However, work relative value units per minute and dollars per minute were found to be higher for prosthetic reconstruction in all comparisons (p < 0.0001). Conclusion: In the authors’ analysis, more complex and time-consuming procedures resulted in a lower reimbursement in dollars and work relative value units per minute for the procedure.

BACKGROUND: Nipple-sparing mastectomy (NSM) is reserved for patients who meet specific criteria to optimize considerations in the oncologic domain and reduce complications. 1 Trend toward the development of more broader reconstructive indications for NSM is directly related to patient demand and the possibility to achieve a better esthetic outcomes. 2 Several studies have demonstrated the safety of this procedure in patients with increased risk factors. 3,4 Well-selected high-risk patients can safely undergo NSM and implant reconstruction in 1 stage or 2 stages.

PURPOSE:
To compare risk factors and complications in patients after NSM and implant-based breast reconstruction.

METHODS:
A retrospective chart review was performed in a tertiary institution from 2016 to 2018. All patients who underwent NSM followed by 2-stage or direct-to-implant (DTI) reconstruction had their information collected per reconstructed breast. Patient demographics, previous surgeries, smoking status, radiotherapy history, surgical information, and postoperative complications (delayed wound healing, dehiscence, mastectomy flap necrosis, and infection) were collected. There were no significant differences in complication rates between the groups (28.97% versus 33.63%; P = 0.47) and reoperation rates (12.14% versus 15.45%; P = 0.56).

RESULTS
Number of revision surgery was similar between both groups (P = 0.17). The number of surgeries required on the entire reconstruction process was bigger on the 2 stages group 2.48 ± 1 versus 1.4 ± 0.75 (P < 0.001). Successful implant-based reconstructions were achieved in 90.81% on TE group and 96.36% on DTI group (P = 0.121).
CONCLUSION: Implant-based breast reconstruction after NSM can be successfully achieved in 1 or 2 stages with similar rates of complication, reoperation, and revision. The patients who underwent DTI reconstructions had similar rates of successful reconstructions despite the higher body mass index, older age, higher mastectomy specimens' weights, and higher preoperative ptosis grades.

PURPOSE:
This study aims to compare mean operative times and wRVUs per minute across 3 different modalities of breast reconstruction.

METHODS: A retrospective analysis of the American
College of Surgeons National Surgical Quality Improvement Program database was performed to identify all patients undergoing implant, pedicle, and free flap-based reconstruction over a 6-year period (2012-2017). Calculation and comparison of mean operative times, wRVUs, and wRVU per minute were performed.

RESULTS:
A total of 3,167 patients were included in the analysis. A total of 2,265 (71.5%) underwent immediate implant-based reconstruction, 759 (24%) underwent immediate free flap breast reconstruction, and 143 (4.5%) underwent immediate pedicle flap-based reconstruction. Patients were distributed in unilateral and bilateral cases, and according to the use of acellular dermal matrix during implant-based reconstruction. Consistently, mean operative time was greater for free flap breast reconstruction, followed by pedicle flap and implant-based reconstruction (P < 0.0001). However, wRVU per minute and dollars per minute were found to be higher for prosthetic reconstruction in all comparisons (P < 0.0001).

CONCLUSION:
In our analysis, the more complex and time-consuming procedures resulted in a lower reimbursement in dollars and wRVU per minute for the procedure. It has been proven that breast reconstruction and the improvement of the breast sensation for postmastectomy patients can improve both satisfaction and quality of life for patients. 1 Spontaneous sensory recovery after deep inferior epigastric perforator (DIEP) flap has been showed due to ingrowth of peripheral cutaneous nerves from the wound edges or from deeper structures but usually is poor and variable. Neurotization has been used in breast reconstruction since 1992, and the limitation of only using the intercostal nerves for coaptation is the need of a greater chest dissection to have an appropriate nerve length that generates scar formation and tension on the suture line. 2,3,4 Using a nerve conduit with a nerve graft will reduce excess nerve dissection that will jeopardize nerve regeneration and can help to overcome the size mismatch between the intercostal nerve and the DIEP intercostal nerve. 4,3 PURPOSE: To evaluate breast sensation outcomes after combined nerve conduit and allograft in DIEP reconstructions.

METHODS:
Dynamic and static sensation recovery tests were performed in all breast quadrants of consecutive patients who underwent DIEP reconstruction with neurotized (group 1) and non-neurotized DIEP reconstructions (group 2). Demographics information, surgical details, and postoperative complications were collected.

RESULTS:
A total of 74 patients (96 breasts) underwent this technique since June 2016: 46 breasts from group 1 and 15 from group 2. The groups had similar age, body mass index, smoking status, history of radiation therapy, and timing of reconstruction. No difference was found for complications and reoperation between groups. The mean time interval among the surgery, first, and second tests were similar in groups 1 and 2. Thresholds on the first and second recovery tests were statistically similar. Compared to group 2, group 1 had 56% of the total areas evaluated (static and dynamic) with better sensation thresholds. On the second round of sensation tests, the clinical difference between the groups was more evident with all areas with better sensation thresholds in the neurotized group.
CONCLUSION: There is a positive trend for breast sensation recovery after reconstruction with neurotized DIEP flaps. Nerve regeneration takes time to be achieved, and a longer follow-up is necessary to evaluate the final sensation recovery.