Questions about breast reconstruction

I got a late question in the "mailbag" from a Plastic Surgery resident asking

"When I was applying to programs last year and traversing the country visiting programs, there were a few trends which enticed applicants, probably none more that microvascular breast reconstruction. I was curious whether you think this trend will persist, or do you think increased insurance skepticism and comparability of implant based reconstruction and rotational flap reconstruction will leave this procedure for the uber rich willing to pay the difference?"

One thing to understand with questions like this is that while quality in healthcare is applauded, it is not paid for in a vacuum. With rare exception, reimbursement for insurance will continue to be depressed as we creak towards some kind of "federal medicare for all". As the feds and 3rd party payers look at things, quality is measured in things like length of stay and total cost rather then measuring quality in terms of "Does this type of reconstruction look more like a breast?".

Microsurgical expertise is gradually being concentrated in fewer and fewer hands as it has become a financially unsustainable procedure for most surgeons. (you can witness the same phenomena in pediatric plastic surgery & increasingly, hand surgery btw) I don't think there exists a large population of "uber rich" to sustain the field in a robust fashion, and there really is no plausible stimulus pending (50% increase in RVU's for instance) for rekindling interest in free flap surgery when other options exist.



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