PRS Journal Club: Improving Disparities, Long-Term Outcomes, and Financial Metrics in Breast and Mandibular Reconstruction

Over the last several decades, reconstruction after breast and mandibular cancer resection has become more prevalent, given its realized impact on patient quality of life. Nevertheless, the prevalence of these procedures has not necessarily been uniform, demonstrating disparities in patient access to care. Many studies have focused on analyzing and improving these disparities, with simultaneous efforts focusing on harnessing technological advances in preoperative planning and optimizing operative teams to improve efficiency. In the May of 2025 edition of PRS Journal Club, we discuss articles addressing all of these issues that are integral to improving oncoplastic care for these patients. Breast reconstruction may be a large component of many plastic surgery practices today, but overall access to these operations has not always been widespread. Studies in the early 2000s found a 15% to 20% rate of immediate reconstruction, with significant disparities based on age, race and ethnicity, and geographic region. In particular, these studies noted a decreased rate of postoncologic reconstruction in Black and Hispanic patients as compared with White patients.1,2 In this edition of PRS Journal Club, we discuss the article entitled “Legislative Impact and Persistent Disparities: Postmastectomy Breast Reconstruction Rates in the United States among 224,506 Patients,” by Schafer et al.3 The authors used the National Surgical Quality Improvement Program database to delve into the impact that the Affordable Care Act had on racial and ethnic disparities in breast reconstruction. The authors found that, although overall rates of immediate breast reconstruction increased for several racial groups, disparities still exist in recent years, as many minority patients undergo immediate reconstruction at lower rates. Although uncovering disparities in care and finding ways to improve access to care have long been a part of our field,4 the study by Schafer et al. describes the current landscape of breast reconstruction disparities and challenges us to further improve access going forward. The second article discussed in the May of 2025 edition of PRS Journal Club delves into another important component of care delivery in breast reconstruction, namely, intraoperative efficiency and improving financial margins for autologous breast reconstruction. In “The Financial Impact of a Cosurgeon in Breast Microsurgery,” DeVito et al.5 retrospectively reviewed autologous reconstructions at a single institution over a 5-year period and discovered significant decreases in operative times and hospital length of stay when cases were performed with a cosurgeon. The authors also found overall improved financial metrics relating to improved operative efficiency, which allowed for increased breast microsurgical case volume. This demonstration of the value of the cosurgeon model builds on earlier work by Mericli et al.6 and Weichman et al.,7 who acknowledged the efficiency and potential for reduced costs when 2 surgeons are involved in performing microvascular breast reconstruction. This study also builds on that of Tanna et al.,8 who applied a business quality improvement model to the operating room to improve workflow. The study by DeVito et al., along with the cited classic articles, highlights the importance of closely examining intraoperative efficiency as a means of not only decreasing costs but also improving patient access to care by increasing case volume potential. The third article discussed in this edition of PRS Journal Club, “Computer-Aided Design and Manufacturing in Free Fibula Reconstruction of the Mandible: Comparison of Long-Term Outcomes,” by Bengur et al.,9 investigates how the use of this technological advancement improves intraoperative efficiency and long-term outcomes in mandibular reconstruction. After free fibula mandibular reconstruction was described by David Hidalgo in 1989,10 it became a workhorse flap for this indication.11 The early descriptions of this technique involved manual osteotomies and intraoperative hardware shaping; some argue that the eventual introduction of virtual surgical planning and computer-aided design and manufacturing has improved accuracy and contour.12 Bengur et al. found that computer-aided design and manufacturing are associated with improved operative efficiency, decreased wound dehiscence in the early postoperative period, and decreased hardware removal at long-term follow-up, compared with conventional methods. When considering these 3 PRS Journal Club articles together, we are able to gain an understanding of 3 different, yet equally important, issues in reconstruction after breast and mandibular cancer: disparities in patient access to care, use of technology in preoperative planning, and improvement of intraoperative microsurgical efficiency. Addressing these issues is foundational to optimizing oncologic reconstructive efforts, and the analysis and solutions presented in these articles enable the continued advancement of our field. DISCLOSURE The authors have no funding sources to disclose for this study. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.