Impact of Insurance Type on Access to Pediatric Surgical Care.

Background: This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance. Methods: This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex. Results: A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007). Conclusions: No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.

Infantile Hemangioma of the Breast: Long-Term Assessment of Outcomes.

Background: The literature is meager regarding the natural history and outcomes of infantile hemangiomas (IHs) in the breast. Treatment in childhood may be considered due to psychosocial and physical concerns with breast development. Early surgical intervention may cause iatrogenic breast asymmetry and possibly impair lactation later in life. This study characterizes the clinical presentation, management, and long-term outcomes of IHs arising in the breast. Methods: Female patients aged 11 years or older at presentation were included in a retrospective review of the Vascular Anomalies Center database for patients with IHs of the breast seen at our institution between 1980 and 2020. Breast development was ascertained by a structured telephone interview, physical examination, or photographs. Results: A total of 10 patients met criteria for inclusion in this study. The median age at enrollment was 14 years (11-36 years). Breast asymmetry was noted in 60% of patients (n = 6). Of the four patients who underwent subtotal excision of breast IH, three developed ipsilateral breast hypoplasia. Breast asymmetry was also noted in three of five patients who did not receive medical treatment: two with hypoplasia and one with hyperplasia. No asymmetry was noted in the single patient who received corticosteroid. Conclusions: IHs involving the nipple-areola complex can be associated with breast asymmetry. Hypoplasia was noted in patients not treated with corticosteroid or resection in childhood. These findings suggest that systemic treatment should be considered. Longitudinal follow-up on patients treated with propranolol will elucidate its possible benefits in minimizing breast asymmetry.

The Impact of Tuberous Breast on Adolescents: A Cross-sectional Study.

Background: Tuberous breast deformity is a nondiagnostic, descriptive term for a congenital breast difference that becomes apparent at puberty. Although the negative physical and psychosocial effects of macromastia and breast asymmetry are established, no studies to date have explored the impact of tuberous breasts on health-related quality of life (HRQoL) outcomes using a robust sample size. Methods: In this cross-sectional study, HRQoL surveys were administered to adolescent women with tuberous breasts and healthy female controls, aged 12-21 years. Surveys included the Short-Form 36v2, Rosenberg Self-Esteem Scale, and Eating Attitudes Test-26. Demographics were compared, and linear regressions were fit to determine the effect of tuberous breast deformity on survey scores, with body mass index (BMI) category as a covariate. Results: Thirty-four patients with tuberous breasts and 264 controls participated. Patients with tuberous breasts had higher mean BMI than controls (P < 0.05). After adjusting for differences in BMI category, patients with tuberous breasts scored lower than controls on the Rosenberg Self-Esteem Scale and in Short-Form 36v2 domains related to physical and psychological health (P < 0.05, all). Compared with controls, patients with tuberous breasts had a higher mean score on the Eating Attitudes Test-26 (P < 0.05). Conclusions: Tuberous breast deformity may negatively impact patients' physical and psychosocial HRQoL and increase their risk for disordered eating and higher BMIs. It is imperative that healthcare providers and third-party payors understand tuberous breast deformity is not just a cosmetic issue and tailor care and coverage policies accordingly.

Papillary Hemangioma Harbors Somatic GNA11 and GNAQ Mutations.

Papillary hemangioma (PH) is a small, primarily dermal lesion occurring predominantly in the head and neck in both children and adults. Its signature characteristics are dilated thin-walled channels containing papillary clusters of mainly capillary-sized vessels and endothelial cytoplasmic eosinophilic inclusions. Given certain histopathologic similarities to congenital hemangioma which harbor mutations in GNAQ and GNA11 , we investigated whether similar mutations are present in PH. Seven PH specimens were studied. All presented in the first 4 years of life, with one being noted at birth. With the exception of one lesion, all were in the head and neck. Lesions were bluish and ranged in size from 0.5 to 2.8 cm. Four samples had GNA11 p.Q209L and 3 had GNAQ p.Q209L missense mutations. Mutations in GNA11 and GNAQ are associated with other types of somatic vascular lesions including capillary malformation, congenital hemangioma, anastomosing hemangioma, thrombotic anastomosing hemangioma, and hepatic small cell neoplasm. Shared mutations in GNA11 and GNAQ may account for some overlapping clinical and pathologic features in these entities, perhaps explicable by the timing of the mutation or influence of the germline phenotype.

Understanding Hematoma Risk: Study of Patient and Perioperative Factors in a Large Cohort of Young Women Undergoing Reduction Mammaplasty.

BACKGROUND: Despite high satisfaction rates, reduction mammaplasty can have complications such as hematoma. Factors such as age, tobacco use, and comorbidities are known contributors, whereas the influence of race, BMI, certain medications, and blood pressure (BP) remain contentious. This study investigates hematoma risk factors in young women undergoing reduction mammaplasty. STUDY DESIGN: A retrospective review was conducted including all female patients who underwent bilateral reduction mammaplasty at a single institution between 2012 and 2022. Data on demographics, BMI, medical comorbidities, surgical techniques, medications, and perioperative BP were collected. Differences between patients who developed a hematoma and those who did not were assessed using chi-square, Fisher's exact, and t -tests. The relationship between perioperative BP and hematoma formation was assessed using logistic regression. RESULTS: Of 1,754 consecutive patients, 3% developed postoperative hematoma of any kind, with 1.8% returning to the operating room. Age (odds ratio [OR] 1.14, p = 0.01) and ketorolac use (OR 3.93, p = 0.01) were associated with hematoma development. Controlling for baseline BP, each 10 mmHg incremental increase in peak intraoperative BP (systolic BP [SBP]: OR 1.24, p = 0.03; mean arterial pressure: OR 1.24, p = 0.01) and postoperative BP (SBP: OR 1.41, p = 0.01; mean arterial pressure: OR 1.49, p = 0.01) escalated the odds of hematoma. Postoperative SBP variability also incrementally increased hematoma odds (OR 1.48, p < 0.01). Other factors, including race and surgical technique, were not significantly influential. CONCLUSIONS: Age, ketorolac use, and intra- and postoperative BP peaks and variability are risk factors for hematoma in reduction mammaplasty. This emphasizes the importance of perioperative BP management and optimizing pain management protocols.

The Utility of the Schnur Sliding Scale in Adolescent Patients.

BACKGROUND: Although the Schnur Sliding Scale (SSS) was not intended to be utilized by third-party payors, it has become the national standard for coverage decisions regarding macromastia treatment in women of all demographics. Adolescents were neither included in the cohort that created the SSS, nor have they been represented in subsequent validation studies. METHODS: In this prospective study, health-related quality of life surveys were administered to adolescent females aged 12 to 21 years of age, before and after undergoing reduction mammaplasty to treat macromastia. The SSS was used to preoperatively estimate the amount of tissue to be resected. Before and after surgery, subjects completed the Short Form-36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), Breast-Related Symptoms Questionnaire (BRSQ), and Eating Attitudes Test-26. Demographic data were compared, and linear regressions evaluated the effect of resection amounts meeting the SSS value on survey scores. RESULTS: Resection amounts fell below the SSS for 39 patients and above the SSS for 255 patients. Groups featured no difference in mean age or BMI. Both groups had significant postoperative survey score improvements on the RSES, BRSQ, and in 7/8 SF-36 domains (P < .05, all). Both groups had comparable postoperative survey scores on the RSES, BRSQ, and in 8/8 SF-36 domains (P > .05, all). CONCLUSIONS: Adolescents undergoing reduction mammaplasty above and below the SSS experienced comparable physical and psychosocial benefits. These findings underscore the need for third-party payors to broaden coverage for adolescent reduction mammaplasty, as the common coverage cutoff has no impact on overall postoperative benefit.

Reduction Mammaplasty in Younger Patients: An Evidence-Based Approach to Treatment.

Macromastia is a common condition that can lead to physical pain, emotional burden, and behavioral impairment, with significant decrements in quality of life. Reduction mammaplasty offers the only effective treatment of symptomatic macromastia, and patients experience significant improvements in their physical and psychosocial health through surgical correction. Although symptoms typically arise during adolescence, most women seeking surgical intervention do not undergo reduction mammaplasty until their fifth decade of life. Providers often delay surgery due to speculative concerns about emotional immaturity, postoperative breast regrowth, and future lactation performance. The strict guidelines related to age and body mass index imposed by insurance companies further restrict the options available to younger patients with macromastia. This review offers an evidence-based approach to treating macromastia in younger patients. After more than 15 years of treatment and research centered on adolescents and young adults with macromastia led by the senior author (B.I.L.), a pediatric plastic surgeon, we have found that reduction mammaplasty is a safe and effective treatment option for this patient population. It is our hope that our work will enable care providers to make data-supported decisions when treating younger patients with symptomatic macromastia.

Validation of the Short-Form 36 for Adolescents Undergoing Reduction Mammaplasty.

Health-related quality of life improvements after reduction mammaplasty have been reported by patients. Although instruments exist for adults, a validated outcomes survey is not available for adolescents. This study aims to validate the Short-Form 36 (SF-36) for adolescents undergoing reduction mammaplasty. Methods: Patients aged 12-21 years were prospectively recruited between 2008 and 2021 to unaffected or macromastia cohorts. Patients completed four baseline surveys: SF-36, Rosenberg Self-esteem Scale, Breast-related Symptoms Questionnaire, and Eating Attitudes Test. Surveys were repeated at 6 and 12 months postoperatively (macromastia cohort), and at 6 and 12 months from baseline (unaffected cohort). Content, construct, and longitudinal validity were assessed. Results: A total of 258 patients with macromastia (median age: 17.5 years), and 128 unaffected patients (median age: 17.0 years) were included. Content validity was established, and construct validity was fulfilled: internal consistency was confirmed for all domains (Cronbach alpha >0.7); convergent validity was satisfied through expected correlations between the SF-36 and Rosenberg Self-esteem Scale, Breast-related Symptoms Questionnaire, and Eating Attitudes Test, and known-groups validity was established through significantly lower mean scores in all SF-36 domains in the macromastia cohort compared with unaffected patients. Longitudinal validity was established by significant improvements in domain scores from baseline to 6 and 12 months postoperatively in patients with macromastia (P < 0.05, all). Conclusions: The SF-36 is a valid instrument for adolescents undergoing reduction mammaplasty. Although other instruments have been used for older patients, we recommend the SF-36 when assessing health-related quality of life changes in younger populations.

Mental Health Conditions and Health-related Quality of Life Changes after Reduction Mammaplasty in Younger Patients.

Reduction mammaplasty is increasingly common in younger patients with macromastia. Unfortunately, a recent surge in mental health disorders has been documented in this population. It is unknown how mental health disorders affect patients undergoing reduction mammaplasty. This study examines the impact of concurrent mental health conditions on health-related quality of life outcomes after reduction mammaplasty. Methods: A prospective cohort study was performed on patients aged 12-21 years undergoing reduction mammaplasty. Patients were assigned to unaffected or affected (baseline mental health condition) cohorts based on psychological history. Patients completed the Short-form-36, Rosenberg Self-esteem Scale, Eating Attitudes Test 26, and Breast-related Symptoms Questionnaire at baseline and postoperatively. Results: A total of 250 patients were included (81 affected and 169 unaffected). Mean age at surgery was 17.9 ± 2.0 and 18.1 ± 1.8 years for affected and unaffected patients, respectively. Anxiety (n = 59, 23.6%) and depression (n = 38, 15.2%) were the most prevalent conditions. Affected patients were outscored by controls at baseline and postoperatively in most measures. However, significant score improvements were also reported in the affected cohort. In fact, the magnitude of score improvements observed in both cohorts were similar (P > 0.05, all). Conclusions: Baseline mental health conditions are common in young patients presenting for reduction mammaplasty. After surgery, health-related quality of life in affected patients remains below unaffected peers; however, significant and similar gains are achieved. We advise providers to recommend mental health treatment to affected patients, but not preclude otherwise appropriate candidates from surgery.

Trends in Pediatric Head and Facial Trauma During the COVID-19 Pandemic.

INTRODUCTION: The effect of physical-distancing policies and school closures on pediatric health has been a topic of major concern in the United States during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to assess the immediate impact of these public policies on patterns of head and facial trauma in the pediatric population. MATERIALS AND METHOD: The Pediatric Health Information System (PHIS) was queried to identify patient encounters at 46 children's hospitals across the United States in 2016-2020. Encounters were included if resultant in ICD-10 diagnosis for head or facial trauma in a child under 18 between April 1 and June 30 in 2020 (first COVID-19 school closures) and during the same period in the previous 4 years (for comparison). RESULTS: A total of 170,832 patient encounters for pediatric head and facial trauma were recorded during the study period, including 28,030 (16.4%) in 2020 and 142,802 (83.6%) in 2016-2019. Patient encounters declined significantly in 2020 among children of all age groups relative to previous years. Relative reductions were greatest in children aged 11 to 17 (middle/high school) and 6 to 10 (elementary school), at -34.6% (95% confidence interval: -23.6%, -44%; P <0.001) and -27.7% (95% confidence interval: -18.4%, -36%; P <0.001). Variation in relative reductions by race/ethnicity, sex, and rural/urban status were not statistically significant. CONCLUSIONS: Physical-distancing policies and school closures at the start of the COVID-19 pandemic correlated with significant reductions in pediatric head and facial trauma patient encounters. As in-person activities resume, reductions in head and facial trauma during the pandemic may indicate a range of possible preventable injuries in the future.

Presentation and Referral Patterns in Pediatric Closed Hand Fractures.

BACKGROUND: Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns. METHODS: The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed. RESULTS: There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon (P = .007), fewer required surgery (P < .001). CONCLUSIONS: Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.

Body Mass Index (BMI) Impact on Anesthetic Safety among Adolescents Undergoing Bilateral Reduction Mammaplasty.

Obesity is common in adolescents with macromastia seeking surgery, prompting concerns over anesthesia-related complications due to obesity. This may lead to weight-based surgical policies, despite limited research. This study's purpose is to examine the impact of obesity status on perioperative anesthetic-related adverse events/surgical complications in adolescents/young adults undergoing bilateral reduction mammaplasty. Methods: A medical record query was performed to retrospectively identify patients who underwent bilateral reduction mammaplasty at our institution between January 2021 and December 2021. Patient demographics and clinical/surgical data were obtained from medical records. Pearson's chi-square, Fisher exact, and Median tests were used to examine associations between body mass index (BMI) category and clinical/demographic data. Results: Two hundred patients were included in analyses, with a median age at surgery of 18.0 years. The majority of patients were obese (63.5%, n = 127), and none were underweight. The most common comorbidity was asthma (27.0%, n = 54). There were no anesthetic-related intraoperative complications or delayed waking. The following did not significantly differ by BMI category: proportion of patients who experienced oxygen desaturation (pre-, intra-, or postoperatively), frequency of postoperative complications, and length of postanesthesia care unit and total hospital stays (P > 0.05, all). Conclusions: While institutions may implement weight-based surgical policies due to anesthesia-related complication concerns in patients with obesity, our study showed that BMI category did not significantly impact anesthetic-related adverse events/surgical complications in our sample. This suggests that such policies are not warranted in all situations, and that decisions regarding their necessity be data-driven.

Risk Factors Associated with Severe Macromastia among Adolescents and Young Women.

BACKGROUND: Macromastia is common among adolescents and young women and has well-documented negative physical and psychosocial effects. The pathogenesis of idiopathic macromastia has been attributed to increased end organ sensitivity to circulating gonadal hormones. Despite the known negative effects of macromastia, there is a paucity of literature examining the clinical risk factors associated with macromastia severity in this age group. METHODS: In this cross-sectional study, standardized clinical forms were administered to patients between the ages of 12 and 21 years undergoing reduction mammaplasty. Data were collected pertaining to patient demographics, biometrics, breast symptoms, medical and family history, and breast tissue resection mass at the time of reduction. Resection mass was normalized to patient body surface area in analyses. RESULTS: A total of 375 patients were included in analyses. Mean age at surgery was 18.1 years. The following risk factors were positively associated with macromastia severity in both univariate and multivariate logistic regression models: overweight or obesity, racial or ethnic minority status, patient-reported gynecologic or endocrine complaints, and early menarche ( p < 0.05, all). More severe cases of macromastia were associated with approximately three times the odds of being overweight or obese or achieving menarche before 11 years old. CONCLUSIONS: In our sample, overweight or obesity, racial or ethnic minority status, early menarche, and patient-reported gynecologic or endocrine complaints were all positively associated with macromastia severity. Awareness of these factors can empower physicians to identify and address modifiable risk factors to prevent progression to more severe disease. Macromastia itself should prompt screening for gynecologic or endocrine complaints with referral as indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Combined Oral Contraceptives on Adolescents with Macromastia.

BACKGROUND: The combined oral contraceptive pill, containing both estrogen and progestin, is commonly prescribed to adolescents for numerous health benefits. However, there is concern among patients and providers that its use may exacerbate breast growth. This retrospective, case-control study examined the association between combined oral contraceptive pill use and macromastia-related breast hypertrophy and symptoms in adolescents. METHODS: A total of 378 patients undergoing reduction mammaplasty between the ages of 12 and 21 years were assessed for baseline and postoperative breast symptoms and combined oral contraceptive pill use. In addition, the medical records of 378 female controls of the same age range were retrospectively reviewed. RESULTS: Although a lower proportion of the macromastia cohort used any hormonal contraception compared to controls (37.8 percent versus 64.8 percent; OR, 0.33; 95 percent CI, 0.24 to 0.44; p < 0.001), they were more often prescribed combined oral contraceptive pills (82.5 percent versus 52.7 percent; OR, 1.93; 95 percent CI, 1.29 to 2.68; p < 0.001). Participants with macromastia who used combined oral contraceptive pills had a smaller median normalized amount of breast tissue resected during reduction mammaplasty than those who never used hormonal contraception (639.5 g/m 2 versus 735.9 g/m 2 ; p = 0.003). Combined oral contraceptive pills were not associated with breast-related symptoms or clinical impairment, or postoperative breast growth ( p > 0.05 for all). CONCLUSIONS: Combined oral contraceptive pill use during adolescence may be associated with developing less severe breast hypertrophy. Combined oral contraceptive pills do not appear to exacerbate macromastia-related symptoms or impact postoperative growth in young women following reduction mammaplasty. Although additional research is needed, providers are encouraged to consider combined oral contraceptive pills for their patients with macromastia when indicated and appropriate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Effectiveness of Preoperative Symptom Screening in Identifying Pediatric SARS-CoV-2 Infections: A Retrospective Cohort Analysis.

Evidence-based protocols identifying COVID-19 cases in pediatric preoperative settings are lacking. With COVID-19 positioned to remain a threat to children, this study examines effectiveness of preoperative COVID-19 symptom screening in pediatric patients. Methods: This retrospective cohort study included hospital billing/medical record queries of (1) procedures performed under conscious sedation/general anesthesia and (2) laboratory-confirmed COVID-19 (+) cases from April 6, 2020, to June 15, 2020. Descriptive analyses were performed for demographic, procedural, symptom, and COVID-19 test result data obtained from medical records. Bivariate analyses examined associations between SARS-CoV-2 test results and symptom, demographic, and procedural data. Results: Among 2900 surgical cases, median (interquartile range) age was 8.1 (12.8) years. The majority were male (n = 1609, 55.5%), white (n = 1614, 55.7%), and not Hispanic/Latino (n = 1658, 57.2%). Additionally, 85.4% (n = 2412) of cases were non-emergent. Fifteen COVID-19 (+) cases were identified, for a 0.5% positivity rate. COVID-19 positivity was not associated with sex, American Society of Anesthesiologists physical status, or preoperative symptom status. Notably, 92.9% (n = 13) of COVID-19 (+) cases were asymptomatic. COVID-19 (+) patients were significantly older (15.6 years) than COVID-19 (-) patients (8.0 years). Patients who were not white, were Hispanic/Latino, or had a relatively lower economic status, were more likely to test positive. Conclusions: Preoperative symptom screenings insufficiently identified COVID-19 (+) patients. During outbreaks, testing protocols should be implemented to identify COVID-19 (+) patients. Future research should examine if observations are similar for other variants, and how health disparities associate with COVID-19.

Normative Values for Adolescent Quality of Life in Plastic Surgery: A Longitudinal, Cohort Study.

Background: Adolescence is a challenging time, and an increasing number of young people are seeking plastic surgery. With the rise of health-related quality of life studies in plastic surgery, it is critical to understand the natural variation and changes in health-related quality of life for this population. Methods: In this longitudinal, cohort study validated surveys were administered to cisgender participants aged 12-21 years: Short-Form 36v2, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26. Surveys were administered at baseline and up to 9 years follow-up. At the time of enrollment, participants were in a current state of good health with no considerable past or current medical, surgical, or psychological history. Results: A total of 149 female and 75 male participants were included, with a median (interquartile range) baseline age of 16.0 (4.4) years and follow-up time of 3.3 (4.1) years. Over the study period, girls who were not overweight or obese experienced significant declines in five SF-36 domains (general health, vitality, social functioning, role-emotional, and mental health) and on the Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 (P < 0.05). In contrast, boys' and overweight/obese girls' health-related quality of life largely remained stable (P > 0.05). Conclusions: Adolescence is a challenging time, on which plastic surgery-related concerns are superimposed. Our findings suggest that girls may be more at risk for developing psychosocial deficits that worsen over adolescence and young adulthood. This observation is critical for the interpretation and contextualization of health-related quality of life in adolescent plastic surgery patients.

Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men.

BACKGROUND: Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life. METHODS: Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test. RESULTS: Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively. CONCLUSIONS: Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits.

Distraction Lengthening of the Apert Thumb.

BACKGROUND: The thumbs of patients with Apert syndrome are characteristically short and radially deviated, contributing to functional hand impairment. The authors report a two-staged technique for distraction lengthening of the Apert thumb using a robust cohort of pediatric patients. METHODS: The authors retrospectively reviewed medical records of pediatric patients with Apert syndrome who underwent thumb distraction lengthening between 1999 and 2019. The technique was two-staged: (1) application of uniplanar distractor and phalangeal osteotomy, followed by (2) distractor removal, bone grafting, and fixation. Clinical records, preoperative and postoperative radiographs, and photographs were reviewed. RESULTS: Twenty-two patients (41 thumbs) with Apert syndrome were identified and treated (mean age at initial distraction, 11.5 years). A mean distraction gap of 31.3 mm was achieved over a median time of 40.0 days. The mean healing index was 26.3 days per centimeter. The thumbnail complex was lengthened a median length of 3.0 mm. The median follow-up time was 5.0 years, with complications occurring in 36.4 percent (eight out of 22) of patients. A delayed bone union occurred in one patient, and rotational malunion occurred in one patient. CONCLUSION: Although long-term outcomes data are needed, thumb distraction lengthening following syndactyly release in patients with Apert syndrome is safe and should be considered to augment the overall appearance and functionality of the hand. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Incidental Pathologic Findings in Young Men with Gynecomastia.

BACKGROUND: Pathologic examination of young adult gynecomastia tissue is controversial given the low incidence of breast carcinoma in this population. The authors examined the pathologic findings in a large cohort of adolescents with gynecomastia to evaluate the need for routine tissue analysis in this population. METHODS: A retrospective review of men who underwent unilateral or bilateral mastectomy for gynecomastia at a single institution between February of 2007 and November of 2019 identified demographics, medical history, surgical characteristics, and pathologic findings. Descriptive statistics were performed. RESULTS: A total of 268 male patients were included. Mean age was 16.6 years. Mean body mass index was 27.8 kg/m2, and 42.5 percent of the sample was obese. The majority (83.2 percent) underwent bilateral subcutaneous mastectomy. There were no abnormal histopathologic findings in 95.1 percent. Among the 13 patients with abnormalities, eight (3 percent) had nonproliferative changes, two (0.8 percent) had proliferative changes without atypia, two (0.8 percent) had atypical ductal hyperplasia, and one (0.4 percent) had both bilateral atypical ductal hyperplasia and unilateral ductal carcinoma in situ. No patients had invasive carcinoma. The three patients with atypical ductal hyperplasia and/or ductal carcinoma in situ were obese but had no other breast cancer or gynecomastia risk factors. CONCLUSIONS: Findings conferring potentially increased risk of developing breast cancer were identified in three male adolescents (1.2 percent). Incidence of these findings is similar between male adolescents and similarly aged female adolescents undergoing breast reduction surgery. Although worrisome pathology results are rare, too little is known about the natural history of atypical proliferation and ductal carcinoma in situ in young men to recommend against routine analysis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

American Society of Plastic Surgeons Evidence-Based Clinical Practice Guideline Revision: Reduction Mammaplasty.

SUMMARY: A multidisciplinary work group involving stakeholders from various backgrounds and societies convened to revise the guideline for reduction mammaplasty. The goal was to develop evidence-based patient care recommendations using the new American Society of Plastic Surgeons guideline methodology. The work group prioritized reviewing the evidence around the need for surgery as first-line treatment, regardless of resection weight or volume. Other factors evaluated included the need for drains, the need for postoperative oral antibiotics, risk factors that increase complications, a comparison in outcomes between the two most popular techniques (inferior and superomedial), the impact of local anesthetic on narcotic use and other nonnarcotic pain management strategies, the use of epinephrine, and the need for specimen pathology. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development and Evaluation methodology). Evidence-based recommendations were made and strength was determined based on the level of evidence and the assessment of benefits and harms.