Disparities in pathways to reduction mammaplasty: A single institution review of 425 women with macromastia.

BACKGROUND: Reduction mammaplasty improves the quality of life by providing functional and aesthetic benefits to women with macromastia. This study contributes to the existing literature on socioeconomic and clinical barriers to referral for plastic surgery procedures by focusing specifically on reduction mammaplasty. METHODS: Patients with macromastia were identified via a chart review in a single institution from 2021-2022. The treatment pathway for each patient was characterized by reception of referral, completion of plastic surgery consultation, and eventual reception of surgery. After controlling for clinical covariates, multivariate logistic regression was applied to quantify the independent impact of race, insurance, and language status on the completion of surgery (p < 0.05). RESULTS: The final patient cohort included 425 women with macromastia. Among the 151 patients who were first seen by a primary care physician, 64 (42%) completed an initial plastic surgery consultation. Among all patients, 160 (38%) eventually underwent reduction mammaplasty. Multivariate regression predictions indicated a lower likelihood of completing breast reduction surgery in patients with current smoking history (OR: 0.08, 95% CI: 0.01-0.59) and higher body mass index (BMI) (OR: 0.94, 95% CI: 0.90-0.97) (p < 0.05). Minority race and ethnicity, private insurance status, and primary language status were not significant predictors of this outcome (p > 0.05). CONCLUSIONS: In this study, the socioeconomic variables were not independent predictors of breast reduction surgery completion. However, the association of minority race and ethnicity and nonprivate insurance status with the most common reasons for breast reduction deferral suggest an indirect influence of socioeconomic status on the treatment pathway.

Disaggregation of Asian American, Native Hawaiian, and Pacific Islander populations in postmastectomy breast reconstruction.

PURPOSE: Asian American, Native Hawaiian, and Pacific Islander (AANHPI) patient populations are often defined as one monolithic group in medical research despite cultural, socioeconomic, and clinical heterogeneity. Although the general AANHPI population is underrepresented in reception of postmastectomy breast reconstruction, existing literature has not characterized the disaggregation of such rates for AANHPI ethnic subgroups. METHODS: Patients who underwent mastectomy were identified in the 2007 to 2020 registries within the Surveillance, Epidemiology and End Results database. Patients were stratified by race and ethnicity, and additional demographic and oncologic variables were collected. Multivariate binary logistic regression was conducted to assess for reception of postmastectomy immediate breast reconstruction (p < 0.05). RESULTS: Among 33,422 AANHPI patients who underwent mastectomy, South Asian patients were associated with the highest breast reconstruction rates (33%) and Melanesians with the lowest (15%). Overall, AANHPI patients were associated with a lower breast reconstruction rate than non-Hispanic Whites (27% vs. 35%; p < 0.001). This difference increased from 6.4% in 2007 to 10% in 2020. After controlling for demographic and oncologic covariates, all AANHPI ethnic subgroups predicted a lower likelihood of breast reconstruction than non-Hispanic Whites (p < 0.001). Odds ratios for reconstruction ranged from 0.17 [95% confidence interval (95% CI), 0.11-0.27] for Melanesian patients to 0.45 (95% CI, 0.42-0.48) for South Asian patients. CONCLUSIONS: Disparities in the receipt of immediate breast reconstruction exist within the AANHPI patient population in the United States. This analysis supported the need for disaggregation in plastic surgery research for improved knowledge and targeted interventions.

Racial and ethnic disparities in reception of muscle flap closure during oncologic spinal surgery.

BACKGROUND: Racial disparities persist in surgical outcomes after spine surgery for primary and metastatic cancers. Muscle flap closure of spinal defects after oncologic resection has been shown to reduce wound complication rate with favorable cost-effectiveness. It is currently unknown whether racial disparities may affect the reception of this treatment. METHODS: Spinal surgery procedures for tumor resection and subsequent reconstruction were identified in the 2011-2022 National Surgical Quality Improvement Program databases. Cases were propensity score matched for covariates like age, comorbidities, number of vertebral levels reconstructed, and length of stay to isolate the predictive impact of race on reception of muscle flap closure (p < 0.05). RESULTS: A total of 9467 patients who underwent oncologic spine surgery and had known race and ethnicity were identified in the final cohort. Two hundred thirty-two (2.5%) cases included muscle flap closure during the index surgery. After matching (n = 4196), minority race/ethnicity was associated with lower rates of muscle flap closure (2.2%) than non-Hispanic White race/ethnicity (3.8%) (p = 0.0037). Upon weighted univariate logistic regression, minority racial and ethnic identification also predicted lower likelihood of muscle flap closure (OR: 0.57, 95% CI: 0.52-0.63, p < 0.001). Among patients who received muscle flap closure, the overall rate of all major or minor thirty-day postoperative complications was not different depending on race and ethnicity (p > 0.05). CONCLUSION: There are evident racial disparities in the reception of muscle flap closure after oncologic spine surgery. Further work may investigate the role of intersecting socioeconomic factors like insurance status and hospital characteristics. LAY SUMMARY: Muscle flap closure is a surgical technique within plastic surgery that has been associated with lower rates of complications after spine surgery to remove tumors. Our study shows that minority racial and ethnic groups are less likely on average to receive muscle flap closure.

The State of Surgical Research in Sub-Saharan Africa: An Urgent Call for Surgical Research Trainers.

Background: Surgery in low- and middle-income countries (LMICs) is poorly developed because of years of neglect. Sustained research on global surgery led to its recognition as an indivisible and indispensable part of primary healthcare in 2015. However, this has had little visible effect on surgical ecosystems within LMICs, especially in sub-Saharan Africa (SSA). SSA surgical research systems strengthening, which includes skills transfer, with local priority setting driving the research agenda, is needed to propel global surgery into the future. Methods: The authors performed a literature review of the state of surgical research within SSA and also report the initial efforts of two research training nonprofits to empower young African surgeons with research skills. Results: Surgical research in SSA is disadvantaged even before it is birthed, facing monumental challenges at every stage of development, from research agenda determination to funding, study execution, and publication. Compared with a global output of 17.49 publications per 100,000 population, SSA produces 0.9 (P < 0.0001). The Surgeons in Humanitarian Alliance for Reconstructive, Research, and Education and Enabling Africa Clinical Health Research programs are involved in the longitudinal research mentorship of surgical residents within SSA; the improved quality of research and successful publications by participants suggest nascent steps in growing young surgical scientists. Conclusions: In the absence of an existing surgical research infrastructure within LMICs, global surgery research trainers should link up and collaborate to help develop a surgical research community that will provide the local data required to help transform the SSA surgical ecosystem.

Systematic under-ascertainment of anaplastic large cell lymphoma cases in cancer registries: report from a comprehensive cancer center.

INTRODUCTION: Breast implant-associated anaplastic large cell lymphoma (ALCL) has been rapidly rising in the US and around the world, leading to a mandated "black-box" label on all silicone- and saline-filled implants by the Food and Drug Administration (FDA). Because regulatory decisions in the US and around the world have been influenced primarily by risk estimates derived from cancer registries, it is important to determine their validity in identifying cases of ALCL. METHOD: We reviewed all cases of ALCL submitted to the New York State Cancer Registry from a large comprehensive cancer center in New York City from 2007 to 2019. To determine the possibility of misdiagnosis or under-diagnosis of ALCL cases reported to cancer registries, we accessed the sensitivity and specificity of the ICD-O-3 codes 9714 (ALCL) and 9702 (Mature T-cell lymphoma, not otherwise specified [T-NOS]) to identify pathologically-proven ALCL. RESULTS: We reviewed 2286,164 pathology reports from 47,466 unique patients with primary cancers. Twenty-eight cases of histologically-proven ALCL were identified. The sensitivity and specificity of the ICD-O-3 code 9714 (ALCL) were 82% and 100%, respectively. The sensitivity of the combined codes 9714/9702 (ALCL/T-NOS) was 96% and the specificity was 44%. CONCLUSION: Previous epidemiological studies that influenced regulatory decisions by the FDA may have systematically underestimated the risk of ALCL by at least 20%. We encourage updated global risk estimates of breast ALCL using methods that ensure adequate case ascertainment.

Out-of-Pocket Costs and Payments in Autologous and Implant-Based Breast Reconstruction: A Nationwide Analysis.

BACKGROUND: Many factors influence a patient's decision to undergo autologous versus implant-based breast reconstruction, including medical, social, and financial considerations. This study aims to investigate differences in out-of-pocket and total spending for patients undergoing autologous and implant-based breast reconstruction. METHODS: The IBM MarketScan Commercial Databases were queried to extract all patients who underwent inpatient autologous or implant-based breast reconstruction from 2017 to 2021. Financial variables included gross payments to the provider (facility and/or physician) and out-of-pocket costs (total of coinsurance, deductible, and copayments). Univariate regressions assessed differences between autologous and implant-based reconstruction procedures. Mixed-effects linear regression was used to analyze parametric contributions to total gross and out-of-pocket costs. RESULTS: The sample identified 2079 autologous breast reconstruction and 1475 implant-based breast reconstruction episodes. Median out-of-pocket costs were significantly higher for autologous reconstruction than implant-based reconstruction ($597 vs $250, P < 0.001) as were total payments ($63,667 vs $31,472, P < 0.001). Type of insurance plan and region contributed to variable out-of-pocket costs (P < 0.001). Regression analysis revealed that autologous reconstruction contributes significantly to increasing out-of-pocket costs (B = $597, P = 0.025) and increasing total costs (B = $74,507, P = 0.006). CONCLUSION: The US national data demonstrate that autologous breast reconstruction has higher out-of-pocket costs and higher gross payments than implant-based reconstruction. More study is needed to determine the extent to which these financial differences affect patient decision-making.

Comparative Analysis of Recurrence-Free Survival and Mortality in Postmastectomy Patients: Insights From Multidecade, Multiinstitutional Propensity Score Matching.

INTRODUCTION: Disparities in postmastectomy reconstructive care are widely acknowledged. However, there is limited understanding regarding the impact of reconstructive services on cancer recurrence and breast cancer-related mortality. Therefore, this study aims to examine how patient-specific factors and breast reconstruction status influence recurrence-free survival and mortality rates in breast cancer patients. METHODS: Retrospective chart review was performed to collect data on patients who underwent mastectomy at 2 institutions within the New York-Presbyterian system from 1979 to 2019. Sociodemographic information, medical history, and the treatment approach were recorded. Propensity score matching, logistic regression, unpaired t test, and chi-square test were used for statistical analysis. RESULTS: Overall, cancer recurrence occurred in 6.62% (317) of patients, with 16.8% (803) overall mortality rate. For patients who had relapsed disease, completion of the reconstruction sequence was correlated with an earlier detection of cancer recurrence and improved survival odds (P < 0.05). Stratified analysis of the reconstruction group alone showed mortality benefit among patients who underwent free flap procedures (P < 0.05). CONCLUSION: Patients undergoing breast reconstruction after mastectomy are likely to have better access to follow-up care and improved interfacing with the healthcare system. This may increase the speed at which cancer recurrence is detected. This study highlights the need for consistent plastic surgery referral and continued monitoring by all members of the breast cancer care team for cancer recurrence among patients.

Existing Psychiatric Diagnoses Among Breast Cancer Patients Interact with Outcomes After Autologous and Implant-Based Bilateral Breast Reconstruction: A Propensity Score Matched Analysis.

BACKGROUND: Breast reconstruction is an integral postoncologic procedure that has been associated with improved mental health and psychological outcomes. The possible interaction between existing psychiatric diagnoses hospital courses and postoperative complications warrants further exploration. METHODS: Bilateral breast reconstruction patients were identified from the 2016 to 2018 Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP - NIS). Number and type of psychiatric diagnoses within the cohort were then evaluated using a host of ICD-10 codes. A propensity score analysis was applied to control for confounding variables such as demographics, existing comorbidities, and hospital characteristics. A binary logistic regression model was then used to identify the prediction value of psychiatric diagnosis and its interaction with modality of reconstruction for objective outcomes like length of hospital stay, treatment charge, and postoperative complications. RESULTS: A total of 10,114 patients were identified as the final cohort of breast reconstruction patients. 2621 (25.9%) patients possessed an average of 1.4 ± 0.6 existing psychiatric diagnoses. Presence of at least 1 psychiatric diagnosis was a strong predictor alone for extended length of stay (OR: 1.34, 95% CI: 1.28-1.41, P < .001) and occurrence of postoperative complications (OR: 1.31, 95% CI: 1.21-1.41, P < .001). Psychiatric diagnosis displayed a significant interaction with modality of breast reconstruction and conferred a lower increase in risk of extended length of stay in autologous reconstruction when compared to implant-based reconstruction (OR: 0.80, 95% CI: 0.72-0.89, P < .001). CONCLUSION: Existing psychiatric diagnoses were shown to strongly predict and modulate risk of adverse postoperative outcomes depending on modality of reconstruction.

Characterizing differential risk effects of body mass index for Asian patients in the United States undergoing breast reconstruction.

BACKGROUND: Asian patient populations continue to be underrepresented in both plastic surgery research and rates of breast reconstruction. Better elucidation of reconstruction in Asian women may help guide patient-directed counseling. This study investigates the differential effect of body mass index (BMI), a well-known risk factor, for Asian patients in outcomes after breast reconstruction. METHODS: Asian and White breast reconstruction patients were identified by CPT code in the National Surgical Quality Improvement Program. Within each cohort, BMI was converted into percentile ranks for standardized comparisons between cohorts. The effects of BMI on occurrence of complications for Asian and White patients were then quantified with multivariate logistic regression models. RESULTS: The final cohort included 86,514 White patients and 4813 Asian patients, of which 9876 (11%) and 424 (8.8%) experienced at least one postoperative complication. The average BMI of White patients who experienced complications was 29.2 ± 6.3 kg/m2, a higher average than that of Asian patients, 25.6 ± 4.8 kg/m2. Higher BMI percentile was a significant predictor of increased risk of complications in White patients (OR: 1.005, 95% CI: 1.004-1.006, p < 0.001). In Asian patients, however, BMI percentile was not a significant predictor of postoperative complications (OR: 1.001, 95% CI: 0.997-1.005, p = 0.62). BMI percentile significantly predicted risk of unplanned reoperation in both cohorts (p < 0.001 and p = 0.029, respectively). CONCLUSIONS: Whereas BMI is a direct predictor of complications in White populations, this effect is held more inconsistently for Asian patients. Such trends can guide more informed interpretations of BMI in current risk algorithms.

When a Good Flap Turns Bad: A Temporal Predictive Model for Free Flap Complications.

BACKGROUND: Microsurgical cases are complex plastic surgery procedures with a significant risk of acute postoperative complications. In this study, we use a large-scale database to investigate the temporal progression of complications after microsurgical procedures and the risk imparted by acute postoperative complications on subsequent reconstructive outcomes. METHODS: Microsurgery cases were extracted from the National Surgical Quality Improvement Program database by Current Procedural Terminology codes. Postoperative complications were collected for 30 days after surgery and stratified into four temporal periods (postoperative days [PODs] 0-6, 7-13, 14-20, 21-30). Postoperative complication occurrences were incorporated into a weighted multivariate logistic regression model to identify significant predictors of adverse outcomes (p < 0.05). Separately, a regression model was calculated for the time between index operation and reoperation and additional complications. RESULTS: The final cohort comprised 19,517 patients, 6,140 (31.5%) of which experienced at least one complication in the first 30 days after surgery. The occurrence of prior complications in the postoperative period was a significant predictor of future adverse outcomes following the initial week after surgery (p < 0.001). Upon predictive analysis, overall model performance was highest in PODs 7 to 13 (71.1% accuracy and the area under a receiver operating characteristic curve 0.684); 2,578 (13.2%) patients underwent at least one reoperation within the first 2 weeks after surgery. The indication for reoperation (p < 0.001) and number of days since surgery (p = 0.0038) were significant predictors of future complications after reoperation. CONCLUSION: Prior occurrence of complications in an earlier postoperative week, as well as timing and nature of reoperation, were shown to be significant predictors of future complications.

The financial toxicity of postbariatric body contouring surgery: a survey study of an urban tertiary care center's patients.

BACKGROUND: Patients with obesity who undergo bariatric surgery achieve sustained weight loss but are often left with excess skin folds that cause functional and psychological deficits. To remove excess skin, patients can undergo postbariatric BCS; however, cost and lack of insurance coverage present a significant barrier for many patients. OBJECTIVES: This study aimed to characterize the financial impact of treatment on all patients who received bariatric surgery and to compare between those receiving only bariatric surgery and those with postbariatric BCS. SETTING: Email-based survey study at an urban tertiary care center. METHODS: Surveys that included the COST-FACIT were sent to patients with a history of bariatric surgery and/or post-bariatric BCS. RESULTS: One hundred and five respondents completed the survey, of which 19 reported having postbariatric BCS. Patients with postbariatric BCS had slightly higher COST scores than those receiving bariatric surgery only, but this difference was not significant (15.6 versus 17.8, P = .23). Most patients (76%) did not have an awareness of BCS or BCS cost prior to bariatric surgery, and many (68%) had more loose skin than anticipated. CONCLUSIONS: Financial toxicity was similar across all postbariatric surgery patients surveyed regardless of history of BCS. However, survey respondents noted a gap between patient education and expectations around loose skin and body contouring that can be addressed through improved presurgical counseling.

The Most-Cited Publications in Gender-Affirming Surgery: A Cross-Sectional Bibliometric Analysis.

Background: Gender-affirming surgery is becoming more common among reconstructive surgeons. Bibliometric analyses are statistical evaluations of published scientific correspondence and are a validated method of measuring influence in the scientific community. As no such bibliometric analysis has been done as of yet, the purpose of this study is to identify the characteristics of the 50 most-cited peer-reviewed articles on gender-affirming surgery. Methods: The Scopus abstract and citation database was utilized in April 2020 to search for English-language publications related to gender-affirming surgery. The 50 most-cited publications that met inclusion criteria were reviewed for various metric tabulations. Results: The 50 publications have been cited a total of 4402 times. Thirty-one (62%) were published in 2000 or later. Phalloplasty was the most discussed surgical technique, and 18 of the articles focused on female-to-male (FtM) patients. Case series (46%) and review articles (24%) were most common and there were no Level I or Level II studies. The Netherlands contributed the most, with 13 articles. Among the most frequent keywords in the 50 abstracts were "flap" and "complication". The earliest author keywords used were "transsexual" and "sex reassignment". Conclusions: The keyword usage in these abstracts over time seems to follow the trend of a more socially inclusive lexicon. A focus on studies with a higher level of evidence may optimize surgeon education and more appropriately guide clinical practice. This study reveals that the most influential and commonly referenced studies may not be sufficient to appropriately guide clinical practices.

Contexte: La chirurgie d'affirmation du genre devient plus fréquente pour les chirurgiens spécialistes de chirurgie reconstructrice. Les analyses bibliométriques sont des évaluations statistiques de la correspondance scientifique publiée et c'est un moyen de mesure de l'influence dans la communauté scientifique. Considérant qu'une telle analyse bibliométrique n'a pas encore été réalisée, le but de la présente étude est d'identifier les caractéristiques des 50 articles évalués par des pairs le plus souvent cités sur la chirurgie d'affirmation de genre. Méthodes: La base de données de résumés et citations Scopus a été utilisée en avril 2020 pour rechercher des publications en anglais liées à la chirurgie d'affirmation du genre. Les 50 publications les plus citées répondant aux critères d'inclusion ont été analysées pour tabuler différentes mesures. Résultats: Au total, les 50 publications ont été citées 4 402 fois. Trente-et-une (62%) ont été publiées en 2000 ou plus récemment. La phalloplastie a été la technique chirurgicale la plus discutée et 18 de ces articles portaient sur les patients féminins à masculins. Les séries de cas (46%) et les articles de synthèse (24%) étaient les plus fréquents, mais il n'y avait aucune étude de niveau I ou de niveau II. Les Pays-Bas ont le plus contribué avec 13 articles. Parmi les mots-clés les plus fréquents dans les 50 résumés, on trouve « lambeau/volet ¼ (flap) et « complication ¼. Les mots-clés les plus anciens utilisés par les auteurs étaient « transsexuel ¼ et « changement de sexe ¼. Conclusions: L'utilisation de mots clés au fil du temps dans ces résumés semble suivre la tendance d'un lexique plus socialement inclusif. Une focalisation sur des études ayant un plus haut niveau de données probantes peut améliorer la formation des chirurgiens et guider de manière plus adaptée la pratique clinique. Cette étude révèle que les études les plus influentes et le plus souvent référencées peuvent être insuffisantes pour correctement guider les pratiques cliniques.

Results of a Pilot Virtual Microsurgery Course for Plastic Surgeons in LMICs.

Background: The Plastic Surgery Foundation's Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program seeks to expand surgical capacity worldwide through mentorship and training for local plastic surgeons. This study aims to define the need for microsurgery training among SHARE global fellows and describe results of a pilot course. Methods: Ten participants of the SHARE Virtual Microsurgical Skills Course were asked to complete an anonymous survey. Pre- and post-course response rates were 100% and 50.0%, respectively. Results: There was a high incidence of microsurgical problems encountered in the clinical setting. Resource availability was varied, with high access to loupes (100%), yet limited access to microsurgery instruments (50%), medications (40%), operating microscope (20%), skilled nursing (0%) and appropriate peri-operative care settings (0%). Participants identified vessel preparation, instrument selection, and suture handling as priority learning objectives for a microsurgery skills course. Post-course satisfaction with learning objectives was high (60% "very good," 40% "excellent"). Participants reported high levels of improvement in suture handling (Likert 4.60±0.55), end-to-end anastomosis (4.40±0.55), instrument selection (4.20±0.45), vessel preparation (4.20±0.45), and economy of motion (4.20±0.45). Conclusions: This study demonstrates a high frequency of reconstructive problems encountered by global fellows yet low access to appropriate resources to perform microsurgical procedures. Initial results from a pilot virtual microsurgery course demonstrate very high satisfaction and high self-rated improvement in key microsurgical skills. The virtual course is an effective and accessible format for training surgeons in basic microsurgery skills and can be augmented by providing longitudinal opportunities for remote feedback.

Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data.

BACKGROUND: Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population. METHODS: Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications. RESULTS: A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008). CONCLUSIONS: Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

Management of Human Bites in a Rural Kenyan Setting: A Plastic Surgeon's 8-Year Experience.

INTRODUCTION: The treatment of human bites is a common issue facing healthcare practitioners in the developing countries of Sub-Saharan Africa where it has been noted as a growing public health concern. Generally, the desired outcomes from surgical management are healing, function, and aesthetics. We share our 8-year experience at Kapsowar Hospital in Kenya with the presentation, management, and outcome of human bites. We are uniquely situated to do so given the prevalence of human biting in our community and the full-time presence of a plastic surgeon at our institution. To the best of our knowledge, this study is the first to present human bite surgical management by a plastic surgeon certified by the American Board of Surgery working full-time on the African continent. METHODS: A retrospective chart review was conducted on all patients who presented to the operating theater at Kapsowar Hospital with a human bite between 2013-2021. After identification of eligible patients, charts were reviewed assessing parameters including age, gender, timing from injury to presentation at hospital, localization of bite, severity of facial wounds using Lackmann's classification, surgical procedure(s), postoperative complications, surgical revisions, antibiotics administered, and circumstance of incident. Data were analyzed using SPSS 29.0.0.0. RESULTS: Forty-four patients were identified. Seventeen (38.6%) were female and 27 (61.4%) were male. Thirty-one patients had facial bites and 13 patients had bites to other parts of the body. Of facial bites, 70.3% resulted in amputation of the affected part while 29.7% were lacerations. Using Lackmann's classification for facial bite severity, IIIA bites (complete avulsion) were most common for both males (9) and females (7). Females comprised 68.4% of total lip bite victims. Bites to the extremity were associated with late presentation and infection. We report a salvage rate of 85.7% for infected digits. CONCLUSIONS: Compared with most other studies on human bites, our patient population presents with a higher rate of avulsive lip injuries, most commonly among women. Our postoperative infection rate is lower than many others reported in the literature. Satisfactory cosmetic outcome with low risk of infection can be achieved by following well-established principles of wound healing and tension-free closure.

Applying unsupervised machine learning approaches to characterize autologous breast reconstruction patient subgroups: an NSQIP analysis of 14,274 patients.

BACKGROUND: Autologous breast reconstruction is composed of diverse techniques and results in a variety of outcome trajectories. We propose employing an unsupervised machine learning method to characterize such heterogeneous patterns in large-scale datasets. METHODS: A retrospective cohort study of autologous breast reconstruction patients was conducted through the National Surgical Quality Improvement Program database. Patient characteristics, intraoperative variables, and occurrences of acute postoperative complications were collected. The cohort was classified into patient subgroups via the K-means clustering algorithm, a similarity-based unsupervised learning approach. The characteristics of each cluster were compared for differences from the complementary sample (p < 2 ×10-4) and validated with a test set. RESULTS: A total of 14,274 female patients were included in the final study cohort. Clustering identified seven optimal subgroups, ordered by increasing rate of postoperative complication. Cluster 1 (2027 patients) featured breast reconstruction with free flaps (50%) and latissimus dorsi flaps (40%). In addition to its low rate of complications (14%, p < 2 ×10-4), its patient population was younger and with lower comorbidities when compared with the whole cohort. In the other extreme, cluster 7 (1112 patients) almost exclusively featured breast reconstruction with free flaps (94%) and possessed the highest rates of unplanned reoperations, readmissions, and dehiscence (p < 2 ×10-4). The reoperation profile of cluster 3 was also significantly different from the general cohort and featured lower proportions of vascular repair procedures (p < 8 ×10-4). CONCLUSIONS: This study presents a novel, generalizable application of an unsupervised learning model to organize patient subgroups with associations between comorbidities, modality of breast reconstruction, and postoperative outcomes.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy.

BACKGROUND: Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy. METHODS: A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected. RESULTS: In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients. CONCLUSIONS: There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Concordance of National Insurance Criteria with WPATH Standards of Care for Gender-Affirming Surgery.

BACKGROUND: Given that gender-affirming surgery (GAS) is considered medically necessary for transgender and gender diverse (TGD) individuals who desire it, the aim of this study is to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (SOC-8). METHODS: Insurance policies for coverage of gender-affirming genital ("bottom surgery"), chest ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. Policies were classified into three categories: no-coverage (NC), case-by-case (CC), and preauthorization (PA). Among PA policies, criteria for coverage of specific surgeries were analyzed for adherence to WPATH SOC-8. RESULTS: Bottom surgery policies were most concordant for age and gender dysphoria criteria, and transmasculine top surgery policies were most concordant for hormone therapy, continuous living in a congruent gender role, and referral criteria. transfeminine top surgery criteria were more restrictive than transmasculine criteria. The most discordant criteria was for hormone therapy, being required for at least 12 months prior to surgery in the majority of surveyed policies. Many specific procedures and treatments were excluded, especially facial GAS with cosmetic overlap. Additionally, reversal and revisionary surgeries were covered in less than 25% of policies. CONCLUSION: Compared to previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care are still present for GAS.