Trends of Medicare reimbursement rates for gender affirmation procedures.

BACKGROUND: While nearly 1 in 5 Americans receives health insurance coverage through Medicare, literature suggests that Medicare reimbursement is lagging behind inflation for many plastic surgery procedures. AIM: This article evaluates trends in Medicare reimbursement for gender affirmation procedures. METHODS: The most common gender affirmation procedures performed at an urban academic medical center were identified in this cross-sectional study (level 4 evidence). Five nongender surgery codes were evaluated for reference. A standardized formula utilizing relative value units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure. OUTCOME: The main outcome was inflation-adjusted difference of charges from 2014 to 2021. RESULTS: Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% (vs +5.63% for the selected nongender codes) and an inflation-adjusted change of -10.03% (vs -5.54% for the selected nongender codes). Trends in reimbursement varied by category of gender-affirming procedure. The overall average compound annual growth rate had a change of -0.99% (vs -0.53% for the selected nongender codes). The average changes in work, facility, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively. CLINICAL IMPLICATIONS: Gender surgeons and patients should be aware that the decrease in reimbursement may affect access to gender-affirming care. STRENGTHS AND LIMITATIONS: Our study is one of the first evaluating the reimbursement rates associated with the full spectrum of gender affirmation surgery. However, our study is limited by its cross-sectional nature. CONCLUSIONS: From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation.

A Historical Perspective on Brachial Plexus Palsy Management: From Ancient Civilizations to the Modern Era.

Evidence of brachial plexus palsies and potential therapies have been identified by investigators across cultures and civilizations. It could be argued that there are early records of brachial plexus injuries in not only literary work but also paintings, sculptures, and ancient medical texts. The compiled ancient evidence in this review provides a historical framework of brachial plexus palsies and potential management techniques that have been utilized from ancient to modern time.

Strategic Planning and Essential Steps for Establishing a Uterine Transplant and Rehabilitation Program: From Idea to Reality.

UTx is performed to address absolute uterine infertility in the presence of uterine agenesis, a nonfunctional uterus, or after a prior hysterectomy. After the initial success of UTx resulting in a livebirth (2014) in Sweden, there are over 70 reported UTx surgeries resulting in more than 40 livebirths worldwide. Currently, UTx has been performed in over 10 countries. As UTx is transitioning from an "experimental procedure" to a clinical option, an increasing number of centers may contemplate a UTx program. This article discusses essential steps for establishment of a successful UTx program. These principles may be implemented in cis- and transgender UTx candidates.

Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals.

BACKGROUND: As the field of gender-affirming care continues its advancement, a clinical gap in the definition and evaluation of sexual function in transgender and non-binary (TGNB) individuals is becoming increasingly apparent. Recent speculations propose the modification of cis-gender heteronormative sexual function measurement tools as a useful way to close this knowledge gap. METHODS: Although the use of previously validated tools creates an easier platform for modification, the assumption of cis-gender sexual function as baseline will further disrupt patient-provider relationships, leading to inaccurate scientific conclusions, and increase the healthcare barriers faced by this community. RESULTS: As the definition of health has grown to include sexual function, the responsibility of the physician has evolved to include the treatment of sexual dysfunction as well. Without the imminent establishment of a scientific definition of sexual function with an accompanying measurement tool, this lack of understanding continues a precedent that may further stigmatize and distance this population from healthcare. Although this challenge may seem daunting, it should be noted that this has been accomplished for both cis-gender heterosexual men and women. This failure to scrupulously address the needs of the TGNB community directly contradicts the medical profession's revered values of equity and compassion. This branch of sexual medicine and gender-affirming care is critical for maximizing the quality of life as well as equity of the TGNB community to their cis-gender, heteronormative counterparts. CONCLUSION: A careful, kinder, and more inclusive approach is necessary, and the TGNB community deserves optimized care which requires a uniquely developed definition of sexual function and the required measurement tools. Whitney N., Samuel A., Douglass L., et al. Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals. J Sex Med 2022;19:1032-1034.

A Historical Perspective on the Management of Facial Paralysis: From Ancient Civilizations to the Modern Era.

ABSTRACT: Documented evidence of facial nerve paralysis (FNP) and its treatment have been discovered in many early civilizations dating back centuries. Early records are present in art and scripts across ancient civilizations and have laid the groundwork for the implementation of many managements used in modern practice. Although the current management of FNP is still evolving, it includes a complex and multimodal spectrum of options ranging from pharmacologic therapy to facial physical therapy and neuromuscular training, and surgical facial reanimation interventions via static and dynamic procedures. The aim of this review is not to provide an up-to-date glossary of modern management options but rather to discuss the historical evidence of FNP and treatments leading up to current techniques and practices.

Eye Sphincter Reanimation in Facial Paralysis: Evaluation, Indications, Techniques, and Outcomes.

ABSTRACT: Facial nerve paralysis (FNP) sequela includes dysregulation of the ocular surface protective mechanism, nasolacrimal system pump failure and punctal eversion causing chronic epiphora, foreign body sensation, corneal injury, and, in the most severe cases, visual loss, particularly in the presence of comorbid corneal hypesthesia. Concerns over the ocular surface protection in FNP patients have led to the development of numerous static and dynamic procedures. While initial assessment of the FNP patients is complex and requires a comprehensive understanding of the blink reflex physiology, clinical evaluation and the use of additional work should be directed toward potential eye sphincter reanimation using a multidisciplinary approach. As with any treatment algorithm, numerous factors must be considered to provide an individualized treatment plan. In the case of FNP, it is important to consider denervation time, patient age, cause of paralysis, and neurologic severity of the paralysis. The aim of this article is to provide a thorough review of the physiology of the blink reflex, evaluation of the eye sphincter mechanism in FNP, and a comprehensive treatment algorithm incorporating static and dynamic procedures, along with a historical perspective.

An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know.

Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.

Significant association between Taq1 gene polymorphism in vitamin D receptor and chronic spontaneous urticaria in the Northeast of Iran.

OBJECTIVE: Chronic spontaneous urticaria (CSU) is defined as urticaria with an unknown etiology which persists for more than 6 weeks. CSU is an uncomfortable cutaneous condition that occurs due to an immune-mediated inflammatory reaction. Many studies have demonstrated that vitamin D deficiency and single-nucleotide polymorphisms in the vitamin D receptor (VDR) impact the immune response. In the current study, the frequency of the Taq1 polymorphism in the VDR gene were compared between patients with CSU and individuals without CSU. METHODS: In a case-control study, a group of CSU patients (n = 100) was compared with a group of healthy age- and gender-matched individuals as a control group (n =100) who visited our center between 2015 and 2017. After DNA extraction from EDTA-containing blood, polymerase chain reaction (PCR-RFLP) was used to determine the presence of the Taq1 polymorphism. Serum vitamin D levels were measured using ELISA method (Abcam, Cambridge, USA). RESULTS: Genotyping for Taq1 polymorphism showed that TT, Tt and tt genes frequency in the CSU group were 36%, 54%, and 10% respectively. The TT, Tt and tt genotypes had a distribution of 50%, 47% and 3% respectively in the control group. The mean serum vitamin D level in the CSU group was 19.88 ± 8.14 ng/ml, which was not significantly correlated with the Taq1 polymorphism (P = 0.841). There was a significant relationship between Taq1 gene polymorphism (tt genotype) and CSU (P = 0.038). Tt genotype increased the risk of CSU (odds ratio = 1.596), and inheritance of tt genotype increased the risk even further (odds ratio = 4.630). CONCLUSION: The frequency of Taq1 genotype polymorphism in the VDR gene was significantly higher in patients with CSU compared to the control group. The tt genotype polymorphism may be a risk factor for CSU.

Temporoparietal Fascial Free Flap: A Systematic Review.

ABSTRACT: The temporoparietal fascial flap (TPFF) is a versatile tool used in head and neck reconstructive surgeries as well as distal upper and lower extremity reconstructions. Depending on the anatomical location and characteristics of the recipient site soft tissue defects, harvesting techniques for TPFF retrieval may include elevation as a pedicle or a free flap, inclusion of the temporalis muscle and/or adjacent calvarial bone as a composite flap. The TPFF as a free flap is not only used for soft tissue coverage of various defects, and it can be used as a joint gliding surface with coverage of nerve and tendons after repair or trauma. This article includes a systematic search of the medical literature for indications, historical background, techniques, current perspective, and complications along with the pros and cons of the free TPFF compared with other potential reconstructive options.

Implications of Free Temporoparietal Fascial Flap Reconstruction in the Pediatric Population.

ABSTRACT: The temporoparietal fascial flap (TPFF) is a versatile tool that can be used in the reconstruction of head and neck and distal upper and lower extremity defects. The TPFF may be harvested as a pedicle or free flap as well as with the temporalis muscle and/or adjacent calvarial bone as a composite flap. As a free flap, the TPFF has been used as a joint gliding surface with coverage of nerves and tendons, for extremity soft tissue repair, for tracheal and pharyngeal coverage and for defects of the nose, scalp, and auricle. This article focuses on the use of the free TPFF in the pediatric population through systemic review of the medical literature. Current perspectives on the use of this flap and microsurgery in general in pediatric patients are addressed.

Comprehensive Review of the Submental Flap in Head and Neck and Facial Reconstruction: What Plastic Surgeons Need to Know.

ABSTRACT: Since its first introduction by Martin and colleagues (1993) and with further revisions by Sterne et al (1996), the submental artery flap (SMAF) has proven to be an effective, reliable, safe, and valuable option in head, neck, and facial reconstructive surgeries. The SMAF utilizes a long pedicle based on the submental artery, a branch of the facial artery, which provides good reach to the lower two-thirds of the face with excellent cosmetic outcomes. It also maintains a good skin color match for facial and cervical defects with a mostly hidden donor site scar (in the majority of cases the donor site can be primarily closed after raising the flap). Although the use of the SMAF is associated with high patient and surgeon satisfaction along with low rates of complications, disadvantages including flap thickness and the hair-bearing nature of the submental skin, which may be problematic for coverage of orofacial defects, especially in male patients. Although it has been almost 30 years since its introduction, and the SMAF has been successfully used in over 500 reported cases of pediatric and adult patients, a comprehensive review of the different aspects of the SMAF is lacking in the medical literature.

Why African Americans Are a Potential Target for COVID-19 Infection in the United States.

Since the World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic, significant changes have occurred in the United States as the infection spread reached and passed its exponential phase. A stringent analysis of COVID-19 epidemiologic data requires time and would generally be expected to happen with significant delay after the exponential phase of the disease is over and when the focus of the health care system is diverted away from crisis management. Although much has been said about high-risk groups and the vulnerability of the elderly and patients with underlying comorbidities, the impact of race on the susceptibility of ethnic minorities living in indigent communities has not been discussed in detail worldwide and specifically in the United States. There are currently some data on disparities between African American and Caucasian populations for COVID-19 infection and mortality. While health care authorities are reorganizing resources and infrastructure to provide care for symptomatic COVID-19 patients, they should not shy away from protecting the general public as a whole and specifically the most vulnerable members of society, such as the elderly, ethnic minorities, and people with underlying comorbidities.

The Current Status of the Autologous Fat Grafting for Pediatric Craniofacial Patients.

Since its first introduction, autologous fat grafting (AFG) has undergone multiple refinements and has become a common treatment option within plastic surgery. It is a safe, quick, economical, and minimally invasive method for volume augmentation and is finding its own indications in the pediatric craniofacial surgery patients. Because there is currently a paucity of literature regarding the use of AFG in the pediatric population compared with the adults, the authors performed a systematic review of the literature using PubMed, Cochrane Library databases, and the Journal of Plastic and Reconstructive Surgery using the terms of fat grafting/lipofilling, fat grafting, and craniofacial surgery to include articles that contained pediatric patients. While reviewing AFG in the pediatric craniofacial patients, indications, technique, and challenges were specifically evaluated and an algorithm of approach was proposed. In current practice, the choice of microvascular free flap versus AFG is one of the surgeon preferences on a case-by-case basis. With the low complication rate and ease of use, selection of AFG for the repair of soft tissue defects in pediatric craniofacial patients is increasing and may come to surpass use of traditional invasive methods such as free flaps. It should also be considered as a useful adjunct to other concurrent invasive procedures, that is, bony adjustments.

The Financial Impacts of the COVID-19 Crisis on the Practices of Cosmetic/Aesthetic Plastic Surgeons.

The global pandemic of coronavirus 2019, or COVID-19, has undeniably impacted all facets of healthcare, affecting both its function and provision. Due to the cessation of all non-emergent surgical cases in the USA and worldwide, the professional lives and practices of many physicians have been negatively affected. However, among different physicians and specifically plastic surgeons, cosmetic/aesthetic plastic surgeons have been disproportionately affected by the COVID-19 pandemic as the majority of their cases are semi-elective and elective. The ability to perform semi-elective and elective cases is dependent on state and local authorities' regulations, and it is currently uncertain when the ban, if ever, will be completely lifted. Financial constraints on patients and their future inability to pay for these procedures due to the COVID-19-related economic recession are things to consider. Overall, the goal of this unprecedented time for cosmetic/aesthetic plastic surgeons is for their medical practices to survive, to conserve cash flow although income is low to none, and to maintain their personal finances. In this paper, the authors review the financial impacts of the current COVID-19 pandemic on the practices of cosmetic plastic surgeons in the USA and worldwide, along with some potential approaches to maintain their practices and financial livelihoods. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Location and Extent of A1, A2 Release and Its Impact on Tendon Subluxation and Bowstringing-A Cadaveric Study.

Surgical treatment of trigger finger involves release of A1 pulley. Some authors have theorized that the loss of A1 pulley can lead to ulnar subluxation of flexor tendons, which can be prevented by release of A1 pulley radially, even in a nonrheumatoid hand. However, there is no evidence in literature to either support or oppose this hypothesis. Occasionally, difficulty is encountered to precisely identify where A1 ends and A2 begins. While incomplete release of A1 can cause relapse of triggering, release of substantial A2 can cause bowstringing. Knowledge of the safe limit of concomitant A2 release is beneficial. The study was conducted in 12 cadaver upper extremity specimens. A1 pulleys of 48 fingers were divided at the radial (24 fingers) or ulnar (24 fingers) attachment. A 20lb traction force was applied on the flexor tendons. Any subluxation or bowstringing was noted. The experiment was repeated following serial release of the A2-initially 25%, followed by 50% and 100%. No bowstringing or subluxation was noted when A1 pulley was opened, either by radial or ulnar incision. The same was true for A1 + 25% A2 release. When A1 + 50% A2 pulley were released, bowstringing was observed in 3/48 fingers. When A1 + 100% of the A2 pulley were released, bowstringing occurred in all cases. The location of incision for release of the A1 pulley has no effect on bowstringing or tendon subluxation. Release of additional 25% of the A2 pulley can be performed safely, which corresponds to the level of palmar digital crease.

Evaluation of urine fibrinogen level in a murine model of contrast-induced nephropathy.

OBJECTIVE: The mechanisms of contrast-induced nephropathy are not fully understood and sensitive biomarkers of contrast-induced nephropathy are yet to be found. We investigated whether urinary fibrinogen could be a potential biomarker for contrast-induced nephropathy. METHODS: To create a contrast-induced nephropathy model, mice received a prostaglandin synthesis inhibitor (indomethacin) and a nitric oxide synthase inhibitor (Nω-Nitro-L-arginine methyl ester) intraperitoneally followed by a different dose of iodixanol. In the control group, normal saline was administered. Urinary fibrinogen and serum creatinine were analyzed using enzyme-linked immunosorbent assay. Kidneys were used to quantify fibrinogen using qRT-PCR and Western blot and for histopathological examination. RESULTS: Histopathological examination demonstrated mild renal injury in the low-dose group, and moderate renal injury in the high-dose group. Urinary fibrinogen levels were significantly increased in an iodixanol dose-dependent manner (control vs. low-dose group, P < 0.05; control vs. high-dose group P < 0.01). Serum creatinine levels were only increased in the high-dose group (P < 0.01 compared to control), but not in the low-dose group. For fibrinogen-gene expression, in the low-dose group, Fgγ increased (qRT-PCR, Western blot, P < 0.05) in the high-dose group, Fgß and Fgγ decreased (qRT-PCR, P < 0.01; Western blot, P < 0.05), and Fgα increased (qRT-PCR, P < 0.05; Western blot, P < 0.05). CONCLUSIONS: We propose that urinary fibrinogen could be used as a potential biomarker for early contrast-induced nephropathy diagnosis.