United States insurance coverage of immediate lymphatic reconstruction.

INTRODUCTION: Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS: The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS: Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS: Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Jaw Thrust: A Simple Predictor of Success in Mandibular Distraction Osteogenesis.

BACKGROUND: The hypoplastic mandible in the congenital condition Pierre Robin sequence (PRS) displaces the base of the tongue posteriorly, which results in upper airway obstruction (UAO) that can potentially be corrected with mandibular distraction osteogenesis (MDO). Jaw thrust (JT) is routinely performed during evaluation of the airway; similar to MDO, it projects the mandible and tongue anteriorly to open the airway. The authors demonstrate that JT can be used as a criterion to predict successful MDO outcomes in infants with PRS. METHODS: The study was a single-center, retrospective chart review of infants diagnosed with PRS between 2016 and 2023. Data regarding their demographics, comorbid diagnoses, JT success, airway anomalies, laryngeal grade of view, apnea-hypopnea index, and perioperative course were statistically analyzed. RESULTS: Of the 16 patients included in the study, 11 had successful relief of their airway obstruction with JT and proceeded with MDO. The unsuccessful JT group had significantly greater proportions of females, birth prematurity, gastrostomies, tracheostomies, and longer hospital stays. In the successful JT group, both the mean laryngeal grade of view ( P =0.029) and mean apnea-hypopnea index ( P =0.025) improved significantly post-MDO. Post-MDO tracheostomy was also avoided in all but 1 patient who was not previously tracheostomized. CONCLUSIONS: There is no widely accepted algorithm to guide craniofacial surgeons on the optimal intervention for relieving UAO in infants with PRS. In our institutional experience, patients whose preoperative JT relieved UAO also successfully relieved UAO with MDO. In patients with PRS, JT may be a useful criterion for selecting appropriate candidates for MDO.

Gender-affirming DIEP Flap Breast Augmentation.

Implant-based techniques have been the mainstay of gender-affirming breast augmentation (GABA). Here we describe a novel autologous technique for GABA. We provide a single-patient case report of gender-affirming deep inferior epigastric artery perforator (DIEP) flap breast augmentation. World Professional Association for Transgender Health guidelines were followed according to Standards of Care, version 8. Prepectoral tissue expanders were placed at the time of the patient's facial feminization surgery. DIEP flaps were then used for bilateral breast augmentation. Planned revisions were made about 5 months later. Breast augmentation was performed successfully with DIEP flaps, and the patient was satisfied with her outcome. No complications occurred. Anatomic differences to cisgender women were noted, including relatively thick musculature of the abdominal wall and chest as well as tight anterior abdominal fascial closure. Advantages compared with implant-based GABA were also noted, including feminization of the abdomen and avoidance of potential implant related complications. We report a novel approach to GABA. Our approach borrows well-established techniques with demonstrated efficacy and high satisfaction in postmastectomy breast reconstruction and even cosmetic purposes. However, sex- and hormone-influenced anatomic differences required some modifications compared with postmastectomy DIEP flap reconstruction.

Patients prescribed antithrombotic medication in elective implant-based breast reconstruction are high risk for major thrombotic complications.

INTRODUCTION: Implant-based reconstruction (IBR) is the most frequently performed breast reconstruction procedure in the USA. As the US population ages, an increasing number of these patients suffer from comorbidities requiring the use of chronic antithrombotic therapy. Outcomes following IBR in patients prescribed these medications are not well understood. MATERIALS/PATIENTS AND METHODS: An all-payor administrative claims database (52 million patients) was queried for patients undergoing IBR from 2010 through 2018. Patients who were prescribed therapeutic antithrombotic therapy, and those who were not, were matched in a one-to-one fashion for comorbidities independently associated with bleeding and thrombo-ischemic events following first-stage IBR. Cox proportional hazards models investigated the 90-day risk of bleeding and major thrombo-ischemic events following IBR. RESULTS: Of the 36,379 patients found to have undergone IBR, 2,024 patients were perfectly matched for age and high-risk comorbidities. Patients prescribed antithrombotic drugs had increased 90-day risk for all thrombo-ischemic complications (HR: 5.62, 95% CI: 3.53-8.95, p < 0.0001), as well as a significantly increased risk for 90-day DVT, 90-day PE, 90-day myocardial infarction, and 90-day stroke. Patients specifically prescribed antiplatelet drugs, direct oral anticoagulants (DOAC), and warfarin had a significantly increased risk for transfusion. CONCLUSION: Patients prescribed antithrombotic therapy had a significantly increased risk for life-threatening thrombotic events and transfusion following elective IBR. This suggests a role for further monitoring and a potential role for multi- and interdisciplinary interventions to help mitigate this risk. These interventions can be the subject of future prospective studies.

The 100 Most-disruptive Articles in Plastic and Reconstructive Surgery and Sub-specialties (1954-2014).

Alternative bibliometrics have recently been the subject of significantly increased interest. The disruption index is a new bibliometric that was recently applied to surgery and urology and identifies papers that shift paradigms and eclipse previous research in a given field. METHODS: The 100 most-disruptive publications in the 14 most prominent plastic and reconstructive surgery and subspecialty journals were identified. RESULTS: We present the 100 most-disruptive studies as well as the 100 most-cited studies for comparison in n=14 of the most popular plastic and reconstructive surgery (and subspecialty) journals between 1954 and 2014. The 100 most-disruptive publications in these journals were more disruptive than 99.8% of all PubMed papers. Plastic and Reconstructive Surgery (PRS) had the most papers in the top 100 (n=64) followed by British Journal of Plastic Surgery (currently Journal of Plastic, Reconstructive & Aesthetic Surgery, n=15), and Journal of Oral and Maxillofacial Surgery (n=7). PRS had 9 of the top 10 papers. However, Clinics in Plastic Surgery had the highest average disruption score for all its published papers (0.0029). The correlation coefficient linking disruption scores and citation counts was 0.01 and 0.11, respectively. The most common decade represented in the top 100 was the 1980's (n=31) and the least common was the 2000's (n=9). CONCLUSIONS: This is the first application of the disruption index to plastic and reconstructive surgery. The disruption score provides a unique ability to identify research that has shifted paradigms and driven the innovation that defines our specialty.