Timing of Pediatric Breast Reduction and Insurance Coverage: Single-institution Retrospective Study.

Background: Although long-term benefits of reduction mammaplasty have been proven, the appropriate age for adolescent reduction mammaplasty has been highly debated due to possible need for revision surgery. Practitioners often delay offering breast reduction to adolescents below age 18 based on presumed insurance denial. We reviewed trends in insurance denial at a single children's hospital to analyze whether age and/or insurance carriers have a significant impact on coverage of breast reduction. Methods: A retrospective chart review from 2012 to 2022 of cisgender female patients with macromastia aged 12-20 years at the time of diagnosis was analyzed for differences in breast reduction insurance coverage based on age and body mass index at the time of diagnosis, referral to plastic surgery, and surgery. Results: A total of 121 cisgender women were included. There were no significant differences in the mean ages of patients who underwent breast reduction versus those who did not (16.46 years versus 16.96 years, respectively; P = 0.089), or in the mean body mass index for patients who did versus those who did not receive breast reduction (28.58 kg/m² versus 29.05kg/m², P = 0.382). Furthermore, there were no significant differences in the proportion of patients undergoing breast reduction by age (P = 0.200) or by insurance class (P = 0.403). Conclusion: Although insurance varies with carrier, the present findings suggest that surgeons need not delay in facilitating preauthorization for breast reduction in symptomatic patients presenting anytime during their teenage years.

Do Absorbable Sutures Work for Rectus Diastasis Repair in Abdominoplasty Patients?

Background: The standard treatment for rectus diastasis is rectus sheath plication during abdominoplasty. Lasting correction of diastasis is essential, but there is currently a debate as to whether absorbable or nonabsorbable rectus plication achieves a lower rate of recurrence. Objectives: The goal of this study is to assess long-term patient outcomes and the recurrence of rectus diastasis after plication with long-lasting absorbable sutures. Methods: A retrospective study of abdominoplasties performed by the senior author between 2018 and 2022 was performed. Only female patients with >6 months of follow-up were included. Plication of the rectus muscles was performed with a combination of interrupted, buried, figure of eight #0 polydioxanone suture and running #0 Maxon (Covidien, Mansfield, MA). Outcomes were assessed by physical examination at postoperative visits. A retrospective chart review was used to obtain demographic and perioperative information. Results: Seventy-one patients underwent abdominoplasty with an average follow-up of 21.1 months. The average age was 43 years, and the average BMI was 27 kg/m2. Correction of rectus diastasis was performed using absorbable sutures in all patients with no recurrence of diastasis in any patient (0% diastasis recurrence rate). Complications included delayed wound healing (11%), seroma (8.5%), hematoma (2.8%), and deep vein thrombosis/pulmonary embolism (2.8%). No patients needed reoperation. Conclusions: Abdominal wall plication using a double-layered, long-lasting absorbable suture closure is a safe, reliable, and effective method to address rectus diastasis during abdominoplasty. Our technique achieved no recurrence of diastasis in any patient and a low complication profile.

Direct Subscarpal Lipectomy Combined With Liposuction in Abdominoplasty: An Analysis of Safety and Efficacy in 200 Consecutive Patients.

BACKGROUND: Abdominoplasty procedures continue to evolve because combining techniques such as suction-assisted lipectomy or direct subscarpal lipectomy have proven to be powerful adjuncts to achieve optimal aesthetic results. However, concern has been expressed about combining techniques simultaneously given the potential to damage the vascularity of the abdominoplasty flap. OBJECTIVES: The aim of this study was to assess the safety and efficacy of simultaneous direct subscarpal lipectomy combined with liposuction in abdominoplasty patients. METHODS: A 4-year retrospective review of consecutive abdominoplasties (n = 200) performed by a single surgeon was conducted. Liposuction of the abdominal flap and flanks was performed in all patients. After raising the abdominoplasty flap, undermining was performed to just beyond the xyphoid, the lower rib margins superiorly, and the anterior axillary line laterally. Fat deep to Scarpa's fascia was then removed by direct tangential excision in all zones of the abdominal flap. RESULTS: The patients had a mean age of 42.19 years and BMI of 28.10 kg/m2; the mean follow-up time was 7 months. Seroma occurred in 13 patients (6.5%), superficial wound dehiscence treated with local wound care in 16 patients (8%), hypertrophic scarring in 16 patients (8%), partial umbilical necrosis in 1 patient (0.5%), and partial umbilical epidermolysis in 6 patients (3%). No patients experienced major or minor full-thickness tissue loss. No patients needed reoperation. CONCLUSIONS: Simultaneous direct excision of subscarpal fat with liposuction of the abdomen and flanks does not appear to subject any zone of the abdominoplasty flap to increased risks of vascular compromise. No flap necroses were observed. The technique described is safe and may provide superior abdominoplasty results.

Evidence-Based Practices in Cleft Palate Surgery.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Understand the embryologic origins, cause, and incidence of cleft palate. (2) Review the anatomy and common classifications of cleft palate and associated defects. (3) Describe surgical techniques for palatoplasty and understand their respective indications. (4) Gain an awareness of general perioperative care considerations, timing of repair, and risk factors for and operative mitigation of complications. SUMMARY: Cleft palate affects 0.1 to 1.1 per 1000 births, with a higher incidence in certain ethnic groups but affecting both sexes equally. Cleft palate may occur in isolation or in combination with cleft lip or in association with other congenital anomalies including various syndromes. The goals of cleft palate repair are to anatomically separate the oral and nasal cavities for normal feeding and improved speech and minimize the risk of oronasal fistulas, velopharyngeal dysfunction, and disruption of facial growth. This review discusses the incidence, causes, and classification of cleft palate; surgical techniques for palatoplasty and perioperative patient management; and complications of palatoplasty.

Speech Outcomes of Buccal Myomucosal Flap Palatal Lengthening for Treatment of Velopharyngeal Insufficiency: Systematic Literature Review and Meta-Analysis.

OBJECTIVE: Buccal myomucosal flaps (BMF) anatomically lengthen the palate in the treatment of velopharyngeal insufficiency (VPI). We systematically reviewed the existing literature on speech outcome of BMF palatal lengthening. DESIGN: Three databases were used to identify studies of interest published in English. Studies that did not use standardized speech assessments were excluded. PRISMA checklist was followed, and the risk of bias in the included studies was assessed. SETTING: Long-term follow up of patients. PATIENTS: With history of cleft palate presenting with VPI. INTERVENTION: BMF palatal lengthening. MAIN OUTCOME MEASURE: Random-effects model meta-analyses were performed for hypernasality, intelligibility, and nasal air emission score improvements, which were derived from reported preoperative and postoperative scores, and controlled for variability of scales and timing of postoperative assessment. RESULTS: From the initial 7115 articles, 13 were included in this review. Two of these had a significant patient overlap and a study with a smaller patient population was excluded. All 12 included articles met the National Institutes of Health Quality Assessment Tool criteria. Six retrospective studies evaluated 230 patients and six prospective studies evaluated 181 patients. The most common indications for BMF were large size of the velopharyngeal gap and prior surgery for VPI. Meta-analyses demonstrated effect sizes below zero, confirming the improvement of standardized assessment scores in patients with VPI after BMF palatal lengthening. Egger regressions revealed low risk of publication bias. CONCLUSIONS: BMF palatal lengthening provides adequate treatment for VPI in patients with large velopharyngeal gap size and a history of prior unsuccessful surgery.

Single-stage Palatal Lengthening Using Modified Buccinator Myomucosal and Buccal Fat Flaps.

Surgical treatment of velopharyngeal insufficiency (VPI) after primary palatoplasty poses a difficult challenge in cleft care management. Traditional treatment options have shown improved speech outcomes but oftentimes lead to airway obstruction by constriction of the posterior pharynx. The buccinator myomucosal flap is an alternative flap used for VPI correction that re-establishes palatal length and velar sling anatomy by recruiting tissue from the buccal mucosa and buccinator muscle. We present innovative modifications to the original buccinator myomucosal flap by performing the procedure in one stage without a mucosal bridge, incorporating full-thickness buccinator muscle during flap elevation, and placement of bilateral buccal fat flaps. These refinements facilitate wound healing by providing a tension-free closure with both a well-vascularized myomucosal flap and interposed buccal fat flap to prevent scar contracture. Furthermore, no additional surgery is necessary for pedicle division.

A Single-Center Study of Adherence to Breast Cancer Screening Mammography Guidelines by Transgender and Non-Binary Patients.

BACKGROUND: Adherence to screening guidelines among transgender and non-binary (TGNB) populations is not well studied. This study examines breast cancer screening patterns among TGNB patients at an urban academic medical center. METHODS: Demographic information, risk factors, and screening mammography were collected. Mammography rates were calculated in populations of interest according to national guidelines, and mammogram person-years were also calculated. Univariate and multivariate logistic regression was performed. RESULTS: Overall, 253 patients were analyzed: 193 transgender women and non-binary people designated male at birth (TGNB DMAB) and 60 transgender men and non-binary people designated female at birth (TGNB DFAB). The median (interquartile range) age was 53.2 years (42.3-62.6). Most patients had no family history of breast cancer (n = 163, 64.4%) and were on hormone therapy (n = 191, 75.5%). Most patients where White (n = 164, 64.8%), employed (n = 113, 44.7%), and had public insurance (n = 128, 50.6%). TGNB DFAB breast screening rates were low, ranging from 2.0 to 50.0%, as were TGNB DMAB screening rates, ranging from 7.1 to 47.6%. The screening rates among the TGNB DFAB and TGNB DMAB groups did not significantly differ from one another. Among TGNB DFAB patients, univariate analyses showed no significant predictors for mammography. Among TGNB DMAB patients, not being on hormone therapy resulted in fewer odds of undergoing mammography. There were no significant findings on multivariate analyses. CONCLUSION: Mammography rates in the TGNB population are lower than institutional and national rates for cisgender patients, which are 77.3% and 66.7-78.4%, respectively. Stage of transition, organs present, hormone therapy, and risk factors should be considered to guide screening.

Simultaneous Ventral Hernia Repair and Panniculectomy: A Systematic Review and Meta-Analysis of Outcomes.

BACKGROUND: Simultaneous ventral hernia repair and panniculectomy (SVHRP) is a procedure that is more commonly being offered to patients with excess skin and subcutaneous tissue in need of a ventral hernia repair; however, there are concerns about surgical-site complications and uncertainty regarding the durability of repair. SVHRP outcomes vary within the literature. This study assessed the durability, complication profile, and safety of SVHRP through a large data-driven repository of SVHRP cases.360 METHODS:: The current SVHRP literature was queried using the MEDLINE, PubMed, and Cochrane databases. Predefined selection criteria resulted in 76 relevant titles yielding 16 articles for analysis. Meta-analysis was used to analyze primary outcomes, identified as surgical-site occurrence and hernia recurrence. Secondary outcomes included review of techniques used and systemic complications, which were analyzed with pooled weighted mean analysis from the collected data. RESULTS: There were 917 patients who underwent an SVHRP (mean age, 52.2 ± 7.0 years; mean body mass index, 36.1 ± 5.8 kg/m; mean pannus weight, 3.2 kg). The mean surgical-site occurrence rate was 27.9 percent (95 percent CI, 15.6 to 40.2 percent; I = 70.9 percent) and the mean hernia recurrence rate was 4.9 percent (95 percent CI, 2.4 to 7.3 percent; I = 70.1 percent). Mean follow-up was 17.8 ± 7.7 months. The most common complications were superficial surgical-site infection (15.8 percent) and seroma formation (11.2 percent). Systemic complications were less common (7.8 percent), with a thromboembolic event rate of 1.2 percent. The overall mortality rate was 0.4 percent. CONCLUSIONS: SVHRP is associated with a high rate of surgical-site occurrence, but surgical-site infection seems to be less prominent than previously anticipated. The low hernia recurrence rate and the safety of this procedure support its current implementation in abdominal wall reconstruction.

Outcomes and Predictors of Success for Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty.

A stiff total knee arthroplasty (TKA) can manifest as pain and decreased range of motion (ROM). When conservative management including physical therapy and manipulation under anesthesia fails, arthroscopic lysis of adhesions (LOA) is frequently pursued. The authors examined the efficacy of LOA for the stiff TKA. They retrospectively reviewed the records of 18 patients who underwent LOA for stiff TKA between April 2013 and June 2016 and who failed to meet 90° ROM at 6 weeks postoperatively. They recorded patient demographics, ROM prior to TKA, and incidence of manipulation under anesthesia between initial TKA and LOA as well as pre- and postoperative outcomes of ROM, pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The mean time from TKA to LOA was 117 days, with a mean follow-up of 449 days. Mean improvements in ROM flexion contracture, flexion, and arc were 6.11° (P<.05), 29.45° (P<.001), and 35.56° (P<.001), respectively. Range of motion improved for 17 of 18 patients. The WOMAC was completed by 15 of 18 patients, with a mean improvement in scores of 32.23% (P<.001); all 15 patients with available WOMAC scores improved. Pain score improved by a mean of 2.17 (P<.001), with 14 of 18 patients reporting decreased pain. Improvements in flexion contracture, flexion, ROM arc, WOMAC scores, and pain were all statistically significant (P<.05). Age, weight, body mass index, and time to LOA were found to be statistically significant predictors of outcome. Finally, pre-TKA and pre-LOA ROM parameters were found to be statistically significant predictors of post-LOA ROM outcomes. [Orthopedics. 2017; 40(6):e1062-e1068.].