The Impact of Political Advocacy on the Plastic Surgeon: A Data-Driven Analysis.

BACKGROUND: Despite successful legislative efforts by the American Society of Plastic Surgeons (ASPS), the Plastic Surgery Political Action Committee remains underused. Participation in advocacy and financial contributions of ASPS members fall below those of similar surgical subspecialties. This study aims to perform a data-driven investigation into the impact of Plastic Surgery Political Action Committee efforts on the practicing plastic surgeon. METHODS: A retrospective review of the ASPS procedural database from 1992 to 2018 and Plastic Surgery Political Action Committee contributions from 2012 to 2018 was performed. Postmastectomy breast and congenital anomaly reconstructions were analyzed. To determine significant variations in trends, change-point analyses were conducted. Changes in surgical volume were correlated to implementation of federal legislative efforts. RESULTS: Three significant trends of increased breast reconstruction volume were detected with associations to three specific legislative changes: 1992 to 1998, which correlates with the Women's Health and Cancer Rights Act; 2006 to 2009, which correlates with the U.S. Food and Drug Administration's approval of silicone breast implant use; and 2013 to 2015, which correlates with the Breast Cancer Patient Education Act. During the study period, breast reconstruction procedures increased substantially compared with all reconstructive procedures (146.6 percent versus 3.6 percent). There were no significant trends detected for birth defect reconstructions. Although contributions were relatively stagnant, resident member contributions increased after 2015, correlating with formation of the Political Action Committee's Resident's Club. CONCLUSIONS: This study demonstrates a correlation in timing between Plastic Surgery Political Action Committee legislative accomplishments and the resulting case volume increase in some areas of plastic surgery. The data highlight the importance of political advocacy and how political action committee activities can directly impact patient access to care and the practice of plastic surgery.

BREAST-Q Outcomes before and after Bilateral Reduction Mammaplasty.

BACKGROUND: The BREAST-Q is the only questionnaire specific to bilateral breast reduction that was developed according to federal and international standards. Many payors mandate minimum resection weights for preapproval, despite lacking supportive evidence for this practice. This study aimed to assess changes in BREAST-Q scores after bilateral breast reduction, and determine whether compliance with Schnur requirements impacts improvement in patient-reported outcomes. METHODS: Patients presenting for bilateral breast reduction from 2011 to 2017 were asked to complete the BREAST-Q preoperatively and postoperatively. Multivariate regression analysis was performed to isolate factors associated with favorable outcomes. RESULTS: Complete data were available for 238 patients. Mean time to postoperative BREAST-Q was 213 days. Complications occurred in 31 patients (13.0 percent). Mean preoperative BREAST-Q scores were below normative values (p < 0.001), and mean postoperative scores were above normative values (p < 0.001 for Satisfaction with Breasts, Psychosocial Well-being, and Sexual Well-being; and p = 0.05 for Physical Well-being). Postoperative Physical Well-being scores were similar to normative values for resections less than Schnur (p = 0.32), but below norms for resections greater than Schnur (p < 0.0001). On multivariate regression (n = 230), complication and surgeon experience were the only independent predictors of lesser improvement on the Satisfaction with Breasts subscale. CONCLUSIONS: This study is the largest to include both preoperative and postoperative bilateral breast reduction BREAST-Q scores, and to compare multiple subscales to normative data. Scores overwhelmingly increased, regardless of age or Schnur compliance. Complications negatively impacted degree of BREAST-Q improvement. Interestingly, postoperative Physical Well-being was slightly higher in women with non-Schnur-compliant resections. Bilateral breast reduction substantially improves patient welfare, and our data question the validity of insurer-mandated minimum resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Macromastia: an economic burden? A disease cost analysis based on real-world data in Germany.

PURPOSE: Symptomatic macromastia causes physical and psychological problems that can lead to restrictions in the patients' social and working lives and a reduced quality of life. Associated medical treatments also have a considerable impact on health-care costs. Several studies have assessed these costs, but the total disease costs of macromastia have never been evaluated on the basis of real-world data. METHODS: The data for 76 patients who underwent reduction mammoplasty between 2008 and 2016 were collected using a two-part questionnaire (preoperative and postoperative), as well as the patient files. Topics surveyed, besides demographic data, included physician visits, medical imaging, medical procedures, medical treatments, rehabilitation and convalescent measures, drug intake, medical aids, exercise activity, and sick leave days before surgery, to calculate the costs per year of conservative treatment of symptomatic macromastia. RESULTS: The mean time from start of symptoms to surgery was 11.82 years. The data for this group of patients with symptomatic macromastia show that costs per patient amount to €1677.55 per year. These costs include medical consultation, radiological imaging, medical treatments and procedures, physical therapy and rehabilitation, medication, special brassieres, exercise classes costs for sick leave due to problems with macromastia, and travel expenses. CONCLUSIONS: These results show that considerable health-care costs arise due to macromastia with conservative treatment. Overall, macromastia costs €1677.55 per patient/year. In particular, lost productivity due to sick days and the costs of physiotherapy are factors driving the high costs.

Navigating the Insurance Landscape for Coverage of Reduction Mammaplasty.

BACKGROUND: Reduction mammaplasty provides symptomatic relief to patients with macromastia. Insurance companies act as gatekeepers of health care by determining the medical necessity of surgical procedures, including reduction mammaplasty. The authors sought to evaluate insurance coverage and policy criteria for reduction mammaplasty. METHODS: The authors conducted a cross-sectional analysis of U.S. insurance policies on reduction mammaplasty. Insurance providers were selected based on their enrolment data and market share. The authors conducted telephone interviews and Web-based searches to identify the policies. Medical necessity criteria were abstracted from the publicly available policies that offered coverage. RESULTS: The authors reviewed 63 insurers. One in 10 insurers had no established policy for reduction mammaplasty. Of the 48 publicly available policies, shoulder pain and backache were the most common symptoms required for preapproval (98 percent and 98 percent). A minimum resection volume was requested by 88 percent of policies. One-third of policies (31 percent) offered a choice between removal of a minimum weight per breast or a volume based on body surface area. Over half of companies (54 percent) used body surface area calculations to predict minimum resection volume. Medical necessity that extended beyond national recommendations included trial of weight loss (23 percent) and nipple position (10 percent). CONCLUSIONS: Insurance policy criteria for reduction mammaplasty are discordant with current national recommendations and current clinical evidence. Many policies use outdated criteria that do not correlate with symptom relief and consequently limit access to reduction mammaplasty. Here, the authors propose a comprehensive guideline to maximize coverage of reduction mammaplasty.

Insurance Denials in Reduction Mammaplasty: How Can We Serve Our Patients Better?

BACKGROUND: Reduction mammaplasty is the standard of care for symptomatic macromastia. The process of requesting insurance coverage for reduction mammaplasty is cumbersome and potentially controversial, and insurance policies vary significantly. The goal of our analysis is to identify trends in insurance coverage rates, assess for the presence of disparities, and propose ways to increase chances of successful preauthorization. METHODS: The authors performed a retrospective review of preauthorizations for reduction mammaplasty at a single institution from 2012 to 2017. Insurance company names were deidentified. Preauthorization denial rates were assessed by year, insurance carrier, and reason for denial. Multiple regression analysis was performed to identify predictors for predetermination denial by insurance companies. RESULTS: Among 295 preauthorizations, 212 were approved (72 percent) and 83 were denied (28 percent), among which 18 were appealed, 13 successfully. Rates of insurance denials have been increasing steadily, from 18 percent to 41 percent. Medicaid had the lowest denial rates (9.3 percent), whereas private carriers denials ranged from 21.4 to 62.1 percent. In terms of reason for denial, 30 percent were because of contract exclusion, 39 percent were because of inadequate documentation or not meeting medical criteria, and 12 percent were because of inadequate predicted resection weight. Certain private insurance carriers were the only independent predictors of predetermination denial. CONCLUSIONS: Rate of preauthorization denials is high and has been increasing steadily. Insurance criteria remain arbitrary. A proper documentation and appeal process by the plastic surgeon may improve rates of insurance approval. Although resection weight does not correlate with symptom relief, predicted breast tissue resection weight continues to be critical for insurance approval.

Outpatient Reduction Mammaplasty Offers Significantly Lower Costs with Comparable Outcomes: A Propensity Score-Matched Analysis of 18,780 Cases.

BACKGROUND: Breast reduction mammaplasty is a common plastic surgery operation. Although many contemporary surgeons provide breast reduction mammaplasty as an outpatient procedure, roughly 15 percent of patients are still observed postoperatively. The authors hypothesize that observation confers no safety benefit but engenders significant cost. METHODS: The authors reviewed cases of breast reduction mammaplasty in a commercial database and formulated three propensity score-matched cohorts: inpatient, 23-hour observation, and outpatient. Comparisons were made between inpatients and outpatients and between 23-hour observation patients and outpatients. The primary outcome variable was 14-day re-presentation rate to the emergency department or readmission. Financial data were also collected. RESULTS: Comparison of inpatients and outpatients included 1237 patients each (n = 2474 total patients). The 23-hour observation-outpatient comparison included 8153 patients each (n = 16,306 total patients). For inpatients versus outpatients, the 14-day re-presentation rate was 1.4 percent for inpatients and 0.3 percent for outpatients (p < 0.01). The overall surgical complication rate was higher for inpatients (7.8 percent) than for outpatients (4.9 percent) (p < 0.01). Comparing outpatients to 23-hour observation patients, the 14-day re-presentation rate was similar (0.5 percent observation versus 0.3 percent outpatient; p = 0.10). The complication rate was higher for 23-hour observation patients (4.8 percent) than for outpatients (3.2 percent) (p < 0.01). When compared with outpatients (median, $9077), inpatients (median, $19,975) generated $10,898 more in costs. Similarly, 23-hour observation patients (median, $12,451) generated $4050 more in costs than outpatients (median, $8401) (p < 0.01). CONCLUSIONS: Outpatient breast reduction mammaplasty is equally safe when compared to observation or admission. Non-outpatient breast reduction mammaplasty had median costs of 148 to 220 percent that of outpatient breast reduction mammaplasty. In an era of cost consciousness, ambulatory reduction mammaplasty may offer a relatively simple method of decreasing expenditures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Redefining the Role of Resection Weight Prediction in Reduction Mammaplasty and Breaking the "One-Scale-Fits-All" Paradigm.

BACKGROUND: Reduction mammaplasty is a highly effective procedure for treatment of symptomatic macromastia. Prediction of resection weight is important for the surgeon and the patient, but none of the current prediction models is widely accepted. Insurance carriers are arbitrarily using resection weight to determine medical necessity, despite published literature supporting that resection weight does not correlate with symptomatic relief. What is the most accurate method of predicting resection weight and what is its role in breast reduction surgery? METHODS: The authors conducted a retrospective review of patients who underwent reduction mammaplasty at a single institution from 2012 to 2017. A senior biostatistician performed multiple regression analysis to identify predictors of resection weight, and linear regression models were created to compare each of the established prediction scales to actual resected weight. Patient outcomes were evaluated. RESULTS: Three-hundred fourteen patients were included. A new prediction model was created. The Galveston scale performed the best (R = 0.73; p < 0.001), whereas the Schnur scale performed the worst (R = 0.43; p < 0.001). The Appel and Descamps scales had variable performance in different subcategories of body mass index and menopausal status (p < 0.01). Internal validation confirmed the Galveston scale's best predictive value; 38.6 percent and 28.9 percent of actual breast resection weights were below Schnur prediction and 500-g minimum, respectively, yet 97 percent of patients reported symptomatic improvement or relief. CONCLUSIONS: The authors recommend a patient-specific and surgeon-specific approach for prediction of resection weight in breast reduction. The Galveston scale fits the best for older patients with higher body mass indices and breasts requiring large resections. Medical necessity decisions should be based on patient symptoms, physical examination, and the physician's clinical judgment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Pathology Evaluation of Reduction Mammaplasty Specimens and Subsequent Diagnosis of Malignant Breast Disease: A Claims-Based Analysis.

BACKGROUND: This study aimed to measure the use of pathology evaluation of breast specimens among patients undergoing reduction mammaplasty and assess rates of new diagnoses of breast disease and associated cost. METHODS: We analyzed the Truven MarketScan Databases from 2009 to 2015 to identify adult female patients undergoing reduction mammaplasty for macromastia. We recorded patient age, rates of obtaining pathology evaluation, new diagnoses of benign or malignant breast disease after pathology evaluation, and total cost for the surgery encounter. RESULTS: Among 17,738 macromastia patients undergoing reduction mammaplasty, 91.3% (n = 16,193) received pathology evaluation. Pathology evaluation rates were clinically similar across age groups <70 years (90.8-92.1%) and slightly lower for patients ≥70 (85.0%). Among 6987 patients less than 40 years who received pathology evaluation, 0.06% (n = 4) were subsequently diagnosed with malignant breast disease within 3 months, compared to 0.23% in the entire cohort (n = 37/16,193). Pathology claims resulted in an added $307 (SD 251) on average for the breast reduction surgery encounters. CONCLUSIONS: Breast tissue after reduction mammaplasty is routinely submitted for pathology evaluation, without consideration of age-based risk for breast cancer. Routine pathology evaluation of breast tissue in patients in lower risk age groups (less than 40 years) required an additional $536,000 on average to detect a single occult breast cancer compared to an added $85,600 to detect a new malignancy in patients 40 years and older. Clinicians and policy makers should consider whether routine pathology evaluation of breast tissue should be individualized based on risk factors for breast cancer.

Quick Calculation of Breast Resection Mass Using the Schnur Scale.

In 1991, Dr Paul Schnur and his colleagues published an article correlating the weight of breast tissue to be removed in a breast reduction operation with the total body surface area (BSA) of the patient. They presented a very cogent argument for selecting three groups of patients: those with medical indications for operation, those who merit review, and those whose operation could be considered cosmetic. The Schnur Sliding Scale is widely used by insurance companies in the western United States in the process of preauthorizing breast reduction operations, and its use may be spreading eastward. The Schnur group presented a nomogram for calculating BSA and a scale in the form of a table for guiding a determination of whether the patient is a reconstructive patient as opposed to an aesthetic patient. We have combined the scale and the BSA nomogram for a simplified nomogram calculator that facilitates rapid determination of anticipated tissue weight of resection for a patient of a given size. This calculator yields the required weight of tissue to remove with just knowledge of the patient's height and weight and the use of a straight edge. We demonstrate and compare performance of this calculation by hand and by nomogram. There is ample evidence that the practice of applying the Schnur Sliding Scale may be prohibitive to symptomatic patients seeking reduction mammaplasty and should be abandoned. While this practice continues, our simplified Schnur Sliding Scale nomogram is meant to help easily determine the insurer-required minimum breast resection weight and thereby both improve patient counseling prior to planning surgery and assist the surgeon with achieving insurer reimbursement for the procedure while avoiding rejected claims.

Insurance Appeals for Pediatric Reconstructive Surgery: A Micro Cost Analysis and How-to Guide.

BACKGROUND: When insurance coverage for pediatric reconstructive procedures is denied, a stressful and time-consuming appeals process ensues. This article discusses the results of a micro cost analysis performed to better understand the time and monetary burden that the insurance process places on our clinic and families. We also advise plastic surgeons on how to appeal insurance denials for necessary reconstructive procedures. METHODS: Our micro cost analysis focused on patients with congenital breast anomalies who were denied insurance coverage during the preservice insurance authorization process. We surveyed staff and family members to determine the steps involved in the insurance process and how long each person spent on each step. We combined this with average compensation data to calculate cost. RESULTS: For the 5 patients included in our analysis, the insurance process took an average of 7.4 hours of institutional time and cost $521.43 per patient. All patients were denied coverage during prior authorization and required a peer-to-peer, and all denials occurred because surgery was deemed cosmetic or not medically necessary. CONCLUSIONS: This analysis estimated the time and monetary cost of the insurance process in our department. Access to care was limited by prior authorization and the opinion of medical directors that these procedures are unnecessary or cosmetic. We encourage plastic surgeons to continue to perform patient-centered outcomes research in their practice to build on literature that proves the functional and psychosocial benefits of reconstructive procedures.

Superomedial Pedicle Vertical Scar Breast Reduction: Objective and Subjective Assessment of Breast Symmetry and Aesthetics.

BACKGROUND: The superomedial vertical scar breast reduction (SVBR) described by Hall-Findlay is gaining popularity among surgeons worldwide. The aim of this study was to evaluate its long-term aesthetic outcome, the extent of quality of life improvement and the factors that influence patient satisfaction and reviewers' evaluation of aesthetic/surgical outcome. METHODS: In this historical prospective study, we included women who underwent SVBR at least one year prior to enrollment and responded to a quality of life questionnaire. Their breasts were photographed, measured and evaluated by the plastic surgery staff. RESULTS: A total of 40 patients responded to the questionnaire, and the breasts of 31 of them were measured and photographed. All 31 patients had good breast symmetry according to objective breast measurements. There was a clear correlation between the patients' and the reviewers' scores of breast symmetry, scar appearance and breast shape (r = 0.4-0.65, r = 0.432-0.495 and r = 0.335-0.403, respectively). The factor that most influenced reviewers' and patients' satisfaction with the overall aesthetic outcome was the breast-to-body proportion. CONCLUSIONS: The proportions between the breast size and the patient's body habitus are pivotal to patient satisfaction and should be taken into consideration when planning a reduction mammaplasty. The SVBR technique for breast reduction provided good cosmetic outcome and symmetry over a long-term follow-up. LEVEL OF EVIDENCE IV: 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 .

Volumetric Mammogram Assessment: A Helpful Tool in the Treatment of Breast Asymmetries.

The surgical approach to breast asymmetry depends on several factors, including the surgeon's experience, the anatomy of the patient, and several methods that may help to choose a technique and define the size of the implant or the amount of breast tissue to be excised. The aim of this study is to assist in evaluation of breast volumes with the Quantra™ software application, intended for use with Hologic™ digital mammography systems. Twenty-eight women were studied with full-field digital mammography (FFDM) with the Quantra™ software application, for use with Hologic™ digital mammography systems preoperatively. The case diagnoses were as follows: breast hypertrophy, ptosis, hypoplasia, and reconstruction, and the surgeries included breast reduction, mastopexy, mastopexy and breast reduction, mastoplasty and breast augmentation, breast augmentation, and immediate or delayed breast reconstruction. Patients were evaluated from 6 to 18 months after surgery. Volumetric mammogram studies help to decide the amount of tissue to be excised, the size of the implants, and the combination of both. The results of this study were evaluated by surgeons and patients and found to be highly satisfactory. The use of full-field digital mammography with adequate software should be considered as another tool to assist in making decisions regarding the correction of breast asymmetries. Level of Evidence IV 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 .

Understanding the Health Burden of Macromastia: Normative Data for the BREAST-Q Reduction Module.

BACKGROUND: The BREAST-Q Reduction module evaluates outcomes in reduction mammaplasty. However, there are currently no published normative scores, limiting the interpretation of BREAST-Q data. METHODS: The BREAST-Q Reduction module was administered via the Army of Women, an online community of women (with and without breast cancer) engaged in breast-cancer related research. Normative data were generated from women aged 18 years and older, without a history of breast cancer or breast surgery. Data analysis was performed using descriptive statistics and a linear multivariate regression. Generated normative data were compared to published BREAST-Q Reduction findings. RESULTS: The preoperative version of the BREAST-Q Reduction module was completed by 1206 women. Participant mean age was 55 ± 13 years, mean body mass index was 27 ± 6 kg/m, and 40 percent (n = 481) had a bra cup size ≥ D. Mean normative scores were as follows: Satisfaction with Breasts, 57 ± 16; Psychosocial Well-being, 68 ± 19; Sexual Well-being, 55 ± 19; and Physical Well-being, 76 ± 11. Normative scores were lower in women with body mass index ≥ 30 and bra cup size ≥ D. In comparison to normative Army of Women scores, published BREAST-Q scores for women undergoing reduction mammaplasty were lower (worse) for preoperative patients and higher (better) for postoperative patients. CONCLUSION: These new Army of Women normative data provide insights into breast-related satisfaction and well-being in women not pursuing breast reduction, giving new clinical context to better understand the health burden of macromastia, and to demonstrate the value of reduction mammaplasty in certain patients.

A new three-dimensional conformal radiotherapy (3DCRT) technique for large breast and/or high body mass index patients: evaluation of a novel fields assessment aimed to reduce extra-target-tissue irradiation.

OBJECTIVE: To develop an alternative three-dimensional treatment plan with standardized fields class solution for whole-breast radiotherapy in patients with large/pendulous breast and/or high body mass index (BMI). METHODS: Two treatment plans [tangential fields and standardized five-fields technique (S5F)] for a total dose of 50 Gy/25 fractions were generated for patients with large breasts [planning target volume (PTV) >1000 cm(3) and/or BMI >25 kg m(-2)], supine positioned. S5F plans consist of two wedged tangential beams, anteroposterior: 20° for the right breast and 340° for the left breast, and posteroanterior: 181° for the right breast and 179° for the left breast. A field in field in medial-lateral beam and additional fields were added to reduce hot spot areas and extra-target-tissue irradiation and to improve dose distribution. The percentage of PTV receiving 95% of the prescribed dose (PTV V95%), percentage of PTV receiving 105% of the prescribed dose (PTV V105%), maximal dose to PTV (PTV Dmax), homogeneity index (HI) and conformity index were recorded. V10%, V20%, V105% and V107% of a "proper" normal tissue structure (body-PTV healthy tissue) were recorded. Statistical analyses were performed using SYSTAT v.12.0 (SPSS, Chicago, IL). RESULTS: In 38 patients included, S5F improved HI (8.4 vs 10.1; p ≤ 0.001) and significantly reduced PTV Dmax and PTV V105%. The extra-target-tissue irradiation was significantly reduced using S5F for V105% (cm(3)) and V107% (cm(3)) with a very high difference in tissue irradiation (46.6 vs 3.0 cm(3), p ≤ 0.001 for V105% and 12.2 vs 0.0 cm(3), p ≤ 0.001 for V107% for tangential field and S5F plans, respectively). Only a slight increase in low-dose extra-target-tissue irradiation (V10%) was observed (2.2719 vs 1.8261 cm(3), p = 0.002). CONCLUSION: The S5F technique in patients with large breast or high BMI increases HI and decreases hot spots in extra-target-tissues and can therefore be easily implemented in breast cancer radiotherapy. ADVANCES IN KNOWLEDGE: The treatment planning strategy proposed in this study has several advantages: (a) it is extremely reliable as the standard supine positioning is used; (b) the standardized class solution allows for widespread use;

Pediatric reduction mammaplasty: A retrospective analysis of the Kids' Inpatient Database (KID).

BACKGROUND/PURPOSE: Pediatric breast reduction mammaplasty is a procedure commonly performed in children suffering from excess breast tissue, back pain, and social anxiety. Minimal information exists regarding demographics, epidemiology, and complications in adolescents. As health care reform progresses, investigating the socioeconomic and patient-related factors affecting cost and operative outcomes is essential. METHODS: The Kids' Inpatient Database (KID) was used from 2000 to 2009. Patients with an International Classification of Diseases, 9th Revision code of macromastia and procedure code of reduction mammaplasty 20 and less were included. Demographic data, including age, sex, payer mix, and location, were collected. Significant independent variables associated with complications and duration of stay were identified with bivariate and multiple regression analysis. RESULTS: A total of 1,345 patients between the ages 12 and 20 were evaluated. The majority of patients were white (64%), from a zip code with greatest income (36%), and had private insurance (75%). Overall comorbidity and complication rates were 30% and 3.2%, respectively. Duration of stay was associated with race, income quartile, insurance type, having complications, and hospital type. African-American race, Medicaid, lower income, and private-investor owned hospitals were predictive of greater hospital charges. CONCLUSION: In this large retrospective database analysis, pediatric reduction mammaplasty had a relatively low early complication rate and short duration of stay. Complications, total charges, and duration of stay discrepancies were associated with race, location, and socioeconomic status. Although demonstrably safe, this is the first study demonstrating the negative effect of race and socioeconomic status on a completely elective procedure involving children. These results demonstrate the intricate association between socioeconomic and patient-related factors influencing overall outcomes in the pediatric population.