Patient-Specific Implant Customization for Treatment of Internal Orbital Fractures Using Office-Based Three-Dimensional Printing.

OBJECTIVE: Three-dimensional (3D) modeling technology aids the reconstructive surgeon in designing and tailoring individualized implants for the reconstruction of complex craniofacial fractures. Three-dimensional modeling and printing have traditionally been outsourced to commercial vendors but can now be incorporated into both private and academic craniomaxillofacial practices. The goal of this report is to present a low-cost, standardized office-based workflow for restoring bony orbital volume in traumatic orbital fractures. METHODS: Patients with internal orbital fractures requiring open repair were identified. After the virtual 3D models were created by iPlan 3.0 Cranial CMF software (Brainlab), the models were printed using an office-based 3D printer to shape and modify orbital plates to correctly fit the fracture defect. The accuracy of the anatomic reduction and the restored bony orbital volume measurements were determined using postoperative computed tomography images and iPlan software. RESULTS: Nine patients fulfilled the inclusion criteria: 8 patients had unilateral fractures and 1 patient had bilateral fractures. Average image processing and print time were 1.5 hours and 3 hours, respectively. The cost of the 3D printer was $2500 and the average material cost to print a single orbital model was $2. When compared with the uninjured side, the mean preoperative orbital volume increase and percent difference were 2.7 ± 1.3 mL and 10.9 ± 5.3%, respectively. Postoperative absolute volume and percent volume difference between the orbits were -0.2 ± 0.4 mL and -0.8 ± 1.7%, respectively. CONCLUSIONS: Office-based 3D printing can be routinely used in the repair of internal orbital fractures in an efficient and cost-effective manner to design the implant with satisfactory patient outcomes.

A 10-Year Retrospective Review on the Use of Prophylactic Spinal Reconstruction in Spinal Surgery Involving High-Risk Patients.

BACKGROUND: Spinal surgeries are being offered to a broader patient population who are both medically and surgically complex. History of prior spinal surgery, advanced age, and presence of comorbidities, such as obesity, malnutrition, steroid use, and tobacco use, are risk factors for postoperative complications. Prophylactic spinal reconstruction at the time of spinal surgery has been shown to have improved outcomes and decreased wound complications; however, outcomes focusing specifically on complex patients with a history of previous spinal surgery (or surgeries) have not been well described. METHODS: This is a retrospective study performed at the University of Maryland Medical Center (Baltimore, MD) of high-risk patients who underwent complex spinal surgery with prophylactic spinal reconstruction from 2011 to 2022. One hundred forty-three consecutive surgeries from 136 patients were included in the study. Patients younger than 17 years or who had an incomplete medical record were excluded. RESULTS: Most patients were female (63.6%) versus male (31.5%). The average American Society of Anesthesiologists score was 3. All but 6 patients (11%) had a history of at least 1 spinal surgery, with nearly half of patients having had between 2 and 5 spinal surgeries. Reconstruction was performed with paraspinous flaps in most cases (n = 133 [93%]). The overall complication rate was 10.5%, with surgical site infection being the most common complication. Seventeen patients (12.5%) underwent reoperation within 90 days of initial surgery. Average length of follow-up was 4.18 months (range, 0.03-40.53 months). CONCLUSIONS: In appropriately selected patients, prophylactic spinal reconstruction offers improved outcomes with decreased wound complications compared with salvage. For large defects, paraspinous flaps are recommended over other reconstructive options. Prolonged drain placement is felt to be protective against complications.

Gender and Racial Representation of Invited Speakers From The Aesthetic Society Annual Meetings Over a 5-Year Period.

BACKGROUND: Increased representation from both women and non-White ethnicities remains a topic of discussion in plastic surgery. Speakers at academic conferences are a form of visual representation of diversity within the field. This study determined the current demographic landscape of aesthetic plastic surgery and evaluated whether underrepresented populations receive equal opportunities to be invited speakers at The Aesthetic Society meetings. METHODS: Invited speaker's names, roles, and allotted time for presentation were extracted from the 2017 to 2021 meeting programs. Perceived gender and ethnicity were determined by visual analysis of photographs, whereas parameters of academic productivity and professorship were collected from Doximity, LinkedIn, Scopus, and institutional profiles. Differences in opportunities to present and academic credentials were compared between groups. RESULTS: Of the 1447 invited speakers between 2017 and 2021, 20% (n = 294) were women and 23% (n = 316) belonged to a non-White ethnicity. Representation from women significantly increased between 2017 and 2021 (14% vs 30%, P < 0.001), whereas the proportion of non-White speakers did not (25% vs 25%, P > 0.050) despite comparable h-indexes (15.3 vs 17.2) and publications (54.9 vs 75.9) to White speakers. Non-White speakers oftentimes had more academic titles, significant in 2019 ( P < 0.020). CONCLUSIONS: The proportion of female invited speakers has increased, with room for further improvement. Representation from non-White speakers has not changed. However, significantly more non-White speakers holding assistant professor titles may indicate increased ethnicity diversity in years to come. Future efforts should focus on improving diversity in positions of leadership while promoting functions that target young minority career individuals.

Insurance Coverage of Prophylactic Mastectomies: A National Review of the United States.

BACKGROUND: Breast cancer is associated with a multitude of risk factors, such as genetic predisposition and mutations, family history, personal medical history, or previous radiotherapy. A prophylactic mastectomy (PM) may be considered a suitable risk-reducing procedure in some cases. However, there are significant discrepancies between national society recommendations and insurance company requirements for PM. MATERIALS AND METHODS: The authors conducted a cross-sectional analysis of insurance policies for a PM. One-hundred companies were selected based on the greatest state enrolment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS: Preauthorized coverage of PMs was provided by 39% of insurance policies (n = 39) and 5 indications were identified. There was consensus amongst these policies to cover a PM for BRCA1/2 mutations (n = 39, 100%), but was more variable for other genetic mutations (15%-90%). Coverage of PM for the remaining indications varied among insurers: previous radiotherapy (92%), pathological changes in the breast (3%-92%), personal history of cancer (64%) and family history risk factors (39%-51%). CONCLUSION: There is a marked level of variability in both the indications and medical necessity criteria for PM insurance policies. The decision to undergo a PM must be carefully considered with a patient's care team and should not be affected by insurance coverage status.

In vitro fertilization: a cross-sectional analysis of 58 US insurance companies.

PURPOSE: Infertility affects one in eight women in the USA. In vitro fertilization (IVF) is an effective but costly treatment that lacks uniform insurance coverage. We evaluated the current insurance coverage landscape for IVF in America. METHODS: We conducted a cross-sectional analysis of 58 insurance companies with the greatest state enrollment and market share, calculated to represent the majority of Americans with health insurance. Individual companies were evaluated for a publicly available policy on IVF services by web-based search, telephone interview, or email to the insurer. Coverage status, required criteria, qualifying risk factors, and contraindications to coverage were extracted from available policies. RESULTS: Fifty-one (88%) of the fifty-eight companies had a policy for IVF services. Thirty-five (69%) of these policies extended coverage. Case-by-case coverage was stated in seven policies (14%), while coverage was denied in the remaining nine (18%). The most common criterion to receive coverage was a documented diagnosis of infertility (n = 23, 66%), followed by care from a reproductive endocrinologist (n = 9, 26%). Twenty-three (45%) of the companies with a policy had at least one contraindication to coverage. Three companies (6%) limited the number of IVF cycles to be covered, capping payments after 3-4 lifetime cycles. CONCLUSION: Most Americans with health insurance are provided a public policy regarding IVF. However, there is great variation in coverage and requirements to receive coverage between insurers. Coupled with inconsistencies in state-level mandates and available choices for employer-sponsored plans, this may limit coverage of IVF services and, therefore, access to infertility treatment.

An In Vitro Model of the Efficacy of Breast Implant Irrigant Solutions Against Gram-Negative Infections.

BACKGROUND: In implant-based breast surgery, infections remain a clinically challenging complication. Surgeons often prophylactically address this risk by irrigating the implant at the time of placement. However, there remain few data on the ideal irrigant for gram-negative species. METHODS: The authors assessed the relative efficacy of 10% povidone-iodine, triple-antibiotic solution, Prontosan, Clorpactin, and normal saline (negative control) against 3 gram-negative bacterial backgrounds: Escherichia coli , Pseudomonas aeruginosa , and Proteus species. A laboratory-adapted strain and a clinical isolate were selected for each group of bacteria. Sterile, smooth implant discs were immersed in each irrigant solution and then incubated in suspensions of each bacterial strain overnight at 37°C. Each disc was then rinsed and sonicated to displace biofilm-forming bacteria from the implant surface. The displaced bacteria were enumerated by plating, and normalized values were calculated for the bacterial counts of each irrigant. RESULTS: Povidone-iodine resulted in the greatest reduction of bacterial load for all 6 strains by a factor of 10 1 to 10 6 . Prontosan had a lesser, yet significant reduction in all bacterial strains. Triple-antibiotic solution demonstrated the greatest reduction in one Proteus species strain, and Clorpactin reduced bacterial counts in only half of the bacterial strains. When comparing laboratory strains to clinical isolates, significant differences were seen in each bacterial species in at least 2 irrigant solutions. CONCLUSIONS: Povidone-iodine has been proven the most effective at reducing bacterial contamination of E. coli, P. aeruginosa , and Proteus species in both laboratory-adapted strains and clinical isolates. CLINICAL RELEVANCE: This study proves that povidone-iodine is the most effective at preventing gram-negative infections in breast implant surgery.

A critical analysis of American insurance coverage for imaging and surgical treatment of lymphedema.

BACKGROUND: Over 35 million Americans have lymphedema. Nonetheless, lymphedema is underdiagnosed and undertreated worldwide. We investigated whether the rates of coverage for imaging and surgical procedures may contribute to the limited care provided for lymphedema. METHODS: We performed a cross-sectional evaluation of 58 insurers, chosen based on state enrollment and market share. A web-based search or phone call determined whether a publicly available policy on lymphedema-specific imaging, physiological procedures, and excisional procedures was available. Coverage status and corresponding criteria were extracted. RESULTS: Of the two-thirds of insurers who included a policy on imaging, 4% (n = 2) provided coverage and 4% (n = 2) specified coverage only on a case-by-case basis. Forty-eight percent (n = 28) of insurers had a statement of coverage on lymphovenous bypass or vascularized lymph node transfer, in which reimbursement was almost universally denied (96%, n = 26; 93%, n = 26). Liposuction and debulking procedures were included in 25 (43%) and 13 (22%) policies, in which seven (28%) and four (31%) insurers would provide coverage, with over 75% having criteria. Coverage of liposuction was significantly more than for lymphovenous bypass (P < .04). CONCLUSIONS: Nearly one-half of American insurers do not have a publicly available policy on most imaging, physiological, or excisional procedures, leaving coverage status ambiguous. Reimbursement was uncommon for imaging and physiological procedures, whereas the majority of insurers who did offer coverage for excisional procedures also had multiple criteria to be met. These elements may together be a limiting factor in receiving appropriate care for lymphedema.

A review of American insurance coverage and criteria for conservative management of lymphedema.

OBJECTIVE: Lymphedema affects >1 in 1000 Americans, most often resulting from breast cancer surgery. Conservative treatment, such as compression garments, combined decongestive therapy (CDT), and pneumatic compression pumps, is the current standard of care. Despite the wide availability of these therapies, lymphedema has remained undertreated worldwide. We investigated whether third-party insurance coverage might be a barrier to obtaining conservative treatment in the United States. METHODS: We conducted a cross-sectional analysis of publicly accessible insurance policies. A total of 58 insurers were included in accordance with their state enrollment data and market share. The analysis was conducted using a web-based search and individual telephone interviews. For those policies that extended coverage, the medical necessity criteria were abstracted. RESULTS: A total of 50 insurance companies (86%) had a policy in place addressing conservative management. Included in 37 policies (64%), compression garments were covered the least often (n = 33; 89%). Although CDT was included in only 22 policies (38%), it was universally covered. Noncalibrated pneumatic compression pumps were the most frequently addressed intervention (n = 46; 79%), significantly more often than CDT (P < .01) and were universally covered, significantly more often than were compression garments (P < .04). Criteria for reimbursement were present for more than one half of the policies that provided coverage. CONCLUSIONS: A large proportion of U.S. insurers provided coverage for conservative treatment of lymphedema. However, only 38% of the policies included a statement of coverage for CDT. Most of the policies that did provide coverage for these four therapies also had multiple criteria that were required to be met before considering reimbursement. These requirements could create barriers to the receipt of treatment.

Wound Closure with Transcutaneous Absorbable Polyglactin Sutures after Hidradenitis Suppurativa Excision.

OBJECTIVE: Wide surgical excision is the standard treatment for severe hidradenitis suppurativa (HS). Because of the nature of HS, these wounds are often nonsterile, located in moist intertriginous regions, and closed under tension, increasing the risk for surgical site complications. Although uncommon, absorbable sutures may confer benefits over nonabsorbable material for skin closure. Accordingly, the authors evaluated the use of absorbable, braided, transcutaneous polyglactin sutures after wide surgical excision of HS. METHODS: The authors performed a retrospective chart review for all consecutive patients who underwent wide surgical excision of HS at a tertiary university hospital between January 2009 and March 2020. RESULTS: Sixty consecutive patients with 174 operative sites were included in the study. The surgical site complication rate was 17.8%. Postoperative complications included wound dehiscence (n = 18), surgical site infection (n = 2), and scar contracture (n = 1). Sutures were removed from 12 (6.9%) operative sites. Factors influencing complications were Hurley grade and area of excision. Complications did not differ significantly among disease locations (P = .6417). CONCLUSIONS: The results support the growing evidence that absorbable sutures are an appropriate option after wide surgical excision of HS.

Insurance Coverage of Pediatric Bariatric Surgery: a Cross-Sectional Analysis of the USA.

PURPOSE: Pediatric bariatric surgery is increasingly recognized as a safe and effective option for the management of obesity and obesity-related conditions. However, insurance coverage is a key barrier to accessing these procedures. Criteria are variable and often not evidence-based. In an effort to characterize common patterns in insurance coverage, we report coverage criteria for adolescents relative to adults. MATERIALS AND METHODS: We surveyed medical policies of the 50 highest market share health insurance providers in the USA. Private insurer coverage criteria included age, Tanner staging, skeletal maturity, body mass index, procedures covered, medical weight management requirements, co-morbidities, and multidisciplinary team criteria. These were then compared to the American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines. RESULTS: Two thirds (n = 33, 66%) of companies provided inclusion criteria for adolescents. All policies covered RYGB (n = 33), most covered sleeve gastrectomy (n = 32, 97.0%). Obstructive sleep apnea (OSA) (n = 32, 97%), hypertension (HTN) (n = 27, 81.8%), and gastroesophageal reflux disease (GERD) (n = 11, 33.3%) were the three most commonly cited co-morbidities used as inclusion criteria. Tanner staging or skeletal maturity were most commonly used (n = 10, 30.3%). Similarly, twenty (60.6%) insurers required medical weight management programs. Multi-disciplinary teams were required by 81.8% of adolescent policies (n = 27) as described by the ASMBS. Seventeen (51.5%) policies defined providers for these teams, and 10 (30.3%) provided other defined criteria. CONCLUSION: Contrary to ASMBS guidelines, companies commonly require Tanner staging and/or skeletal maturity criteria as well as participation in medical weight management programs. Also, multi-disciplinary team are frequently required but not well defined.

Insurance Coverage of Dermabrasion and Chemical Peel Procedures: A Critical Analysis of 58 American Insurance Companies.

Introduction Dermabrasion and chemical peels are infrequently utilized methods of treatment for medical-grade conditions despite demonstrations of favorable outcomes. Insurance coverage status has previously been shown to impact availability and accessibility to specific treatments. The purpose of this study is to evaluate the rate of insurance coverage provided for dermabrasion and chemical peel procedures in the treatment of acne, acne scarring, and non-melanoma skin cancers (NMSC). Methods A cross-sectional analysis of 58 insurance companies by web-based search or phone interview determined the number of insurers with a publicly available policy on dermabrasion or chemical peels. Coverage status and any corresponding criteria were extracted from existing company policies. Results Thirteen (22%) and 22 (38%) policies discussed dermabrasion in the treatment of basal cell carcinoma and actinic keratosis, with 62% and 73% of these policies providing coverage. Acne scarring was discussed in significantly more dermabrasion policies than basal cell carcinoma (45% vs 22%; p=0.018). However, significantly more insurers denied coverage of dermabrasion for active acne and acne scarring when compared to dermabrasion to treat basal cell carcinoma or actinic keratosis (p<0.001). Eighty-seven percent of companies (n=20) with a chemical peel policy for premalignant lesions would provide coverage, with required criteria present in 95% (n=19) of the policies that would cover chemical peels for actinic keratosis specifically. Of the 25 companies (43%) that discussed the treatment of acne with chemical peel procedures, 14 (56%) provided coverage, and 11 (44%) denied coverage. Coverage was denied by significantly less insurers for the treatment of active acne with chemical peel procedures compared to treatment with dermabrasion (44% vs 83%; p<0.006). Conclusion Significant discrepancies were noted in both the presence of a public policy and the coverage status of dermabrasion or chemical peel procedures among the United States health insurance companies. These inconsistencies, along with multiple criteria required for coverage, may create an artificial barrier to receiving care for specific medical-grade conditions.

Contralateral prophylactic mastectomy in the setting of breast cancer diagnosis and their insurance coverage in the United States.

BACKGROUND: Contralateral prophylactic mastectomy (CPM) is more common in the United States than the rest of the world. However, the benefit of this procedure is still under question in many breast cancer scenarios. CPM utilization in the United States is in part dependent on a patient's health insurance coverage of breast oncology surgery and any desired reconstruction. However, there are great discrepancies in the coverage provided by insurers. METHODS: The authors conducted a cross-sectional analysis of insurance policies for a CPM in the setting of diagnosed breast cancer. One hundred companies were selected based on their state enrollment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS: Of the 100 companies assessed, 36 (36%) had a policy for CPM. Within those, significantly more provided coverage than denied the procedure (72% vs. 25%, p < 0.0001), with the remainder providing case-by-case coverage. Eleven criteria were identified from preauthorized policies, the most common prerequisite was breast cancer diagnosis under 45 years old (n = 9, 35%). Most policies did not differentiate between gender in their policies (n = 25, 69%), but of those that did, 100% (n = 11) provided coverage for men and women, with 82% (n = 9) requiring further criteria from the female patients. CONCLUSION: The coverage of CPM in the United States varies from complete denial to unrestricted approval. This may be due to conflicting reports in the literature as to the utility of the procedure. The decision to undergo this procedure must be taken with thoughtful consideration and the support of a multidisciplinary approach.

A Cross-Sectional Analysis of American Insurance Coverage of Prominauris Otoplasty.

BACKGROUND: Prominent ears affect up to 5% of the population and can lead to social and psychological concerns at a critical time of social development. It can be addressed with an otoplasty, which is often considered a cosmetic procedure. The authors assessed insurance coverage of all indications of otoplasty and their medical necessity criteria. METHODS: A cross-sectional analysis was conducted of 58 insurance policies for otoplasty. The insurance companies were selected based on their state enrolment and market share. A web-based search and telephone interviews were utilized to identify the policies. Medically necessary criteria were then abstracted from the publicly available policies. RESULTS: Of the 58 insurance policies assessed, 25 (43%) provide coverage of otoplasty. There were 2 indications for coverage: hearing loss (n = 20, 80%) and normal approximation (n = 14, 56%), which would encompass prominent ears. Normal approximation was a covered indication for significantly fewer insurers than hearing loss (56% versus 80%, P = 0.0013). Of all the otoplasty policies which covered normal approximation, 21% (n = 3) addressed protruding ears as an etiology. Prominent ears were not included in any policies which covered hearing loss. All policies inclusive of prominent ears required a protrusion of >20 mm from the temporal surface of the head (n = 3, 100%). CONCLUSIONS: There is a great discrepancy in insurance coverage of otoplasty. A greater proportion of policies cover hearing loss compared to normal approximation. The authors encourage plastic surgeons to advocate for the necessity and coverage of normal approximation by insurers.

Vacuum-Assisted Incisional Closure Therapy After Groin Reconstruction With Muscle Flap.

Background Groin reconstruction with muscle flap coverage is associated with high wound complication rates. Incisional vacuum-assisted closure (iVAC) therapy may lower wound complications. We evaluated the impact of iVAC on postoperative outcomes in patients following groin reconstruction with muscle flap coverage. Methods We conducted a retrospective review of patients who underwent groin reconstruction with muscle flap coverage in 2012-2018. Patients were divided into those who received iVAC therapy and those who received standard sterile dressings (SSD). Results Of the 57 patients included, most received iVAC therapy (71%, n = 41) and the rest received SSD (28%, n = 16). The iVAC group had higher rates of diabetes, hypertension, coronary artery disease, and peripheral artery disease (p < 0.05). However, iVAC patients had comparable length of hospital stay (12 vs 8.5 days p = 0.0735), reoperations (34% vs 31%, p = 0.8415), and readmissions (32% vs 37%, p = 0.6801) with SSD patients. iVAC placement was less likely in prophylactic flaps (odds ratio 0.08, p = 0.0049). Conclusion Patients with a prophylactic flap were less likely to receive vacuum therapy, which may highlight a selection bias where surgeons pre-emptively use iVAC therapy in surgical candidates identified as high risk. The pre-emptive use of iVAC may minimize adverse postoperative outcomes in high-risk patients.

Reno-appendiceal fistula in autosomal dominant polycystic kidney disease.

We present a very rare Case of a 53-year-old female with autosomal dominant polycystic kidney disease (ADPKD) who was incidentally found to have a reno-appendiceal fistula while undergoing open bilateral nephrectomy. The mid-portion of the appendix was fistulized to a cyst in the lower pole of the right kidney. The etiology was likely due to chronic inflammation. An appendectomy was performed along with the planned right nephrectomy to ensure complete removal of the fistulous tract.

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL): Are You Covered?

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a locally aggressive T-cell lymphoma that can develop following breast implantation. In 2017, and updated in 2019, the National Comprehensive Cancer Network (NCCN) recommended total capsulectomy with implant removal as definitive therapy. OBJECTIVES: The aim of this study was to evaluate the US insurance coverage for the management of BIA-ALCL and compare it to the NCCN recommendations. METHODS: A cross-sectional analysis of US insurance policies for coverage of BIA-ALCL treatment was conducted. Insurance companies were selected based on their market share and state enrollment. Medical necessity criteria were abstracted from the publicly available policies. RESULTS: Of the 101 companies assessed, only 30 (30%) had a policy for the management of BIA-ALCL. Of those policies, all (n = 30, 100%) provided coverage of the implant removal of the breast diagnosed with BIA-ALCL. For the contralateral breast implant, 20 policies (67%) covered their removal, but significantly fewer did so if the implant was placed for cosmetic reasons vs medically necessary (n = 13 vs n = 20, 43% vs 67%; P = 0.0026). Twenty-one policies (70%) covered an implant reinsertion, but fewer would do so if the implant was cosmetic rather than medically necessary (n = 5, 17% vs 70%; P < 0.0001). CONCLUSIONS: There was notable intercompany variation in the coverage of BIA-ALCL treatment, some of which is unnecessarily based on whether the original reason for the breast implant was cosmetic or medically necessary. This variability may significantly reduce access to definitive treatment in patients with a BIA-ALCL diagnosis.

Post-Abdominal Transplant Hernia: Can We Predict Size and Onset?

INTRODUCTION: Abdominal organ transplant is a life-saving treatment. However, the resultant weakening of abdominal muscles leaves patients susceptible to incisional hernia. Obesity, smoking, and diabetes mellitus are common risk factors for post-transplant hernia. However, the literature is void on the impact these risk factors have on timing and size of hernia. METHODS: We performed a retrospective review of all post-abdominal transplant patients who underwent hernia repair in 2010-2017 at a single institution. Primary outcomes were hernia size and time from transplant to hernia repair. RESULTS: We identified 31 patients. The majority of patients were female (15 male, 16 female), and the average patient was 56 ± 8.7 years old and obese (body mass index 30.6). Smoking (26.7%, n = 8) and diabetes mellitus (51.6%, n = 16) were prevalent. Transplant types represented were renal (n = 24), simultaneous pancreas-kidney (n = 5), liver (n = 1), and liver with subsequent kidney (n = 1). The median size of hernia was 100.0 cm2 (interquartile range [IQR]: 78.5-234.0), and median time to hernia repair was 53.0 months (IQR: 12.5-110.0). Risk factors (obesity, smoking, and diabetes) did not influence hernia size, nor alter time to hernia repair. CONCLUSION: Obesity, smoking, and diabetes mellitus are not prognostic of size or onset of post-transplant incisional hernia. Large cohort studies are needed to determine predictive factors of size and onset of hernia.

Gender-Affirming Health Insurance Reform in the United States.

INTRODUCTION: In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change. METHODS: Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision. RESULTS: Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation. CONCLUSIONS: After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.

Surgical Treatment and Visual Outcomes of Adult Orbital Roof Fractures.

BACKGROUND: Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis. METHODS: The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses. RESULTS: In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases. CONCLUSIONS: Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.