Patterns of Perioperative Hormone Therapy for Gender-Affirming Surgery.

INTRODUCTION: There is no consensus regarding perioperative hormone replacement therapy (HRT) for gender-affirming surgery (GAS). Common concerns for continuing perioperative HRT included risk of deep vein thrombosis (DVT) or hematoma. However, discontinuing HRT is not risk free and may cause mood swing or increased anxiety. Our study aimed to investigate current patterns of HRT before GAS worldwide. METHODS: The first stage of Delphi technique was implemented by sending a 27-item survey to all surgeons (total n = 150; 94 plastic surgeon, 35 urologist, and 21 gynecologists) of the World Professional Association for Transgender Health who perform GAS. Survey themes included the hormone type, duration, and usage of DVT prophylaxis. RESULTS: Overall survey response rate was 34% (total n = 51; 8 urologists, 35 plastic surgeons, and 8 gynecologists). The majority of surgeons are US-based (n = 39, 76%). The most common HRTs are in injection form (n = 28, 55%). The majority of surgeons do not stop HRT before GAS and do provide DVT prophylaxis to all patients <1 week after GAS. The most common procedure that surgeons discontinue HRT is feminizing bottom surgery (43%). For surgeons who discontinue HRT before GAS, there is a wide variation on discontinuation schedule. CONCLUSIONS: There is considerable variation in perioperative HRT patterns for GAS. Further research is needed to develop a data-driven consensus guideline to provide high quality of care for transgender and nonbinary patients.

Vanderbilt Mini-PROM-Breast for Breast Reconstruction: A Short-Form, Patient-Reported Outcomes Measure.

BACKGROUND: Breast reconstruction procedures are among the most commonly performed plastic surgery operations. Although there are well-validated patient-reported outcomes measures (PROMs) for breast reconstruction, there are several patient-, provider-, and service-level barriers to their implementation in routine clinical settings. Therefore, we developed a short-form PROM to evaluate breast reconstruction outcomes. METHODS: Using a mixed-methods approach, the Vanderbilt Mini-PROM-Breast (VMP-B) was constructed and validated to assess patient-reported outcomes from breast reconstruction. Classic test theory methods were used to evaluate acceptability, reliability, and validity. External validation was subsequently performed using the BREAST-Q as a reference standard. RESULTS: The VMP-B is a 16-item instrument composed of three domains: quality of life, body image, and breast satisfaction. Psychometric properties including acceptability, reliability, and validity exceeded reference criteria. When tested with 104 patients, the authors found significant benefits of breast reconstruction on quality of life, body image, and breast satisfaction. These results were associated with sizeable effect sizes (g) (g = 0.421, g = 0.520, and g = 1.25) demonstrative of clinically meaningful results. When tested concurrently in 70 patients, the VMP-B and the BREAST-Q showed similar results, exhibiting excellent convergent validity. CONCLUSIONS: The VMP-B is a validated short-form PROM that reliably assesses breast reconstruction outcomes. As a short form, the VMP-B decreases both patient and provider burden, which allows for routine, point-of-care collection of breast reconstruction outcomes.

Geographic Differences in Patient Demographics and Performance of Gender-Affirming Surgery From 2016 to 2019.

BACKGROUND: Although legislation prohibiting gender identity discrimination in health insurance has shown some improvement in insurance coverage for gender-affirming surgery (GAS), recent bills criminalizing GAS providers in the South and Midwest regions pose threats to patient care. OBJECTIVES: To investigate the influence of US census region on patient demographics and GAS rates in the ambulatory surgery setting. METHODS: Individuals with gender dysphoria who underwent GAS in the ambulatory setting from 2016 to 2019 were identified in the Nationwide Ambulatory Surgery Sample (NASS) with billing codes. Demographic and clinical characteristics were analyzed and stratified by US census region. RESULTS: The data set included a weighted estimate of 33,174 encounters with 72.8% (95% CI, 69.1-76.2) for chest reconstruction; 24.1% (95% CI, 20.9-27.5) for surgery on the genitals and reproductive organs; and 6.0% (95% CI, 4.6-7.8) for facial surgery. Overall, the rates of GAS increased by 187%, from 4320 encounters in 2016 to 12,396 encounters in 2019. In the Midwest, GAS increased by 257% compared to 203% in the Northeast, 218% in the South, and 154% in the West. Compared to patients in the West, those in other regions had higher odds of anxiety and depression (odds ratio, 1.57; 95% CI, 1.09-2.26; P < .05) and were more likely to have lower incomes than other ambulatory surgery patients in the region (P < .001). CONCLUSIONS: Between 2016 and 2019, there was substantial growth of GAS in the Midwest, South, and Northeast. Regional differences in insurance coverage, socioeconomic status, availability of facial surgery, and comorbidities were observed.

National patterns in the use of International Statistical Classification of Diseases and Health Related Problems, tenth revision Z codes in ambulatory surgery from 2016 to 2019.

BACKGROUND: In the tenth revision of the International Statistical Classification of Disease and Health Related Problems (ICD-10), Z codes were added to improve documentation and understanding of health-related social needs. We estimated national Z code use in the ambulatory surgery setting from 2016 to 2019. METHODS: Using the Nationwide Ambulatory Surgery Sample (NASS), we identified encounters for ambulatory surgery with an ICD-10 code between Z55.0 and Z65.9. Data were stratified by Z code domains from the Centers for Medicare and Medicaid Services (CMS). RESULTS: This analysis of 41,827 ambulatory surgery encounters with documented Z codes found that the most documented determinants of health related to multiparity or unwanted pregnancy, homelessness, and incarceration. There was a 16.1% increase in the use of Z codes from 2016 to 2019. CONCLUSION: Rates of Z code use in the ambulatory surgery setting are increasing with current documentation serving as a specific but not sensitive measure of socioeconomic need.

Effect of an Oncology Focused High School Outreach Event in Increasing Interest in Cancer Care and Healthcare Careers.

Despite widely heralded efforts to improve diversity, equity, and inclusion in oncology, few outreach programs exist to inspire high school students to pursue a career in medicine. Doctors' Day is an event developed and organized by medical trainees that features both didactic and hands-on learning components to provide high school students with exposure to the healthcare field and knowledge about cancer and cancer screening. We investigated in the influence of Doctors' Day on students' interest in healthcare careers and oncology. On March 30, 2023, health professions students and residents organized and led Doctors' Day, a half-day educational program for eight public high schools in Nashville, TN. After the event, high school student participants were invited to complete a 21-item survey. The questionnaire collected demographic information, feedback regarding the session, and comfort with various activities related to the program. Among the 8 public high schools involved in Doctors' Day, 91 participants completed the survey. Few (9, 9.9%) participants were White or European American, and 30 (33.0%) and 23 (25.3%) were Black and Hispanic, respectively. There were 20 (22.0%) participants who identified as LGBTQI+ with 2 (2.2%) indicating they were unsure. Feedback regarding the program was positive across all domains, and students reported increased interest in healthcare careers and oncology along with an increased comfort level in describing the importance of cancer screening. Our community outreach program for high school students with backgrounds underrepresented in medicine was effective in increasing interest in healthcare careers and oncology.

Patient Perspectives on Selecting an Academic Aesthetic Surgeon: A Qualitative Analysis.

BACKGROUND: Growth of the aesthetic surgery marketplace has increased patient choice in provider selection. This study aimed to characterize how patients choose an aesthetic surgeon, identify knowledge gaps in this decision-making process, and understand why patients select academic aesthetic surgeons. METHODS: A qualitative interview study of aesthetic surgery patients from an academic center was conducted. Purposive sampling maximized representation regarding surgeon, surgery type, and patient demographics. An interview guide was developed in collaboration with content and methodology experts, then refined through pilot testing. Emergent themes were identified using a codebook constructed by grounded theory. RESULTS: Thematic saturation was achieved with 24 patients. When selecting a surgeon, participants valued bedside manner (24 of 24) and past patients' satisfaction (18 of 24). Most participants (16 of 24) ascribed low importance to board certification. Reasons given for choosing an academic practice included the institution's reputation (13 of 24) and the availability of medical records and other specialties if complications arise (8 of 24). Participants demonstrated knowledge gaps regarding medical training and licensure. No participant (0 of 24) was aware that any licensed physician can offer aesthetic surgery, and nearly all participants (23 of 24) expressed discomfort with this. CONCLUSIONS: Patients prioritize subjective elements when selecting an aesthetic surgeon, relying less on objective and meaningful qualifications like board certification and training background. Academic aesthetic practice is valued because of reputation and ability to function as a medical home. Given the lack of public understanding regarding physician training, initiatives promoting transparency are needed to ensure that patients can make safe, informed decisions.

The True Cost of Antitransgender Legislation.

A large body of research finds that sexual and gender minorities experience disparities in health equity that stem from structural discrimination. In particular, transgender and gender diverse (TGD) patients face barriers in access to gender-affirming care (GAC). As of December 2021, 35 state legislatures have introduced >100 bills that categorically deny TGD individuals' human rights and outlaw medically necessary GAC. Importantly, the economic consequences of discriminatory legislation and denial of health care for TGD individuals are void in the literature. This perspective outlines the economic impact of antitransgender policy and calls for federal intervention to protect TGD rights.

Multidimensional Assessment of Patient-Reported Outcomes After Gender-Affirming Surgeries Using a Validated Instrument.

INTRODUCTION: Limited literatures used validated instruments to evaluate patient-reported outcomes (PROs) for transgender and gender-diverse population undergoing gender-affirming surgeries (GASs). This study aimed to evaluate PROs using a newly validated psychometric instrument, Vanderbilt Mini Patient-Reported Outcome Measures-Gender (VMP-G). METHODS: Vanderbilt Mini Patient-Reported Outcome Measures-Gender assesses 4 scales: quality of life, self-concept, satisfaction, and gender dysphoria. Scores range from 20 to 100, with higher scores representing superior PROs. Descriptive analysis was performed, and outcomes were compared in different races/ethnicities, gender identities, age, types of GAS, and time. Patients seeking GAS at Vanderbilt University Medical Center from October 11, 2021, to October 11, 2022, were included. Data were collected anonymously via the Research Electronic Data Capture survey tool at preoperative or postoperative clinic visits. RESULTS: A total of 207 patients completed VMP-G. Average age was 31.8 years (SD, ±11.5 years). Fifty-three percent of patients were postoperative GAS. In bivariate and linear regression analyses, postoperative patients scored higher on all scales compared with preoperative patients ( P < 0.001). After adjustment, postoperative patients scored 12.5 higher on VMP-G compared with preoperative patients ( P < 0.01). In subset analyses, GAS was associated with improved PROs in White, non-White, binary, and nonbinary and patients younger than 21 years ( P < 0.05). After GAS, patients younger than 21 years reported similar outcomes, compared with patients older than 21 years ( P > 0.05). No PROs differences were reported between patients who underwent top versus bottom surgery ( P = 0.2). Postoperative patients reported low rates of regret (2.8%). Scores on the VMP-G were sustained even 1 year after GAS. Each month after GAS was associated with a score improvement of 0.02 in the gender dysphoria domain after adjusting for patient demographics ( P = 0.02). CONCLUSIONS: Using a validated GAS-specific measure, we found that surgery sustainably improves patients' self-reported outcomes including gender dysphoria.

Delayed Versus Immediate Breast Reconstruction in the Ambulatory Surgery Setting: A Cross-Sectional Analysis of the Nationwide Ambulatory Surgery Sample.

BACKGROUND: Breast reconstruction remains an important part of a patient's journey after the diagnosis of breast carcinoma and treatment with mastectomy. Although inpatient immediate breast reconstruction has been described, there is a paucity information about whether similar procedures are performed in the ambulatory setting. OBJECTIVE: The authors sought to investigate rates and patterns for delayed and immediate breast reconstruction in the ambulatory surgery setting using nationally representative data from 2016 to 2019. METHODS: Using the Nationwide Ambulatory Surgery Sample database, we identified patients with an International Statistical Classification of Disease and Related Health Problems, Tenth Revision, procedure code for breast reconstruction. Demographic and clinical characteristics were recorded for each encounter of breast reconstruction, and linear regression and logistic regression were used to assess for trends and disparities. RESULTS: National weighted estimates for ambulatory breast reconstruction increased by 15.6% from 89 237 in 2016 to 103 134 in 2019, resulting in 377 109 procedures during the study period. Inflation-adjusted total charges for ambulatory breast reconstruction were $14 billion between 2016 and 2019, or 1.7% of overall charges for ambulatory surgery. Immediate reconstruction was performed in 34.7% (95% CI, 33.4%-36.1%) of cases and increased by 46.9% from 26 930 in 2016 to 39 559 in 2019. Racial disparities were observed in access, comorbidities, and spending. CONCLUSIONS: Our findings indicate a moderate increase in ambulatory breast reconstruction with a substantial growth in the performance of immediate breast reconstruction in the ambulatory setting.

Perioperative Experiences of Transgender Adults Seeking Gender-Affirming Surgery: A Qualitative Interview Study.

Purpose: Transgender individuals have been systemically excluded from U.S. health care, creating barriers and disparities that other populations do not face. Gender-affirming surgery represents an emerging treatment modality for gender dysphoria, however, little is known about how transgender patients experience the perioperative pathway. This study sought to characterize the experiences of transgender patients seeking gender-affirming surgery and identify opportunities for improvement. Methods: A qualitative study was conducted at an academic medical center between July and December 2020. Semistructured interviews were conducted after a postoperative encounter with adult patients who had undergone gender-affirming surgery within the past year. A purposive sampling strategy was used to maximize representation across surgery types and surgeons. Recruitment continued until thematic saturation was reached. Results: All invited patients agreed to participate, yielding 36 interviews (response rate=100%). Four major themes emerged. First, gender-affirming surgery was described as a major life event, often reflecting years of personal decision making and research. Second, participants stressed the importance of surgeon investment, surgeon experience caring for transgender patients, and individualized care in developing a strong relationship with their care team. Third, self-advocacy was necessary to navigate the perioperative pathway and overcome barriers. Last, participants discussed a lack of equity and provider awareness regarding transgender health issues, including correct pronoun usage, terminology, and insurance coverage. Conclusion: Patients undergoing gender-affirming surgery encounter unique perioperative barriers to care, which would benefit from targeted interventions in the health care system. To improve the pathway, our findings support the creation of multidisciplinary gender-affirmation clinics, greater emphasis on transgender care in medical education, and insurance policy reforms aimed at promoting consistent and equitable coverage.

The Utility of the Plastic Surgery Standardized Letter of Recommendation Form in Predicting Residency Match Outcomes.

BACKGROUND: Letters of recommendation play an important role in resident selection. While plastic surgery's Standardized Letter of Recommendation (SLOR) form most commonly serves as an adjunct to narrative letters, the SLOR provides objective data in the review process and could eventually replace narrative letters. The utility of the SLOR in predicting Match outcomes has not been studied. METHODS: Applicant data from 225 first-time residency applicants in 2020-21 were collected. Logistic regression modeling was used to predict Match outcomes. This model was validated using 100 randomly selected applicants from 2019-20. RESULTS: Rank placement (SLOR Question 6) was the most important factor when predicting Match outcomes (p<0.0001). All other SLOR questions were not predictive and subject to notable score inflation. No SLOR score differences were noted based on race; female applicants were rated higher in two of ten domains (p<0.05). CONCLUSIONS: One question on the plastic surgery SLOR was highly predictive of an applicant matching. However, the remaining SLOR questions had little utility and were subject to gross score inflation. Further work should be done to optimize the utility of the SLOR in differentiating applicants. This has important implications in ensuring the selection of professional, competent residents according to the aims of the Accreditation Council of Graduate Medical Education.

Alpha Defensin-1 Biomarker Outperforms Culture in Diagnosing Breast Implant-Related Infection: Results from a Multicenter Prospective Study.

BACKGROUND: Prompt diagnosis of breast implant infection is critical to reducing morbidity. A high incidence of false-negative microbial culture mandates superior testing modalities. Alpha defensin-1 (AD-1), an infection biomarker, has outperformed culture in diagnosing periprosthetic joint infection with sensitivity/specificity of 97%. After previously demonstrating its feasibility in breast implant-related infection (BIRI), this case-control study compares the accuracy of AD-1 to microbial culture in suspected BIRI. METHODS: An institutional review board-approved, prospective, multicenter study was conducted of adults with prior breast implant reconstruction undergoing surgery for suspected infection (cases) or prosthetic exchange/revision (controls). Demographics, perioperative characteristics, antibiotic exposure, and implant pocket fluid were collected. Fluid samples underwent microbial culture, AD-1 assay, and adjunctive markers (C-reactive protein, lactate, cell differential); diagnostic performance was assessed by means of sensitivity, specificity, and accuracy from receiver operating characteristic curve analysis, with values of P < 0.05 considered significant. RESULTS: Fifty-three implant pocket samples were included (cases, n = 20; controls, n = 33). All 20 patients with suspected BIRI exhibited cellulitis, 65% had abnormal drainage, and 55% were febrile. All suspected BIRIs were AD-1 positive (sensitivity, 100%). Microbial culture failed to grow any microorganisms in four BIRIs (sensitivity, 80%; P = 0.046); Gram stain was least accurate (sensitivity, 25%; P < 0.001). All tests demonstrated 100% specificity. Receiver operating characteristic curve analyses yielded the following areas under the curve: AD-1, 1.0; microbial culture, 0.90 ( P = 0.029); and Gram stain, 0.62 ( P < 0.001). Adjunctive markers were significantly higher among infections versus controls ( P < 0.001). CONCLUSIONS: Study findings confirm the accuracy of AD-1 in diagnosing BIRI and indicate superiority to microbial culture. Although further study is warranted, AD-1 may facilitate perioperative decision-making in BIRI management in a resource-efficient manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Overlapping Surgeries From the Patient's Perspective.

INTRODUCTION: Overlapping surgery (OS) occurs when a single surgeon is concurrently caring for patients in multiple operating rooms (OR) but is present for all critical portions of each surgery. Although this is common practice, most studies have found public disapproval of OS. This study aims to better understand attitudes toward OS of patients who gave informed consent for OS. METHODS: Participant interviews covered topics including trust, OR personnel roles, and attitudes toward OS. Four representative transcripts were distributed among researchers for independent code identification. These were aggregated into a codebook, applied by two coders. Iterative and emergent thematic analyses were done. RESULTS: Twelve participants were interviewed to reach thematic saturation. Three themes shaped how participants felt about OS: trust in their surgeon, worries about OS, and understanding of OR personnel roles. Factors contributing to trust included personal research and the surgeon's experience. Frequently cited concerns were unpredictability of complications during operations and the surgeon's divided attention. Two participants inaccurately understood personnel roles, believing the surgeon did most or all the hands-on work while trainees were observers. Most participants felt a high or neutral level of comfort toward OS and indicated trust as the reason. CONCLUSIONS: In contrast to prior research, this study found that most participants had a neutral or positive view of OS. This suggests that a trusting relationship with their surgeon and informed consent are important factors in increasing comfort for OS. Participants who misunderstood OR roles felt less comfortable toward OS. This highlights an opportunity for patient education on trainee roles.