Trends of Medicare reimbursement rates for gender affirmation procedures.

BACKGROUND: While nearly 1 in 5 Americans receives health insurance coverage through Medicare, literature suggests that Medicare reimbursement is lagging behind inflation for many plastic surgery procedures. AIM: This article evaluates trends in Medicare reimbursement for gender affirmation procedures. METHODS: The most common gender affirmation procedures performed at an urban academic medical center were identified in this cross-sectional study (level 4 evidence). Five nongender surgery codes were evaluated for reference. A standardized formula utilizing relative value units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure. OUTCOME: The main outcome was inflation-adjusted difference of charges from 2014 to 2021. RESULTS: Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% (vs +5.63% for the selected nongender codes) and an inflation-adjusted change of -10.03% (vs -5.54% for the selected nongender codes). Trends in reimbursement varied by category of gender-affirming procedure. The overall average compound annual growth rate had a change of -0.99% (vs -0.53% for the selected nongender codes). The average changes in work, facility, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively. CLINICAL IMPLICATIONS: Gender surgeons and patients should be aware that the decrease in reimbursement may affect access to gender-affirming care. STRENGTHS AND LIMITATIONS: Our study is one of the first evaluating the reimbursement rates associated with the full spectrum of gender affirmation surgery. However, our study is limited by its cross-sectional nature. CONCLUSIONS: From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation.

A Historical Perspective on Brachial Plexus Palsy Management: From Ancient Civilizations to the Modern Era.

Evidence of brachial plexus palsies and potential therapies have been identified by investigators across cultures and civilizations. It could be argued that there are early records of brachial plexus injuries in not only literary work but also paintings, sculptures, and ancient medical texts. The compiled ancient evidence in this review provides a historical framework of brachial plexus palsies and potential management techniques that have been utilized from ancient to modern time.

Spectrum, Procedural Feasibility, and the Value of a Surgeon's Opinion in Varying Gender-Affirming Surgeries.

The understanding of gender has expanded contributing to gaps in gender-affirming care. Traditional gender-affirming surgeries focus on binary results, diminishing room for affirmation of other identities. Surgeons are faced with the challenge of deciding whether a variation of gender-affirming surgery can be safely performed per request. The ethical question of when a surgeon may say yes or no to these varying requests comes after the consideration of premorbid conditions, body habitus, age, social and family support, individuals' goals, and risk assessment. Preoperative evaluations must take into account surgical experience, barriers to care, increased risk profile, and the surgeon's personal biases.

Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery.

BACKGROUND: Literature focused on cancer screening and management is lacking in the transgender population. AIM: To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients. METHODS: We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories. RESULTS: Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated. CONCLUSION: When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.

Racial Disparity in Gender Affirming Surgery: A Comparative Study on Plastic Surgeon Social Media Use.

In the past 5 years, social media use among plastic surgeons has grown to become a common modality used to promote one's practice. However, surgeons lack the necessary ethical training to understand how their published content impacts patient opinions and behavior. Social media trends among plastic surgeons may contribute to the reduced rate of Black (non-White) patients accessing gender affirming surgery. Methods: In total, 250 gender affirming surgeons and 51,698 individual posts from social media platform, Instagram, were manually extracted and analyzed. Posts were assessed for inclusion and categorized by the subject's skin color (White versus non-White) using the Fitzpatrick scale. Results: Of the 3101 included posts, 375 (12.1%) portrayed non-White subjects. Of the 56 included surgeons, White surgeons were found to be 2.3 times less likely to include non-White subjects in their posts, compared with non-White surgeons. Regionally, surgeons practicing in the Northeast had the most racially diverse social media accounts, with over 20% of all posts including a non-White subject. Analyzing data over the past 5 years demonstrated no relative increase in the amount of non-White subjects being displayed on social media, while social media use by gender affirming surgeons had increased by over 200%. Conclusions: The low number of non-White individuals portrayed by surgeons on social media perpetuates the racial disparity seen in patients accessing gender affirming surgery. Surgeons must be conscious of the demographic they portray on social media, as a lack of representation may influence patients' self-identify and decision to utilize gender affirming surgical treatment.

Chondrolaryngoplasty with Endoscopic Direct Visualization of the Vocal Cords: Demonstration of Technique.

SUMMARY: Chondrolaryngoplasty is a surgical procedure that reduces a prominent thyroid cartilage. Demand for chondrolaryngoplasty has significantly increased over recent years in transgender women and nonbinary individuals and has been shown to alleviate gender dysphoria and improve quality of life. When performing chondrolaryngoplasty, surgeons must carefully balance the desire for maximal cartilage reduction with the potential for damage to surrounding structures (ie, the vocal cords) that may result because of overaggressive or imprecise resection. Our institution has adopted the technique of direct vocal cord endoscopic visualization using a flexible laryngoscope for increased safety. Briefly, surgical steps include dissection and preparation for translaryngeal needle placement, endoscopic visualization of the needle placed above the level of the vocal cords, marking of the corresponding level, and resection of the thyroid cartilage. The following article and supplemental video provide further detailed descriptions of these surgical steps as a resource for training and technique refinement.

Laryngochondroplasty: A Systematic Review of Safety, Satisfaction, and Surgical Techniques.

BACKGROUND: Since first performed in 1975, two main surgical techniques for laryngochondroplasty have evolved: anatomical localization and direct endoscopic visualization. The aim of this study was to evaluate which method is safest and had the highest patient-reported satisfaction rates, and to determine whether these outcomes have changed over time. METHODS: A systematic review and meta-analysis following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed to find and analyze all medical publications related to laryngochondroplasty. Of these studies, patients who underwent laryngochondroplasty for gender-affirmation surgery were evaluated. Surgical and patient-reported outcomes were compared between different surgical techniques and between studies before and after the year 2010. RESULTS: A total of 226 patients have been reported to have undergone laryngochondroplasty for gender-affirmation surgery. Overall transient and long-term complication rates were 14% and 0%, respectively. A 97% satisfaction rate was reported overall. Endoscopic visualization techniques were associated with lower short-term complications (OR, 21.11; 95% CI, 7.56 to 58.93); there was no difference in long-term complications (OR, 7.81; 95% CI, 0.31 to 194.37) or patient satisfaction (OR, 5.73; 95% CI, 0.32 to 101.97). Studies performed before the year 2010 had a significantly greater number of short-term complications compared to studies performed after the year 2010 (OR, 10.16; 95% CI, 3.71 to 27.82), with no difference in long-term complications (OR, 4.56; 95% CI, 0.18 to 113.25) or patient satisfaction (OR, 4.99; 95% CI, 0.59 to 42.20). CONCLUSIONS: All laryngochondroplasty techniques result in high patient satisfaction. Endoscopic visualization may help facilitate safe surgery and should be used in conjunction with anatomical familiarity. Technique choice should be dictated by the surgeon's experience and patient desires.

Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional.

SUMMARY: Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.

Ethical and Legal Considerations Regarding Parenthood in Transgender Patients Following Uterine Transplant.

In modern society, acceptance of gender diversity and fluidity is increasing; however, parenthood is still largely considered to be a binary construct. A hypothetical case of a transgender woman who undergoes uterus transplant and carries a pregnancy conceived with her own sperm is presented. This situation raises unique ethical and legal issues regarding the parental designation of the transgender woman. Parallels can be drawn to the real-life examples of transgender men who have given birth and desire legal recognition as their child's father. Should "motherhood" and "fatherhood" be based on parental genetic contribution to the child? Should these labels be based on who has carried and gave birth to the child? Or have we reached a time where these titles no longer serve a constructive purpose? Here, we investigated these considerations regarding parenthood designation in the context of rapidly evolving gender constructs and surgical reproductive options.

Associations between SARS-CoV-2 infections and thrombotic complications necessitating surgical intervention: A systematic review.

BACKGROUND: Several unique clinical features of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019 (COVID-19) infection, have been identified and characterized. One such feature, mostly among patients with severe COVID-19 infection, has become known as COVID-19-induced coagulopathy. Surgical patients with a history of or active COVID-19 infection bear a significantly higher risk for postoperative thrombotic complications. These patients may require surgical intervention to treat severe thrombotic complications. Few studies have been carried out to better characterize this association. The purpose of this study was to perform a systematic review and meta-analysis of the literature on COVID-19 infections that led to thrombotic complications necessitating surgical intervention. We hypothesized that patients with recent or active COVID-19 infection would have high rates of thromboembolic complications both arterial and venous in origin. AIM: To perform a systematic review and meta-analysis of the literature on COVID-19 infections that led to thrombotic complications necessitating surgical intervention. METHODS: The current systematic review implemented an algorithmic approach to review all the currently available English medical literature on surgical interventions necessitated by COVID-19 thrombotic complications using the preferred reporting items for systematic reviews and meta-analysis principles. A comprehensive search of the medical literature in the "PubMed", "Scopus", "Google Scholar" top 100 results, and archives of Plastic and Reconstructive Surgery was performed using the key words "COVID-19" AND "surgery" AND "thromboembolism" AND "complication". The search string was generated and the records which were not specific about surgical interventions or thrombotic complications due to COVID-19 infection were excluded. Titles and abstracts were screened by two authors and full-text articles were assessed for eligibility and inclusion. Finally, results were further refined to focus on articles that focused on surgical interventions that were necessitated by COVID-19 thrombotic complications. RESULTS: The database search resulted in the final inclusion of 22 retrospective studies, after application of the inclusion/exclusion criteria. Of the included studies, 17 were single case reports, 3 were case series and 2 were cross sectional cohort studies. All studies were retrospective in nature. Twelve of the reported studies were conducted in the United States of America, with the remaining studies originating from Italy, Turkey, Pakistan, France, Serbia, and Germany. All cases reported in our study were laboratory confirmed SARS-CoV-2 positive. A total of 70 cases involving surgical intervention were isolated from the 22 studies included in this review. CONCLUSION: There is paucity of data describing the relationship between COVID-19 infection and thrombotic complications necessitating the need for surgical intervention. Intestinal ischemia and acute limb ischemia are amongst the most common thrombotic events due to COVID-19 that required operative management. An overall postoperative mortality of 30% was found in those who underwent operative procedures for thrombotic complications, with most deaths occurring in those with bowel ischemia. Physicians should be aware that despite thromboprophylaxis, severe thrombotic complications can still occur in this patient population, however, surgical intervention results in relatively low mortality apart from cases of ischemic bowel resection.

Impact of gender-affirming hormone therapy on the development of COVID-19 infections and associated complications: A systematic review.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can produce a wide range of clinical manifestations from asymptomatic to life-threatening. Various researchers have worked to elucidate the pathogenic mechanisms underlying these variable presentations. Differences in individual responses to systemic inflammation and coagulopathy appear to be modulated by several factors, including sex steroid hormones. Transgender men or non-binary individuals who undergo gender-affirming hormone therapy (GAHT) are a unique population of interest for exploring the androgen-mediated coronavirus disease 2019 (COVID-19) hypothesis. As the search for reliable and effective COVID-19 treatments continues, understanding the risks and benefits of GAHT may mitigate COVID-19 related morbidity and mortality in this patient population. AIM: To investigate the potential role of GAHT in the development of COVID-19 infections and complications. METHODS: This systematic review implemented an algorithmic approach using PRISMA guidelines. PubMed, Scopus, Google Scholar top 100 results, and archives of Plastic and Reconstructive Surgery was on January 12, 2022 using the key words "gender" AND "hormone" AND "therapy" AND "COVID-19" as well as associated terms. Non-English articles, articles published prior to 2019 (prior to COVID-19), and manuscripts in the form of reviews, commentaries, or letters were excluded. References of the selected publications were screened as well. RESULTS: The database search resulted in the final inclusion of 14 studies related to GAHT COVID-19. Of the included studies, only two studies directly involved and reported on COVID-19 in transgender patients. Several clinical trials looked at the relationship between testosterone, estrogen, and progesterone in COVID-19 infected cis-gender men and women. It has been proposed that androgens may facilitate initial COVID-19 infection, however, once this occurs, testosterone may have a protective effect. Multiple clinical studies have shown that low baseline testosterone levels in men with COVID-19 are associated with worsening outcomes. The role of female sex hormones, including estrogen and progesterone have also been proposed as potential protective factors in COVID-19 infection. This was exemplified in multiple studies investigating different outcomes in pre- and post-menopausal women as well as those taking hormone replacement therapy. Two studies related specifically to transgender patients and GAHT found that estrogen and progesterone could help protect men against COVID-19, and that testosterone hormone therapy may increase the risk of contracting COVID-19. CONCLUSION: Few studies were found related to the role of GAHT in COVID-19 infections. Additional research is necessary to enhance our understanding of this relationship and provide better care for transgender patients.

Management of Tourniquet-Related Nerve Injury (TRNI): A Systematic Review.

Tourniquet-related nerve injuries (TRNIs) are a rare but feared complication of operative tourniquet use. While the literature contains multiple discussions regarding tourniquet use as well as reported cases of its complications, there does not exist a consensus guideline for a safe tourniquet pressure, application time, or management of TRNI. This paper conducts a comprehensive review of the available literature for cases of TRNI with a specific focus on analyzing the management of cases of TRNI and their functional recovery. One hundred nine articles were retrieved in a search of medical literature (PubMed) using the keywords: tourniquet, nerve injury, paralysis, and palsy. The initial search was further narrowed down to seven case series and 10 case reports totaling 203 reported cases of TRNI. Of the 203 cases, 64 cases involved upper extremity tourniquet use, and 139 cases involved lower extremity tourniquet use. Most patients (89.75%) experienced a complete recovery. TRNI may occur over a wide range of tourniquet application times and tourniquet pressures; hence, it is a necessity for surgeons to consider it as a potential complication and understand the methodology for diagnosis and long-term management.

Improving Postoperative Care Through Mindfulness-Based and Isometric Exercise Training Interventions: Systematic Review.

BACKGROUND: Mindfulness-based cognitive therapy and isometric exercise training (IET) interventions are relatively new approaches to maintain physical functioning, alleviate pain, prevent joint stiffness and muscular atrophy, and positively influence other postoperative care outcomes. OBJECTIVE: The aim of this review was to identify the impacts of mindfulness-based interventions (MBIs) and IET and, more specifically, their combination, which have not previously been assessed to our knowledge. METHODS: Studies were identified by searching the PubMed and Cochrane databases within the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) algorithm format and using relevant keyword combinations, which resulted in 39 studies meeting the inclusion criteria. RESULTS: In general, MBI was shown to positively impact both pain relief and physical functioning, while IET positively impacted physical functioning. Numerous other benefits, including improved quality of life and decreased postoperative opioid use, were also described from both interventions; however, further research is needed to confirm these findings as well as to determine other possible benefits. No studies were found that combined MBI and IET. CONCLUSIONS: Despite many positive results from each individual intervention, there is a lack of information about how the combination of MBI and IET might impact postoperative care. The combination of these two interventions might prove to be more effective than each individual intervention alone, and the findings from this review show that they could even be complementary. Going forward, research should be expanded to study the possible benefits of the combination of MBI and IET in postoperative care routines as well as other possible combinations.

Potential prognostic value of the lymph node ratio and its correlation with circulating sex hormone concentration in pathological T1/2 breast cancer patients: a retrospective study.

Background: The lymph node ratio (LNR) is an additional informative factor complementing anatomic TNM staging in breast cancer patients. The aim of this study was to evaluate the role of LNR in the cancer-specific and overall survival (OS) in a cohort of pT1/2 breast cancer patients and examine its correlation with circulating sex hormone concentrations in postmenopausal cases of the cohort from eastern China islands. Methods: Clinical and pathological characteristics, preoperational sex hormone and tumor markers concentrations, and breast cancer-specific survival (BCSS) and OS were analyzed retrospectively in 732 pathological T1/2 breast cancer patients. Results: The LNR was calculated, and the cut-off value was defined as 0.042 by receiver operative characteristic (ROC) curve according to the patient's mortalities. Patients with LNR ≥0.042 exhibited worse BCSS and OS than others (P<0.001) in pT1/2 breast cancer. Among patients with non-triple negative breast cancer (TNBC) and TNBC subtypes, the LNR ≥0.042 group also exhibited worse BCSS and OS than the LNR <0.042 group (P=0.003, 0.001, and P=0.032, 0.001, respectively). In univariate analysis, unfavorable BCSS and OS were both related with LNR ≥0.042 (P=0.001, <0.001). However multivariate analysis demonstrated TNBC subtypes were independent predictor for BCSS and OS [hazard ratio (HR) =1.449, 95% CI: 1.097-1.914, P=0.009; HR =1.365, 95% CI: 1.093-1.705, P=0.006, respectively]. Notably, Pearson or spearman correlation analysis revealed follicle-stimulating hormone (FSH) and, luteinizing hormone (LH) levels were significantly negatively associated with the LNR (P=0.007, 0.011, respectively) in postmenopausal cases, whereas CA153, CA125 and CEA were positively correlated with it (P<0.001, <0.001, 0.001, respectively) in all cases. Conclusions: Among pT1/2 breast cancer patients from eastern China islands, the LNR is a predictive prognosis factor; a higher LNR seems to correlate with a worse survival outcome both overall and in the subgroups. Strikingly, the current results reveal that serum FSH and LH level inversely associated with axillary node invasion in postmenopausal cases, whereas tumor markers directly related with it. The LNR is an informative factor complementing TNM staging.