United States insurance coverage of immediate lymphatic reconstruction.

INTRODUCTION: Immediate Lymphatic Reconstruction (ILR) is a prophylactic microsurgical lymphovenous bypass technique developed to prevent breast cancer related lymphedema (BCRL). We investigated current coverage policies for ILR among the top insurance providers in the United States and compared it to our institutional experience with obtaining coverage for ILR. METHODS: The study analyzed the publicly available ILR coverage statements for American insurers with the largest market share and enrollment per state to assess coverage status. Institutional ILR coverage was retrospectively analyzed using deidentified claims data and categorizing denials based on payer reason codes. RESULTS: Of the 63 insurance companies queried, 42.9% did not have any publicly available policies regarding ILR coverage. Of the companies with a public policy, 75.0% deny coverage for ILR. In our institutional experience, $170,071.80 was charged for ILR and $166 118.99 (97.7%) was denied by insurance. CONCLUSIONS: Over half of America's major insurance providers currently deny coverage for ILR, which is consistent with our institutional experience. Randomized trials to evaluate the efficacy of ILR are underway and focus should be shifted towards sharing high level evidence to increase insurance coverage for BCRL prevention.

Clinical Outcomes Following Resection of Distal Lower Extremity Soft Tissue Sarcomas.

OBJECTIVE: Resection of soft tissue sarcoma (STS) in the distal lower extremity can result in large soft tissue defects that create difficult wounds to manage and significant risks for complications. Often, the anticipated or resultant tissue defect or loss of functional anatomy is an indication for amputation over limb salvage. Soft tissue reconstruction managed by plastic and reconstructive surgery (PRS) may help offer limb salvage as a therapeutic option with acceptable oncologic outcomes and wound complication rates. METHODS: This was a review of 52 patients who underwent resection of STS at the level of the knee or distal between 2010 and 2020. Plastic and reconstructive surgery soft tissue management was utilized in 40.4% (n = 21) of cases, most of whom would have otherwise been considered candidates for amputation. RESULTS: The overall rate of limb salvage was 76.9%. The overall rate of wound complications was 19.2%. The overall rate of negative margins of resection was 92.3%. The 1-, 5-, and 10-year overall survival probabilities were 92%, 85%, and 85%, respectively. Of the 40 limb salvage procedures, two required subsequent amputation, one for multiply recurrent disease and one for necrosis. The wound complication rate was 14.3% in the PRS management group and 22.6% in cases of wound closure managed by the primary surgeon. There were zero instances of total wound or flap loss in PRS- managed closures. When comparing patients with wound complications to those without, there was no difference in age (59.5 ± 21 vs. 51 ± 18 years, p = 0.42), body mass index (31.1 ± 4.8 vs. 26.1 ± 7.1 kg/m2 , p = 0.19), or tumor size (6.8 ± 5.0 vs. 6.4 ± 4.7 cm, p = 0.82). At final follow-up, 67% (n = 35) of patients were alive and disease-free. CONCLUSIONS: Wound complications are not uncommon after resection of distal lower extremity STS. Our experience has been successful in achieving limb salvage in these challenging cases. Without PRS soft tissue management, however, many patients may alternatively be candidates for amputation.

Trends of Medicare Reimbursement Rates for Lower Extremity Procedures.

INTRODUCTION: Data collected across many surgical specialties suggest that Medicare reimbursement for physicians consistently lags inflation. Studies are needed that describe reimbursement rates for lower extremity procedures. Our goal is to analyze the trends in Medicare reimbursement rates from 2010 to 2021 for both lower extremity amputation and salvage surgeries. METHODS: The Physician Fee Schedule Look-Up Tool of the Centers for Medicare and Medicaid Services was assessed and Current Procedural Terminology codes for common lower extremity procedures were collected. Average reimbursement rates from 2010 to 2021 were analyzed and adjusted for inflation. The rates of work-, facility-, and malpractice-related relative value units (RVUs) were also collected. RESULTS: We found an overall increase in Medicare reimbursement of 4.73% over the study period for lower extremity surgery. However, after adjusting for inflation, the average reimbursement decreased by 13.19%. The adjusted relative difference was calculated to be (-)18.31 and (-)11.34% for lower extremity amputation and salvage procedures, respectively. We also found that physician work-related RVUs decreased by 0.27%, while facility-related and malpractice-related RVUs increased. CONCLUSION: Reimbursement for lower extremity amputation and salvage procedures has steadily declined from 2010 to 2021 after adjusting for inflation, with amputation procedures being devaluated at a greater rate than lower extremity salvage procedures. With the recent marked inflation, knowledge of these trends is crucial for surgeons, hospitals, and health care policymakers to ensure appropriate physician reimbursement. LEVEL OF EVIDENCE: IV (cross-sectional study).

Pressure injuries in COVID-19 patients: A tertiary center experience.

Pressure ulcers continue to severely impact patient outcomes and increase health care costs. We aimed to examine the incidence and risk factors related to pressure ulcers among COVID-19 patients. A retrospective was conducted between March 2020-April 2021. Baseline differences were examined using chi-square and Fischer's exact test. Logistic regression was employed to examine the association of the collected variables to development of new pressure ulcers. 4608 patients were included, of which eighty-three acquired new pressure ulcers. Risk factors were increased age, peripheral artery disease, abnormal albumin levels, but not prone position.

Safety and Efficacy of Extended Postdischarge Venous Thromboembolism Prophylaxis in Microsurgical Breast Reconstruction.

Discharging patients on extended postoperative venous thromboembolism (VTE) prophylaxis is trending in microsurgical breast reconstruction (MBR). This study investigated contemporary bleeding and thromboembolic complications after MBR and reported postdischarge enoxaparin outcomes. Methods: The PearlDiver database was queried for MBR patients who did not receive postdischarge VTE prophylaxis (cohort 1) and MBR patients discharged with enoxaparin for at least 14 days (cohort 2), then queried for hematoma, deep venous thrombosis (DVT), and/or pulmonary embolism. Concurrently, a systematic review was undertaken to identify studies investigating VTE with postoperative chemoprophylaxis. Results: In total, 13,541 patients in cohort 1 and 786 patients in cohort 2 were identified. The incidence of hematoma, DVT, and pulmonary embolism were 3.51%, 1.01%, 0.55% in cohort 1, and 3.31%, 2.93%, and 1.78% in cohort 2, respectively. There was no significant difference in hematoma between these two cohorts (P = 0.767); however, a significantly lower rate of DVT (P < 0.001) and pulmonary embolism (P < 0.001) occurred in cohort 1. Ten studies met systematic review inclusion. Only three studies reported significantly lower VTE rates with postoperative chemoprophylaxis. Seven studies found no difference in bleeding risk. Conclusions: This is the first study utilizing a national database and a systematic review to investigate extended postoperative enoxaparin in MBR. Overall, rates of DVT/PE seem to be declining compared with previous literature. The results of this study suggest that there remains a lack of evidence supporting extended postoperative chemoprophylaxis, although the therapy appears safe in that it does not increase bleeding risk.

Nationwide Bibliometric Analysis of Integrated Plastic Surgery Program Directors.

Studies have linked bibliometric indices with the academic level of plastic surgeons, but this relationship has not been explored with residency program directors (PDs). As teachers of the next generation, PDs' academic performance is an important component of residency program success. We sought to identify distinguishing characteristics of integrated plastic surgery programs, focusing on their PD bibliometric indices. Methods: We identified plastic surgery programs based on 2021 Doximity reputation and research output rankings, respectively, and then divided them into four quartiles (Q1-Q4). PD academic history and bibliometric indices (h-index, the number of publications, and citations) were collected through Doximity profiles and program websites: PubMed, Scopus, Google Scholar, American Society of Plastic Surgeons, and Accreditation Council for Graduate Medical Education. Results: Eighty-four programs were identified. There was a significant positive relationship between h-index, the number of publications, and type of research with reputation ranking (P < 0.05). After adjusting for years of experience post-training, h-index (OR = 1.24; P < 0.001) and the number of publications (OR = 1.05, P < 0.001) were significantly associated with reputation ranking. There was a statistically significant relationship between PD research fellowship completion and research output ranking (P < 0.01). After adjusting for years of experience post-training, h-index (OR = 1.05; P = 0.047) and the number of publications (OR = 1.01; P = 0.04) were significantly associated with research output ranking. Conclusion: Higher ranked programs tend to have PDs who have a strong record of scholarly activity, as evidenced by certain bibliometric indices.

Burden of Pressure Injuries: Findings From the Global Burden of Disease Study.

Background: Pressure injuries remain among the most common problems faced by plastic surgeons and comprise a large portion of wound clinic practice. However, little is known about the overall morbidity related to the disease. This research sought to identify the burden related to the diagnosis of pressure injuries. Methods: We used the Global Burden of Disease Study 2017 to extract information about incidence and disability-adjusted life years (DALYs) related to pressure injuries from 1990 to 2017. Descriptive statistics were used to identify changes in the outcomes of interest. Results: A relative though not statistically significantly decrease in the incidence and burden of pressure injuries was observed between 1990 and 2017. Rates of incidence in the US appear higher than other higher socio-demographic index countries. No clinically and statistically significant changes were observed based on age or sex. Conclusions: Pressure injury incidence and burden have remained relatively stable between 1990 and 2017 with no significant improvement noted. There is room for improvement on a national performance level, and further research is needed regarding inconsistencies in regional outcomes.

Trends in Skin Melanoma Burden: Findings From the Global Burden of Disease Study.

Background: Melanoma is the third most common skin cancer and the leading cause of skin cancer mortality. This study sought to investigate trends in melanoma incidence, mortality, and burden of disease. Methods: The authors assessed the records of the Global Burden of Disease Study 2017 to extract information about the incidence, mortality, and disability adjusted life years (DALY) related to melanoma during 1990-2017 in the US and other countries based on their socio-demographic index (SDI). Results: Melanoma incidence in the US increased 1.6 times, although the difference was not statistically significant. For patients over the age of 60, the incidence was significantly increased by 1.72 to 164.6 times. Mortality was relatively stable during the study period; however, it was increased for patients over 65 years of age (range: 1.03 to 70 times), although not statistically significant. Mortality-to-incidence ratio was decreased, but the difference was not statistically significant. For patients over 75 years of age, DALYs were statistically significantly increased by 1.34 to 1.71 times. Conclusions: This study highlights differences in melanoma incidence and mortality from 1990-2017. Physicians involved in melanoma care should be aware of these changes in order to anticipate care needs.

Plastic Surgeon Financial Compensation-Incentivization Models in Surgical Care Delivery: The Past, Present, and Future.

BACKGROUND: Surgeons are critical for the success of any health care enterprise. However, few studies have examined the potential impact of value-based care on surgeon compensation. METHODS: This review presents value-based financial incentive models that will shape the future of surgeon compensation. The following incentivization models will be discussed: pay-for-reporting, pay-for-performance, pay-for-patient-safety, bundled payments, and pay-for-academic-productivity. Moreover, the authors suggest the application of the congruence model-a model developed to help business leaders understand the interplay of forces that shape the performance of their organizations-to determine surgeon compensation methods applicable in value-based care-centric environments. RESULTS: The application of research in organizational behavior can assist health care leaders in developing surgeon compensation models optimized for value-based care. Health care leaders can utilize the congruence model to determine total surgeon compensation, proportion of compensation that is short term versus long term, proportion of compensation that is fixed versus variable, and proportion of compensation based on seniority versus performance. CONCLUSION: This review provides a framework extensively studied by researchers in organizational behavior that can be utilized when designing surgeon financial compensation plans for any health care entity shifting toward value-based care.

Trends of Medicare Reimbursement Rates for Common Plastic Surgery Procedures.

BACKGROUND: Knowledge of Medicare reimbursement is essential for plastic surgeons providing care to Medicare beneficiaries. The authors sought to evaluate changes in Medicare reimbursement for common plastic surgery procedures from 2010 to 2020. METHODS: The authors assessed the Physician Fee Schedule of the Centers for Medicare and Medicaid Services website. Rates of work-, facility-, or malpractice-related relative value units and total monetary units for 26 common plastic surgery procedures between 2010 and 2020 were evaluated. Descriptive statistics were used to calculate relative differences and to compare observed changes over time with the rate of inflation. RESULTS: For the selected procedures, the authors found an average relative difference in terms of monetary units of an increase by 2.02 percent. However, after adjusting for inflation, the average relative difference was a decrease by 14.31 percent. The authors' analysis indicates that, on average, there was a 1.55 percent decrease in physician relative value units between 2010 and 2020. CONCLUSIONS: Medicare reimbursement rates have changed significantly over the past decade. However, these changes did not keep pace with the rate of inflation. Plastic surgeons should be aware of these trends and advocate for more fair reimbursement rates.

The Affordable Care Act and Its Impact on Plastic and Gender-Affirmation Surgery.

SUMMARY: The Affordable Care Act's provisions have affected and will continue to affect plastic surgeons and their patients, and an understanding of its influence on the current American health care system is essential. The law's impact on pediatric plastic surgery, craniofacial surgery, and breast reconstruction is well documented. In addition, gender-affirmation surgery has seen exponential growth, largely because of expanded insurance coverage through the protections afforded to transgender individuals by the Affordable Care Act. As gender-affirming surgery continues to grow, plastic surgeons have the opportunity to adapt and diversify their practices.

Urban Frostbite: Strategies for Limb Salvage.

Under ideal circumstances, severely frostbitten extremities are rapidly rewarmed and treated with thrombolytic therapy within 6 to 24 hours. In an "inner city," urban environment, most patients who suffer frostbite injuries present in a delayed fashion, sustain repeated injuries further complicated by psychological issues or intoxication, and are rarely ideal candidates for thrombolytic therapy within the prescribed timeframe. We describe our experience with the treatment of urban frostbite injuries. A retrospective review of patients with cold injuries sustained between November 2013 and March 2014 treated at a verified burn center in an urban setting was performed. Fifty-three patients were treated (42 males, 11 females). Average patient age was 41.8 years (range 2-84 years). No patients met criteria for thrombolytic therapy due to multiple freeze-thaw cycles or presentation greater than 24 hours after rewarming. Deep frostbite was seen in 10 patients. Of these patients, nine underwent debridement, resulting in partial limb amputations at levels guided by Tri-phasic technetium (Tc-99m) bone scans. Wound closure and limb-length salvage was then achieved by: free flap coverage (n = 2), local flaps (n = 8), split-thickness skin grafting (n = 22), and secondary intention healing (n = 6). While tissue plasminogen activator has been successful in reducing the need for digital amputation following frostbite injuries, in our experience, this treatment modality is not applicable to the urban patient population who often present late and after cycles of reinjury. Therefore, our approach focused on salvaging limb length with durable coverage, as the injuries were unable to be reversed.

Immediate Dental Implantation in Oncologic Jaw Reconstruction: Workflow Optimization to Decrease Time to Full Dental Rehabilitation.

Full dental rehabilitation following segmental mandibulectomy or maxillectomy for oncologic tumor ablation should be the goal for every patient. But despite advances in technology and reconstructive techniques, many patients do not achieve timely or complete oral rehabilitation. Recognizing this fault, we recently adopted an innovative workflow to increase the number of patients undergoing dental restoration, irrespective of tumor pathology or need for adjuvant radiotherapy. Preoperatively, every osseous jaw reconstruction undergoes virtual surgical planning to incorporate the placement of endosseous implants into the fibula osteocutaneous free flap. The dental implants are then placed intraoperatively at the time of tumor ablation and reconstruction. Four-to-six weeks following the initial surgery, the patient returns to the operating room for vestibuloplasty and exposure of the dental implants. Within 3 days of the vestibuloplasty, a temporary dental prosthesis is placed in the dental clinic, and the patient can then begin radiation therapy if needed. Following adjuvant radiation therapy, the temporary prosthesis can be replaced with a permanent one. At our institution, this innovative workflow has allowed for earlier aesthetic restoration of the jaw and greatly expanded the number of patients able to achieve oral rehabilitation. Herein, we describe this innovative workflow and provide technical pearls for successful execution.

Autologous Breast Reconstruction after Failed Implant-Based Reconstruction: Evaluation of Surgical and Patient-Reported Outcomes and Quality of Life.

BACKGROUND: There is a subset of patients who initially undergo implant-based breast reconstruction but later change to autologous reconstruction after failure of the implant reconstruction. The purpose of this study was to examine outcomes and quality of life in this group of patients. METHODS: After institutional review board approval, a retrospective chart review of a prospectively maintained database was performed and BREAST-Q surveys were evaluated. RESULTS: One hundred thirty-seven patients underwent autologous breast reconstruction following failed implant-based reconstruction with 192 total flaps. Failure of implant reconstruction was defined as follows: capsular contracture causing pain and/or cosmetic deformity [n = 106 (77 percent)], dissatisfaction with the aesthetic result [n = 15 (11 percent)], impending exposure of the implant/infection [n = 8 (6 percent)], and unknown [n = 8 (6 percent)]. Complications requiring operative intervention included partial flap loss [n = 5 (3 percent)], hematoma [n = 5 (3 percent)], vascular compromise requiring intervention for salvage [n = 2 (1 percent)], and total flap loss [n = 1 (1 percent)]. Thirty-four patients (23 percent) had BREAST-Q surveys. There was a statistically significant increase in overall outcomes (p < 0.001), satisfaction with appearance of breasts (p < 0.001), psychosocial well-being (p < 0.001), and physical well-being of the chest (p = 0.003). A statistically significant decrease in physical well-being of the abdomen was observed (p = 0.001). CONCLUSIONS: Autologous breast reconstruction after failed implant-based reconstruction has an acceptable complication rate and is associated with significantly improved patient satisfaction and quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Virtual planning and navigational technology in reconstructive surgery.

Reconstructive technologies have expanded to include the use of virtual surgical planning (VSP) and computer-aided design and manufacturing (CAD-CAM), and 3-Dimensional printing. The advantages of VSP over traditional techniques are highlighted in many scenarios: (a) delayed reconstruction, (b) maxillary reconstruction, (c) placement of dental implants, and (d) precision guided oncology. Microsurgery is undergoing a paradigm shift with virtual planning at its foreground. Herein, we describe the versatile uses for CAD-CAM and key operative steps.

Superficial Inferior Epigastric Artery Flap Salvage Technique Using Deep Inferior Epigastric Artery Graft.

Superficial inferior epigastric artery (SIEA) flap salvage remains challenging, particularly in cases of arterial insufficiency due to vessel spasm, pedicle kinking, or thrombosis. The already small, short SIEA pedicle, in addition to its inherent tendency toward spasm, renders the SIEA flap more difficult to manage when anastomotic revision is required. Furthermore, arterial thrombosis will cause dilation of the internal mammary artery, exacerbating vessel mismatch. In our previously published experience with 145 SIEA flaps, no flap with postoperative arterial thrombosis was salvageable. Following this experience, a new salvage technique using deep inferior epigastric artery grafts has been utilized and is described here.

SSET Project: Cost-effectiveness Analysis of Surgical Specialty Emergency Trays in the Emergency Department.

BACKGROUND: We hypothesize that reusable, on-site specialty instrument trays available to plastic surgery residents in the emergency department (ED) for bedside procedures are more cost-effective than disposable on-site and remote re-usable operating room (OR) instruments at our institution. METHODS: We completed a cost-effectiveness analysis comparing the use of disposable on-site kits and remote OR trays to a hypothetical, custom, reusable tray for ED procedures completed by PRS residents. Material costs of existing OR trays were used to estimate the purchasing and use-cost of a custom on-site tray for the same procedures. Cost of per procedure 'consult time' was estimated using procedure and resident salary. RESULTS: Sixteen bedside procedures were completed over a 4.5 month period. A mean of 2.14 disposable kits were used per-procedure. Mean consultation time was 1.66 hours. Procedures that used OR trays took 3 times as long as procedures that used on-site kits (4 vs. 1.1 hours). Necessary, additional instruments were unavailable for 75% of procedures. Mean cost of using disposable kits and OR trays was $115.03/procedure versus an estimated $26.67/procedure cost of using a custom tray, yielding $88.36/procedure cost-savings. Purchase of a single custom tray ($1,421.55) would be redeemed after 2.3 weeks at 1 procedure/day. Purchasing 4 trays has projected annual cost-savings of $26,565.20. CONCLUSION: The purchase of specialized procedure trays will yield valuable time and cost-savings while providing quality patient care. Improving time efficiency will help achieve the Accreditation Council of Graduate Medical Education (ACGME) goals of maintaining resident well-being and developing quality improvement competency.

Body contouring after obesity surgery is associated with a weight loss benefit among patients.

BACKGROUND: Patients who undergo obesity surgery often require body contouring procedures to eliminate excess skin. Recent studies suggest that body contouring surgery may provide psychological benefits to patients after obesity surgery. However, it remains unclear how body contouring may affect weight loss maintenance after obesity surgery. METHODS: This is a retrospective review of patients who underwent obesity surgery with or without body contouring at a single institution from 2000 to 2005. Charts were reviewed for demographic, medical, and surgical information. The primary outcome of interest was the difference in weight loss maintenance among patients who underwent body contouring versus those who did not. RESULTS: A total of 318 patients were included for analysis in this study, of which 70 underwent obesity surgery with body contouring and 248 underwent obesity surgery without body contouring. The mean change in BMI among patients who did not undergo body contouring was 19.7 kg/m2. The mean change in BMI among patients who underwent body contouring was 22.1 kg/m2. Among patients who underwent body contouring surgery, 2.9% (2/70) of patients did not maintain at least a 20% decrease in body weight during the entire follow-up period (mean follow-up time 92.2 months). Among patients who did not undergo body contouring surgery, 10% (25/248) of patients did not maintain at least a 20% decrease in body weight during the entire follow-up period (mean follow-up time 39.0 months) (χ2 = 3.67, p = 0.055). CONCLUSIONS: Body contouring surgery may have a positive effect on weight loss maintenance after body contouring determined from the mean weight change and on percentage of patients who maintain at least a 20% decrease in body weight.