Comparative Analysis of Recurrence-Free Survival and Mortality in Postmastectomy Patients: Insights From Multidecade, Multiinstitutional Propensity Score Matching.

INTRODUCTION: Disparities in postmastectomy reconstructive care are widely acknowledged. However, there is limited understanding regarding the impact of reconstructive services on cancer recurrence and breast cancer-related mortality. Therefore, this study aims to examine how patient-specific factors and breast reconstruction status influence recurrence-free survival and mortality rates in breast cancer patients. METHODS: Retrospective chart review was performed to collect data on patients who underwent mastectomy at 2 institutions within the New York-Presbyterian system from 1979 to 2019. Sociodemographic information, medical history, and the treatment approach were recorded. Propensity score matching, logistic regression, unpaired t test, and chi-square test were used for statistical analysis. RESULTS: Overall, cancer recurrence occurred in 6.62% (317) of patients, with 16.8% (803) overall mortality rate. For patients who had relapsed disease, completion of the reconstruction sequence was correlated with an earlier detection of cancer recurrence and improved survival odds (P < 0.05). Stratified analysis of the reconstruction group alone showed mortality benefit among patients who underwent free flap procedures (P < 0.05). CONCLUSION: Patients undergoing breast reconstruction after mastectomy are likely to have better access to follow-up care and improved interfacing with the healthcare system. This may increase the speed at which cancer recurrence is detected. This study highlights the need for consistent plastic surgery referral and continued monitoring by all members of the breast cancer care team for cancer recurrence among patients.

Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data.

BACKGROUND: Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population. METHODS: Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications. RESULTS: A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008). CONCLUSIONS: Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

The Lost and Variable Cause: A Systematic Review of Shunt-Related Craniosynostosis Occurrence.

OBJECTIVE: Shunt-related craniosynostosis (SRC) is the premature fusion of cranial sutures possibly due to a loss of tension across dura and suture lines after placement of a shunt for hydrocephalus. As modifications in approaches toward shunting represent a modifiable risk factor, prior literature has investigated the determinants and outcomes. However, the data remain highly variable and are limited by single-institution studies. METHODS: A systematic search of PubMed, Embase, and Web of Science from inception to February 2022 was conducted. Studies were screened by 2 reviewers for eligibility based on predefined inclusion/exclusion criteria. RESULTS: In the 9 included articles, the average follow-up time for the entire cohort ranged from 1.5 to 4.2 years. The pooled incidence of SRC across all 9 studies was 6.5% (140/2142), with an individual range of 0.53% (1/188) to 48.8% (61/125). The average time from shunt placement to SRC diagnosis ranged from 0.25 years to 4.6 years. 61% (65/110) of cases included only one suture, 88% (25/28) of these involved the sagittal suture, and those cases with multiple fusions also had 98% involvement of the sagittal suture (45/46). Overall, 94% (1783/1888) of patients had a fixed shunt placed. CONCLUSIONS: Shunt-related craniosynostosis is likely an underreported complication in the treatment of hydrocephalus. Older age at shunt placement, increased number of shunt revision procedures, and lower valve pressure settings may be risk factors for SRC development. Results also indicate that craniosynostosis can develop months to years after shunting. Future quality studies with standardization of data reporting processes are warranted to investigate this clinical problem.

"A Retrospective Evaluation of the Impact of Prenatal Diagnosis of Facial Clefts. Does Prenatal Diagnosis Matter?"

BACKGROUND: With the advent of improved prenatal detection, some patients with facial clefting are diagnosed prenatally while others are diagnosed postnatally. There is limited data regarding the utility of prenatal diagnosis and how this affects care of patients with facial clefts. METHODS AND MATERIALS: A retrospective chart review was performed. Children with incomplete demographic data and those with syndromic conditions were excluded. The data were analyzed via Fisher's exact tests and Kruskal-Wallis tests (p < 0.05). RESULTS: 106 patients met inclusion criteria. Facial clefting was diagnosed prenatally at different frequencies depending on type of facial cleft- patients with cleft palate alone were less likely to be identified prenatally (p < 0.0001). Patients diagnosed prenatally were seen by craniofacial specialists at an earlier age compared to those diagnosed after birth (0.27 months vs 0.7 months, p < 0.001). Similarly, those with prenatal diagnosis underwent surgery at a younger age compared to those who were diagnosed postnatally (median: 3.6 months vs 10.67 months, p < 0.001) and experienced shorter lag time (median: 3.4 months vs 8.4 months, p = 0.027) from consultation to surgery. Importantly, prenatal diagnosis resulted in pre-surgical therapy more often than in children diagnosed postnatally (86% vs 22.2%, p < 0.001). CONCLUSIONS: Our data suggests that patients with prenatal diagnosis of facial clefts were more likely to undergo pre-surgical therapy, presented to a craniofacial specialist at an earlier age, underwent surgery at an earlier age, and experienced less lag time between initial visit and surgery. More study is warranted to improve protocols for prenatal diagnoses to improve surgical outcomes.

Estimated Time of Arrival: Impact of Healthcare Disparities on Access to and Outcomes of Multidisciplinary Cleft Lip and Palate Care.

OBJECTIVE: To determine the impact of sociodemographic and clinical factors on patient presentation into the cleft care pathway and determine how delayed interventions may affect post-surgical outcomes. DESIGN: Retrospective study. SETTING: Multidisciplinary craniofacial clinics of two university hospitals. PATIENTS, PARTICIPANT: 135 patients with cleft lip and/or palate. INTERVENTIONS: Primary cheiloplasty, primary palatoplasty. MAIN OUTCOME MEASURES: Age at initial presentation, age at first surgery, lag time, delayed surgery, rate of return to the emergency department (ED), readmission rate, reoperations, and oronasal fistula development. RESULTS: Patients referred by OBGYN who underwent cheiloplasty had an earlier age at initial presentation (p < 0.01), earlier age at first surgery (p = 0.01), and a shorter lag time (p < 0.01) compared to children from other referral pathways. African American children had an older age at first surgery (p = 0.01) and a longer lag time (p = 0.02) when compared to non-African American children. Children with syndromes had an older age at first surgery (p < 0.01) and a longer lag time (p < 0.01) than children without syndromes. Patient race, cleft type, and syndromic status increased the odds of receiving delayed surgery. Patients who received delayed palatoplasty returned to the ED at a higher rate than patients who received non-delayed palatoplasty (p = 0.02). CONCLUSIONS: Our data suggest that referral source, race, and syndromic status influence the timeliness of cleft care. Surgeons should develop strong referral networks with local OBGYNs and hospitals to allow for an early entry into the cleft care pathway.

Management of Total Frontal Bone Loss After Surgery for Craniosynostosis: The Modified Visor Bone Flap With Brain Cage.

Complications after craniosynostosis surgery occur in 11% to 36% of cases and may be precipitated by poor soft tissue coverage and concomitant exposure of non-sterile regions; sequelae may result in infection, osteomyelitis, and bone loss requiring complex reconstruction. In the pediatric population, autologous cranioplasty remains the gold standard due to growth potential and a more favorable complication profile than synthetic cranioplasty. Virtual surgery planning (VSP) and computer-assisted design (CAD)/computer-assisted manufacturing (CAM) technology can be utilized to create innovative, patient-specific autologous solutions, similar to the approach with synthetic cranioplasty. A novel surgical approach using VSP was used for an 18-month-old female with near total bifrontal bone loss. Surface area measurements were used to determine the amount of bone available to replace the infected frontal bone. VSP was utilized to determine the most efficient construct configuration possible to achieve maximal coverage via calculation of cranial bone surface area measurements. Surgical reconstruction of the defect was planned as a Modified Visor Bone Flap with Posterior Brain Cage. A construct was fashioned from available cranial bone struts to obtain widespread coverage. 3D Recon images from before and after surgery demonstrate almost complete re-ossification of the cranial vault with significant resulting clinical improvement. Reconstruction of total frontal bone loss is possible by utilizing this technique. VSP can improve the safety and efficiency of complex autologous cranial bone reconstructions. We propose a treatment algorithm to address the problem of near total frontal bone loss in young children for whom alloplastic implants are not suitable.

An Evaluation of Native Breast Dimension and Tissue Expander Inflation Rate on the Risk of Capsular Contracture Development in Postmastectomy Reconstruction.

INTRODUCTION: Capsular contracture is a common complication after 2-stage breast reconstruction. The relationships between native breast size, the rate of tissue expander expansion, and capsule formation have not been elucidated. This study aims to evaluate how these factors contribute to capsular contracture and establish cutoff values for increased risk. METHODS: A data set consisting of 229 patients who underwent 2-stage breast reconstruction between 2012 and 2021 was included in the study. The rate of expansion is estimated as the final expanded volume subtracted by the initial filling volume of the tissue expander over time elapsed. The native breast size was estimated using various preoperative breast measurements and the weight of mastectomy specimen (grams). Further stratified analysis evaluated patients separately based on postoperative radiation status. RESULTS: Greater nipple-inframammary fold distance and faster tissue expander enlargement rate conferred decreased odds of developing capsular contracture ( P < 0.05). On stratified analysis, faster tissue expansion rate was not significant in the nonradiated cohort but remained a significant negative predictor in the radiation group (odds ratio, 0.996; P < 0.05). Cut-point analysis showed an expansion rate of <240 mL/mo and a nipple-inframammary fold value of <10.5 cm as conferring a greater risk of capsular contracture. CONCLUSION: Smaller inframammary fold distance may be associated with a higher risk of capsular contracture. Slower expansion rates correlate with increased odds of contracture in patients undergoing adjuvant radiation. Breast geometry should be considered when risk stratifying various reconstruction approaches (implant vs autologous). In addition, longer delays between implant exchange and initial tissue expansion should be avoided if clinically feasible.

Return of the Flap; The Empire State Mandate: A Multi-decade Multi-institutional Analysis of the 2010 New York State Legislature's Impact on Postmastectomy Immediate Flap-Based Reconstruction.

PURPOSE: Immediate postmastectomy breast reconstruction plays an integral role in patient care because of its psychosocial benefits. New York State (NYS) passed the 2010 Breast Cancer Provider Discussion Law with the aim of increasing patient awareness of reconstructive options through mandating plastic surgery referral at the time of cancer diagnosis. Short-term analysis of the years surrounding implementation suggests the law increased access to reconstruction, especially for certain minority groups. However, given the continued presence of disparities in access to autologous reconstruction, we aimed to investigate the longitudinal effects of the bill on access to autologous reconstruction along various sociodemographic cohorts. METHODS: Retrospective review identified demographic, socioeconomic, and clinical data for patients undergoing mastectomy with immediate reconstruction at Weill Cornell Medicine and Columbia University Irving Medical Center from 2002 to 2019. Primary outcome was receiving implant or autologous-based reconstruction. Subgroup analysis was based on sociodemographic factors. Multivariate logistic regression identified predictors of autologous reconstruction. Interrupted time series modeling analyzed differences in reconstructive trends for subgroups before and after the 2011 implementation of the NYS law. RESULTS: We included 3178 patients; 2418 (76.1%) and 760 (23.9%) patients underwent implant and autologous-based reconstruction, respectively. Multivariate analysis indicated that race, Hispanic status, and income were not predictors of autologous reconstruction. Interrupted time series showed that with each year leading up to 2011 implementation, patients were 19% less likely to receive autologous-based reconstruction. Following implementation, there was a 34% increase in the odds of receiving autologous-based reconstruction with each passing year. Following implementation, Asian American and Pacific Islander patients experienced a 55% greater increase in the rate of flap reconstruction than White patients. Following implementation, the highest-income quartile experienced a 26% greater increase in the rate of autologous-based reconstruction compared with the lowest-income quartile. After implementation, Hispanic patients experienced a 30% greater decrease in the rate of autologous-based reconstruction compared with non-Hispanic patients. CONCLUSIONS: Our data indicate the long-term efficacy of the NYS Breast Cancer Provider Discussion Law in increasing access to autologous-based reconstruction, especially for certain minority groups. These findings underscore the importance of this bill and encourage its adoption into other states.

Closing the Gap: A Systematic Review and Meta-Analysis of Enhanced Recovery After Surgery Protocols in Primary Cleft Palate Repair.

OBJECTIVE: Assess the evidence for Enhanced Recovery After Surgery (ERAS) protocols in the cleft palate population. DESIGN: A systematic review of MEDLINE, Embase, Cochrane, and CINAHL databases for articles detailing the use of ERAS protocols in patients undergoing primary palatoplasty. SETTING: New York-Presbyterian Hospital. PATIENTS/PARTICIPANTS: Patients with cleft palate undergoing primary palatoplasty. INTERVENTIONS: Meta-analysis of reported patient outcomes in ERAS and control cohorts. MAIN OUTCOME MEASURE(S): Methodological quality of included studies, opioid use, postoperative length of stay (LOS), rate of return to emergency department (ED)/readmission, and postoperative complications. RESULTS: Following screening, 6 original articles were included; all were of Modified Downs & Black (MD&B) good or fair quality. A total of 354 and 366 were in ERAS and control cohorts, respectively. Meta-analysis of comparable ERAS studies showed a difference in LOS of 0.78 days for ERAS cohorts when compared to controls (P < .05). Additionally, ERAS patients utilized significantly less postoperative opioids than control patients (P < .05). Meta-analysis of the rate of readmission/return to ED shows no difference between ERAS and control groups (P = .59). However, the lack of standardized reporting across studies limited the power of meta-analyses. CONCLUSIONS: ERAS protocols for cleft palate repair offer many advantages for patients, including a significant decrease in the LOS and postoperative opioid use without elevating readmission and return to ED rates. However, this analysis was limited by the paucity of literature on the topic. Better standardization of data reporting in ERAS protocols is needed to facilitate pooled meta-analysis to analyze their effectiveness.

Prepectoral Breast Reconstruction Without the Use of Acellular Dermal Matrix: A 3-Year Review.

INTRODUCTION: Acellular dermal matrix (ADM) is frequently used during prepectoral tissue expander-based breast reconstruction. However, there has been a paucity of literature describing the experience of prepectoral reconstruction without the accompanying use of ADM. We seek to highlight our institutional experience with immediate prepectoral tissue expander placement without the use of ADM in breast reconstruction. METHODS: A retrospective, single-institution review of patient records was performed to identify all patients who underwent either skin sparing or nipple-sparing mastectomy with immediate tissue expander placement without the use of ADM. Demographics including age, body mass index, comorbidities, history of smoking or steroid use, perioperative radiation or chemotherapy, intraoperative details, and complication profiles during the tissue expander stage were retrospectively collected and analyzed. At the time of tissue expander placement, all mastectomy flaps were evaluated clinically and with indocyanine green laser angiography. Postoperative outcomes were tracked. RESULTS: Between 2017 and 2020, 63 patients (for a total of 108 breasts) underwent either skin sparing (16%) or nipple-sparing mastectomy (84%) with immediate prepectoral tissue expander without ADM placement. Fourteen percent of breasts developed postoperative cellulitis, 19% of breasts developed skin compromise, and 5% required a postoperative revisional procedure that did not result in immediate expander explant. There was a 13% (n = 14 breasts) explant rate occurring at a mean time of 74 days. Of those breasts that developed skin compromise, 45% went on to require eventual explant. Patients in the study were followed for an average of 6.3 months. CONCLUSIONS: Immediate prepectoral breast reconstruction using tissue expanders without ADM offers a viable alternative to established reconstructive paradigms. The major complication rate for prepectoral reconstruction without the use of ADM (17%) was found to be comparable with our historical subpectoral tissue expander reconstruction with ADM use. Tissue expander explant rates were also comparable between the prepectoral without ADM (13%) and the subpectoral with ADM cohorts. These preliminary data suggest that immediate breast reconstruction with tissue expander placement without accompanying ADM is viable alternative in the breast reconstructive algorithm.

Patients and Procedures of Facial Gender Confirmation Surgery: A NSQIP Study.

ABSTRACT: Various recent developments, including legislation in 2014 banning healthcare discrimination against gender minorities, have contributed to expanding insurance coverage for gender-affirming care, which includes facial gender confirmation surgery (FGCS). Increasing evidence suggests FGCS improves quality-of-life outcomes, but literature evaluating FGCS patient demographics, surgical risk factors, procedures, and complications is limited. Therefore, the authors conducted a study of a national surgical database from 2005 to 2019 attempting to fill in these literature gaps. Statistics were used to assess temporal trends after 2014. A total of 203 FGCS cases were identified, with the earliest occurring in 2013. Case volume increased annually from 2015-2019. The average patient age was 34.0 years and racial demographics largely mirrored national estimates for the transgender/non-binary population. Obesity (20.7%) and hypertension (3.9%) were the only patient co-morbidities, although a relatively high proportion were underweight (5.4%). The majority of cases were outpatient procedures (66.5%) conducted by either plastic surgery (38.9%) or otolaryngology (61.1%). Comparing FGCSs by anatomic site, the proportion of tracheal procedures decreased between 2015-17 and 2018-19 (25.6% vs. 10.7%, P = 0.0002) whereas the proportion of brow/forehead reconstructions increased (32.6% versus 63.1%, P = 0.0005). These changes coincided with an increase in mean operative time (168.6 minutes versus 260.0, P = 0.0002). Complications were rare (3.9%), and the most common was surgical site infection (3.4%), a previously unreported outcome in the FGCS literature. Overall, FGCS patients are mostly young healthy individuals from diverse racial/ethnic backgrounds, and they have few surgical complications. The increasing volume and complexity of FGCSs may be a result of expanding insurance coverage for previously unaffordable procedures.

Department Versus Division: An In-Depth Analysis of Units of Plastic Surgery and Other Surgical Specialties at Their Institutions.

ABSTRACT: An increasing number of plastic and reconstructive surgery (PRS) units have transitioned from divisions to departments in recent years. This study aimed to identify quantifiable differences that may reflect challenges and benefits associated with each type of unit. We conducted a cross-sectional analysis of publicly-available data on characteristics of academic medical institutions housing PRS units, faculty size of surgical units within these institutions, and academic environments of PRS units themselves. Univariate analysis compared PRS divisions versus departments. Matched-paired testing compared PRS units versus other intra-institutional surgical departments. Compared to PRS divisions (n = 64), departments (n = 22) are at institutions with more surgical departments overall (P = 0.0071), particularly departments that are traditionally divisions within the department of surgery (ie urology). Compared to PRS divisions, PRS departments have faculty size that more closely resembles other intra-institutional surgical departments, especially for full-time surgical faculty and faculty in areas of clinical overlap with other departments like hand surgery. Plastic and reconstructive surgery departments differ from PRS divisions by certain academic measures, including offering more clinical fellowships (P = 0.005), running more basic science laboratories (P = 0.033), supporting more nonclinical research faculty (P = 0.0417), and training residents who produce more publications during residency (P = 0.002). Institutions with PRS divisions may be less favorable environments for surgical divisions to become departments, but other recently-transitioned divisions could provide blueprints for PRS to follow suit. Bolstering full-time surgical faculty numbers and faculty in areas of clinical overlap could be useful for PRS divisions seeking departmental status. Transitioning to department may yield objective academic benefits for PRS units.

The Epidemiology of Carpal Tunnel Revision Over a 1-Year Follow-Up Period.

PURPOSE: To establish the incidence of revision carpal tunnel surgery within a 1-year postoperative period using a national administrative database. This information has been unknown until this point because of the absence of laterality-specific coding with the International Classification of Diseases, Ninth Edition and earlier coding systems. METHODS: Data were collected from the Humana insurance database using PearlDiver patient records from 2015 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes related to carpal tunnel diagnosis and release. Codes were used to identify patients who underwent carpal tunnel release (CTR) and had revision CTR within a 1-year follow-up period. Patient demographic characteristics, including age, sex, medical comorbidities, and smoking status, were collected. In addition, multivariable analysis of the risk of a revision procedure within 1 postoperative year was performed to determine independent risk factors, including the surgical approach, associated with revision CTR. RESULTS: Among 4,549 patients who underwent a primary CTR during the study period, 207 patients (4.8%) underwent a revision CTR within 1 year. The average time from the primary CTR to the revision CTR was 135 days (standard deviation, 99.1 days; range, 21-365 days). Primary endoscopic CTR was associated with an increased rate of revision CTR (odds ratio, 1.3; 95% confidence interval, 1.2-1.6). Patient factors associated with a higher likelihood of requiring revision CTR included diabetes mellitus, tobacco use, psychiatric condition, cervical disease, and history of cubital tunnel release. CONCLUSIONS: This study identified a rate of revision CTR of 4.8% within the first postoperative year. Both the surgical technique and patient-specific risk factors influence the likelihood of requiring revision surgery. Notably, an endoscopic approach is associated with a higher risk of revision surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Reconstruction trends in New York City: A multi-decade, multi-institutional experience before and after the implementation of the Breast Cancer Provider Discussion Law.

INTRODUCTION: The potential benefits of breast reconstruction for achieving greater patient satisfaction, wellbeing, and functional outcomes after mastectomy have been widely acknowledged. However, sociodemographic and economic disparities exist in accessing reconstruction. This study aimed to characterize the influence of various factors on access to reconstruction and investigate the impact of the Breast Cancer Provider Discussion Law (BCPDL), legislation that mandates patient education and referral to plastic surgery at the time of breast cancer diagnosis, on utilization of reconstructive services. METHODS: Retrospective chart review was performed to collect data on patients who underwent mastectomy at two institutions within the New York-Presbyterian system from 1998-2019. Sociodemographic, past medical history, and treatment approach information were recorded. Interrupted time series analysis and logistic regression were used for statistical analysis. RESULTS: The cohort included 6122 patients, of which 3737 (61.04%) underwent reconstruction and 2385 (38.96%) did not. Older age, Medicaid/Medicare insurance, higher tumor staging, and Asian American/Pacific Islander identity were negative predictors of undergoing reconstruction. The interrupted time series analysis of the years before and the years after implementation of the 2010 BCPDL revealed that while there was an immediate increase in the proportion of patients who received reconstruction, the effects were not sustained. CONCLUSION: Our data indicates that patient-physician communication alone may not be sufficient to bridge the gap in reconstructive care. This study highlights the need for consistent plastic surgery referral for sustained equal access to reconstructive services.

The Role of Virtual Surgical Planning in Surgery for Complex Craniosynostosis.

Background: Virtual surgical planning (VSP) decreases reliance on intraoperative subjective assessment of aesthetic and functional outcomes in craniofacial surgery. Here, we describe our experience of using VSP for complex craniosynostosis surgery to inform preoperative decision making and optimize postoperative outcomes. Methods: Chart review was performed for children treated with craniosynostosis at our institution from 2015 to 2021. Eight VSP maneuvers were defined and assigned to each patient when applicable: (1) complex cranioplasty: combined autologous and synthetic; (2) autologous cranioplasty; (3) synthetic cranioplasty; (4) vector analysis and distractor placement; (5) complex osteotomies; (6) multilayered intraoperative plans; (7) volume analysis; and (8) communication with parents. Outcomes between VSP and non-VSP cohorts were compared. Results: Of 166 total cases, 32 were considered complex, defined by multisutural craniosynostosis, syndromic craniosynostosis, or revision status. Of these complex cases, 20 underwent VSP and 12 did not. There was no difference in mean operative time between the VSP and non-VSP groups (541 versus 532 min, P = 0.82) or in unexpected return to operating room (10.5% versus 8.3%, P = 0.84). VSP was most often used to communicate the surgical plan with parents (90%) and plan complex osteotomies (85%). Conclusions: In this cohort, VSP was most often used to communicate the surgical plan with families and plan complex osteotomies. Our results indicate that VSP may improve intraoperative efficiency and safety for complex craniosynostosis surgery. This tool can be considered a useful adjunct to plan and guide intraoperative decisions in complex cases, reducing variability and guiding parental expectations.

Incidence of Trigger Finger in Surgically and Nonsurgically Managed Carpal Tunnel Syndrome.

Purpose: The purpose of this study was to determine whether extremities undergoing carpal tunnel release (CTR) have an increased rate of trigger finger (TF) compared with conservatively managed carpal tunnel syndrome. Methods: Data were collected from the Humana Insurance Database, and subjects were chosen on the basis of a history of CTR with propensity matching performed to develop a nonsurgical cohort. Following propensity matching, 16,768 patients were identified and equally split between surgical and nonsurgical treatments. Demographic information and medical comorbidities were recorded. Univariate and multivariate analyses were performed to identify risk factors for the development of TF within 6 months of carpal tunnel syndrome diagnosis. Results: Patients in the surgical cohort were more likely to develop TF than those in the nonsurgical cohort whether in the ipsilateral or contralateral extremity. Whether managed surgically or nonsurgically, extremities with carpal tunnel syndrome demonstrated an increased prevalence of TF than their contralateral, unaffected extremity. Conclusions: Surgeons should be aware of the association of TF and CTR both during the presurgical and postsurgical evaluations as they might impact patient management. With knowledge of these data, surgeons may be more attuned to detecting an early TF during the postsurgical period and offer more aggressive treatment of TF pathology during CTR. Type of study/level of evidence: Prognostic III.

Concordance of National Insurance Criteria with WPATH Standards of Care for Gender-Affirming Surgery.

BACKGROUND: Given that gender-affirming surgery (GAS) is considered medically necessary for transgender and gender diverse (TGD) individuals who desire it, the aim of this study is to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (SOC-8). METHODS: Insurance policies for coverage of gender-affirming genital ("bottom surgery"), chest ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. Policies were classified into three categories: no-coverage (NC), case-by-case (CC), and preauthorization (PA). Among PA policies, criteria for coverage of specific surgeries were analyzed for adherence to WPATH SOC-8. RESULTS: Bottom surgery policies were most concordant for age and gender dysphoria criteria, and transmasculine top surgery policies were most concordant for hormone therapy, continuous living in a congruent gender role, and referral criteria. transfeminine top surgery criteria were more restrictive than transmasculine criteria. The most discordant criteria was for hormone therapy, being required for at least 12 months prior to surgery in the majority of surveyed policies. Many specific procedures and treatments were excluded, especially facial GAS with cosmetic overlap. Additionally, reversal and revisionary surgeries were covered in less than 25% of policies. CONCLUSION: Compared to previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care are still present for GAS.

National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery.

BACKGROUND: Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender diverse patients seeking gender-affirming surgeries (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aims to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage. METHODS: Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital and facial surgery. Policies were categorized based on previously published methodologies: never-covered (N), case-by-case (CC), and preauthorization (PA). The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions. RESULTS: Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%), respectively. Higher legislative scores in the Northeast and West, as well as individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS. CONCLUSION: Compared to previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap.

Magnetic Resonance Angiography of the Hand Vasculature in Patients With Systemic Sclerosis and Systemic Lupus Erythematosus.

BACKGROUND: When patients with systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) develop digital ischemia, conventional angiography (CA) is traditionally used to assess hand vasculature. Recently, Chang et al described an angiographic classification system for patients with SSc. Conventional angiography uses intravascular contrast agents that are nephrotoxic and vasoconstrictive. Owing to these limitations, this study assesses the use of contrast-enhanced magnetic resonance angiography (MRA) as an alternative to CA to evaluate hand vasculature in patients with digital ischemia. METHODS: This retrospective case series reports on 38 contrast-enhanced MRAs of hand vasculature from 30 symptomatic patients with SSc (N = 21) or SLE (N = 9). The radial and ulnar arteries (RA, UA) and the superficial and deep palmar arches were evaluated at standard reference points both quantitatively and qualitatively for their diameter, patency, and Chang classification. RESULTS: In SSc MRAs (n = 26), the UA was significantly smaller than the RA and was occluded in 46%. In SLE MRAs (n = 12), the UA and RA had no difference in diameter and the UA was occluded in 25%. In SSc, the most common Chang classification was type 2 (UA involvement) in 44%. In SLE, the most common Chang classification was type 4 (UA and RA involvement) in 45%, with 18% classified as type 2. CONCLUSIONS: Contrast-enhanced MRA used to assess hand vasculature in SSc patients with digital ischemia shows similar patterns of vascular involvement as previously demonstrated by CA. While vascular involvement in SSc predominantly involves the UA, the RA is also frequently involved in SLE.

Complications Associated with Contralateral Prophylactic Mastectomy: A Systematic Review and Meta-Analysis.

BACKGROUND: No meta-analysis has examined whether contralateral prophylactic mastectomy increases complication risk for unilateral breast cancer patients undergoing unilateral mastectomy. METHODS: Fifteen studies on complications of unilateral mastectomy plus contralateral prophylactic mastectomy met inclusion criteria. Meta-analyses compared complications of (1) diseased versus contralateral breasts in unilateral plus contralateral prophylactic mastectomy patients and (2) patients undergoing unilateral plus contralateral prophylactic mastectomy versus unilateral alone when grouped by reconstructive method. RESULTS: For all unilateral plus contralateral prophylactic mastectomy patients, the diseased breast was significantly more prone to complications versus the contralateral breast (relative risk, 1.24; p = 0.03). In studies that stratified by reconstructive method, the complication risk was significantly higher for unilateral plus contralateral prophylactic mastectomy versus unilateral mastectomy alone for patients with no reconstruction (relative risk, 2.03; p = 0.0003), prosthetic-based reconstruction (relative risk,1.42; p = 0.003), and autologous reconstruction (relative risk, 1.32; p = 0.005). The only prospective trial showed similar results, including for more severe complications. Smaller retrospective studies without stratification by reconstructive method showed similar complications for unilateral plus contralateral prophylactic mastectomy versus unilateral mastectomy alone (relative risk, 1.06; p = 0.70). These groups had similar incidences of complication-related delay in adjuvant therapy, as demonstrated by one study. CONCLUSIONS: After unilateral plus contralateral prophylactic mastectomy, diseased breasts are at higher risk for complications. Stronger evidence supports higher complication risk for unilateral plus contralateral prophylactic mastectomy than unilateral alone. More work is needed to determine the effect of complications on timing of adjuvant therapy.