Preferences and Barriers of Male Patients Seeking Aesthetic Procedures

BACKGROUND

As social attitudes toward plastic surgery continue to evolve, the prevalence of men seeking plastic surgery has been increasing. By delving into the factors that encourage male patients to seek plastic surgery and the obstacles they encounter, this study aims to facilitate the development of more inclusive and effective approaches for this population.

METHOD

An anonymous 41-question survey was conducted among adult men in the USA via the Amazon Mechanical Turk crowdsourcing platform. Questions assessed demographic information and identified factors that influenced males to seek plastic surgery care, the barriers they experienced while seeking care, and their preferences. Multivariate logistic regression was used to assess relationships between demographic variables and likelihood of undergoing cosmetic surgery.

RESULTS

Four hundred and eleven complete responses were analyzed. The median (IQR) age of respondents was 32 (30, 40) years old. Of the respondents, 60% had undergone cosmetic surgery. Functional improvement (40%), personal aspiration (32%), and partners' opinions (22%) were the most commonly cited reasons for undergoing procedures. The most common barriers faced by this population were recovery time following a procedure (52%), perceived risk of complications (48%), cost (43%), fear of being identified as having had plastic surgery (32%), and surgeons not being able to meet expectations (31%). Eighty-nine percent of respondents who underwent plastic surgery procedures reported facing at least one barrier. Multivariate regression demonstrated that higher education levels were strongly associated with a likelihood of undergoing cosmetic surgery (p < 0.001). Income (p = 0.44) and region (p = 0.23) did not significantly affect the likelihood of undergoing plastic surgery.

CONCLUSION

Despite improving societal stigma, many male patients continue to face barriers when obtaining plastic surgery care. Efforts may be made to alleviate these barriers and surgeons looking to expand their practice may benefit from increased outreach to male patients. This may be compounded with improved education targeting stigma and risks of procedures, increasing male-specific marketing communications to make them feel welcome in an industry predominantly focused on female patients, and offering male-tailored procedures.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND

The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes.

METHODS

A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases.

RESULTS

Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04).

CONCLUSIONS

Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Racial and ethnic representation in united states plastic surgery clinical trials: A systematic review and meta-analysis

In 1993, the National Institutes of Health Revitalization Act mandated increasing minority and women enrollment in clinical trials (CTs). This study aimed to investigate trends in race and ethnicity enrollment and reporting in US plastic and reconstructive surgery (PRS) CT.

METHODS

A comprehensive systematic review was performed. All CTs in PRS from 2012 to 2022 were included. To assess racial and ethnic representation within CTs, a random-effects meta-analysis of proportion was conducted to pool the prevalence of the binomial data.

RESULTS

A total of 3609 studies were initially identified in the search strategy, with 154 later classified as CTs in PRS. Only 36 met the eligibility criteria for reporting race and ethnicity and were included in the analysis. A total of 7281 participants were included: 446 (6.1%) males and 6835 (93.9%) females. From CTs that correctly reported race, the pooled prevalence of races were as follows: Whites 78% (95% confidence interval [CI] 73-82%), Black or African Americans 8% (95% CI 5-11%), Asians 1% (95% CI <1-2%), American Indians <1% (95% CI <1-<1%), and Pacific Islanders <1% (95% CI <1-<1%). From the studies that reported ethnicity correctly, the pooled prevalence of Hispanics was 7% (95% CI 5-9%), and Non-Hispanics was 12% (<1-38%).

CONCLUSIONS

Disparities in minority representation were present among PRS CTs. This suggests clear limitations in generalizing PRS CT results to the population. Efforts to decrease the gap in minority enrollment and accurately report race and ethnicity are needed in all fields, including plastic surgery.

The impact of race and ethnicity in outpatient breast reconstruction decision-making and postoperative outcomes: A propensity score-matched NSQIP analysis

BACKGROUND

Recent literature has established outpatient breast reconstruction (BR) to be a safe alternative to inpatient BR. However, the impact of race and ethnicity on BR patient decision-making and postsurgical outcomes remains unexplored. This study aims to assess the impact of race and ethnicity on outpatient BR timing and postoperative complication rates.

METHODS

The 2013-2020 ACS-NSQIP database was utilized to identify women undergoing outpatient BR. Propensity score-matched analysis was conducted to generate balanced cohorts based on race and ethnicity. t-tests and Fisher's exact tests were used to assess group differences. Logistic regressions were modeled to evaluate differences in complications between groups.

RESULTS

A total of 63,526 patients underwent outpatient BR. After propensity score matching, 7664 patients and 3948 patients were included in the race and ethnicity-based analysis, respectively. There were statistically significant differences in the timing of BR patients received across cohorts. NW patients had lower rates of immediate BR (IBR) compared with White patients (47% vs. 53%, p < 0.001), and this also was seen in Hispanic patients (97% vs. 3%, p = 0.018). Subsequently, there were higher rates of delayed BR (DBR) in the NW cohort (55% vs. 45%, p < 0.001) and in the Hispanic cohort (95% vs. 5%, p = 0.018). There were no significant differences in the rates of 30-day postoperative complications across cohorts.

CONCLUSIONS

Ultimately, our findings suggest that minority patients are more likely to undergo DBR than nonminority patients. However, there were no differences in 30-day postoperative outcomes across race or ethnicity. Future studies to elucidate patients' decision-making process in choosing optimal BR types and timing are necessary to better understand the impact of the observed differences in patient care.

Women in Plastic Surgery Innovation: A 10-Year Review of Gender Representation in Mammary Device Patents

BACKGROUND

This study aims to pioneer in evaluating women's representation in plastic surgery innovations, focusing on mammary prosthesis devices' inventorship. Despite growing gender parity in the field, women's involvement in innovation remains underexplored. This is especially crucial, as the predominant recipients of these innovative technologies are women, urging a necessity for broader female engagement in pioneering surgical advancements.

METHOD

Patents under the "A61F2/12: Mammary prostheses and implants" classification between the dates January 1, 2011, to December 31, 2020, were identified using Google Patents Advanced. Inclusion criteria included patents (not designs) in English and applications (not grants), with no litigation limitations. Data collected included ID, title, assignee (categorized as industry, academic, private, individual), inventors, and dates (priority, filing, and publication). Sex of inventors was identified with the literature validated gender API, with manual resolution of unresolved genders or with ga_accuracy scores of less than 75%. Data were analyzed using 2-tailed Student t tests, χ2 analysis, and Pearson correlation coefficient (significance set at P ≤ 0.05).

RESULTS

Of the more than 130,000 plastic surgery patents in English identified between the 10-year period, 1355 were classified as A61F2/12. A total of 374 unique patents were included for analysis (841 duplicates were removed, and 140 patents were excluded because of non-English character author names). There was a significant increase in patents over the decade (from 15 in 2011 to 88 in 2020, R2 = 0.74, P < 0.05), with a decrease in number of inventors per patent (R2 = 0.12, P < 0.05). Of the 1102 total inventors, 138 were female (11.2%), with a 4-fold increase in representation over the decade (R2 = 0.58, P < 0.05), including increase in patents filed with a woman first inventor (0%-14.8%). Women were equally likely to be first 3 inventors versus middle to last inventors (12.8% vs 11.1%, respectively).

CONCLUSIONS

Over a decade, mammary device innovations rose significantly. Although women inventors' representation improved, it remains disproportionate compared with women in residency/practice. Hence, interventions should aim to align inventor representation with training ratios, through institutional optimization, reducing gender segmentation, and enhancing funding opportunities.

Utilization of patient-reported outcome measures in plastic surgery clinical trials: A systematic review

BACKGROUND

Patient-reported outcomes (PROs) have evolved to validated questionnaires assessing health-related quality of life. This systematic review evaluates the utilization of PROs in United States plastic and reconstructive surgery (PRS) clinical trials (CTs).

METHODS

A medical librarian conducted a search strategy for PRS CTs from 2012 to 2022. CTs were identified and assessed for PRO utilization. Summary statistics were performed, and Fisher's exact test was used for subgroup analysis.

RESULTS

Of the 3609 studies initially identified, 154 were PRS CTs. Approximately half (80 studies) employed PROs, encompassing 13,190 participants, 95% (12,229) of whom were female. Among the CTs, 37 (48%) were in the field of reconstruction, while 25 (32%) were cosmetic. Pain (35%) and patient satisfaction (24%) were the most common primary outcomes. Validated PROs were the main outcome in 61% of these trials, with the visual analog scale (19%) and BREAST-Q (15%) as the top instruments. Funding was primarily private (34%) or not reported (49%). No significant trend in validated PRO usage was observed over the examined decade.

CONCLUSIONS

The use of PROs is relevant for healthcare delivery and improvement as they provide insight into the efficacy of treatments from a patient-centered viewpoint. PROs are reported in just over half of PRS CTs, and within those CTs, the use of validated questionnaires is inconsistent. Therefore, emerging CTs should strive to incorporate PRO measures and utilize the existing validated tools to assess novel interventions and ensure that the data reported is objective.

Does Frailty Predict Outcomes in Patients Undergoing Free or Pedicled Flap Procedures for Lower Extremity Limb Salvage? An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND

 Older and frailer patients are increasingly undergoing free or pedicled tissue transfer for lower extremity (LE) limb salvage. This novel study examines the impact of frailty on postoperative outcomes in LE limb salvage patients undergoing free or pedicled tissue transfer.

METHODS

 The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2010-2020) was queried for free and pedicled tissue transfer to the LE based on Current Procedural Terminology and the International Classification of Diseases9/10 codes. Demographic and clinical variables were extracted. The five-factor modified frailty index (mFI-5) was calculated using functional status, diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. Patients were stratified by mFI-5 score: no frailty (0), intermediate frailty (1), and high frailty (2 + ). Univariate analysis and multivariate logistic regression were performed.

RESULTS

 In total, 5,196 patients underwent free or pedicled tissue transfer for LE limb salvage. A majority were intermediate (n = 1,977) or high (n = 1,466) frailty. High frailty patients had greater rates of comorbidities-including those not in the mFI-5 score. Higher frailty was associated with more systemic and all-cause complications. On multivariate analysis, the mFI-5 score remained the best predictor of all-cause complications-with high frailty associated with 1.74 increased adjusted odds when compared with no frailty (95% confidence interval: 1.47-2.05).

CONCLUSION

 While flap type, age, and diagnosis were independent predictors of outcomes in LE flap reconstruction, frailty (mFI-5) was the strongest predictor on adjusted analysis. This study validates the mFI-5 score for preoperative risk assessment for flap procedures in LE limb salvage. These results highlight the likely importance of prehabilitation and medical optimization prior to limb salvage.

The impact of metabolic syndrome in breast reconstruction decision-making and postoperative outcomes: A nationwide analysis

BACKGROUND

Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities including hypertension, obesity, insulin resistance, and dyslipidemia. The safety profiles of patients with MetS undergoing breast reconstruction remain underreported. This study aims to evaluate the impact of MetS on the BR decision-making process and postoperative complication rates.

METHODS

The ACS-NSQIP database was utilized to identify women who underwent BR between 2012 and 2021. Baseline characteristics were compared based on the presence of MetS, defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Group differences were assessed using t tests and Fisher's exact tests. Multivariate logistic regression models evaluated postoperative complications between the groups.

RESULTS

A total of 160,115 patients underwent BR. A total of 4570 had a diagnosis of MetS compared to 155,545 without MetS. No statistically significant differences were observed in the type of BR patients received across cohorts. Logistic regression models demonstrated a higher likelihood of postoperative wound complications (OR 2.21; 95% CI 1.399, 3.478; p = 0.001), and readmission rates (OR 2.045; 95% CI 1.337, 3.128; p = 0.001) in the MetS group compared to the non-MetS patients. No significant differences were identified in other postoperative complications between groups.

CONCLUSIONS

Patients with MetS appear to have an increased risk of postoperative wound complications and readmission after breast reconstruction. The synergistic effects of these comorbidities on postoperative outcomes underscore the importance of addressing MetS as a holistic condition and considering choosing Delayed breast reconstruction over Immediate Breast Reconstruction in this population. Thus, integrating MetS management and patient counseling at various stages of BR may improve outcomes and facilitate patient decision-making.

Beyond Accreditation Council for Graduate Medical Education Required Scholarship: The Academic Journey of Plastic Surgery Residents

INTRODUCTION

Research productivity is an important part of required Accreditation Council for Graduate Medical Education scholarship during residency training and critical to trainees who intend to pursue careers in academia. This study aims to determine plastic surgery residents' experiences with and attitudes toward research.

METHODS

Accredited independent (52) and integrated (86) plastic surgery program websites were manually searched for currently active residents' names and email addresses. Identified residents were emailed a survey consisting of 25 questions through Research Electronic Data Capture.

RESULTS

A total of 45 plastic surgery residents responded to the survey request (14.6% response rate). Respondents were 57% female and 43% male, with an average age of 30.7 y. At the time of survey participation, 95% of surgery residents were involved in research endeavors, voluntarily or as part of their residency training. Of the respondents, 13 (32%) previously participated in a research fellowship compared to 28 (68%) respondents who did not. Interestingly, respondents who completed fellowships were 2.84 times (95% confidence interval: 0.52-15.38, P = 0.2269) more likely to intend continuing research endeavors after residency. Participants were most in agreement with statements suggesting their research fellowship benefitted their application in the plastic surgery match process (4 [interquartile range (IQR): 4, 4]), improved their ability to conduct research (4 [IQR: 4, 4]), and helped to better understand medical literature (4 [IQR: 3, 4]).

CONCLUSIONS

Plastic surgery programs' robust research emphasis has a favorable translation into residents' self-perceived understanding of medical literature and clinical knowledge.

Geographic Variability of Genital Gender-Affirming Surgery Centers and Costs of Hospitalization

PURPOSE

The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS.

METHODS

This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians.

RESULTS

A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively).

CONCLUSIONS

There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.

Outcomes of patients in rural communities undergoing autologous breast reconstruction: A comparison of cost and patient demographics with implications for rural health policy

BACKGROUND

Patients with breast cancer living in rural areas are less likely to undergo breast reconstruction. Further, given the additional training and resources required for autologous reconstruction, it is likely that rural patients face barriers to accessing these surgical options. Therefore, the purpose of this study is to determine if there are disparities in autologous breast reconstruction care among rural patients on the national level.

METHODS

The Healthcare Cost and Utilization Project Nationwide Inpatient Sample Database was queried from 2012 to 2019 using ICD9/10 codes for breast cancer diagnoses and autologous breast reconstruction. The resulting data set was analyzed for patient, hospital, and complication-specific information with counties comprised of less than 10,000 inhabitants classified as rural.

RESULTS

From 2012 to 2019, 89,700 weighted encounters for autologous breast reconstruction involved patients who lived in non-rural areas, while 3605 involved patients from rural counties. The majority of rural patients underwent reconstruction at urban teaching hospitals. However, rural patients were more likely than non-rural patients to have their surgery at a rural hospital (6.8% vs. 0.7%). Rural-county residing patients had lower odds of receiving a deep inferior epigastric perforator (DIEP) flap compared to non-rural-county residing patients (OR 0.51 CI: 0.48-0.55, p < .0001). Further, rural patients were more likely to experience infection and wound disruption than urban patients (p < .05), regardless of where they underwent surgery. Complication rates were similar among rural patients who received care at rural hospitals versus urban hospitals (p > .05). Meanwhile, the cost of autologous breast reconstruction was higher (p = .011) for rural patients at an urban hospital ($30,066.2, SD19,965.5) than at a rural hospital ($25,049.5, SD12,397.2).

CONCLUSION

Patients living in rural areas face disparities in health care, including lower odds of being potentially offered gold-standard breast reconstruction treatments. Increased microsurgical option availability and patient education in rural areas may help alleviate current disparities in breast reconstruction.

The Effect of Preoperative Diagnosis of Depression and/or Anxiety on Patient-Reported Outcomes Following Chest Wall Masculinization Surgery

BACKGROUND

Individuals with gender dysphoria have disproportionately high rates of depression and anxiety compared to the cisgender population. Although the benefits of gender affirmation surgery have been well documented, it is unclear whether depression and anxiety affect postoperative patient-reported outcomes (PRO).

OBJECTIVES

The authors evaluated the impact of preoperative anxiety or depression on clinical and PRO in patients undergoing chest masculinization surgery.

METHODS

Patients who underwent chest masculinization surgery within a 5-year period were reviewed. Demographics and clinical variables were abstracted from medical records. PRO of chest, nipple, and scar satisfaction were obtained postoperatively with the BODY-Q. Groups were stratified by preoperative anxiety, preoperative depression, both, or no history of mental health diagnosis. Univariate and multivariate analyses were performed.

RESULTS

Of 135 patients with complete survey responses, 10.4% had anxiety, 11.9% depression, 20.7% both diagnoses, and 57.0% no diagnosis. Clinical data and outcomes were similar. Patients with preoperative depression correlated with lower satisfaction scores for scar appearance (P = .006) and were significantly more likely to report feelings of depression postoperatively (P = .04). There were no significant differences in chest or nipple satisfaction among groups.

CONCLUSIONS

Although anxiety and depression are prevalent in gender minorities, we found no association with postoperative clinical outcomes. Patients with preoperative depression were more likely to report lower satisfaction with scar appearance and feelings of depression postoperatively. However, there were no differences in chest or nipple satisfaction. These results highlight the importance of perioperative mental health counseling but also suggest that patients can be satisfied with their results despite a coexisting mental health diagnosis.

LEVEL OF EVIDENCE: 4

A 4-Year Institutional Experience of Immediate Lymphatic Reconstruction

BACKGROUND

Up to one in three patients may go on to develop breast cancer-related lymphedema (BCRL) after treatment. Immediate lymphatic reconstruction (ILR) has been shown in early studies to reduce the risk of BCRL, but long-term outcomes are limited because of its recent introduction and institutions' differing eligibility requirements. This study evaluated the incidence of BCRL in a cohort that underwent ILR over the long term.

METHODS

A retrospective review of all patients referred for ILR at the authors' institution from September of 2016 through September of 2020 was performed. Patients with preoperative measurements, a minimum of 6 months of follow-up data, and at least one completed lymphovenous bypass were identified. Medical records were reviewed for demographics, cancer treatment data, intraoperative management, and lymphedema incidence.

RESULTS

A total of 186 patients with unilateral node-positive breast cancer underwent axillary nodal surgery and an attempt at ILR over the study period. Ninety patients underwent successful ILR and met all eligibility criteria, with a mean patient age of 54 ± 12.1 years and median body mass index of 26.6 kg/m 2 [interquartile range (IQR), 24.0 to 30.7 kg/m 2 ]. The median number of lymph nodes removed was 14 (IQR, eight to 19). Median follow-up was 17 months (range, 6 to 49 months). Eighty-seven percent of patients underwent adjuvant radiotherapy, and among them, 97% received regional lymph node irradiation. The overall rate of lymphedema was 9% at the end of the study period.

CONCLUSIONS

With the use of strict follow-up guidelines over the long term, the authors' findings support that ILR at the time of axillary lymph node dissection is an effective procedure that reduces the risk of BCRL in a high-risk patient population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Trends of Autologous Free-Flap Breast Reconstruction and Safety during the Coronavirus Disease 2019 Pandemic

BACKGROUND

 Autologous free-flap breast reconstruction (ABR) is a valuable surgical option for patients following mastectomy. The coronavirus disease 2019 (COVID-19) pandemic has led to a myriad of factors that have affected access to care, hospital logistics, and postoperative outcomes. This study aims to identify differences in patient selection, hospital course and severity, and postoperative outcomes for patients who underwent ABR during and prior to the COVID-19 pandemic.

METHODS

 Patients undergoing ABR from the American College of Surgeons National Surgical Quality Improvement Program 2019 to 2020 database were analyzed to compare sociodemographics, hospital course, and outcomes over the first postoperative month. Multivariable logistic regression was used to identify factors predictive of complications based on the operative year.

RESULTS

 In total, 3,770 breast free flaps were stratified into two groups based on the timing of reconstruction (prepandemic and pandemic groups). Patients with a diagnosis of disseminated cancer were significantly less likely to undergo ABR during the COVID-19 pandemic. On univariate analysis, there were no significant differences in postoperative complications between the two groups. When controlling for potentially confounding sociodemographic and clinical risk factors, the COVID-19 group was significantly more likely to undergo reoperation compared with the prepandemic group (p < 0.05).

CONCLUSION

 When comparing outcomes for patients who underwent ABR prior to and during the COVID-19 pandemic, we found a significant increase in the odds of reoperation for those who had ABR during the pandemic. Debridement procedures and exploration for postoperative hemorrhage, thrombosis, or infection increased in the prepandemic group compared to the COVID-19 group. Notably, operative times decreased.

Identification of genetic variants associated with anterior cruciate ligament rupture and AKC standard coat color in the Labrador Retriever

Canine anterior cruciate ligament (ACL) rupture is a common complex disease. Prevalence of ACL rupture is breed dependent. In an epidemiological study, yellow coat color was associated with increased risk of ACL rupture in the Labrador Retriever. ACL rupture risk variants may be linked to coat color through genetic selection or through linkage with coat color genes. To investigate these associations, Labrador Retrievers were phenotyped as ACL rupture case or controls and for coat color and were single nucleotide polymorphism (SNP) genotyped. After filtering, ~ 697 K SNPs were analyzed using GEMMA and mvBIMBAM for multivariate association. Functional annotation clustering analysis with DAVID was performed on candidate genes. A large 8 Mb region on chromosome 5 that included ACSF3, as well as 32 additional SNPs, met genome-wide significance at P < 6.07E-7 or Log10(BF) = 3.0 for GEMMA and mvBIMBAM, respectively. On chromosome 23, SNPs were located within or near PCCB and MSL2. On chromosome 30, a SNP was located within IGDCC3. SNPs associated with coat color were also located within ADAM9, FAM109B, SULT1C4, RTDR1, BCR, and RGS7. DZIP1L was associated with ACL rupture. Several significant SNPs on chromosomes 2, 3, 7, 24, and 26 were located within uncharacterized regions or long non-coding RNA sequences. This study validates associations with the previous ACL rupture candidate genes ACSF3 and DZIP1L and identifies novel candidate genes. These variants could act as targets for treatment or as factors in disease prediction modeling. The study highlighted the importance of regulatory SNPs in the disease, as several significant SNPs were located within non-coding regions.

Impact of financial well-being on gender affirmation surgery access and hospital course

BACKGROUND

Although gender affirmation surgery (GAS) can effectively treat gender dysphoria, it remains one of the most expensive components of gender affirming care. This study aims to identify the impact of financial well-being on GAS access and hospital course in the United States.

METHODS

The National Inpatient Sample database was queried from 2012 to 2019. US transgender patients undergoing GAS were identified. Predictors included patient sociodemographic variables. Outcomes included hospitalization course variables. Regression modeling was used to assess the relationship between predictor and outcome variables. Significance was set at α = 0.05.

RESULTS

A total of 5620 weighted GAS encounters were identified (genital surgery 92.3%, chest surgery 16.6%). 1825 (32.5%) patients were in the highest income bracket, compared with 1120 (19.9%) patients in the lowest bracket. Higher income was associated with younger age at the time of GAS. Patients in the highest income quartile were also 3.7 times more likely to be funded by private insurance and self-pay options than those in the lowest income quartile (95% confidence interval [CI]: 3.1-4.4, p < 0.0001). Additionally, patients in the lowest income quartile were 4.2 times more likely to require either home healthcare or transfer to a nursing facility post discharge than those in the highest income quartile (95% CI: 3.1-5.8, p < 0.001).

CONCLUSIONS

To promote equitable care to transgender patients, efforts to reduce financial barriers to healthcare access are much needed, particularly through broader insurance coverage of GAS procedures. Broadly, our results highlight the impact of socioeconomic variables on healthcare access and outcomes.

Sources of Facial Injury Across Age Groups: A Nationwide Overview Using the National Electronic Injury Surveillance System Database

BACKGROUND

Facial trauma comprises a significant portion of injuries that occur each year in the United States, with injuries ranging from lacerations to complex facial fractures. This study aims to provide a broad epidemiologic overview of facial trauma in the United States to direct preventative safety measures.

METHODS

A cross-sectional study was conducted utilizing the National Electronic Injury Surveillance System database to identify the weighted national incidence of facial injuries from 2017 to 2021. Descriptive and inferential statistical analysis was used to compare the demographics of patients, the settings where the injury occurred, and the products resulting in the injury.

RESULTS

A total of 8,465,538 out of 64,312,132 weighted encounters involved facial injuries. Less than 10 years was the highest-represented age group (36.8%). The most frequent disposition was treated and released (91.1%), with increasing age associated with higher rates of hospitalization (odds ratio: 1.04, P < 0.001). Cases predominantly occurred at home (49.0%), and the most common type of injury was laceration (36.5%). At-home injuries increased with age, comprising 39.2% of facial injuries for 21 to 40 years, 52.0% for 41 to 64 years, and 58.0% for older than 65 years. Building structures (21.4%) were the most prevalent source of injury, composed predominantly of floors (58.3%) and ceilings and walls (10.4%).

CONCLUSIONS

There is an understated burden of at-home facial injuries across all age groups, beyond the pediatric and geriatric population. Fall prevention and home environmental hazards education could benefit all ages, reducing the incidence of facial trauma.

Variable Anatomy of the Lateral Upper Arm Lymphatic Channel: An Anatomical Risk Factor for Breast Cancer-Related Lymphedema

BACKGROUND

The lateral upper arm channel is an accessory lymphatic pathway that drains the upper extremity by means of the deltopectoral groove and supraclavicular nodes, thereby bypassing the axilla. Its variable connectivity to the forearm has not been studied in vivo.

METHODS

Indocyanine green (ICG) lymphography was performed preoperatively to map the superficial and functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, ICG imaging, and surgical data.

RESULTS

Sixty patients underwent ICG lymphography before axillary lymph node dissection between June of 2019 and October of 2020. In 59%, the lateral upper arm lymphatic channel was contiguous with the forearm (long bundle). In 38%, the lateral upper arm lymphatic channel was present but not contiguous with the forearm (short bundle). In 3%, the lateral upper arm pathway was entirely absent. Seven patients developed at least one sign of lymphedema during postoperative surveillance, of which 71% demonstrated the short bundle variant.

CONCLUSION

Although the lateral upper arm pathway is most often present, its connections to the forearm are frequently absent (short bundle), which, in this pilot report, appears to represent a potential risk factor for the development of lymphedema.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, V.

A National Analysis of Socioeconomic Variables of Access to Inpatient Body Contouring Procedures After Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery often results in excess skin, which has led to a population of patients seeking body contouring surgery (BCS). This study aimed to investigate the prevalence of patients who underwent BCS following bariatric surgery using the national inpatient sample (NIS) database and to assess the demographic and socioeconomic variables of this cohort.

METHODS

NIS database was queried from 2016 to 2019 using ICD-10 codes to identify patients that underwent bariatric surgery procedures. Patients who subsequently underwent BCS were compared to those who did not. Multivariate logistic regression was used to identify factors associated with receipt of BCS.

RESULTS

A total of 263,481 patients that underwent bariatric surgery were identified. Of those, 1777 (0.76%) patients underwent subsequent inpatient BCS. Being female was associated with greater odds of undergoing body contouring (OR 1.28 95% CI 1.13-1.46, p = 0.0001). Patients who underwent BCS were more likely to have their procedure performed in large and government-controlled hospitals than bariatric surgery-only patients (55% vs. 50%, p < 0.0001, and 11% vs. 9.4%, respectively). Higher-income did not impose higher odds of receiving BCS compared to lowest income quartile (OR 0.99, 95% CI 0.86-1.16, p = 0.99066). Lastly, compared to Medicare holders, self-payers (OR 3.5, 95% CI 2.83-4.30, p < 0.0001) or private insurance (OR 1.23, 95% CI 1.09-1.40, p = 0.001) had greater odds of undergoing BCS.

CONCLUSIONS

There is a gap in access to BCS procedures, with cost and insurance coverage being the principal barriers. Developing policies that allow for holistic evaluation of patients is crucial to improve access to these procedures.

Edematous Dermal Thickening on Magnetic Resonance Imaging as a Biomarker for Lymphatic Surgical Outcomes

Background and Objectives: One of the surgical treatments for breast cancer-related lymphedema (BCRL) is debulking lipectomy. The aim of this study is to investigate whether dermal thickness could be utilized as an objective indicator of post-operative changes following debulking. Materials and Methods: A retrospective review of BCRL patients who underwent debulking lipectomy was conducted. MRI-based dermal thickness was measured by two separate trained readers at 16 regions of the upper extremity. Pre- and post-operative reduction in dermal thickness was compared across the affected and unaffected (control) arms for each patient. The Wilcoxon rank sum test was used to assess for significant change. Univariate linear regression was used to assess the relationship between dermal thickness reduction and changes to LYMPH-Q scores, L-Dex scores, and relative volume change. Results: Seventeen patients were included in our analysis. There was significant reduction in dermal thickness at 5/16 regions in the affected arm. Dermal thickness change was significantly correlated with LYMPH-Q scores, L-Dex scores, and relative volume change in 2/16 limb compartments. There was predominant dermal thickening in the dorsal compartment of the upper arm and in the ventral and ulnar compartments of the forearm. Conclusions: Dermal thickness shows promising utility in tracking post-operative debulking procedures for breast cancer-related lymphedema. Further studies with larger patient populations and a variety of imaging modalities are required to continue to develop a clinically objective and reproducible method of post-surgical lymphedema staging and monitoring.

Non-Linear Lymphatic Anatomy in Breast Cancer Patients Prior to Axillary Lymph Node Dissection: A Risk Factor For Lymphedema Development

Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has become increasingly utilized for the prevention of breast cancer related lymphedema. Preoperative indocyanine green (ICG) lymphography is routinely performed prior to an ILR procedure to characterize baseline lymphatic anatomy of the upper extremity. While most patients have linear lymphatic channels visualized on ICG, representing a non-diseased state, some patients demonstrate non-linear patterns. This study aims to determine potential inciting factors that help explain why some patients have non-linear patterns, and what these patterns represent regarding the relative risk of developing postoperative breast cancer related lymphedema in this population. A retrospective review was conducted to identify breast cancer patients who underwent successful ILR with preoperative ICG at our institution from November 2017-June 2022. Among the 248 patients who were identified, 13 (5%) had preoperative non-linear lymphatic anatomy. A history of trauma or surgery of the affected limb and an increasing number of sentinel lymph nodes removed prior to ALND appeared to be risk factors for non-linear lymphatic anatomy. Furthermore, non-linear anatomy in the limb of interest was associated with an increased risk of postoperative lymphedema development. Overall, non-linear lymphatic anatomy on pre-operative ICG lymphography appears to be a risk factor for developing ipsilateral breast cancer-related lymphedema. Guided by the study's findings, when breast cancer patients present with baseline non-linear lymphatic anatomy, our institution has implemented a protocol of prophylactically prescribing compression sleeves immediately following ALND.