Medicaid coverage for gender-affirming surgery: A state-by-state review.

OBJECTIVE: To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage. DATA SOURCES AND STUDY SETTING: Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals. STUDY DESIGN: A cross-sectional study evaluating Medicaid coverage for numerous gender-affirming surgeries. DATA COLLECTION/EXTRACTION METHODS: We previously reported on state health policies that protect gender-affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender-affirming surgery. We analyzed Medicaid coverage for gender-affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described. PRINCIPAL FINDINGS: Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender-affirming chest procedure and at least one gender-affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate. CONCLUSIONS: In 2022, 52.9% of states had health policies that protected gender-affirming care under Medicaid; however, coverage for various gender-affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction.

Domestic and International Cosmetic Tourism Complications Presenting to a U.S. Tertiary Hospital.

BACKGROUND: Cosmetic surgery tourism has become a significant global industry. Oftentimes, patients who develop postoperative complications present for care in their home U.S. state. OBJECTIVES: This study evaluated patients who either traveled abroad or to other states within the United States for cosmetic surgeries and returned with complications treated in the authors' center. We sought to compare rates of complications between patients that underwent cosmetic surgery internationally and domestically. METHODS: This retrospective cross-sectional study reviewed patients who presented from June 2014 to June 2022 with concerns related to cosmetic surgeries performed in another state or abroad. Binary logistic regressions were performed to assess differences in outcomes between domestic and international cases, including complications, interventions, and admissions. RESULTS: One-hundred twenty-three patients (97.6% female, me an age 34.0 ± 8.7 years, range 16-62 years) comprised 159 emergency department consultations. The most common procedures included abdominoplasty (n=72) and liposuction (n=56). Complications included wound dehiscence (n=39), infection (n=38), and seroma (n=34). Over one-half of patients required intervention. Twenty-nine patients (23.6%) required hospital admission. On multivariate regression analyses, incidence of seroma (p=0.025) and oral (p=0.036) and intravenous antibiotic prescriptions (p=0.045) were significantly greater among the international cohort compared to domestic, whereas all other complication variables were non-significant. There were no other significant differences in operative interventions or hospital admissions between international and domestic cohorts. CONCLUSIONS: Compared to domestic tourism cases, international tourism cases were associated with significantly higher rates of seroma formation and antibiotic use. There were no significant differences otherwise in overall complications including infections, operative interventions, or hospital admissions.

United States Health Policies on Gender-Affirming Care in 2022.

BACKGROUND: Within the United States, access to gender-affirming operations covered by health insurance has increased dramatically over the past decade. However, the perpetually changing landscape and inconsistencies of individual state health policies governing private and public insurance coverage present a lack of clarity for reconstructive surgeons and other physicians attempting to provide gender-affirming care. This work systematically reviewed the current U.S. health policies for both private insurance and Medicaid on a state-by-state basis. METHODS: Individual state health policies in effect as of August of 2022 on gender-affirming care were reviewed using the LexisNexis legal database, state legislature publications, and Medicaid manuals. Primary outcomes were categorization of policies as protective, restrictive, or unclear for each state. Secondary outcomes included analyses of demographics covered by current health policies and geographic differences. RESULTS: Protective state-level health policies related to gender-affirming care were present in approximately half of the nation for both private insurance (49.0%) and Medicaid (52.9%). Explicitly restrictive policies were found in 5.9% and 17.6% of states for private insurance and Medicaid, respectively. Regionally, the Northeast and West had the highest rates of protective policies, whereas the Midwest and South had the highest rates of restrictive policies on gender-affirming care. CONCLUSIONS: State-level health policies on gender-affirming care vary significantly across the United States with regional associations. Clarity in the current and evolving state-specific health policies governing gender-affirming care is essential for surgeons and physicians caring for transgender and gender-diverse individuals.

Long-term outcomes of sphincter pharyngoplasty in patients with cleft palate.

OBJECTIVE: The purpose of this study was to evaluate long-term outcomes of sphincter pharyngoplasties, including speech outcomes, revision surgeries, and postoperative incidence of obstructive sleep apnea (OSA). DESIGN: Retrospective matched-cohort study SETTING: Two craniofacial centers in Los Angeles, CA PATIENTS: Patients (n = 166) with cleft lip and palate (CLP) or isolated cleft palate (iCP) who underwent sphincter pharyngoplasty from 1992 to 2022 were identified. An age- and diagnosis-matched control group of 67 patients with CLP/iCP without velopharyngeal insufficiency (VPI) was also identified. INTERVENTIONS: The pharyngoplasty group underwent sphincter pharyngoplasty, whereas the non-VPI group had no history of VPI surgery or sphincter pharyngoplasty. MAIN OUTCOME MEASURES: Postoperative speech outcomes, revision surgeries, and incidence of OSA were evaluated. Multivariable regression was used to evaluate independent predictors of OSA. RESULTS: Among the patients in the pharyngoplasty cohort, 63.9% demonstrated improved and sustained speech outcomes after a single pharyngoplasty, with a median postoperative follow-up of 8.8 years (interquartile range [IQR], 3.6-12.0 years). One-third of the patients who underwent pharyngoplasty required a revision surgery, with a median time to primary revision of 3.9 years (IQR, 1.9-7.0 years). OSA rates increased significantly among the pharyngoplasty cohort, from 3% before surgery to 14.5% after surgery (p < 0.001). The average time from sphincter pharyngoplasty to OSA diagnosis was 4.4 ± 2.4 years. Multivariable analysis results indicated that sphincter pharyngoplasty surgery was independently associated with a fourfold increase in OSA (p = 0.03). CONCLUSIONS: Although sphincter pharyngoplasty remains successful in improving long-term speech outcomes, persistent OSA is a sequela that should be monitored beyond the immediate postoperative period.

Bone-Anchored Maxillary Protraction for Adolescents with Cleft Palate and Class III Malocclusion: A Case Series.

To describe the long-term treatment course of bone-anchored maxillary protraction (BAMP) and evaluate orthognathic surgical indications after BAMP.Retrospective case series.Craniofacial/Cleft Palate Program at the Orthopaedic Institute for Children in Los Angeles, CA.Twelve male patients with cleft palate (CP), unilateral cleft lip and palate (UCLP), or bilateral cleft lip and palate (BCLP) and Class III malocclusion treated with BAMP (mean age: 11.4 ± 2.6 years) were included.BAMP treatment was performed by placement of bone-anchored maxillary and mandibular plates connected with intraoral Class III dental elastics or maxillary plates connected to a facemask.We retrospectively assessed BAMP treatment variables, including age at surgery, revision surgeries, and treatment duration. The primary goal was correction to class I occlusion.Twelve patients underwent BAMP treatment for an average of 4.4 ± 2.4 years. Two patients were corrected to class I occlusion at the time of this report. Le Fort I advancement was no longer required in two patients (16.7%), it was required for nine patients (75.0%) and was completed for one patient following BAMP treatment (8.3%).This preliminary report demonstrated that BAMP treatment may be associated with a minimal reduction in the requirement for Le Fort I advancement at skeletal maturity. Future studies with larger sample sizes are necessary to confirm this association.

Duration of Feminizing Hormone Therapy on Facial Fat Volumes.

BACKGROUND: Gender-affirming feminizing hormone therapy induces body fat redistribution. However, the amount and timing of facial fat changes in response to feminizing hormone therapy are unknown, albeit relevant to counseling and surgical planning for facial gender-affirming surgery. In this work, we assessed the influence of feminizing hormone therapy duration on malar and temporal fat volume. METHODS: Malar and temporal fat volumes were compared using computed tomography in transfeminine patients (age 20-29 years, body mass index [BMI] 18.5-24.9) treated with feminizing hormone therapy for <2 years versus ≥2 years. Patients with prior surgical or non-surgical facial soft-tissue interventions were excluded. Multivariable linear regressions evaluated the contribution of hormone therapy duration to malar and temporal fat volumes. RESULTS: 45 patients were included with 30 patients (66.7%) treated with feminizing hormone therapy for ≥2 years and 15 patients (33.3%) treated for <2 years (median[interquartile range, IQR]: 44.5[33.5-65.6] vs. 15.0[11.0-18.0] months, p<0.001). Patients treated with hormone therapy for ≥2 years demonstrated a 1.6-fold greater malar fat volume (5.5[4.2-6.3] vs. 3.4[2.3-4.2] cm 3,p<0.001) and 1.4-fold greater temporal fat volume (2.8[2.4-3.6] cm 3 vs. 2.0[1.7-2.4] cm 3, p=0.01) compared to those treated for <2 years. When accounting for other contributory variables such as BMI, skull size, and total soft-tissue depth in multivariable linear regression models, hormone therapy duration ≥2 years independently predicted higher malar (ß=0.51, p<0.001) and temporal (ß=0.32, p=0.02) fat volumes. CONCLUSIONS: Feminizing hormone therapy increases malar and temporal fat volumes by approximately 2 cm 3 and 0.8 cm 3 for each area, respectively, after 2 years of treatment.

Sarcopenia Best Predicts Complications in Free Flap Breast Reconstruction.

Breast reconstruction remains a major component of the plastic surgeon's repertoire, especially free-flap breast reconstruction (FFBR), though this is a high-risk surgery in which patient selection is paramount. Preoperative predictors of complication remain mixed in their utility. We sought to determine whether the sarcopenia score, a validated measure of physiologic health, outperforms the body mass index (BMI) and modified frailty index (mFI) in terms of predicting outcomes. Methods: All patients with at least 6-months follow-up and imaging of the abdomen who underwent FFBR from 2013 to 2022 were included in this study. Appropriate preoperative and postoperative data were included, and sarcopenia scores were extracted from imaging. Complications were defined as any unexpected outcome that required a return to the operating room or readmission. Statistical analysis and regression were performed. Results: In total, 299 patients were included. Patients were split into groups, based on sarcopenia scores. Patients with lower sarcopenia had significantly more complications than those with higher scores. BMI and mFI both did not correlate with complication rates. Sarcopenia was the only independent predictor of complication severity when other factors were controlled for in a multivariate regression model. Conclusions: Sarcopenia correlates with the presence of severe complications in patients who undergo FFBR in a stronger fashion to BMI and the mFI. Thus, sarcopenia should be considered in the preoperative evaluation in patients undergoing FFBR.

Legal Penalties for Physicians Providing Gender-Affirming Care.

This Viewpoint explains the "legal limbo" physicians may find themselves in, straddling state laws banning gender-affirming care and federal nondiscrimination law, both of which remain unclear due to ongoing legal challenges in the courts.