ABSTRACT
Background: Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals. Methods: The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects. Results: For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed. Conclusions: In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.
ABSTRACT
OBJECTIVES: Military surgeons have been providing humanitarian care in Afghanistan since 2002. There are scant published reports on the details of that care. We report here the experience of deployed U.S. Army general surgeons in the management of an endemic problem, bladder stones in Afghan children. METHODS: A retrospective review was performed of pediatric patients presenting to an International Security Assistance Force humanitarian clinic over a 12-month period from October 2010 to November 2011. Symptoms at presentation, diagnostic modalities, and treatment provided were analyzed. The general surgeons of the 126th Forward Surgical Team (FST) provided surgical consultations for this military humanitarian clinic on a remote base in western Afghanistan. RESULTS: Eight male pediatric patients of an average age of 4 years presented with dysuria and underwent further evaluation. In five patients, the use of a portable ultrasound machine led to the diagnosis of bladder stones. Three other patients presented with ultrasound exams from an Afghan clinic. Four patients underwent surgical removal of their bladder stones by the FST and 4 four patients, including one with a recurrent bladder stone, were referred to a distant Afghan Regional Hospital. No short-term complications occurred in the five patients available for follow-up. CONCLUSIONS: Military surgeons providing humanitarian care in rural areas of Afghanistan, and humanitarian surgeons serving in endemic areas, can expect to encounter multiple cases of bladder stones in pediatric patients. Dysuria is a typical presenting symptom. The FST has the resources to diagnose and treat this disorder. If accessible, Afghan regional hospitals can provide curative surgery.
