Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System.

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.

Applying Principles of Evolutionary Biology to Plastic Surgery at an Organizational Level Predicts an Extinction Event.

As an organized profession, plastic surgery struggles delivering a clear message regarding scope of practice to patients given the diversity of procedures performed. Whereas granting licensure to practice medicine resides with governmental bodies, certification rests with organizations. However, certification is not required to practice plastic surgery. Since plastic surgery operationalizes techniques rather than working within a defined body organ, competition for patients is intense. Mapping territorial interactions between healthcare providers while parsing taxonomy elucidates individual, community, organizational, and governmental levels, creating various selection pressures. Applying evolutionary biology as a framework predicts the termination of plastic surgery over time as a unique specialty. An entirely new domain, Restorative Healthcare, is proposed which circumvents an extinction outcome.

Downstream Impact for Plastic Surgeons in the United States from the "No Surprises Act".

The No Surprises Act, signed into the US federal law in 2020, establishes a floor for reimbursement determined by insurance payors for out-of-network charges rendered by providers in emergency services. Physicians are not permitted to balance bill patients for the difference. An arbitration process is outlined for mediation between provider and payor if needed. Methods: Policy analysis demonstrates many plastic surgeons utilize a revenue stream including both fee-for-service cosmetic work and insurance-covered reconstructive intervention. For Maintenance of Certification from the American Board of Plastic Surgery and/or membership to the American Society of Plastic Surgeons, plastic surgeons must operate only in accredited facilities, which in turn require that similar privileges are held in a hospital. Results: Given rapidly developing economic pressures, hospitals no longer remain neutral sites for surgical privileging as they seek strategies to mitigate financial loss by directly competing for patients. A downstream consequence of the requirement for hospital privileging is that plastic surgeons are forced to manage increasing on-call responsibilities despite shrinking reimbursement. Plastic surgeons whose board certification was the first to be time-limited are now reaching the stage of practice where they may transition exclusively to out-patient services. Conclusions: Plastic surgeons in independent solo or small group practices are rendered vulnerable since they may not be able to find coverage of in-patient responsibilities at lower reimbursement rates. Rather than allowing loss of board certification in this population, rational alternatives on an organizational level are proposed for keeping the process equitable as plastic surgeons progress along the practice pathway.

Socio-Ecologic Perspective: Barriers Complicating Post-Intensive Care Syndrome Mitigation.

Objective:Post-intensive care syndrome (PICS) is a phenomenon whereby survivors of an intensive care unit (ICU) admission subsequently experience issues with physical, cognitive, or mental health status persisting beyond the acute hospitalization. Risk factors for developing PICS include prolonged mechanical ventilation with sedation and immobility. PICS is a devastating illness that negatively alters the life path of many individuals with tremendous economic impact. Methods: This qualitative study employed a grounded theory approach to understand the systemic barriers blocking mitigation and treatment of PICS in all seven ICUs across Essex County, New Jersey (NJ) through semi-scripted interviews conducted with 11 members of the healthcare teams with at least one from each site. Thematic analysis was performed with open, axial, and selective coding. Results: Applying socio-ecologic viewpoint to data illustrate significant barriers on both an interpersonal and organizational level that decrease the operationalization of PICS mitigation measures as identified by healthcare providers. Of those interviewed, eight (73%) were physicians and the remaining were nurses. Significant thematic issues included understanding the risk factors of PICS but feeling powerless to institute mitigation efforts; experiencing lack of enthusiasm due to the absence of institutionalized mitigation protocols; noting frustration about closing the gap between academic recommendations and the ability to operationalize these appropriately; and feeling unable to effectuate meaningful change. Conclusion: Providing education to the target population and healthcare provider stakeholders regarding the barriers against PICS mitigation can alter the status quo.

Non-Melanoma Skin Cancers in the Older Patient.

PURPOSE OF REVIEW: The incidence of non-melanomatous skin cancer (NMSC) increases with age and there are specific considerations regarding management of NMSC for the older patient population. Here we will review current data regarding treatment considerations and options for older patients with NMSC. RECENT FINDINGS: Hypofractionated regimens and high-dose brachytherapy may be non-surgical treatment options for older patients with NMSC. Other less aggressive strategies such as active surveillance can also be considered in some settings. Management of NMSC in the older patient population requires a thorough assessment of comorbidities, frailty, and life expectancy. Additionally, discussions regarding goals of care and quality of life (QOL) issues are especially important in this population. Older patients with NMSC in particular may benefit from a tailored treatment plan based on current available data rather than a broad application of general treatment guidelines for NMSC.

Consultation for Simple Laceration Repair When On-Call in the Emergency Department: Potential Quagmire.

What are the forces obligating a plastic surgeon who is on-call for the emergency department to respond to a consultation request for repair of a simple laceration? Although the duties are clear in cases of obvious surgical emergency, ambiguity and subsequent conflict may arise when the true nature of the emergency is less clear. Does the consultant's clinical discretion dictate the obligation in the case of a simple laceration; or is it subservient to either the discretion of the requesting health-care provider or even the patient? Do federal statutes such as the Emergency Medical Treatment and Labor Act, or perhaps more local rules apply, such as the by-laws of the hospital? It would behoove all medical practitioners to familiarize themselves with both the legal and moral implications of these issues. Having legitimate policies in place which actively address those situations where the consultative obligation is unclear is critical to resolve potential conflict.

Closing the Generational Gap in Surgery: Why So Angry?

Significant and rapid changes in healthcare delivery are forcing surgeons into collaborative teams. Additionally, surgeons are faced with new bureaucratic requirements that do not directly impact patient care, but nevertheless require allocation of time and attention. Surgeons are required to communicate with an expanding group of individuals at various professional levels, adding further stress to daily tasks. Even the method of communication is undergoing rapid transformation. Some surgeons, especially those who are members of the Boomer or X Generation, find this revolution difficult to manage; whereas those who are members of the Y Generation may in fact be better equipped. Surgeons who either refuse to acknowledge these changes or simply lack emotional self-awareness run the risk of being labeled as disruptive. Behavioral techniques are explored which may help those surgeons who are having difficulty.

Identifying and managing those patients at risk for aborted mohs micrographic surgery.

BACKGROUND: Treatment of nonmelanoma cutaneous carcinoma with Mohs micrographic surgery (MMS) is a well-recognized therapy. However, there are infrequent times when MMS must be aborted before achieving adequately clear margins. Reasons cited by those who have aborted MMS include patient discomfort and/or concern regarding damage to deeper structures. METHODS: A retrospective cohort was created consisting of patients who were referred for reconstructive procedures following MMS during a 4-year period. Patients who experienced aborted MMS were identified from this cohort, and a chart review performed. RESULTS: The overall occurrence of aborted MMS in the community was significantly less than 1% with a cumulative frequency in this particular reconstructive cohort of 1.7%. Approximately one-third of patients had persistent tumor on subsequent treatment, and approximately 14% required multiple excisional procedures to clear tumor. Risk factors for experiencing aborted MMS include histology of dermatofibroma sarcoma protuberans, significant pain during MMS, and location of tumor over a cranial nerve. Follow-up failed to reveal recurrence after further treatment. CONCLUSIONS: Preoperative identification of patients at risk for aborted MMS would allow for direct referral using surgical excision, hence decreasing anxiety, morbidity, and cost. A treatment algorithm is proposed for patients who experience aborted MMS.

An evidence-based approach to secondary cleft lip nasal deformity.

The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.

The disruptive physician: righteous Maverick or dangerous Pariah?

BACKGROUND: "Disruptive physician" is a term appearing more frequently in many hospital bylaws. It has significant negative implications that can lead to loss of privileges for plastic surgeons. METHODS: Exploring the various definitions of disruptive physician reveals palpable differences between those of the Joint Commission and the American Medical Association. These discrepancies expose plastic surgeons to potential harm when actively addressing quality issues in the hospital environment. RESULTS: The disruptive label can be inappropriately leveraged by hospital administrators against plastic surgeons who confront quality issues. Moreover, the term disruptive is open to subjective interpretation. Challenging the disruptive label in court reveals only that the justice system is concerned that the actual process leading to the disruptive charge is followed appropriately as outlined within the organizational bylaws; the courts are not interested in the actual quality issues and generally will not second-guess the judgment of peer review panels or hospital administrators. CONCLUSIONS: Plastic surgeons would benefit from familiarizing themselves with these issues. Hospitals should be required to use root cause analysis when dealing with quality issues raised by members of the medical staff. Furthermore, findings from root cause analysis should be privileged from legal discovery in all jurisdictions to permit honest exploration of quality issues. When a conflict does arise, consideration of mediation should be given to resolve disputes.

Ethical issues for the plastic surgeon in a tumultuous health care system: dissecting the anatomy of a decision.

BACKGROUND: Society anticipates that plastic surgeons will make ethical decisions that are solely in the best interest of their patients. However, a variety of competing factors exert an influence on all decision-making processes. METHODS: Multiple competing factors that commonly influence decision-making by plastic surgeons, on both conscious and subconscious levels, are identified. By exploring the ramifications of these factors, a more ethical outcome can be achieved. RESULTS: Some of these competing interests that can sidetrack ethical decision-making include personal finances (e.g., ownership of surgical centers, selection of procedures, pricing); outside regulations (e.g., Emergency Medical Treatment and Active Labor Act of 1986 and care of the uninsured); and professional duty (e.g., informed consent, discussion of error). CONCLUSIONS: Plastic surgeons who are aware of the competing interests that influence their decision-making processes stand a greater chance of achieving ethical outcomes. Nevertheless, with the growing volume of nonreimbursed care and expectations of perfect outcomes, achieving uniformly ethical decisions without burdensome self-sacrifice is difficult at best.

MOC-PSSM CME article: Nonmelanoma facial skin malignancy.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the environmental and genetic risk factors in developing nonmelanoma facial skin malignancy. 2. Understand the proper evaluation of a patient presenting with nonmelanoma facial skin malignancy. 3. Outline the various treatment options available for patients with nonmelanoma facial skin malignancy and understand the specific technique of Mohs' micrographic surgery versus surgical excision with frozen section control. 4. Describe the various options for reconstruction and the associated anesthetic requirements. BACKGROUND: The incidence of nonmelanoma facial skin malignancy is rising dramatically. Physicians should be well versed on the appropriate methodology required to both evaluate and treat these patients. METHODS: A literature review was performed regarding the evaluation and various management options for patients with nonmelanoma facial skin malignancy. Specific attention was paid to the Mohs' technique versus surgical excision with frozen section control for treatment of these patients. RESULTS: An algorithm is presented regarding the appropriate assessment and treatment of patients with nonmelanoma facial skin malignancy. Comparison of the Mohs' technique with frozen section control showed potentially similar disease-free outcomes. However, the lack of adequate scientific studies for surgical excision with frozen section control was identified. CONCLUSIONS: Various treatment algorithms exist for nonmelanoma facial skin malignancy. Consideration must be given by the physician to patient comorbidities, anesthesia requirements, appropriate monitoring, and cost of excision.

Structured diabetes therapy and education improves the outcome of patients with insulin treated diabetes mellitus. The 10 year follow-up of a prospective, population-based survey on the quality of diabetes care (the JEVIN Trial).

AIMS/HYPOTHESIS: JEVIN (Jena's St. Vincent Trial) is a prospective, 10 year follow-up, population-based survey of all insulin treated patients with type 1 and type 2 diabetes mellitus aged 16 to 60 years and living in the city of Jena (100,000 inhabitants), Thuringia, Germany. It aims to show the effects of implementation of the St. Vincent Declaration and to evaluate the effect of recent changes in the health care system and new treatment strategies. PATIENTS AND METHODS: 190 patients (83% of the target population), 244 patients (90%) and 261 patients (90%) were studied in 1989/90, 1994/95 and 1999/2000, respectively. RESULTS: Up to 1994/95, the HbA1c of patients with type 1 diabetes mellitus increased (1994/95: 8.50+/-1.80% versus 1989/90: 7.83+/-1.60%, p=0.002). For patients with type 2 diabetes mellitus, it remained constant (9.01+/-2.06% versus 9.17+/-1.60%, n. s.). During the period from 1994/95 to 1999/2000, there was a substantial improvement in the relative HbA1c of both, patients with type 1 (7.62+/-1.55%, p<0.0001), and with type 2 diabetes (7.57+/-1.29%, p<0.0001). Up to 1999/2000, 87.7% of the patients with type 1 (1989/90: 0%, 1994/95: 73.2%) and 96.6% of the patients with type 2 diabetes (1989/90: 0%, 1994/95: 89.7%) participated in TTP's. The incidence of acute and the prevalence of long-term complications remained constant. CONCLUSIONS: Results of the population-based, prospective trial to optimise patients' quality of diabetic control suggest: For patients with insulin treated type 2 diabetes mellitus, excellent treatment can be available by primary care physicians interested, educated and highly engaged in diabetes therapy. Moreover, structured diabetes therapy consisting of treatment and teaching programmes, regular self-monitoring, patients' insulin dose adjustment and patients' empowerment, should be offered to all patients with diabetes mellitus.

Improvement of the quality of diabetes control and decrease in the concentrations of AGE-products in patients with type 1 and insulin-treated type 2 diabetes mellitus: results from a 10 year-prospective, population-based survey on the quality of diabetes care in Germany (JEVIN).

BACKGROUND: Advanced glycation end (AGE)-products are a complex group of compounds that have been implicated in diabetes related long-term complications. Up to the present only few data exist about serum levels of the AGE-proteins N-epsilon-Carboxymethyllysine (CML) and pentosidine in patients with diabetes mellitus. PATIENTS AND METHODS: In the present 10-year, population-based trial of a selection-free cohort of patients with insulin-treated diabetes mellitus, serum CML and pentosidine levels were examined in correlation to the patients' quality of diabetes control and the prevalence of diabetes related long-term complications. RESULTS: Following the reunification of Germany in 1989 the health care system was decentralised. Up to 1994/95 the relative HbA1c (HbA1c/mean normal) of patients with type 1 diabetes increased (1.65 +/- 0.35 versus 1.52 +/- 0.31, p = 0.002). For patients with type 2 diabetes it remained constant (1.75 +/- 0.4 versus 1.78 +/- 0.31, p = 0.669). During the following period (from 1994/95 to 1999/2000) specialised diabetes care, structured treatment and teaching programmes (TTP), intensified insulin therapy and blood glucose self-monitoring for all patients were broadly implemented. This was accompanied by a substantial improvement in the relative HbA1c of both, patients with type 1 (1.48 +/- 0.3, p<0.0001), and insulin-treated type 2 diabetes mellitus (1.47 +/- 0.25, p<0.0001). During the same period the mean concentration of the AGE-product CML in the sera of patients with type 1 and insulin-treated type 2 diabetes decreased (type 1: 1994/95: 1158.1 +/- 410.0 ng/ml versus 1999/2000: 938.5 +/- 422.4 ng/ml, p<0.0001, type 2: 1994/94: 1244.7 +/- 1231.3 ng/ml versus 1999/2000: 970.9 +/- 458.6 ng/ml, p = 0.007). For pentosidine the same tendency was found for patients with type 1 diabetes (1994/95: 253.6 +/- 280.7 pmol/ml versus 1999/2000: 148.2 +/- 91.4 pmol/ml, p<0.0001). For patients with type 1 diabetes there was a positive correlation between the relative HbA1c-value calculated over the total follow-up period of 10 years and the CML-concentration in 1999/2000 (r = 0.405, p = 0.017). In 1999/2000 a reduced creatinine clearance (

Repair of congenital nasal anomalies involving redundancy of structures.

OBJECTIVE: Rare congenital nasal anomalies include symmetric complete nasal duplication and asymmetric supernumerary nostrils. Complete nasal duplication may be either vertically stacked or horizontally oriented. It is a result of duplication of the nasal placode pair. Supernumerary structures include nostrils (with or without accessory cartilage) or fistulas that result from a fissure of the lateral nasal process. A case report is described whereby an adult accessory nostril, complete with an extra lower lateral cartilage, is repaired through direct excision and tip suturing. The importance of removing superfluous structures and reconstructing the normal anatomy by using an open rhinoplasty technique is stressed to achieve an aesthetic outcome.

The clinical application of a urine albumin:creatinine ratio point-of-care device.

INTRODUCTION: Microalbuminuria is an accepted predictive marker for the early detection of renal disease and the identification of patients at high risk of developing complications of diabetes and hypertension. The Bayer Clinitek 50 is a urine chemistry point-of-care analyser for the semi-quantitative measurement of albumin and creatinine and calculation of albumin:creatinine ratio (ACR). METHOD: Urine samples were obtained from 252 consecutive patients attending a city center diabetic clinic, and from 40 patients on admission to the ICU. Albumin and creatinine measurements were carried out using the Clinitek 50 and by the central laboratory. RESULTS: The Clinitek 50 results agreed with the central laboratory results in 89% of the diabetic patient samples and 80% of the ICU patient samples. Excluding samples defined as normal by the Clinitek 50 (ACR<3.4 mg/mmol) would have resulted in an 80% reduction in samples sent to the lab for further quantification. The average length of stay in the group of ICU patients with normal ACR was significantly less than for those patients with an abnormal ACR (p<0.005). CONCLUSIONS: The Clinitek 50 provides useful, immediate clinical information regarding the microalbuminuria status for use in the diabetic clinic setting or as a potential immediate risk management tool in intensive care.

The JEVIN trial: a population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990.

Since 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90% (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbA1c (HbA1c/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54 +/- 0.27, n = 47) to 1989/1990 (1.52 +/- 0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 +/- 0.38, n = 80, p = 0.0087). In the total group of NIDDM patients there was no significant change in HbA1c (1994/1995: 1.75 +/- 0.4, n = 117, vs 1989/1990: 1.78 +/- 0.4, n = 59, p = 0.67), but with a tendency to higher HbA1c under non-specialized (1.81 +/- 0.4, n = 79) compared to specialized care (1.66 +/- 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35%) and neuropathy (24%; 38%) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM.

Approach to maintaining comparability of biochemical data during long-term clinical trials.

Our objective was to design a structured approach to maintaining comparability of biochemical data during a long clinical trial. Maintaining the comparability of clinical and biochemical data obtained in long-term studies is essential, even though analytical methods in the laboratory may be changed, conventions on specimen handling and storage revised, calibration procedures updated, quality-control systems replaced, and secular changes may occur. The United Kingdom Prospective Diabetes Study (UKPDS), a large randomized control trial investigating therapy for type 2 diabetes, was the setting for the study. Data were collected from 5102 subjects randomized since 1977. Our techniques included quality control, external quality assurance, direct comparison of laboratory methods when updating assays and statistical techniques for the detection of unsuspected changes in assay bias, laboratory comparisons of new with old assay methodologies, the realigning of data to current methods, the use of a suitable reference population for long-term monitoring, and rules to aid decision-making about clinical vs statistical significance. Procedures by which comparability of data is assured should be specified for all long-term trials and, where possible, comparison with reference methods should be detailed to allow results from different laboratories to be compared.