Impact of Insurance Type on Access to Pediatric Surgical Care.

Background: This study aimed to measure the impact of insurance type on access to pediatric surgical care, clinical and surgical scheduling decisions, provider-driven cancelations, and missed care opportunities (MCOs). We hypothesize that patients with public health insurance experience longer scheduling delays and more frequently canceled surgical appointments compared with patients with private health insurance. Methods: This retrospective study reviewed the demographics and clinical characteristics of patients who underwent a surgical procedure within the plastic and oral surgery department at our institution in 2019. Propensity score matching and linear regressions were used to estimate the effect of insurance type on hospital scheduling and patient access outcomes while controlling for procedure type and sex. Results: A total of 457 patients were included in the demographic and clinical characteristics analyses; 354 were included in propensity score matching analyses. No significant differences in the number of days between scheduling and occurrence of initial consultation or number of clinic cancelations were observed between insurance groups (P > 0.05). However, patients with public insurance had a 7.4 times higher hospital MCO rate (95% CI [5.2-9.7]; P < 0.001) and 4.7 times the number of clinic MCOs (P = 0.007). Conclusions: No significant differences were found between insurance groups in timely access to surgical treatment or cancelations. Patients with public insurance had more MCOs than patients with private insurance. Future research should investigate how to remove barriers that impact access to care for marginalized patients.

Risk Factors Associated with Severe Macromastia among Adolescents and Young Women.

BACKGROUND: Macromastia is common among adolescents and young women and has well-documented negative physical and psychosocial effects. The pathogenesis of idiopathic macromastia has been attributed to increased end organ sensitivity to circulating gonadal hormones. Despite the known negative effects of macromastia, there is a paucity of literature examining the clinical risk factors associated with macromastia severity in this age group. METHODS: In this cross-sectional study, standardized clinical forms were administered to patients between the ages of 12 and 21 years undergoing reduction mammaplasty. Data were collected pertaining to patient demographics, biometrics, breast symptoms, medical and family history, and breast tissue resection mass at the time of reduction. Resection mass was normalized to patient body surface area in analyses. RESULTS: A total of 375 patients were included in analyses. Mean age at surgery was 18.1 years. The following risk factors were positively associated with macromastia severity in both univariate and multivariate logistic regression models: overweight or obesity, racial or ethnic minority status, patient-reported gynecologic or endocrine complaints, and early menarche ( p < 0.05, all). More severe cases of macromastia were associated with approximately three times the odds of being overweight or obese or achieving menarche before 11 years old. CONCLUSIONS: In our sample, overweight or obesity, racial or ethnic minority status, early menarche, and patient-reported gynecologic or endocrine complaints were all positively associated with macromastia severity. Awareness of these factors can empower physicians to identify and address modifiable risk factors to prevent progression to more severe disease. Macromastia itself should prompt screening for gynecologic or endocrine complaints with referral as indicated. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Combined Oral Contraceptives on Adolescents with Macromastia.

BACKGROUND: The combined oral contraceptive pill, containing both estrogen and progestin, is commonly prescribed to adolescents for numerous health benefits. However, there is concern among patients and providers that its use may exacerbate breast growth. This retrospective, case-control study examined the association between combined oral contraceptive pill use and macromastia-related breast hypertrophy and symptoms in adolescents. METHODS: A total of 378 patients undergoing reduction mammaplasty between the ages of 12 and 21 years were assessed for baseline and postoperative breast symptoms and combined oral contraceptive pill use. In addition, the medical records of 378 female controls of the same age range were retrospectively reviewed. RESULTS: Although a lower proportion of the macromastia cohort used any hormonal contraception compared to controls (37.8 percent versus 64.8 percent; OR, 0.33; 95 percent CI, 0.24 to 0.44; p < 0.001), they were more often prescribed combined oral contraceptive pills (82.5 percent versus 52.7 percent; OR, 1.93; 95 percent CI, 1.29 to 2.68; p < 0.001). Participants with macromastia who used combined oral contraceptive pills had a smaller median normalized amount of breast tissue resected during reduction mammaplasty than those who never used hormonal contraception (639.5 g/m 2 versus 735.9 g/m 2 ; p = 0.003). Combined oral contraceptive pills were not associated with breast-related symptoms or clinical impairment, or postoperative breast growth ( p > 0.05 for all). CONCLUSIONS: Combined oral contraceptive pill use during adolescence may be associated with developing less severe breast hypertrophy. Combined oral contraceptive pills do not appear to exacerbate macromastia-related symptoms or impact postoperative growth in young women following reduction mammaplasty. Although additional research is needed, providers are encouraged to consider combined oral contraceptive pills for their patients with macromastia when indicated and appropriate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Effectiveness of Preoperative Symptom Screening in Identifying Pediatric SARS-CoV-2 Infections: A Retrospective Cohort Analysis.

Evidence-based protocols identifying COVID-19 cases in pediatric preoperative settings are lacking. With COVID-19 positioned to remain a threat to children, this study examines effectiveness of preoperative COVID-19 symptom screening in pediatric patients. Methods: This retrospective cohort study included hospital billing/medical record queries of (1) procedures performed under conscious sedation/general anesthesia and (2) laboratory-confirmed COVID-19 (+) cases from April 6, 2020, to June 15, 2020. Descriptive analyses were performed for demographic, procedural, symptom, and COVID-19 test result data obtained from medical records. Bivariate analyses examined associations between SARS-CoV-2 test results and symptom, demographic, and procedural data. Results: Among 2900 surgical cases, median (interquartile range) age was 8.1 (12.8) years. The majority were male (n = 1609, 55.5%), white (n = 1614, 55.7%), and not Hispanic/Latino (n = 1658, 57.2%). Additionally, 85.4% (n = 2412) of cases were non-emergent. Fifteen COVID-19 (+) cases were identified, for a 0.5% positivity rate. COVID-19 positivity was not associated with sex, American Society of Anesthesiologists physical status, or preoperative symptom status. Notably, 92.9% (n = 13) of COVID-19 (+) cases were asymptomatic. COVID-19 (+) patients were significantly older (15.6 years) than COVID-19 (-) patients (8.0 years). Patients who were not white, were Hispanic/Latino, or had a relatively lower economic status, were more likely to test positive. Conclusions: Preoperative symptom screenings insufficiently identified COVID-19 (+) patients. During outbreaks, testing protocols should be implemented to identify COVID-19 (+) patients. Future research should examine if observations are similar for other variants, and how health disparities associate with COVID-19.

Normative Values for Adolescent Quality of Life in Plastic Surgery: A Longitudinal, Cohort Study.

Background: Adolescence is a challenging time, and an increasing number of young people are seeking plastic surgery. With the rise of health-related quality of life studies in plastic surgery, it is critical to understand the natural variation and changes in health-related quality of life for this population. Methods: In this longitudinal, cohort study validated surveys were administered to cisgender participants aged 12-21 years: Short-Form 36v2, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26. Surveys were administered at baseline and up to 9 years follow-up. At the time of enrollment, participants were in a current state of good health with no considerable past or current medical, surgical, or psychological history. Results: A total of 149 female and 75 male participants were included, with a median (interquartile range) baseline age of 16.0 (4.4) years and follow-up time of 3.3 (4.1) years. Over the study period, girls who were not overweight or obese experienced significant declines in five SF-36 domains (general health, vitality, social functioning, role-emotional, and mental health) and on the Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 (P < 0.05). In contrast, boys' and overweight/obese girls' health-related quality of life largely remained stable (P > 0.05). Conclusions: Adolescence is a challenging time, on which plastic surgery-related concerns are superimposed. Our findings suggest that girls may be more at risk for developing psychosocial deficits that worsen over adolescence and young adulthood. This observation is critical for the interpretation and contextualization of health-related quality of life in adolescent plastic surgery patients.

Complications and Quality of Life following Gynecomastia Correction in Adolescents and Young Men.

BACKGROUND: Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life. METHODS: Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test. RESULTS: Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively. CONCLUSIONS: Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits.

The Impact of Progestin-only Contraception on Adolescents with Macromastia.

Progestin-only contraception has become increasingly popular among adolescents. However, patients, parents, and providers share concerns regarding the potential impact that progestin-only contraception may have on breast growth. We sought to explore the impact of progestin-only contraception on breast hypertrophy and symptomatology in adolescents with macromastia. METHODS: Patients between the ages of 12 and 21 years undergoing reduction mammaplasty were prospectively assessed for baseline and postoperative breast symptomatology and medication use. The medical records of female controls within the same age range were retrospectively reviewed. RESULTS: A total of 378 participants with macromastia and 378 controls were included in analyses. A higher proportion of controls used progestin-only methods compared with participants with macromastia (28.0% versus 5.3%, P < 0.001). The most commonly prescribed methods were the depot medroxyprogesterone acetate injection (31.0%), levonorgestrel-containing intrauterine device (31.0%), and subdermal implant (26.2%). Patients with macromastia who used progestin-only contraception had a greater amount of breast tissue resected during reduction mammaplasty (P = 0.04), reported greater musculoskeletal pain (P = 0.008), and were roughly 500% more likely to experience breast pain (odds ratio, 4.94; 95% confidence interval, 1.58-15.47; P = 0.005) than those with macromastia who never used hormonal contraception. CONCLUSIONS: Adolescents with macromastia who use progestin-only contraception may have greater breast hypertrophy and worse breast and musculoskeletal pain. When appropriate, providers may wish to consider other contraception methods for patients who are at-risk for breast hypertrophy or those who suffer from macromastia-related symptoms.

Optimal Timing for Reduction Mammaplasty in Adolescents.

BACKGROUND: Reduction mammaplasty effectively alleviates symptoms and restores quality of life. However, operating on adolescents remains controversial, partly because of fear of potential postoperative breast growth. This cross-sectional study provides surgeons with a method to predict the optimal timing, or biological "sweet spot," for reduction mammaplasty to minimize the risk of breast regrowth in adolescents. METHODS: The authors reviewed the medical records of women aged 12 to 21 years who underwent reduction mammaplasty from 2007 to 2019. Collected data included symptomology, perioperative details, and postoperative outcomes. RESULTS: Four hundred eighty-one subjects were included in analyses and were, on average, 11.9 years old at first menses (menarche) and 17.9 years old at surgery. Six percent of subjects experienced postoperative breast growth. Breast size appears to stabilize considerably later in obese adolescents compared to healthy-weight and overweight patients, and breast growth in obese macromastia patients may not end until 9 years after menarche. Operating on obese women before this time point increased the likelihood of glandular breast regrowth by almost 120 percent (OR, 1.18; 95 percent CI, 1.11 to 1.26). Surgery performed less than 3 years after menarche, the commonly regarded end of puberty, increased the likelihood of glandular regrowth by over 700 percent in healthy-weight and overweight subjects (OR, 7.43; 95 percent CI, 1.37 to 40.41). CONCLUSIONS: Findings suggest that reduction mammaplasty age restrictions imposed by care providers and third-party payors may be arbitrary. Surgical readiness should be determined on an individual basis incorporating the patient's biological and psychological maturity, obesity status, potential for postoperative benefit, and risk tolerance for postoperative breast growth. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.