Treatment Choices in Managing Bethesda III and IV Thyroid Nodules: A Canadian Multi-institutional Study.

OBJECTIVE: Patient-centered decision making is increasingly identified as a desirable component of medical care. To manage indeterminate thyroid nodules, patients are offered the options of surveillance, diagnostic hemithyroidectomy, or molecular testing. Our objective was to identify factors associated with decision making in this population. STUDY DESIGN: This is a retrospective cross-sectional study of patients with Bethesda III and IV thyroid nodules. SETTING: Multi-institutional. METHODS: Factors of interest included age, sex, socioeconomic status (SES), nodule size, institution, attending surgeon, surgeon payment model, and hospital type. Our outcome of interest was the initial management decision made by patients. RESULTS: A total of 956 patients were included. The majority of patients had Bethesda III nodules (n = 738, 77%). A total of 538 (56%) patients chose surgery, 413 (43%) chose surveillance, and 5 (1%) chose molecular testing. There was a significant variation in management decision based on attending surgeon (proportion of patients choosing surgery: 15%-83%; P≤.0001). Fee-for-service surgeon payment models (odds ratio [OR], 1.657; 95% CI, 1.263-2.175; P < .001) and community hospital settings (OR, 1.529; 95% CI, 1.145-2.042; P < .001) were associated with the decision for surgery. Larger nodule size, younger patients, and Bethesda IV nodules were also associated with surgery. CONCLUSION: While it seems appropriate that larger nodules, younger age, and higher Bethesda class were associated with decision for surgery, we also identified attending surgeon, surgeon payment model, and hospital type as important factors. Given this, standardizing management discussions may improve patient-centered shared decision making.

A novel approach to earlobe reconstruction using the V to Y advancement flap.

BACKGROUND: The V to Y advancement flap offers an excellent option for reconstructing defects of the lobule and adjacent structures of the external ear. We demonstrate its utility for small defects of the earlobe including those extending to the antitragal and conchal bowl regions. To our knowledge use of this technique for earlobe reconstruction has not been reported. METHODS: A review of the literature was performed on the use of the V to Y flap for earlobe reconstruction. We then described its use in reconstructing lobular defects in 6 patients. All patients had a non-melanoma skin cancer involving the earlobe. All surgeries were performed under local anesthetic at a tertiary care centre in Halifax, Canada. Defects ranged in size from 1.0 to 1.4 cm. All defects were reconstructed with only a V to Y advancement flap. Patient photographs were taken intra-operatively and post-operatively. For all patients, satisfaction of the final aesthetic result was assessed on a 10 point scale in follow-up at 6 months. RESULTS: A review of the literature did not reveal any reports of the V to Y flap used in isolation for lobular reconstruction. At our centre from 2018 to 2020, this method was well tolerated under local anesthetic in 6 patients with non-melanoma skin cancers of the earlobe. All patients reported an aesthetically satisfying result at 6 months with scores ranging between 8 and 10. Scarring in all cases was minimal. CONCLUSION: The V to Y advancement flap is a simple technique for reconstructing small defects of the lobule. This method is technically straight-forward, poses minimal risk to the patient, and in our experience, yields a favourable cosmetic outcome.