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BACKGROUND Surgeons are critical for the success of any health care enterprise. However, few studies have examined the potential impact of value-based care on surgeon compensation. METHODS This review presents value-based financial incentive models that will shape the future of surgeon compensation. The following incentivization models will be discussed: pay-for-reporting, pay-for-performance, pay-for-patient-safety, bundled payments, and pay-for-academic-productivity. Moreover, the authors suggest the application of the congruence model-a model developed to help business leaders understand the interplay of forces that shape the performance of their organizations-to determine surgeon compensation methods applicable in value-based care-centric environments. RESULTS The application of research in organizational behavior can assist health care leaders in developing surgeon compensation models optimized for value-based care. Health care leaders can utilize the congruence model to determine total surgeon compensation, proportion of compensation that is short term versus long term, proportion of compensation that is fixed versus variable, and proportion of compensation based on seniority versus performance. CONCLUSION This review provides a framework extensively studied by researchers in organizational behavior that can be utilized when designing surgeon financial compensation plans for any health care entity shifting toward value-based care.

Uterine transplant (UTx) is performed to address absolute uterine infertility in the presence of uterine agenesis, a non-functional uterus, or following a prior hysterectomy. Following the initial success of UTx resulting in a livebirth (2014) in Sweden, there are over 70 reported UTx surgeries resulting in more than 40 livebirths worldwide. Currently, UTx has been performed in over 10 countries. As UTx is transitioning from an "experimental procedure" to a clinical option, an increasing number of centers may contemplate a UTx program. This article discusses essential steps for establishment of a successful UTx program. These principles may be implemented in cis- and transgender UTx candidates.

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

According to the Center for Disease Control (CDC)’s yearly Behavioral Risk Factor Surveillance System (BRFSS) report, approximately 25 million individuals worldwide, including 1–1.4 million adults ...

Background Knowledge of Medicare reimbursement is essential for plastic surgeons providing care to Medicare beneficiaries. The authors sought to evaluate changes in Medicare reimbursement for common plastic surgery procedures from 2010 to 2020. Methods The authors assessed the Physician Fee Schedule of the Centers for Medicare and Medicaid Services website. Rates of work-, facility-, or malpractice-related relative value units and total monetary units for 26 common plastic surgery procedures between 2010 and 2020 were evaluated. Descriptive statistics were used to calculate relative differences and to compare observed changes over time with the rate of inflation. Results For the selected procedures, the authors found an average relative difference in terms of monetary units of an increase by 2.02 percent. However, after adjusting for inflation, the average relative difference was a decrease by 14.31 percent. The authors' analysis indicates that, on average, there was a 1.55 percent decrease in physician relative value units between 2010 and 2020. Conclusions Medicare reimbursement rates have changed significantly over the past decade. However, these changes did not keep pace with the rate of inflation. Plastic surgeons should be aware of these trends and advocate for more fair reimbursement rates.

Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.

SUMMARY The Affordable Care Act's provisions have affected and will continue to affect plastic surgeons and their patients, and an understanding of its influence on the current American health care system is essential. The law's impact on pediatric plastic surgery, craniofacial surgery, and breast reconstruction is well documented. In addition, gender-affirmation surgery has seen exponential growth, largely because of expanded insurance coverage through the protections afforded to transgender individuals by the Affordable Care Act. As gender-affirming surgery continues to grow, plastic surgeons have the opportunity to adapt and diversify their practices.

To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment.Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress.A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes.Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications.Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.

The restoration of a youthful appearance to the midface can enhance its femininity. In this article, we discuss several strategies and techniques, both surgical and nonsurgical, for augmentation of the lateral and centro-lateral midface.

Background To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. Methods A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. Results Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. Conclusions Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

Objective : To perform the first systematic review of all available gender-affirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment. Summary background data Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. While some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. Methods A systematic review was performed following PRISMA guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data was pooled to assess currently reported complication, satisfaction, and other outcome rates. Results Overall, 15,186 references were identified, 4,162 papers advanced to abstract review, and 1,826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. While 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. Conclusions This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have aggregated a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the two primary barriers to high-quality research where improvement efforts should be focused.

Early surgical techniques for phalloplasty involved the transfer of pedicled, tubed abdominal tissue in order to create or reconstruct a phallus. The advent and advances in the field of microsurgery led to the emergence of free and pedicled axial-pattern flaps as the preferred technique. This chapter discusses the history, preoperative considerations, surgical anatomy, and techniques of the most commonly used flaps in penile reconstruction: the radial forearm fasciocutaneous flap, the anterolateral thigh fasciocutaneous flap, the superficial circumflex iliac perforator flap, and the gracilis muscle flap. Information regarding postoperative management, including flap monitoring, catheter management, and local care are included. Knowledge of the surgical anatomy of the donor and recipient sites is crucial to achieving satisfactory results.

Masculinizing chest surgery is one of the most commonly requested procedures in gender confirmation surgery. The World Professional Association of Transgender Health has established standards of care that offer recommendations for patients and surgeons prior to undergoing gender confirmation surgery. There have been many techniques described to perform masculinizing chest surgery, and the majority of patients are very satisfied with their surgical results. Overall, the complication rate in chest surgery is low. The following is a discussion of chest surgery with a focus on the potential cause, treatment, and some possible methods of prevention of the most common, and uncommon, complications that arise in chest surgery.

INTRODUCTION AND OBJECTIVE:Urethral reconstruction within the context of gender affirming phalloplasty is important as almost half of the patients suffer from some degree of urethral complication p...

Gender confirmation surgery can be an important component in helping individuals alleviate gender dysphoria. Increased advocacy, awareness, and acceptance of these medically necessary procedures have resulted in a greater demand for such procedures, exceeding the number of qualified surgeons able to perform them. It is recognized that formal training guidelines and fellowship programs are needed so as to assure that surgeons performing these procedures are adequately experienced. Here, the authors discuss a potential framework by which a multidisciplinary training program in gender confirmation surgery can be developed and implemented.

Background A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Injury to the lower extremity is one of the most common traumatic injuries encountered in both combat and civilian situations. Improvements in sterile technique, the use of antibiotics, bony fixation, and microvascular reconstruction have shifted the management paradigm from predominantly amputation to limb salvage. We reviewed acute lower-extremity reconstruction in a single suburban trauma center and identified common characteristics of functional and adverse outcomes. The records of patients treated at a level I trauma center for lower-extremity injuries and requiring plastic surgery consultation or intervention were reviewed. Common demographic and clinical characteristics for three functional outcomes (range of motion, return to work, and ambulation) and three adverse outcomes (venous thromboembolism, rehospitalization, and operative revision) were compared. Of the 4039 patients treated for a lower-extremity traumatic injury over a 6-year period, 92 (2.3%) patients met the inclusion criteria. Severity of injury was a common determinant of outcome. On long-term follow-up, the majority of patients were ambulatory (n = 50), albeit frequently with some deficit in range of motion or gait disturbance. When modifiable characteristics were evaluated, an increased length of time to soft-tissue coverage was associated with both an increased incidence of venous thromboembolism and range-of-motion deficit. Delayed definitive soft-tissue coverage of lower-extremity traumatic wounds is associated with thromboembolic events and range-of-motion deficits. Involvement of a plastic surgeon in a multi-disciplinary trauma team could expedite definitive wound coverage and improve clinical outcomes of lower-extremity trauma. Future research evaluating the impact of early plastic surgery involvement on outcome measures is necessary. Level of Evidence: Level IV, risk/prognostic study

Increasingly, facial feminization and masculinization techniques are being employed in the treatment of gender dysphoria. For the facial surgeon, knowledge of the anatomical differences between masculine and feminine facial skeletal structures is of utmost importance. Combining this knowledge with the various surgical and non-techniques that may be employed in order to achieve each patient's goals will allow the facial surgeon to greatly impact the lives of persons of transgender and gender diverse experience. Below, this article discusses these anatomical differences as well as current surgical practices employed in order to masculinize or feminize the face.

Facial surgery can help facilitate an individual's social transition and alleviate gender dysphoria. As such, surgical requests for feminizing and masculinizing procedures continue to increase. Surgical management requires knowledge of anatomy and anatomic differences as well as an understanding of social challenges faced by transgender and gender diverse individuals. Here, the authors provide a brief overview of gender confirmation surgery specific to the head and neck and craniofacial skeleton. In addition, the authors explore barriers to accessing healthcare for transgender and gender diverse individuals throughout the world.

We aimed to review all information on penile prosthetic surgery in patients with prior phalloplasty and give a detailed description of the authors's preferred technique. A nonsytematic review of the articles that were published in English and indexed on Pubmed, Google Scholar, and Embase databases was conducted. The relevant literature reports mainly on the outcomes of penile prosthesis (PP) implantation following gender affirming phalloplasty with the radial forearm free flap technique. Three-piece inflatable penile prostheses (IPP) have been the most commonly utilized hardware in this setting. PP implantation in a neophallus is a complex procedure and contains some technical nuances. Creation of spaces within the neophallus for the cylinder(s), wrapping the cylinder(s) with synthetic materials or allografts, and fixation of the prosthesis to the pubic bony structures can be considered as the most important steps of this procedure. Five-year IPP retention rates in flap phalloplasty range between 42 and 78% which is lower than the rate observed in anatomic phallus. In addition, complication and mechanical failure rates are higher in flap phalloplasty. However, satisfaction rates after PP implantations in anatomic penis versus neophallus seem to be similarly high. Infection, migration, and mechanical failure are the most frequent complications.

Increased advocacy efforts and expanded third-party insurance coverage have improved access to healthcare for transgender individuals. In conjunction with mental health and medical professionals, gender surgeries offer an important step in allowing individuals to realize their true selves. To provide quality multidisciplinary care, primary care doctors need to understand challenges facing transgender individuals and treatment options available to them. In this article, we will review the role of the surgeon and the goals of various gender confirming surgeries. In addition, we will provide an overview of the available surgical options.

A fundamental goal of phalloplasty includes the construction of a sensate neophallus. Both tactile and erogenous sensation are important for protective sensation (including retention of implantable penile prosthesis) as well as sexual satisfaction. This article will describe the sensory innervation of flaps commonly used for phalloplasty including the radial forearm flap, anterolateral thigh flap, and musculocutaneous latissimus dorsi flap. The sensory innervation of the perineum and external genitalia will be reviewed as a basis for selecting recipient nerves. Additionally, surgical techniques, such as neurorrhaphy, will be discussed. Finally, outcome data, although limited, will be assessed.

Phalloplasty represents the most complete genitoperineal transformation. Because it requires complex, staged procedures as well as the use of tissue from remote sites, patients must be well informed as to the nature of surgery. Surgical techniques for phalloplasty continue to evolve. Although many surgeons prefer the radial forearm free flap technique, a visible flap donor site makes this procedure less desirable for some patients. Other surgical options are available and include the anterolateral thigh flap, sometimes in conjunction with secondary flaps, and the musculocutaneous latissimus dorsi flap.

Background At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. Aim To propose guiding principles designed to aid with the development of formal surgical training programs focused on gender confirmation surgery. Methods We use expert opinion to provide a “first of its kind” framework for training surgeons to care for transgender and gender nonconforming individuals. Outcomes We describe a multidisciplinary treatment model that describes an educational philosophy and the institution of quality parameters. Results This article represents the first step in the development of a structured educational program for surgical training in gender confirmation procedures. Clinical Implications The World Professional Association for Transgender Health Board of Directors unanimously approved this article as the framework for surgical training. Strengths and Limitations This article builds a framework for surgical training. It is designed to provide concepts that will likely be modified over time and based on additional data and evidence gathered through outcome measurements. Conclusion We present an initial step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures.

In 2010, the World Professional Association for Transgender Health (WPATH) released a statement declaring the Association's opposition to surgery or sterilization as requirements to change legal ge...

Penetrating pencil-tip injuries are common among children and usually resolve without long-term sequelae. However, failure to detect and remove embedded pencil fragments can result in increased morbidity or misdiagnoses of other, more serious, conditions. We report on the case of a 10-year-old boy stabbed with a pencil on his right chin. Initial treatment in the emergency department included irrigation and closure of the laceration. Following suture removal, the patient returned to the emergency department (with bright-purple drainage from the wound site). Radiographic evaluation led to the discovery of an embedded foreign body requiring surgical removal.