Evaluation of Morphometric Measurements on Preoperative CT Angiograms to Determine Risk of Abdominal Donor Site Complications-A Retrospective Review of 174 Patients.

Introduction: Autologous breast reconstruction remains a popular surgical option following mastectomy; however, it is not without complications. Preoperative CT angiograms (CTAs) are often obtained for surgical planning, and morphometric data such as fat and muscle distribution can be measured. This study aimed to assess if CTA morphometric data predicts abdominal donor site complications in patients undergoing abdominally based autologous breast reconstruction. Methods: A retrospective cohort study was performed for patients who underwent abdominally based autologous breast reconstruction from 2013 to 2018. Along with population and operative characteristics, preoperative morphometric variables were assessed for the following: subcutaneous adipose tissue, visceral adipose tissue, skeletal muscle area and index, rectus and psoas cross-sectional area, and bone density. Statistical comparison to abdominal donor site complications was performed using logistic regression analysis for every 100-unit change. Results: A total of 174 patients were included in this study. Visceral adipose tissue was significantly associated with the development of infection (P = .005), epidermolysis (P = .031), and seroma (P = .04). Subcutaneous adipose tissue, skeletal muscle index, cross-sectional muscle area, and bone density were not associated with abdominal donor site complications. Obesity (P = .024), history of smoking (P = .049), and the number of perforators harvested (P = .035) significantly increased the likelihood of delayed abdominal healing. Conclusions: This study demonstrates that increased visceral adipose tissue, as measured by CTA, is significantly associated with an increased risk of abdominal donor site complications. CTA morphometric data and identifying high-risk patient characteristics can help guide preoperative counseling and better inform surgical risks.

Introduction : La reconstruction mammaire autologue reste une option chirurgicale appréciée après une mastectomie. Toutefois, elle ne va pas sans complications. Des angio-TDM préopératoires sont souvent effectués dans le cadre de la planification chirurgicale et les données morphométriques (comme la répartition du tissu adipeux et musculaire) peuvent être mesurées. Cette étude a eu pour but d'évaluer si les données morphométriques de la TDM prédisent les complications abdominales au site donneur chez les patientes subissant une reconstruction mammaire autologue à partir de tissus abdominaux. Méthodes : Une étude de cohorte rétrospective a été effectuée avec des patients ayant subi une reconstruction mammaire autologue à base abdominale entre 2013 et 2018. Parallèlement aux caractéristiques opératoires et de la population, les variables morphométriques préopératoires suivantes ont été évaluées : tissu adipeux sous-cutané, tissu adipeux viscéral, surface de muscle squelettique et surface transversale index, du grand droit et du psoas, densité osseuse. Une comparaison statistique aux complications du site donneur abdominal a été réalisée au moyen d'une analyse de régression logistique pour chaque changement de 100 unités. Résultats: Cent-soixante-quatorze patientes ont été incluses dans l'étude. Le tissu adipeux viscéral a été associé de manière significative avec le développement d'une infection (P = 0005), d'une épidermolyse (P = 0031 et d'un sérome (P = 0,04). Le tissu adipeux sous-cutané, l'indice de muscle squelettique, la surface musculaire transversale et la densité osseuse n'ont pas été associées à des complications abdominales du site donneur. L'obésité (P = 0024), les antécédents de tabagisme (P = 0049) et le nombre de perforantes collectées (P = 0035) ont significativement augmenté la probabilité du retard de guérison abdominales. Conclusions: Cette étude démontre que l'augmentation de tissu adipeux viscéral, mesurée par angio-TDM, est significativement associée à une augmentation du risque de complications abdominales au site donneur. Les données morphométriques de l'angio-TDM et l'identification des caractéristiques des patients à risque élevé peuvent aider à orienter les conseils préopératoires et à mieux renseigner sur les risques chirurgicaux.

Use of Ambient Light Compatible Fluorescence-Guided Surgical Technology for Objective Assessment of Flap Perfusion in Autologous Breast Reconstruction.

BACKGROUND: Decreased autologous flap vascular perfusion can lead to secondary procedures. Fluorescence angiography during surgery reduces the probability of repeat surgery but suffers from interpretation variability. Recently, the OnLume Avata System was developed, which evaluates real-time vascular perfusion in ambient light. This study aims to predict complications in autologous breast reconstruction using measures of relative intensity (RI) and relative area (RA). METHODS: Patients undergoing autologous breast reconstruction underwent intraoperative tissue perfusion assessment using the OnLume Avata System. Post-hoc image annotation was completed by labeling areas of the flap interpreted to be "Well Perfused," "Questionably Perfused," and "Under Perfused." RIs and RAs were calculated for the marked areas. Primary complications of interest were overall complication rate, fat and mastectomy skin flap necrosis, and surgical revision. Logistic regression was applied to determine the odds of developing a complication based on RI and RA for each image. RESULTS: A total of 25 patients (45 flaps) were included. In total, 17 patients (68%) developed at least one complication. Patients who developed any complication (p = 0.02) or underwent a surgical revision for complications (p = 0.02) had statistically lower RI of under-perfused portions of the flap. Patients with greater areas of under-perfused flap had a significantly higher risk of developing fat necrosis (odds ratio [OR]: 5.71, p = 0.03) and required a revision operation (OR: 1.10, p = 0.01). CONCLUSION: Image-based interpretation using the OnLume Avata System correlated with the risk of developing postoperative complications that standard fluorescence imaging systems may not appreciate. This information can benefit surgeons to improve perfusion assessment and intraoperative decision-making.

From Tip of Brush to Tip of Knife: The Relationship Between Post-mastectomy Breast Reconstruction and the Classical Arts.

Breast reconstruction is highly complex, requiring navigation of not only clinical and operative realities, but of patient expectations as well. The authors sought to identify historical art pieces that exhibit breast asymmetries and deformities for comparison with photographs of breast reconstruction patients seen at the clinic of the senior author (S.O.P.) to demonstrate that achievement of perfect breast cosmesis is challenging in both breast reconstruction and in the classical arts. Open access libraries and Creative Commons images were reviewed to identify appropriate works of art from various time periods and geographic locations. Following artwork selection, photographs of breast reconstruction patients were reviewed and paired with selected artworks exhibiting cosmetically similar breasts. A total of 8 pieces of selected historic art were found to have at least 1 matching patient photograph, with 9 correlative patient photographs ultimately chosen. Common breast asymmetries and deformities identified included ptosis, asymmetric chest wall placement, asymmetric nipple placement, and absence of the nipple. This review identified diverse artworks of varying styles spanning vast expanses of both geography and time that exhibited breast deformities and asymmetries commonly encountered in patients seeking revision of breast reconstruction. This underscores that creating the cosmetically ideal breast is difficult both in the operating room and the art studio. Importantly, the authors emphasized that the arts frequently celebrate that which is considered beautiful, although to the trained eye of a plastic surgeon that which is considered beautiful is often classified as dysmorphic or asymmetric.

Surgical management of adult acquired buried penis syndrome: A systematic review of patient-reported outcome instruments.

PURPOSE: Adult acquired buried penis (AABP) is a morbid condition often necessitating surgical intervention. Accurate assessment of pre- and postoperative symptoms is crucial to understand how AABP impacts a patients' quality of life, verify surgical effectiveness, and practice patient-centered care. There is no validated patient-reported outcome instrument specific for AABP evaluation. We undertook a comprehensive review of existing literature on patient-reported outcome instruments post-AABP surgery to highlight the importance of developing a specific tool. METHODS: Following the preferred reporting items for systematic reviews and meta-analysis 2020 guidelines, we queried three databases using relevant keywords (e.g., "buried penis repair"). Inclusion criteria were studies that discussed surgical management of AABP with patient-reported outcomes. Pediatric and congenital cases were excluded. Information collected included study design, level of evidence, number of participants included in the study, etiology of buried penis, surgical technique, preoperative or postoperative patient-reported outcomes, and patient-reported outcome instrument used. RESULTS: Initial query identified 998 records. After abstract screening and applying the inclusion or exclusion criteria, a total of 19 articles with 440 patients were included. Eight studies implemented patient-reported outcome instruments. The international index of erectile dysfunction-5 and Likert satisfaction scales were used most frequently. Although all instruments were validated, none were validated in the specific context of AABP surgical intervention. CONCLUSIONS: There is considerable heterogeneity within the AABP literature regarding patient symptomatology, postoperative complications, patient-reported outcomes, and instruments used. The results of this study emphasize the need for a patient-reported outcome measure to examine the influence of AABP repair on patient satisfaction and health-related quality of life.

Osteoarthritis Increases the Frequency and Duration of Postoperative Hand Clinic Visits after Carpal Tunnel Release.

Background: Carpal tunnel syndrome affects up to 6% of the general population, and surgical intervention is often required to ameliorate symptoms. Osteoarthritis (OA) is a common condition that often coexists with carpal tunnel syndrome. We hypothesized that patients with preexisting OA use more healthcare resources after carpal tunnel release (CTR) than patients without arthritis. Methods: This was a retrospective cohort study at a single academic center between January 1, 2018 and November 1, 2021. Patients who underwent CTR were included. Preoperative carpal tunnel symptoms, diagnostic tests, medications, and concomitant OA were abstracted. Hand, wrist, and basal joint arthritis were specified. The primary outcome was healthcare utilization represented by duration and frequency of hand clinic and occupational therapy (OT) follow-up. In total, 312 hands were included. Multivariable analysis was performed. Results: The average duration of hand clinic follow-up among patients without arthritis was 25.3 days compared with 87.1 days for patients with any arthritis (P = 0.0375) and 172 days for patients with wrist arthritis (P = 0.012). The average number of postoperative surgeon visits was increased in patients with hand arthritis, with an average of 2.3 visits versus 1.34 visits for patients without arthritis (P = 0.003). Both the number of OT visits and the duration of OT follow-up did not differ between cohorts. Conclusion: After CTR, patients with preexisting OA use more healthcare resources than patients without OA.

Trigeminal or peripheral nerve stimulation improves functional outcomes of nerve recovery in a rodent forelimb gap repair model.

BACKGROUND: The hypothesis of this study was that trigeminal nerve stimulation (TNS) or peripheral nerve stimulation (PNS) could improve functional outcomes of peripheral nerve injury in a rat forelimb model when compared to control rats not receiving electrical stimulation (ES). While PNS is known to improve outcomes after nerve surgery, the role of TNS has not been explored. METHODS: Lewis rats were trained to perform a reach and grasp task before receiving a 2 mm gap repair of the ulnar and median nerves and randomized into four treatment groups: (1) sham injury, (2) nerve injury with sham ES, (3) nerve injury with PNS, and (4) nerve injury with TNS. Functional motor (median pull force and percent success in motor task) and sensory metrics (forelimb paw withdrawal thresholds) were collected both pre-injury and throughout rehabilitation. Nerves stained using Gomori's trichrome were assessed quantitatively and qualitatively. RESULTS: The sham ES group did not recover their pre-injury baseline functional outcomes. In contrast, the TNS and PNS groups fully recovered following injury, with no difference in functional outcomes between the pre-injury baseline and the final week of rehabilitation (P > 0.05, all). Histomorphology results demonstrated no quantitative difference, but qualitative differences in architecture were evident. CONCLUSIONS: Electrical stimulation of the trigeminal nerve or the injured nerve improved the functional outcomes of nerve regeneration in rodents. Histomorphology results of nerves from the TNS group support the proposed central mechanisms. This is an important step in translating this therapy as an adjunct, non-invasive treatment for high, mixed nerve injuries in humans.

Outcomes of enhanced recovery protocols and tranexamic acid on double-incision versus periareolar gender-affirming mastectomy: A retrospective study of postoperative outcomes.

INTRODUCTION: The effects of enhanced recovery protocols and use of tranexamic acid (TXA) to reduce postoperative complications after periareolar and double-incision (DIM) gender-affirming mastectomies have not been previously described. We sought to evaluate the efficacy of our ERP including use of liposomal bupivacaine [Exparel] in these cases, assess the efficacy of TXA in reducing postoperative complications, and compare need for revisionary surgery between periareolar and DI mastectomy techniques. MATERIALS AND METHODS: A retrospective review from November 2017 to June 2022 was performed. Data were collected on patient demographics, operative data, and postoperative outcomes including complications and revisions. Morphine milligram equivalent was used to assess opioid use after surgery. RESULTS: Overall, 260 patients were included: 240 (92.3%) patients in the DI and 20 (7.7%) patients in the periareolar group. Thirty-five (7.3%) breasts in the DIM group and five (12.5%) breasts in the periareolar cohort developed complications (p = 0.220). Significantly more breasts in the periareolar cohort developed hematomas (12.5% vs. 2.9%, p = 0.011). Sixteen (3.3%) breasts in the DIM group developed seromas. Significantly more breasts in the periareolar group required revisionary surgery (15.0% vs. 5.2%, p = 0.025). Patients who received intraoperative liposomal bupivacaine [Exparel] had fewer opioids intraoperatively (p = 0.019) and at discharge (p < 0.001). Use of TXA did not affect rates of complications including hematoma or seroma. CONCLUSIONS: Overall, complication rates for periareolar and DIM are similar. However, the periareolar technique results in a significantly higher rate of hematomas and revisionary surgery. Use of intraoperative liposomal bupivacaine [Exparel] resulted in significantly lower opioid use. Lastly, use of topical TXA did not lower the risk of postoperative hematoma or seroma.

Modified Frailty Index predicts postoperative complications following adult-acquired buried penis surgery: A retrospective cohort study.

BACKGROUND: Given that patients with morbid obesity are predisposed to frailty, we sought to determine whether the 5-Factor Modified Frailty Index (mFI-5) predicts postoperative complications following surgery for adult-acquired buried penis, and secondarily, to compare the mFI-5 to body mass index (BMI) and American Society of Anesthesiologists (ASA) status as preoperative risk stratification measures. METHODS: We included all patients who underwent surgical management for adult-acquired buried penis at an academic Level I trauma center between 2015 and 2023. A manual chart review was performed to collect data on patient demographics, modified frailty index variables, intraoperative data, postoperative outcomes, and complications. RESULTS: A total of 55 patients underwent surgical repair of adult-acquired buried penis, with 26 experiencing postoperative complications (47.3%). Univariable regression analyses revealed that the mFI-5 was a significant predictor of postoperative complications (odds ratio [OR] 3.40, 95% confidence interval [CI]: 1.56-7.42, p = .002), ongoing postoperative urinary problems (OR 2.03, 95% CI: 1.02-4.05, p = .045), patient dissatisfaction with outcomes (OR 3.29, 95% CI: 1.35-8.02, p = .009), and persistent postoperative symptoms (OR 2.42, 95% CI: 1.10-5.35, p = .029). There was no significant association between ASA classification and postoperative complications (OR 1.59, 95% CI:.544-4.63, p = .398). Multivariable analysis demonstrated that the mFI-5 was an independent predictor of postoperative complications (OR 5.34, 95% CI: 1.80-15.9, p = .003) when controlling for BMI and age. CONCLUSION: The mFI-5 is an independent predictor of postoperative complications in patients undergoing surgical repair of adult-acquired buried penis. The simplicity of the index permits efficient preoperative risk stratification of adult-acquired buried penis patients and provides important counseling information that may not be reflected by age or BMI alone.

Expanding Our Role in Headache Management: A Systematic Review and Algorithmic Approach to Surgical Management of Postcraniotomy Headache.

BACKGROUND: Chronic postcraniotomy headache (PCH) is common and debilitating. Unfortunately, the literature on this topic is sparse without clear management algorithms. Possible etiologies of PCH include nerve injury and/or entrapment, hardware, dural adhesions, or musculoskeletal injury. The purpose of this study was to present the results of both a systematic review of the literature and a single-center case series, both of which informed the development of a novel treatment algorithm that may be applied to this patient population. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed a systematic review of the literature, identifying articles describing the surgical management of PCH. A retrospective chart review was performed to identify patients who met the criteria for PCH treated at our institution. A patient's history and physical examination determined the etiology and management, and pain severity scores were the primary outcome measured. RESULTS: Nineteen articles encompassing 131 patients described surgical management techniques for PCH. 83 patients (63.3%) had complete resolution of pain (χ2 = 52.1, P < 0.0001). At our institution, 19 patients underwent surgical management for PCH. A significant reduction in pain scores from 7.57 to 2.16 (P < 0.001) was demonstrated, and 84 percent of patients achieved complete or significant pain reduction. CONCLUSIONS: Through a literature review and our own case series, we demonstrate that surgical management of PCH can achieve remarkable results. Plastic surgeons, with their expanding role in treating migraine and headaches, are well suited to manage these patients. We present an algorithmic approach to simplify the management of this common and debilitating condition.

"Postoperative Outcomes Following Buried Penis Reconstruction: A Single-Institution Experience Using the Wisconsin Classification System".

BACKGROUND: Adult acquired buried penis (AABP) is a complex condition often necessitating surgical intervention. This study seeks to examine the validity of the Wisconsin Classification System (WCS) in guiding the surgical management of AABP. Additionally, we aimed to identify which factors contribute to postoperative complications and persistent symptoms following AABP repair. METHODS: We retrospectively reviewed all patients who underwent surgical repair of AABP from 2015-2021 by the senior author at our institution. Patients were categorized according to anatomic characteristics using the WCS. Preoperative symptoms, postoperative symptoms, and postoperative complications were evaluated. RESULTS: Fifty-two patients underwent AABP repair. The mean age was 56.5±14.8 years, and the mean duration of follow-up was 350.0±517.4 days. The assigned preoperative WCS score was congruent with operative management in most patients (86.0%). Morbid obesity (BMI>40.0kg/m2) and postoperative complications were associated with persistent symptoms following AABP repair (p=0.026 and p=0.021, respectively). Increased WCS score was not associated with persistent postoperative symptoms (p=0.314). Morbid obesity (p=0.003), diabetes (p=0.029) and having a panniculectomy during AABP repair (p=0.046) increased the odds for developing postoperative complications. Patients with Type I AABP had significantly fewer complications than those with Type II, III, or IV (p=0.032). CONCLUSIONS: The Wisconsin Classification System serves as a preoperative guide, an educational tool for patients, and provides a framework for the discussion of intraoperative maneuvers and the likelihood of complications. It is imperative to counsel patients on the surgical management of AABP and the postoperative course, as this may permit realistic patient expectations and optimize outcomes.

"Quantifying the Impact of Prepectoral Implant Conversion on Patient Satisfaction and Quality of Life".

BACKGROUND: Conversion of subpectoral reconstruction to the prepectoral plane has been increasing in popularity. However, there is a paucity of research assessing patient-reported outcomes following this operation. The primary aim of this study is to examine patient-reported outcomes following conversion of implants from the subpectoral to prepectoral plane through utilization of the BREAST-Q. METHODS: We retrospectively examined patients who underwent subpectoral to prepectoral implant conversion by three surgeons at two separate centers from 2017-2021. Patient demographics, primary indication for the conversion, surgical characteristics, postoperative outcomes, and BREAST-Qs were obtained. RESULTS: Sixty-eight breasts in 39 patients underwent implant conversion. The most common primary indications for implant conversion were chronic pain (41%), animation deformity (30%), and cosmetic concerns (27%). Average BREAST-Q scores improved significantly preoperatively to postoperatively in all the domains measured ("satisfaction with breasts", "satisfaction with implants", "physical well-being," "psychosocial well-being," and "sexual well-being") (p<0.01). When examined by primary indication, all cohorts had significant preoperative to postoperative score improvement in "satisfaction with breasts" (p<0.001) and "physical well-being" (p<0.01) domains. Fifteen breasts (22%) developed postoperative complications, with implant loss in 9% of breasts. CONCLUSIONS: :Conversion of subpectoral implants to the prepectoral plane significantly improves BREAST-Q outcomes in all aspects, including patient satisfaction with breasts and implants, as well as psychosocial, physical, and sexual well-being. Implant conversion to the prepectoral plane in now becoming our primary solution to most patients with chronic pain, animation deformity or cosmetic concerns after subpectoral reconstruction.

Diversity in the Plastic Surgery Match: The Effect of Program Chair, Program Director, and Faculties' Race and Sex on Matched Applicants.

INTRODUCTION: Prior studies have identified the lack of diversity within the field of plastic surgery (PS) and associated residency matches. In this study, the authors aimed to examine the effect of PS program chairs (PCs), program directors (PD), and faculty members' race and sex on PS applicants and matriculants within the same program. METHODS: Deidentified applicant data from 2017 to 2021 submitted to the University of Wisconsin-Madison's integrated PS program were analyzed. Applicants' self-reported sex and race were collected. Integrated PS program websites were assessed to determine whether applicants matched the program. Race and sex of PCs, PDs, and faculty members were collected from each program's website. RESULTS: Overall, 79 integrated PS programs' websites and 1470 applicants were reviewed. The majority of PCs, PDs, and faculty members were male (87.3%, 81.0%, and 69.6%, respectively) and white (74.7%, 70.9%, and 68.8%, respectively). Most applicants were male (54.0%) and white (60.8%). For a given program, white PCs and PDs have 5 and 6 times the odds of matching an applicant of the same race ( P <0.001 for both). Having male PCs and PDs did not significantly increase the odds of matching an applicant of the same sex ( P =0.198 and 0.905, respectively). CONCLUSION: Although the field of PS has made great strides to close the sex gap within the residency match process, this study highlights ongoing racial disparities among nonwhite applicants.

Insurance Status Predicts Hand Therapy Adherence Following Flexor Tendon Repair: A Retrospective Cohort Study".

BACKGROUND: Many patients are not adherent to hand therapy rehabilitation following surgical repair of traumatic flexor tendon injuries, which can negatively affect surgical outcomes and long-term hand function. We aimed to identify the factors that predict patient non-adherence to hand therapy following flexor tendon repair surgery. METHODS: This retrospective cohort study included 154 patients who underwent surgical repair of flexor tendon injuries at a level I trauma center between January 2015 and January 2020. A manual chart review was performed to collect demographic data, insurance status, injury characteristics, and details of the postoperative course including health care utilization. RESULTS: Factors significantly associated with occupational therapy no-shows included Medicaid insurance (OR, 8.35; 95% CI, 2.91 to 24.0; p < 0.001), self-identified Black race (OR, 7.28; 95% CI, 1.78 to 29.7; p = 0.006), and current cigarette smoker status (OR, 2.69; 95% CI, 1.18 to 6.15; p = 0.019). Patients without insurance attended 73.8% of their OT visits and patients with Medicaid attended 72.0% of their visits, which were significantly lower rates than those with private insurance 90.7% (p=0.026 and p=0.001, respectively). Patients with Medicaid were 8 times more likely to seek emergency department care postoperatively than patients with private insurance (p=0.002). CONCLUSIONS: Significant disparities in hand therapy adherence following flexor tendon repair surgery exist between patients with different insurance statuses, races, and tobacco use. Understanding these disparities can help providers identify at-risk patients to improve hand therapy utilization and postoperative outcomes.

"Vibration Assisted Volume Optimization Mammoplasty (VAVOM): An Alternative Approach for Large-Volume Fat Grafting to the Breast".

SUMMARY: Fat grafting has become an integral part of aesthetic and reconstructive breast surgery. However, the ideal method for harvesting and injecting the fat remains unclear. We describe an alternative approach for large-volume fat grafting in the breast, Vibration Assisted Volume Optimization Mammoplasty (VAVOM), that builds on the experience of other authors with using the power assisted liposuction machine for fat injection. We implemented this approach in 138 breasts over two years and found low rates of complications (4%). This new approach substantially reduces the time required to inject the fat graft and is simpler and faster to set up than previously described techniques. We believe VAVOM can be utilized to perform large-volume fat grafting safely and efficiently in the breast with an acceptable rate of complications.

Risk Factors for Acute Postoperative Complications Following Operative Management of Le Fort Fractures-A NSQIP Study.

INTRODUCTION: Le Fort fractures comprise a pattern of complex midfacial fractures that arise secondarily to craniofacial trauma. Although management of these fractures has been detailed within the literature, there is a paucity of research examining postoperative outcomes after surgical repair. The primary aim of this study is to assess patient outcomes after operative management of Le Fort fractures, and examine factors influencing the risk for developing postoperative complications, through utilization of the ACS-NSQIP database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases recorded between 2012 and 2019 with International Classification of Disease (ICD)-9 and ICD-10 codes corresponding to Le Fort fractures. Patient demographics, clinical variables, and postoperative variables were recorded. Logistic regression analysis was conducted to identify independent risk factors for postoperative complications. RESULTS: Identification of cases with appropriate ICD codes, and exclusion of those with missing data, yielded 562 patients for analysis. There were no cases of minor complications and 14 cases of severe complications (3 cases of wound dehiscence, 3 cases of transfusion requirement, 1 case of failure to wean from the ventilator for more than 48 h, 1 pulmonary embolism, and 8 cases of reoperation), corresponding to an overall complication rate of 2.49%. Logistic regression analysis revealed steroid use as an independent predictor of severe postoperative complications (OR =13.73, 95% CI: 1.08-128.02, P =0.02). CONCLUSION: The present study is the first to conduct a risk factor analysis of patients with Le Fort fractures using the ACS-NSQIP national database. The overall postoperative complication rate was 2.49%, with 14 cases of complications recorded in 8 years. Although this may suggest that surgical management of Le Fort fractures is generally well-tolerated, it should be noted that this problem is frequently associated with other severe injuries of the head and neck that may influence patient prognosis. Given this, further analysis would benefit from a larger patient cohort and longer postoperative data as the ACS-NSQIP database only records outcomes within 30 days.

The Implications of the Emergency Medical Treatment and Labor Act and the No Surprises Act for Plastic and Reconstructive Surgeons.

SUMMARY: The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986 to protect uninsured patients against economic discrimination. Although this law has been established for several decades, recent passage of the No Surprises Act may invoke new implications for the health care system under EMTALA. Therefore, it is worthwhile to review EMTALA's applications to the practice of plastic surgery and review EMTALA in the context of the recently passed No Surprises Act. First, providers are mandated by EMTALA to administer a medical screening examination to any patient presenting for emergent care. Second, providers must administer medical stabilization if the medical screening examination reveals an emergent condition. If the hospital lacks specialized capabilities to provide stabilizing care, they are required to transfer the patient to a facility that can provide care. Although EMTALA's provisions protect patients and provide them with leverage to obtain emergency care, the act has been associated with out-of-network, or "surprise," medical bills for the insured population and, ultimately, may be detrimental to plastic surgeons in emergency settings. The concerns related to EMTALA within plastic surgery involve the overburdening of surgeons at tertiary care centers because of uncompensated care and high rates of interfacility transfers. In addition, the recent passage of the No Surprises Act to end out-of-network emergency bills may further impact care provided by plastic surgeons in emergency settings under EMTALA's mandate. Potential methods to address these concerns include increasing on-call reimbursement rates and implementation of emergency department telemedicine services.

The Relationship Between Neuropsychiatric Diagnoses and Revision Surgery After Breast Reconstruction.

BACKGROUND: A neuropsychiatric diagnosis (ND) has the potential to affect patient satisfaction after breast reconstruction. However, literature regarding the interplay between neuropsychiatric diagnoses and revision operations after reconstruction remains sparse. In this study, we aim to determine whether neuropsychiatric diagnoses result in increased revision operations and healthcare utilization of plastic surgery resources after alloplastic and autologous breast reconstruction. METHODS: We retrospectively reviewed 200 patients from 2010 to 2019 who underwent postmastectomy alloplastic or autologous breast reconstruction by a single surgeon at our institution. We evaluated for the presence of neuropsychiatric diagnoses, type of neuropsychiatric diagnoses, number of revisions, and number of postreconstruction plastic surgery appointments. Continuous variables were compared using independent samples t tests, and categorical variables were compared using χ 2 tests. RESULTS: Of the 196 patients who met inclusion criteria, the majority underwent at least one revision (65.3%). The presence of an ND did not predict a higher number of revision operations ( P = 0.512) nor was the timing of the diagnosis (preoperative vs postoperative) significantly associated with the number of revision procedures ( P = 0.156). The patients who had a ND at any point during the reconstructive process had a significantly higher number of plastic surgery appointments and a longer duration of follow-up compared with the patients without any neuropsychiatric diagnoses ( P = 0.009 and P = 0.040, respectively). Complications did not impact the number of revision operations ( P = 0.780). CONCLUSIONS: Neuropsychiatric diagnoses do not significantly influence the number of revision operations after breast reconstruction. However, neuropsychiatric diagnoses result in increased healthcare utilization of plastic surgery resources that may lead to increased healthcare costs.

Dual-Innervated Free Gracilis Muscle Transfer for Facial Reanimation in Children.

BACKGROUND: Facial palsy may have deleterious effects for pediatric patients. The most common reconstruction is 2-stage free gracilis muscle transfer (FGMT) after cross-face nerve graft (CFNG). This requires a prolonged period from time of surgery to smile. New techniques using both a CFNG and motor nerve to masseter (MNM) as dual power sources in a single-stage surgery have been described in adults. Here, we examine our experience with this technique in children. METHODS: A retrospective study was performed examining patients who underwent dual-innervated single-stage FGMT at 2 pediatric hospitals from 2016 to 2019. Demographics, etiology, perioperative characteristics, time to mandibular and emotional smile, and Sunnybrook scores were recorded. RESULTS: Five patients met inclusion criteria with a mean age of 11.8 (range, 8-20). Two patients had congenital facial palsy while 3 had acquired facial palsy. Four patients (80%) received dual end-to-end neural coaptations of the CFNG and MNM to the obturator nerve. One (20%) had end-to-side coaptation of the CFNG to the obturator nerve and end-to-end of the MNM to the obturator nerve. The average time to mandibular smile was 103 ± 15.4 days. The average time to emotional smile was 245 ± 48.1 days. The preoperative Sunnybrook scale was 32 ± 7.5 and improved to 55.3 ± 20.6 at 8 months postoperatively. CONCLUSIONS: Dual-innervated FGMT is effective for facial reanimation in children with unilateral facial palsy. Patients can harness a stronger motor source (MNM) and the component of an emotional stimulus (CFNG). This approach may be the new criterion standard pediatric facial reanimation.