Dispelling the Myths of Isotretinoin and Implications for Rhinoplasty.

SUMMARY: Despite concerns from 1980s case reports, oral isotretinoin, a derivative of Vitamin A, has largely proven to be safe in surgical procedures with the exception of deep skin resurfacing. Isotretinoin modulates thinning skin and internal scarring in select rhinoplasty patients who may otherwise have poor definition and excessive scarring. A review of patients undergoing surgical interventions including rhinoplasty in the setting of concomitant isotretinoin was performed to examine safety and therapeutic potential. Forty-nine studies were reviewed. Isotretinoin use appears to be safe in a wide variety of surgical procedures relying on internal scar formation. In rhinoplasty, studies utilized oral isotretinoin to thin skin and improve appearance, patient and surgeon satisfaction. As such, the clinical potential for using oral isotretinoin in select rhinoplasty candidates such as those with thick glaborous sebaceous skin, ethnic, male, and/or revision patients, could mitigate internal scarring processes. Further studies examining the optimal dosing regimen and long-term benefits are warranted.

Modern Approaches to Alternative Flap-Based Breast Reconstruction: Transverse Upper Gracilis Flap.

The transverse upper/myocutaneous gracilis is a medial thigh-based flap primarily reserved as a secondary choice for autologous reconstruction of small to moderate-sized breasts in women without a suitable abdominal donor site. Its consistent and reliable anatomy based on the medial circumflex femoral artery permits expedient flap harvest with relatively low donor site morbidity. The primary disadvantage is the limited achievable volume, often necessitating augmentation such as extended flap modifications, autologous fat grafting, flap stacking, or even implant placement.

Opioid Prescribing Practices in Cleft Lip and Cleft Palate Reconstruction.

INTRODUCTION: Currently, there is no consensus regarding the role of opioids in the management of perioperative pain in children undergoing cleft lip/palate repair. METHOD: The present study evaluated opioid prescribing patterns of surgeon members within the American Cleft Palate-Craniofacial Association surgeons utilizing an anonymous survey. RESULTS: Respondents performing cleft lip repair typically operate on patients 3 to 6 months of age (86%), admit patients postoperatively (82%), and discharge them on the first postoperative day (72%). Comparatively, respondents performed palatoplasty between the ages of 10 and 12 months (62%), almost always admit the patients (99%), and typically discharge on the first postoperative day (78%). Narcotics were more frequently prescribed after palatoplasty than after cleft lip repair, both for inpatients (66%; 49%) and at discharge (38%; 22%). Oxycodone was the most prescribed narcotic (39.1%; 41.4%), typically for a duration of 1 to 3 days (81.5%; 81.2%). All surgeons who reported changing their narcotic regimen (34.4% dose, 32.8% duration) after cleft lip repair, decreased both parameters from earlier to later in their career. Similarly, surgeons who changed the dose (32.2%) and duration (42.5%) of narcotics after palatoplasty, mostly decreased both parameters (96%). Additionally, physicians with >15 years of practice were less likely to prescribe opioids in comparison with colleagues with ≤15 years of experience. Ninety-two percent of respondents endorsed prescribing nonopioid analgesics after prescribing cleft surgery, most commonly acetaminophen (85.7%; 85.4%). CONCLUSION: Cleft surgeons typically prescribe opioids to inpatients and rarely upon discharge. Changes to opioid-prescribing patterns typically involved a decreased dose and duration.

Propeller Flaps in Lower Extremity Reconstruction.

Propeller flaps represent an outstanding alternative to conventional pedicled and free flap options in lower extremity reconstruction, offering significant advantages over the latter. An understanding of the perforasome concept, hot and cold perforator locations, and basic flap design enable the surgeon to readily harvest flaps based on any clinically relevant perforator in freestyle fashion. The purpose of this article is to review fundamentals of propeller flap design and harvest in the lower extremity and discuss reconstructive strategies by level of injury.

Breast Reconstruction in Obese Patients: The Fat Grafted Latissimus versus Abdominal Free Tissue Transfer.

Immediate fat grafting to the pedicled myocutaneous latissimus dorsi (LD) flap has recently gained in popularity as a means to supplement volume for breast reconstruction. The aim of this study is to compare complication rates of the immediately fat-grafted LD to free tissue transfer in the obese population. METHODS: In this retrospective cohort, 82 patients (149 breasts) from 2015 to 2019 were included. Patients underwent either unilateral or bilateral breast reconstruction with either LD with immediate fat grafting or abdominal-based free tissue transfer. Included patients had a body mass index ≥ 30 kg/m2 at the time of surgery. Complication data were recorded as minor, major, and medical complications. Procedure characteristics and postoperative data were also studied. RESULTS: Minor complication rates between the LD with immediate fat grafting and free tissue transfer cases were similar (26.9% versus 26%, respectively). The free tissue transfer group had a significantly higher rate of major complications (20.3% versus 3.8%; P = 0.048) and medical complications (10.6% versus zero). Finally, the LD with immediate fat grafting group had significantly shorter operating room times, hospital length of stay, and fewer donor-site revisions. CONCLUSIONS: LD with immediate fat grafting offers the benefit of a totally autologous reconstruction without the risks of abdominal-based microvascular free tissue transfer or an implant. Favorable complication rates, shorter operative times, and shorter hospital length of stay make this reconstructive option a safe alternative to free tissue transfer in the obese population.

Wound Complications, Additional Ventilation Requirement, Prolonged Stay, and Readmission in Primary Palatoplasty: A Risk Factor Analysis of 3616 Patients.

BACKGROUND: The present study examined risk factors associated with 30-day palatoplasty complications based on analysis of national data. METHODS: Primary palatoplasties were identified in the 2012 to 2015 Pediatric National Surgical Quality Improvement Program database. Cases were analyzed with multivariate regression to investigate predictors for wound healing complications, additional ventilation requirement, prolonged stay (>3 days), and readmission. RESULTS: In 3616 operations, mean age was 12.2 months and operative time was 135.4 minutes. The 30-day complication rate was 7.6 percent overall, including wound dehiscence/infection (3.4 percent), additional ventilation requirement (2.0 percent), and readmission (2.4 percent); 5.1 percent of patients required prolonged stays. Wound healing complications were not predicted by comorbidities. American Society of Anesthesiologists class 3 or greater (OR, 2.8; p = 0.033), neuromuscular disorder (OR, 3.5; p = 0.029), and nutritional support (OR, 2.9; p = 0.035) predicted additional ventilation requirement. Prolonged stays were predicted by requiring additional ventilation (OR, 14.7; p < 0.001) or American Society of Anesthesiologists class 3 or greater (OR, 1.8; p = 0.047), but preoperative ventilator dependence was protective (OR, 0.1; p = 0.012). Mean hospital stay was 1.6 days without an airway complication versus 5.0 days with. Readmissions were increased for patients requiring nutritional support (OR, 2.6; p = 0.025). CONCLUSIONS: This study represents one of the largest cohorts of palatoplasty patients analyzed to date. It identifies what can be learned from a nonspecific 30-day registry regarding cleft outcomes and, from its limitations, discusses what the future of cleft outcomes research might entail. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Evaluating Mastectomy Skin Flap Necrosis in the Extended Breast Reconstruction Risk Assessment Score for 1-Year Prediction of Prosthetic Reconstruction Outcomes.

BACKGROUND: Rates of mastectomy for breast cancer treatment and immediate reconstruction continue to rise. With increasing scrutiny on outcomes and patient satisfaction, there is an impetus for providers to be more deliberate in appropriate patient selection for breast reconstruction. The Breast Reconstruction Risk Assessment (BRA) Score was developed for prediction of complications after primary prosthetic breast reconstruction, focusing on calculating risk estimations for a variety of complications based on individual patient demographic and perioperative characteristics. In this study, we evaluated mastectomy skin flap necrosis (MSFN) as a function of patient characteristics to validate the BRA Score. STUDY DESIGN: We examined our prospective intra-institutional database of prosthetic breast reconstructions from 2004 to 2015. The end point of interest was 1-year occurrence of MSFN after stage I tissue expander placement. RESULTS: Nine hundred and three patients were included; 50% underwent bilateral reconstruction. Median follow-up was 23 months. Mean 1-year complication rates were as follows: MSFN 12.4%, seroma 3.0%, infection 6.9%, dehiscence/exposure 7.1%, and explantation 13.2%. Statistically significantly higher rates of MSFN were found in older patients, smokers, patients with postoperative infections, patients with hypertension, and patients who used aspirin. Neoadjuvant or adjuvant chemotherapy and radiation, diabetes, and seroma formation did not have a statistically significant impact on necrosis rates. CONCLUSIONS: The BRA Score was expanded to estimate complication risk after tissue expander placement up to 1 year postoperatively. The risk of MSFN as calculated by the BRA Score: Extended Length is consistent with published studies demonstrating increased risk with specific comorbidities, and further validates expansion of the BRA score risk calculator.

Development and Internal Validation of the Abdominoplasty Risk Calculator.

BACKGROUND: Risk calculators are an emerging tool that provide granular, individualized risk estimation. Presently, there is a paucity of risk calculators specific to plastic surgery. Abdominoplasty is a popular plastic surgery procedure associated with moderate risks of complications, such as surgical-site infection and dehiscence, and would benefit from the ability to provide patients with accurate, personalized risk assessment. METHODS: Abdominoplasties from the National Surgical Quality Improvement Program 2005 to 2014 database were identified by Current Procedural Terminology code. Relevant perioperative variables included age, body mass index, sex, smoking history, diabetes, American Society of Anesthesiologists class, pulmonary comorbidities, hypertension, bleeding disorders, and operative duration. Multiple logistic regressions were used to generate 30-day risk models for medical complications, surgical-site infection, wound dehiscence, and reoperation. Internal validation of model performance was conducted using C-statistics, Hosmer-Lemeshow tests, and Brier scores. RESULTS: Among the 2499 cases identified, complication rates were as follows: medical complications, 3.8 percent; superficial surgical-site infection, 2.4 percent; deep or organ-space surgical-site infection, 1.6 percent; wound dehiscence, 1.0 percent; and reoperation, 2.0 percent. Risk prediction models were constructed and all demonstrated good predictive performance, with mean predicted risks closely matching observed complication rates. The distributions of predicted risk were wide and contained outliers with very high risk. A user-friendly, open-access online interface for these models is published at AbdominoplastyRisk.org. CONCLUSIONS: The authors developed an internally valid risk calculator for which individual patient characteristics can be input to predict 30-day complications after abdominoplasty. Given that estimated risk can vary widely, individualized risk assessment is a way to enhance shared decision-making between surgeon and patient.

Demystifying the "July Effect" in Plastic Surgery: A Multi-Institutional Study.

BACKGROUND: The "July Effect" refers to a theoretical increase in complications that may occur with the influx of inexperienced interns and residents at the beginning of each academic year in July. OBJECTIVES: We endeavored to determine if a July Effect occurs in plastic surgery. METHODS: Plastic surgery procedures were isolated from the National Surgical Quality Improvement Program registry. Cases involving residents were grouped as either having occurred within the first academic quarter (AQ1) or remaining year (AQ2-4). Groups were propensity matched using patient/operative factors and procedure type to account for baseline differences. Univariate and multivariate regression analyses assessed differences in overall complications, surgical and medical complications, individual complications, length of hospital stay, and operative time. A comparison group comprised of procedures without resident involvement was also analyzed. RESULTS: There were 5967 cases with resident involvement, 5156 of which successfully matched. Both univariate and multivariate regression analyses revealed no significant differences between AQ1 and AQ2-4 in terms of overall, surgical, medical and individual complications, or length of hospital stay. There was a statistically significant, albeit not clinically significant, increase in operative time by 10 minutes per procedure during AQ1 in comparison to AQ2-4 (P = 0.001). For procedures lacking resident participation, there were no differences between AQ1 and AQ2-4 in terms of these outcomes. CONCLUSIONS: A July Effect was not observed for plastic surgery procedures in our study, conceivably due to enhanced resident oversight and infrastructural safeguards. Patients electing to undergo plastic surgery early in the academic year can be reassured of their safety during this period.

Beyond 30 Days: A Risk Calculator for Longer Term Outcomes of Prosthetic Breast Reconstruction.

BACKGROUND: Despite growing use of surgical risk calculators, many are limited to 30-day outcomes due to the constraints of their underlying datasets. Because complications of breast reconstruction can occur well beyond 30 days after surgery, we endeavored to expand the Breast Reconstruction Risk Assessment (BRA) Score to prediction of 1-year complications after primary prosthetic breast reconstruction. METHODS: We examined our prospective intrainstitutional database of prosthetic breast reconstructions from 2004 to 2015. Patients without 1-year follow-up were excluded. Pertinent patient variables include those enumerated in past iterations of the BRA Score. Outcomes of interest include seroma, surgical site infection (SSI), implant exposure, and explantation occurring within 1 year of tissue expander placement. Risk calculators were developed for each outcome using multivariate logistic regression models and made available online at www.BRAScore.org. Internal validity was assessed using C-statistic, Hosmer-Lemeshow test, and Brier score. RESULTS: Nine-hundred three patients met inclusion criteria. Within 1-year, 3.0% of patients experienced seroma, 6.9% infection, 7.1% implant exposure, and 13.2% explantation. Thirty-day, 90-day, and 180-day windows captured 17.6%, 39.5%, and 59.7% of explantations, respectively. One-year risk calculators were developed for each complication of interest, and all demonstrated good internal validity: C-statistics for the 5 models ranged from 0.674 to 0.739, Hosmer-Lemeshow tests were uniformly nonsignificant, and Brier scores ranged from 0.027 to 0.154. CONCLUSIONS: Clinically significant complications of prosthetic breast reconstruction usually occur beyond the 30-day window following tissue expander placement. To better reflect long-term patient experiences, the BRA Score was enhanced with individualized risk models that predicted 1-year complications after prosthetic reconstruction (BRA Score XL). All models performed as well as, if not better than, the original BRA Score models and other popular risk calculators such as the CHA2DS2VASc Score. The patient-friendly BRA Score XL risk calculator is available at www.brascore.org to facilitate operative decision-making and heighten the informed consent process for patients.

Safety and Outcomes of Inpatient Compared with Outpatient Surgical Procedures for Ankle Fractures.

BACKGROUND: As the cost of health-care delivery rises in the era of bundled payments for care, there is an impetus toward minimizing hospitalization. Evidence to support the safety of open reduction and internal fixation (ORIF) of ankle fractures in the outpatient setting is largely anecdotal. METHODS: Patients who underwent ORIF from 2005 to 2013 were identified via postoperative diagnoses of ankle fracture and Current Procedural Terminology codes; patients with open fractures and patients who were emergency cases were excluded. Patients undergoing inpatient and outpatient surgical procedures were propensity score-matched to reduce differences in the baseline characteristics. Primary tracked outcomes included medical and surgical complications, readmission, and reoperation within 30 days of the procedure. Binary logistic regression models were created that determined the risk-adjusted relationship between admission status and primary outcomes. RESULTS: Outpatient surgical procedures were associated with lower rates of urinary tract infection (0.4% compared with 0.9%; p = 0.041), pneumonia (0.0% compared with 0.5%; p = 0.002), venous thromboembolic events (0.3% compared with 0.8%; p = 0.049), and bleeding requiring transfusion (0.1% compared with 0.6%; p = 0.012). Outpatient status was independently associated with reduced 30-day medical morbidity (odds ratio, 0.344 [95% confidence interval, 0.201 to 0.589]). No significant differences were uncovered with respect to surgical complications (p = 0.076), unplanned reoperations (p = 0.301), and unplanned readmissions (p = 0.358). CONCLUSIONS: In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Translational treatment paradigm for managing non-unions secondary to radiation injury utilizing adipose derived stem cells and angiogenic therapy.

BACKGROUND: Bony non-unions arising in the aftermath of collateral radiation injury are commonly managed with vascularized free tissue transfers. Unfortunately, these procedures are invasive and fraught with attendant morbidities. This study investigated a novel, alternative treatment paradigm utilizing adipose-derived stem cells (ASCs) combined with angiogenic deferoxamine (DFO) in the rat mandible. METHODS: Rats were exposed to a bioequivalent dose of radiation and mandibular osteotomy. Those exhibiting non-unions were subsequently treated with surgical debridement alone or debridement plus combination therapy. Radiographic and biomechanical outcomes were assessed after healing. RESULTS: Significant increases in biomechanical strength and radiographic metrics were observed in response to combination therapy (p < .05). Importantly, combined therapy enabled a 65% reduction in persisting non-unions when compared to debridement alone. CONCLUSION: We support the continued investigation of this promising combination therapy in its potential translation for the management of radiation-induced bony pathology. © 2015 Wiley Periodicals, Inc. Head Neck 38: E837-E843, 2016.

A Prospective Study Assessing Complication Rates and Patient-Reported Outcomes in Breast Reconstructions Using a Novel, Deep Dermal Human Acellular Dermal Matrix.

UNLABELLED: The value proposition of an acellular dermal matrix (ADM) taken from the deep dermis is that the allograft may be more porous, allowing for enhanced integration and revascularization. In turn, this characteristic may attenuate complications related to foreign body reactions, seromas, and infection. However, this is juxtaposed against the potential loss of allograft structural integrity, with subsequent risk of malposition and extrusion. Despite the active use of novel, deep dermal ADMs, the clinical outcomes of this new technology has not been well studied. METHODS: This is a prospective study to evaluate surgical and patient-reported outcomes using a deep dermal ADM, FlexHD Pliable. Surgical outcomes and BREAST-Q patient-reported outcomes were evaluated postoperatively at 2- and 6-month time points. RESULTS: Seventy-two breasts (41 patients) underwent reconstruction. Complication rate was 12.5%, including 2 hematomas and 7 flap necroses. One case of flap necrosis led to reconstructive failure. Notably, there were no cases of infection, seroma, or implant extrusion or malposition. Average BREAST-Q scores were satisfaction with outcome (70.13 ± 23.87), satisfaction with breasts (58.53 ± 20.00), psychosocial well being (67.97 ± 20.93), sexual well being (54.11 ± 27.72), and physical well being (70.45 ± 15.44). Two-month postoperative BREAST-Q scores decreased compared with baseline and returned to baseline by 6 months. Postoperative radiation therapy had a negative effect on satisfaction with breasts (P = 0.004) and sexual well being (P = 0.006). CONCLUSIONS: Deep dermal ADM is a novel modification of traditional allograft technology. Use of the deep dermal ADM yielded acceptably low complication rates and satisfactory patient-reported outcomes.

Amifostine preserves osteocyte number and osteoid formation in fracture healing following radiotherapy.

PURPOSE: Radiation is known to decrease osteocyte count and function, leading to bone weakening. A treatment strategy to mitigate these consequences could have immense therapeutic ramifications. The authors previously reported significantly decreased osteocyte count and mineralization capacity in a rat model of fracture healing after radiotherapy. They hypothesized that amifostine (AMF) would preserve osteocyte number and function in this model. MATERIALS AND METHODS: Thirty-six rats were divided into 3 groups: fracture, radiated fracture, and radiated fracture with AMF. Radiated groups underwent human-equivalent radiotherapy to the mandible before fixator placement and mandibular osteotomy. The AMF group received a subcutaneous injection before each dose of radiotherapy. After 40 days, mandibles were harvested for histologic processing. Quantification of osteocyte count (Oc), empty lacunae (EL), and osteoid ratio (osteoid volume [OV] to tissue volume [TV]) was performed and the results were compared using analysis of variance (P < .05). RESULTS: Radiated fractures showed significantly decreased Oc, increased EL, and a decreased capacity to produce new osteoid at the fracture site as measured with OV/TV compared with nonradiated fractures. In mandibles treated with AMF, these metrics were not statistically different than the control, indicating a preservation of osteocyte number and function. CONCLUSIONS: These results support the hypothesis that AMF preserves osteocyte number and function, thereby preventing the pernicious effects of radiotherapy on the cellular environment of fracture healing. Based on these findings, the authors encourage future investigation of this promising therapy for use in the prevention of pathologic fractures and osteoradionecrosis.

Deferoxamine expedites consolidation during mandibular distraction osteogenesis.

BACKGROUND: A limitation of mandibular distraction osteogenesis (DO) is the length of time required for consolidation. This drawback subjects patients to possible pin-site infections, as well as a prolonged return to activities of normal daily living. Developing innovative techniques to abridge consolidation periods could be immensely effective in preventing these problematic morbidities. Deferoxamine (DFO) is an angiogenic activator that triggers the HIF-1α pathway through localized iron depletion. We previously established the effectiveness of DFO in enhancing regenerate vascularity at a full consolidation period (28 days) in a murine mandibular DO model. To investigate whether this augmentation in vascularity would function to accelerate consolidation, we progressively shortened consolidation periods prior to µCT imaging and biomechanical testing (BMT). MATERIALS AND METHODS: Three time points (14d, 21d and 28d) were selected and six groups of Sprague-Dawley rats (n = 60) were equally divided into control (C) and experimental (E) groups for each time period. Each group underwent external fixator placement, mandibular osteotomy, and a 5.1 mm distraction. During distraction, the experimental groups were treated with DFO injections into the regenerate gap. After consolidation, mandibles were imaged and tension tested to failure. ANOVA was conducted between groups, and p < 0.05 was considered statistically significant. RESULTS: At 14 days of consolidation the experimental group demonstrated significant increases in bone volume fraction (BVF), bone mineral density (BMD) and ultimate load (UL) in comparison to non-treated controls. The benefit of treatment was further substantiated by a striking 100% increase in the number of bony unions at this early time-period (C:4/10 vs. E:8/10). Furthermore, metrics of BVF, BMD, Yield and UL at 14 days with treatment demonstrated comparable metrics to those of the fully consolidated 28d control group. CONCLUSION: Based on these findings, we contend that augmentation of vascular density through localized DFO injection delivers an efficient means for accelerating bone regeneration without significantly impacting bone quality or strength.