Reconstruction after Mohs Surgery for Digit Melanoma: Description of Techniques and Postoperative Limb Function.

Introduction: Mohs surgery and reconstruction has enabled tissue-preserving resection of cutaneous malignancies. The goal of our case series evaluation is to present reconstructive techniques and functional outcomes in patients undergoing digit-sparing treatment for primary melanoma. Materials and Methods: A chart review was performed to identify consecutive patients undergoing Mohs surgery and reconstruction for melanoma of the digits. Quality of life (QOL) survey was performed to assess function after the procedure. Results: Thirty-two patients (13 hand, 19 foot, Age: 65.03 +/-17.78 years) who were undergoing Mohs surgery were identified. No recurrence was identified with an average follow-up of 16.1 months (1-95 months). The average defect size was 5.79 +/-4.54 cm2. Reconstruction was performed 0-4 days after resection. The most common techniques included full-thickness skin graft (FTSG) (N = 7), collagen matrix + FTSG (N = 4), and volar advancement flap (N = 7). The reconstructive technique choice appears correlated with defect size (p = 0.0125). Neuro-QOL upper extremity survey results showed a difference that approached statistical significance between patients who underwent digit-sparing treatment (n = 7) versus direct to amputation controls (n = 5) (p = 0.072). No survey differences between digit-sparing treatment (n = 10) and amputation (n = 8) were identified in the lower extremity (p = 0.61). Conclusion: Our results show digit-sparing treatment can confirm clear surgical margins and a trend toward improvement in upper extremity function compared with immediate amputation.

Subungual Schwannoma, a Rare Entity: A Case Report and Literature Review.

We present a case of a 26-year-old right hand dominant male landscaper with a slow growing right ring finger subungual mass. MRI confirmed a 0.9 × 1.5 × 0.9 cm well circumscribed subungual mass believed to be consistent with a glomus tumor, although size and symptoms were not consistent with that diagnosis. The mass was completely excised and diagnosis of schwannoma was confirmed by H&E histology. A literature search was performed utilizing the term "subungual schwannoma." Four case reports were found describing this diagnosis in the hand as well as a single case report describing it in the foot. In summary, this is a 26-year-old male who presents with a schwannoma in the unusual subungual location. Although rare, based on our case and the existing literature, subungual schwannomas should be included in the differential diagnosis of a slow growing subungual mass, particularly if symptoms and exam are inconsistent with more common etiologies.

The Effects of Adjunctive Pain Medications on Postoperative Inpatient Opioid Use in Abdominally Based Microsurgical Breast Reconstruction.

BACKGROUND: The purposes of this study were to quantify the amount of opioid medication used postoperatively in the hospital setting after abdominally based microsurgical breast reconstruction, to determine factors that are associated with increased opioid use, and to identify other adjunctive medications that may contribute to decreased opioid use. METHODS: An electronic medical record data pull was performed at the University of Pennsylvania from November 2016 to October 2018. Cases were identified using Current Procedural Terminology code 19364. Only traditional recovery after surgery protocol patients were included. Patient comorbidities, surgical details, and pain scores were captured. Postoperative medications including non-patient-controlled analgesia opioid use and adjunctive nonopioid pain medications were recorded. Non-patient-controlled analgesia total opioid use was calculated and converted to oral morphine milligram equivalents (mme). Statistical analysis was performed using t test analyses and linear regression. RESULTS: A total of 328 patients satisfied our inclusion criteria. Five hundred forty free flaps were performed (212 bilateral vs 116 unilateral, 239 immediate vs 89 delayed). Bilateral patients used on average 115.2 mme (95% confidence interval [CI], 103.4-127.0 mme) compared with 89.0 mme in unilateral patients (95% CI, 70.0-108.0 mme; P = 0.015). Patients with abdominal mesh placement (n = 249) required 113.0 mme (95% CI, 100.5-125.5 mme) compared with 83.8 mme (95% CI, 68.8-98.7 mme) for patients without mesh (n = 79; P = 0.016). Each additional hour of surgery increased postoperative mme by 9.4 (P < 0.01). Patients with a nonzero preoperative pain score required 100.3 mme (95% CI, 90.2-110.4 mme) compared with 141.1 mme (95% CI, 102.7-179.7 mme) for patients with preoperative pain score greater than 0/10 (P < 0.01). Patients with postoperative index pain score ≤5/10 required 89.2 mme (95% CI, 78.6-99.8 mme) compared with 141.1 mme (95% CI, 119.9-162.2 mme) for patients with postoperative index pain score >5/10 (P < 0.01). After regression analysis, a dose of intravenous acetaminophen 1000 mg was found to decrease postoperative mme by 11.7 (P = 0.024). A dose of oral ibuprofen 600 mg was found to decrease postoperative mme by 8.3 (P < 0.01). CONCLUSIONS: Bilateral reconstruction and longer surgery resulted in increased postoperative mme. Patients with no preoperative pain required less opioids than did patients with preexisting pain. Patients with good initial postoperative pain control required less opioids than did patients with poor initial postoperative pain control. Intravenous acetaminophen and oral ibuprofen were found to significantly decrease postoperative mme.

Strabismus in Unicoronal Craniosynostosis: Effect of Orbital Dysmorphology and Fronto-Orbital Advancement and Remodeling.

BACKGROUND: The purpose of this study was to determine what craniometric changes occur to both orbits of unicoronal craniosynostosis patients undergoing fronto-orbital advancement and remodeling, and which of these changes are associated with new onset of postoperative strabismus. METHODS: A retrospective analysis was performed of the preoperative and postoperative orbits of 24 unicoronal craniosynostosis patients and the orbits of 24 control subjects, totaling 144 orbits. Eight parameters were evaluated using multivariate logistic regression analysis. One of the parameters was modified orbital index, an indicator of severity of harlequin deformity. RESULTS: Significant differences in orbital dimensions and angles were present bilaterally in unicoronal craniosynostosis orbits when compared to controls. Fronto-orbital advancement and remodeling increased the ipsilateral unicoronal craniosynostosis orbital volume from 13,184 ± 2003 mm to 16,220 ± 2323 mm (p < 0.001). Ipsilateral horizontal cone angles were increased from 48 ± 5 degrees to 54 ± 7 degrees (p = 0.004). Ipsilateral vertical cone angles were decreased from 73 ± 8 degrees to 66 ± 10 degrees (p = 0.003). Ipsilateral modified orbital index improved from 0.83 ± 0.06 to 0.88 ± 0.06 (p = 0.003). Three of the 19 unicoronal craniosynostosis patients developed transient postoperative strabismus. Logistic regression analysis displayed a strong significant association between new-onset strabismus and a change in modified orbital index with a coefficient of 30.84 ± 14.51 (p < 0.05). CONCLUSIONS: The orbital dysmorphology in unicoronal craniosynostosis is bilateral in nature, and it is not wholly treated with conventional fronto-orbital advancement and remodeling. The severity of ipsilateral orbital dysmorphology is correlated with the incidence of postoperative strabismus following conventional fronto-orbital advancement and remodeling. Future research is needed to develop strategies to mitigate the risk of development of strabismus in this group of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Flap Reconstruction of the Hand.

LEARNING OBJECTIVES: After studying this article, the participant should: 1. Be familiar with local, regional, and free flaps for reconstruction of the hand. 2. Be able to identify potential sources of tissue for vascularized coverage using an algorithmic approach to provide stable and functional reconstruction of the hand. 3. Recognize the controversies and complications unique to flap reconstruction of the hand. SUMMARY: The goal of this continuing medical education module is to provide the practicing reconstructive surgeon with a framework in which to think about reconstruction of the hand. The hand has unique functional and aesthetic characteristics that must be considered when choosing the optimal methods for reconstruction. There are a number of reliable local and regional flaps that can be used to treat the hand requiring soft-tissue coverage and/or vascularized bone graft. The "reconstructive ladder," originally described by Mathes and Nahai, is based on the principle of using the simplest approach that adequately restores form and ideally optimizes function. In cases where the simplest techniques prove to be inadequate, local and regional flaps and, ultimately, microsurgical tissue transfer should be considered.

International Adoptees With Cleft Lip and/or Palate: Lessons Learned From a Growing Population.

BACKGROUND: International adoptees with cleft lip and palate (CLP) are a growing population in the United States. They represent a clinical challenge, presenting at various ages and stages of cleft repair. METHODS: A retrospective review of patients seen at the CLP Program at the Children's Hospital of Philadelphia (CHOP) between 1998 and 2012 with a history of international adoption was performed. Demographics, surgical histories, and long-term speech outcomes were reviewed. RESULTS: Seventy-four female and 77 male patients were evaluated. Patients were adopted at an average age of 2.3 years (range, 0.4-8.6 years); 80.8% (n = 122) of patients were adopted from China. The rate of international cleft adoption increased by approximately 1.5 patients per year (r = 0.7739, P < 0.001); 13.2% (n = 19) of all subjects with cleft palates had oronasal fistulas (ONFs) that required repair. The ONF rates for primary palatoplasties at CHOP were significantly lower compared to both preadoption repairs (P = 0.002) and postadoption repairs at outside hospitals (P = 0.01); 14.8% (n = 21) of all patients had secondary surgeries for velopharyngeal incompetence (VPI). Rates of secondary surgery for VPI were also significantly lower for primary palatoplasties at CHOP compared to both preadoption repairs (P = 0.0018) and postadoption repairs at outside hospitals (P = 0.0033). CONCLUSIONS: International adoptees with CLP are a growing population and are clinically challenging with high ONF rates and high secondary surgery rates for VPI. We recommend expedited repair of unoperated cleft palates in adoptees older than 18 months. Adopted patients with CLP should be rigorously evaluated for the need for speech therapy and secondary surgeries to correct for VPI.

Surgical Classification of the Mandibular Deformity in Craniofacial Microsomia Using 3-Dimensional Computed Tomography.

BACKGROUND: Grading systems of the mandibular deformity in craniofacial microsomia (CFM) based on conventional radiographs have shown low interrater reproducibility among craniofacial surgeons. We sought to design and validate a classification based on 3-dimensional CT (3dCT) that correlates features of the deformity with surgical treatment. METHODS: CFM mandibular deformities were classified as normal (T0), mild (hypoplastic, likely treated with orthodontics or orthognathic surgery; T1), moderate (vertically deficient ramus, likely treated with distraction osteogenesis; T2), or severe (ramus rudimentary or absent, with either adequate or inadequate mandibular body bone stock; T3 and T4, likely treated with costochondral graft or free fibular flap, respectively). The 3dCT face scans of CFM patients were randomized and then classified by craniofacial surgeons. Pairwise agreement and Fleiss' κ were used to assess interrater reliability. RESULTS: The 3dCT images of 43 patients with CFM (aged 0.1-15.8 years) were reviewed by 15 craniofacial surgeons, representing an average 15.2 years of experience. Reviewers demonstrated fair interrater reliability with average pairwise agreement of 50.4 ± 9.9% (Fleiss' κ = 0.34). This represents significant improvement over the Pruzansky-Kaban classification (pairwise agreement, 39.2%; P = 0.0033.) Reviewers demonstrated substantial interrater reliability with average pairwise agreement of 83.0 ± 7.6% (κ = 0.64) distinguishing deformities requiring graft or flap reconstruction (T3 and T4) from others. CONCLUSION: The proposed classification, designed for the era of 3dCT, shows improved consensus with respect to stratifying the severity of mandibular deformity and type of operative management.

Mortality after inpatient open ventral hernia repair: developing a risk stratification tool based on 55,760 operations.

BACKGROUND: The medical complexity of hernia patients imparts higher risk for complications, and mortality is a distinct reality. No study has stratified patients based on preoperative risk for open ventral hernia repair (VHR) specifically. We utilized the American College of Surgeons National Surgical Quality Improvement Program to create a mortality risk stratification model following VHR. METHODS: Patients undergoing open VHR were identified from American College of Surgeons National Surgical Quality Improvement Program databases. Baseline variables correlated with mortality risk were entered into stepwise regression and bootstrap analysis. ß-Coefficients were used to weigh each factor, yielding the risk assessment tool. RESULTS: A total of 55,760 patients were included with a mortality of 1.34%. Predictors of mortality included the following: functional status (odds ratio [OR] = 2.87), liver disease (OR = 3.61), malnutrition (OR = 1.43), age greater than 65 years (OR = 2.39), American Society of Anesthesiologists 4 or higher (OR = 2.90), systemic inflammation (OR = 1.99), and contamination (OR = 2.15). Patients were risk stratified into low risk (mortality .33%), moderate risk (mortality 1.86%), high risk (mortality 8.76%), and extreme risk groups (mortality 34.2%). Unplanned reoperations and medical complications increased across risk groups. The model demonstrated high discriminatory ability with a C-statistic value of .86. CONCLUSIONS: This study provides an accurate model to predict mortality risk specific to open VHR. The strongest predictors were American Society of Anesthesiologists, liver disease, functional status, and older age. This tool may inform clinical decision making to reduce complications.

A Cost-Utility Assessment of Mesh Selection in Clean-Contaminated Ventral Hernia Repair.

BACKGROUND: Mesh reinforcement can reduce hernia recurrence, but mesh selection is poorly understood, particularly in contaminated defects. Acellular dermal matrix has enabled single-stage ventral hernia repair in clean-contaminated wounds but can be associated with higher complications and cost compared with synthetic mesh. This study evaluated the cost-utility of synthetic mesh and acellular dermal matrix for clean-contaminated ventral hernia repairs. METHODS: A systematic review of articles comparing outcomes for synthetic and acellular dermal matrix repairs identified 14 ventral hernia repair-specific health states. Quality-adjusted life years were determined through Web-based visual analog scale survey of 300 nationally representative individuals. Overall expected cost and quality-adjusted life-years for ventral hernia repair were assessed using a Monte Carlo simulation with sensitivity analyses. RESULTS: Synthetic mesh reinforcement had an expected cost of $15,776 and quality-adjusted life-year value gained of 21.03. Biological mesh had an expected cost of $23,844 and quality-adjusted life-year value gained of 20.94. When referencing a common baseline (do nothing), acellular dermal matrix (incremental cost-effectiveness ratio, 3378 ($/quality-adjusted life years)) and synthetic mesh (incremental cost-effectiveness ratio, 2208 ($/quality-adjusted life years)) were judged cost-effective, although synthetic mesh was more strongly favored. Monte Carlo sensitivity analysis demonstrated that synthetic mesh was the preferred and most cost-effective strategy in 94 percent of simulations, supporting its overall greater cost-utility. Despite varying the willingness-to-pay threshold from $0 to $100,000 per quality-adjusted life-year, synthetic mesh remained the optimal strategy across all thresholds in sensitivity analysis. CONCLUSION: This cost-utility analysis suggests that synthetic mesh repair of clean-contaminated hernia defects is more cost-effective than acellular dermal matrix.

Racial and age disparities persist in immediate breast reconstruction: an updated analysis of 48,564 patients from the 2005 to 2011 American College of Surgeons National Surgery Quality Improvement Program data sets.

BACKGROUND: Immediate breast reconstruction (IBR) rates continue to rise, yet recent patterns based on race, age, and patient comorbidities have not been adequately assessed. METHODS: Women undergoing mastectomy only or mastectomy with IBR from 2005 to 2011 were identified in the American College of Surgeons-National Surgical Quality Improvement (NSQIP) data sets. A multivariate logistic regression was performed to determine factors independently associated with receipt of IBR. Thirty-day surgical complication rates after IBR were also assessed. RESULTS: Rates of IBR increased significantly over the study period from 26% of patients in 2005 to 40% in 2011. Non-Caucasian race, older age (≥45 years), obesity, and presence of comorbid conditions including diabetes mellitus, current smoking, and cardiovascular disease were all negatively associated with receipt of IBR. Surgical complication rates after IBR were not predicted by non-Caucasian race, older age, or presence of diabetes mellitus. CONCLUSIONS: This current assessment of IBR using the American College of Surgeons-National Surgical Quality Improvement data sets demonstrates that non-Caucasian and older women (≥45 years) continue to receive IBR at lower rates despite the lack of association of added risk of surgical morbidity.

An analysis of early oncologic head and neck free flap reoperations from the 2005-2012 ACS-NSQIP dataset.

BACKGROUND: There are limited population-based studies that examine perioperative factors that influence postoperative surgical take-backs to the OR following free flap (FF) reconstruction for head/neck cancer extirpation. The purpose of this study was to critically analyse head/neck free flaps (HNFF) captured in the ACS-NSQIP dataset with a specific focus on postoperative complications and the incidence of factors associated with re-operation. METHODS: The 2005-2012 ACS-NSQIP datasets were accessed to identify patients undergoing FF reconstruction after a diagnosis of head/neck cancer. Patient demographics, comorbidities, and perioperative risk factors were examined as covariates, and the primary outcome was return to OR within 30 days of surgery. A multivariate regression was performed to determine independent preoperative factors associated with this complication. RESULTS: In total, 855 patients underwent FF for head/neck reconstruction most commonly for the Tongue (24.7%) and Mouth/Floor/cavity (25.0%). Of these, 153 patients (17.9%) returned to the OR within 30 days of surgery. Patients in this cohort had higher rates of wound infections and dehiscence (p < 0.01). Medical complications were significantly higher and included pneumonia (12.4% vs 5.0%, p < 0.01), prolonged ventilation (16.3% vs 4.8%, p < 0.01), myocardial infarction (2.6% vs 0.6%, p = 0.017), and sepsis (7.2% vs 3.4%, p = 0.033). Regression analysis demonstrated that visceral flaps (OR = 9.7, p = 0.012) and hypoalbuminemia (OR = 2.4, p = 0.009) were significant predictors of a return to the OR. CONCLUSION: Based on data from the nationwide NSQIP dataset, up to 17% of HNFF return to the OR within 30 days. Although this data-set has some significant limitations, these results can cautiously help to improve preoperative patient optimisation and surgical decision-making.

Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements.

BACKGROUND: Many patients with successful lower extremity salvage have postoperative functional and esthetic concerns. Such concerns range from contour irregularity preventing proper shoe-fitting to esthetic concerns involving color, contour, and texture match. The purpose of this study is to determine the overall incidence as well as factors associated with an increased likelihood of undergoing secondary, esthetic refinements of lower extremity free flaps and to review current revision techniques. METHODS: All patients undergoing lower extremity soft tissue coverage for limb salvage procedures between January 2007 and June 2013 at a single institution were included in the analysis. Patients who underwent secondary refinements for lower extremity free flaps were compared with patients not undergoing secondary procedures. RESULTS: During the study period, 152 patients underwent reconstruction and were eligible for inclusion. Of these, 32 (21.1%) patients underwent secondary, esthetic revisions. Few differences in patient or case characteristics were noted, although revision patients trended toward being younger, having lower body mass index, with defects secondary to acute trauma located below the ankle. The most common revision was complex soft tissue rearrangement or surgical flap debulking/direct excision (87.5% of patients), followed by scar revision (12.5%), suction-assisted lipectomy (3.1%), laser scar revision (3.1%), and tissue expansion with local tissue rearrangement (3.1%). CONCLUSION: A significant portion of patients desire secondary revisions following the initial procedure. This is especially true of younger patients with below ankle reconstruction. In many patients, an esthetic consideration should not be of secondary concern, but should be part of the ultimate reconstructive algorithm for lower extremity limb salvage.

An Assessment of 30-Day Complications in Primary Cleft Palate Repair: A Review of the 2012 ACS NSQIP Pediatric.

OBJECTIVE: This study uses the American College of Surgeons Pediatric National Surgical Quality Improvement Program (ACS NSQIP Pediatric), a multicenter database, to identify risk factors for complications after cleft palate repair. DESIGN: Patients undergoing Current Procedural Terminology (CPT) codes 42200 and 42205 were extracted from the 2012 ACS NSQIP Pediatric. Patients older than 36 months or those who had undergone an additional surgery that altered the risk were excluded. Outcome variables were combined to create a complication variable. Fisher's exact, Pearson chi-square, and Wilcoxon rank-sum tests were used for analysis. RESULTS: Eligibility criteria were met by 751 patients. Of these, 192 (25.6%) had unilateral clefts, 146 (19.4%) bilateral, and 413 (55.0%) were unspecified. The average age at time of surgery for those without and with complications was 421.1 ± 184.8 and 433.6 ± 168.0 days, respectively (P = .76). Of the 21 (2.8%) patients with complications, respiratory complications were the most common. Risk factors associated with complications included American Society of Anesthesiologists classification of 3 (P = .003), nutritional support (P = .013), esophageal/gastric/intestinal disease (P = .016), oxygen support (P = .003), structural pulmonary/airway abnormality (P = .011), and impaired cognitive status (P = .009). Patients undergoing concurrent laryngoscopy (P = .048) or other surgeries (P = .047) were also found to be associated with increased complications. The 30-day fistula rate was 0.5%, and the readmission rate was 1.9%. CONCLUSION: Perioperative complications for primary palatoplasty were 2.8% according to the ACS NSQIP Pediatric. Preoperative patient-related factors as well as concurrent surgeries may affect 30-day complication rates. These results help target those at greater risk for complications and allow for appropriate interventions to mitigate risks.

An Assessment of 30-Day Complications in Primary Cleft Lip Repair: A Review of the 2012 ACS NSQIP Pediatric.

OBJECTIVE: The aim of this study is to identify risk factors associated with complications and readmissions following cleft lip repair using the multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric. DESIGN: Patients undergoing CPT codes 40700, 40701, and 40702 were extracted from the ACS NSQIP Pediatric. Fisher exact, χ(2), and rank-sum tests were used to evaluate risk factors. RESULTS: Of the 525 patients included, 4.2% had complications, with respiratory complications being the most common. Risk factors included congenital malformations (P = .001), ventilator dependence (P = .002), oxygen support (P = .016), tracheostomy (P = .005), esophageal/gastric/intestinal disease (P = .007), impaired cognitive status (P = .034), acquired central nervous system abnormality (P = .040), nutritional support (P = .001), major and severe cardiac risk factors (P = .011 and P = .005), and an American Society of Anesthesiologists score of 3 (P = .002). In addition, complications were associated with undergoing a one-stage bilateral repair (P = .045) or concomitant ear, nose, and throat procedure (P = .045). The readmission rates for ambulatory patients and inpatients were 2.6% and 4.9% (P = .556), with an overall readmission rate of 4.6%. Ambulatory patients were older (P = .005) and had shorter operative times (P < .001). CONCLUSIONS: Perioperative complications are low following cleft lip repair, with respiratory complications being the most common. Readmission rates of 4.6% are higher than expected, and insight into predictors of complications will allow surgeons to identify patients who could benefit from additional resources.

A Comparative Cost Analysis of Cleft Lip Adhesion and Nasoalveolar Molding before Formal Cleft Lip Repair.

BACKGROUND: Patients with complete cleft lip and palate may benefit from cleft lip adhesion or nasoalveolar molding before formal cleft lip repair. The authors compared the relative costs to insurers of these two treatment modalities and the burden of care to families. METHODS: A retrospective analysis was performed of cleft lip and palate patients treated with nasoalveolar molding or cleft lip adhesion at The Children's Hospital of Philadelphia between January of 2007 and June of 2012. Demographic, appointment, and surgical data were reviewed; surgical, inpatient hospital, and orthodontic charges and costs were obtained. Multivariate linear regression and two-sample, two-tailed independent t tests were performed to compare cost and appointment data between groups. RESULTS: Forty-two cleft adhesion and 35 nasoalveolar molding patients met inclusion criteria. Mean costs for nasoalveolar molding were $3550.24 ± $667.27. Cleft adhesion costs, consisting of both hospital and surgical costs, were $9370.55 ± $1691.79. Analysis of log costs demonstrated a significant difference between the groups, with the mean total cost for nasoalveolar molding significantly lower than that for adhesion (p < 0.0001). Nasoalveolar molding patients had significantly more made, cancelled, no-show, and missed visits and a higher missed percentage than adhesion patients (p < 0.0001) for all except no-show appointments, (p = 0.0199), indicating a higher burden of care to families. CONCLUSIONS: Nasoalveolar molding may cost less before formal cleft lip repair treatment than cleft lip adhesion. Third-party payers who cover adhesion and not nasoalveolar molding may not be acting in their own best interest. Nasoalveolar molding places a higher burden of care on families, and this fact should be considered in planning treatment.

Cost-utility analysis of the use of prophylactic mesh augmentation compared with primary fascial suture repair in patients at high risk for incisional hernia.

BACKGROUND: Although hernia repair with mesh can be successful, prophylactic mesh augmentation (PMA) represents a potentially useful preventative technique to mitigate incisional hernia risk in select high-risk patients. The efficacy, cost-benefit, and societal value of such an intervention are not known. The aim of this study was to determine the cost-utility of using prophylactic mesh to augment fascial incisions. METHODS: A decision tree model was employed to evaluate the cost-utility of using PMA relative to primary suture closure (PSC) after elective laparotomy. The authors adopted the societal perspective for cost and utility estimates. A systematic review of the literature on PMA was performed. The costs in this study included direct hospital costs and indirect costs to society, and utilities were obtained through a survey of 300 English-speaking members of the general public evaluating 14 health state scenarios relating to ventral hernia. RESULTS: PSC without mesh demonstrated an expected average cost of $17,182 (average quality-adjusted life-year [QALY] of 21.17) compared with $15,450 (expected QALY was 21.21) for PMA. PSC was associated with an incremental cost-efficacy ratio (ICER) of -$42,444/QALY compared with PMA such that PMA was more effective and less costly. Monte Carlo sensitivity analysis was performed demonstrating more simulations resulting in ICERs for PSC above the willingness-to-pay threshold of $50,000/QALY, supporting the finding that PMA is superior. CONCLUSION: Cost-utility analysis of PSC compared to PMA for abdominal laparotomy closure demonstrates PMA to be more effective, less costly, and overall more cost-effective than PSC.

Venous thromboembolism in body contouring: an analysis of 17,774 patients from the National Surgical Quality Improvement databases.

BACKGROUND: The purpose of this study was to examine the incidence and predictors of venous thromboembolism following body contouring. METHODS: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2012 for all body contouring cases. A multivariate logistic regression was performed to determine predictors of venous thromboembolism, and used to define risk scores for each significant predictor. RESULTS: Seventeen thousand seven hundred seventy-four patients underwent body contouring during the study period. Venous thromboembolism occurred in 99 individuals (0.56 percent). Multivariate logistic regression revealed that age older than 45 years [45 to 60 years (OR, 1.54; p = 0.1); older than 60 years (OR 3.1, p < 0.001)], undergoing contouring of the trunk (OR, 2.75; p < 0.001), obesity [body mass index of 30 to 34.9 (OR, 3.35; p < 0.001); body mass index of 35 to 39.9 (OR, 4.41; p < 0.001); body mass index ≥ 40 (OR, 3.14; p = 0.001)], and admission on an inpatient basis (OR, 3.01; p < 0.001) were associated with increased odds of venous thromboembolism. Patients' total scores were categorized as low (0 to 4), medium (5 to 7), or high risk (8 to 9). The low-risk cohort exhibited a venous thromboembolism incidence of 0.14 percent, the medium-risk cohort experienced an incidence of 0.97 percent, and the high-risk group experienced a venous thromboembolism incidence of 2.95 percent. CONCLUSIONS: This study identifies predictors of venous thromboembolism and creates a simple risk-scoring model using a large, prospective data set. The authors' analysis demonstrates that in the presence of certain risk factors, the incidence of venous thromboembolism increases dramatically; in these cases, venous thromboembolism prophylaxis may be warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Surgical Site Infections after Free Flap Breast Reconstruction: An Analysis of 2,899 Patients from the ACS-NSQIP Datasets.

BACKGROUND: Surgical site infections (SSIs) are a costly complication, resulting in lower patient satisfaction and higher health care expenditures. Incidence varies widely in the literature by surgery type, yet few studies focus exclusively on autologous breast reconstruction, an increasingly common surgery. The aim of this study is to identify risk factors for SSIs in free flap breast reconstruction using the National Surgical Quality Improvement Program Database (NSQIP). METHODS: Patients undergoing breast reconstruction with any flap type were identified by Current Procedural Terminology codes in the NSQIP database. Patients with superficial or deep SSIs within 30 days of surgery were compared with controls by univariate analysis and multivariate logistic regression across various characteristics. RESULTS: Overall, 2,899 patients undergoing autologous reconstruction were identified. Of these, 143 (4.9%) patients developed SSIs. Those who developed wound complications were more likely smokers (18.2 vs. 8.4%, p < 0.001) and diabetics (9.8 vs. 3.4%, p < 0.001) with hypertension (38.2 vs. 25.4%, p < 0.001) and pulmonary (4.5 vs. 1.3%, p = 0.01) history. SSIs occurred in patients with higher American Society of Anesthesiologists (p = 0.003) and the World Health Organization obesity (p < 0.001) classes. On multivariate regression, SSIs were significantly associated with smoking (odds ratio [OR] = 3.59, p < 0.001) and hypertension (OR = 1.86, p = 0.03). CONCLUSIONS: This study demonstrates that patients who are active smokers or have hypertension are at the highest risk for SSIs. Preoperative identification and tailored postoperative management of these patients may decrease the incidence of this complication.

Volumetric changes in cranial vault expansion: comparison of fronto-orbital advancement and posterior cranial vault distraction osteogenesis.

BACKGROUND: Posterior cranial vault distraction osteogenesis has recently been introduced to treat patients with multisuture syndromic craniosynostosis and is believed to provide greater gains in intracranial volume. This study provides volumetric analysis to determine the gains in intracranial volume produced by this modality. METHODS: This was a two-center retrospective study of preprocedure and postprocedure computed tomography scans of two groups of 15 patients each with syndromic multisuture craniosynostosis treated with either fronto-orbital advancement or posterior cranial vault distraction osteogenesis. Scan data were analyzed volumetrically with Mimics software. Volumetric gains attributable to growth between scans were controlled for. RESULTS: The mean advancements were 12.5 mm for fronto-orbital advancement and 24.8 mm for distraction osteogenesis. The mean difference in volume between the preoperative and postoperative scans was 144 cm(3) for fronto-orbital advancement and 274 cm(3) for (p = 0.009). After controlling for growth, the corrected mean volume difference was 66 cm(3) for fronto-orbital advancement and 142 cm(3) for distraction osteogenesis (p = 0.0017). The corrected mean volume difference per millimeter of advancement was 4.6 cm(3) for fronto-orbital advancement and 5.8 cm(3) for distraction (p = 0.357). CONCLUSIONS: In this retrospective study, posterior cranial vault distraction osteogenesis provided statistically greater intracranial volume expansion than fronto-orbital advancement. The volume gains per millimeter advancement were similar between groups, with a trend toward greater gains per millimeter with distraction osteogenesis. Gradual expansion of the overlying soft tissues with posterior cranial vault distraction osteogenesis appears to be the primary mechanism for greater volume gains with this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.