Long-term Health Outcomes of New Persistent Opioid Use After Surgery Among Medicare Beneficiaries.

OBJECTIVE: We examined long-term health outcomes associated with new persistent opioid use after surgery and hypothesized that patients with new persistent opioid use would have poorer overall health outcomes compared with those who did not develop new persistent opioid use after surgery. BACKGROUND: New persistent opioid use is a common surgical complication. Long-term opioid use increases risk of mortality, fractures, and falls; however, less is known about health care utilization among older adults with new persistent opioid use after surgical care. METHODS: We analyzed claims from a 20% national sample of Medicare beneficiaries ≥65 years undergoing surgery between January 1, 2009, and June 30, 2019. We estimated associations between new persistent use and subsequent health events between 6 and 12 months after surgery, including mortality, serious fall/fall-related injury, and respiratory or opioid/pain-related readmission/emergency department (ED) visits using a Cox proportional hazards model to estimate mortality and multivariable logistic regression for the remaining outcomes, adjusting for demographic/clinical characteristics. Our primary outcome was mortality within 6 to 12 months after surgery. Secondary outcomes included falls and readmissions or ED visits (respiratory, pain related/opioid related) within 6 to 12 months after surgery. RESULTS: Of 229,898 patients, 6874 (3.0%) developed new persistent opioid use. Compared with patients who did not develop new persistent opioid use, patients with new persistent opioid use had a higher risk of mortality (hazard ratio 3.44, CI, 2.99-3.96), falls [adjusted odds ratio (aOR): 1.21, 95% CI, 1.05-1.39], and respiratory-related (aOR: 1.67, 95% CI, 1.49-1.86) or pain-related/opioid-related (aOR: 1.68, 95% CI, 1.55-1.82) readmissions/ED visits. CONCLUSIONS: New persistent opioid use after surgery is associated with increased mortality and poorer health outcomes after surgery. Although the mechanisms that underlie this risk are not clear, persistent opioid use may also be a marker for greater morbidity requiring more care in the late postoperative period. Increased awareness of individuals at risk for new persistent use after surgery and close follow-up in the late postoperative period is critical to mitigate the harms associated with new persistent use.

Higher Amounts of Opioids Filled After Surgery Increase Risk of Serious Falls and Fall-Related Injuries Among Older Adults.

BACKGROUND: Despite increasing numbers of older adults undergoing surgery and the known risks of opioids, little is known about the potential association between opioid prescribing and serious falls and fall-related injuries after surgery. OBJECTIVE: To determine the incidence and risk factors of serious falls and fall-related injuries after elective, outpatient surgery. DESIGN: Retrospective cohort study of 20% national sample of Medicare claims among beneficiaries ≥ 65 years of age with Medicare Part D claims and who underwent elective outpatient surgery from January 1, 2009, through December 31, 2014. PARTICIPANTS: Opioid-naïve patients ≥ 65 years undergoing elective, minor, outpatient surgical procedures. The exposure was opioid prescription fills in the perioperative period (i.e., 30 days before up until 3 days after surgery) converted to total oral morphine equivalents (OME) over a period 30 days prior to and 30 days after surgery. MAIN MEASURES: Serious falls and fall-related injuries within 30 days after surgery, examined through Poisson regression analysis with reported fall and fall-related injury rates adjusted for potential confounders. KEY RESULTS: Among 44,247 opioid-naïve surgical patients, 76.3% filled an opioid prescription in the perioperative period. Overall, 0.62% of patients suffered a serious fall or fall-related injury within 30 days after surgery. Risk factors for serious falls or fall-related injuries after surgery included older age (80-84 years: RR 1.64, 95% CI 1.12-2.40; 85 years and older: RR 1.81, 95% CI 1.25-2.86), female sex (RR 3.04, 95% CI 2.29-4.05), Medicaid eligibility (RR 1.63, 95% CI 1.17-2.26), and higher amounts of opioids filled following surgery (≥ 225 OME: RR 2.29, 95% CI 1.72-3.07). CONCLUSIONS: Serious falls after elective, outpatient surgery are uncommon, but correlated with age, sex, Medicaid eligibility, and the amount of opioids filled in the perioperative period. Judicious prescribing of opioids after surgery is paramount and is an opportunity to improve the safety of surgical care among older individuals.

Artificial Intelligent Virtual Assistant for Plastic Surgery Patient's Frequently Asked Questions: A Pilot Study.

BACKGROUND: Artificial Intelligent Virtual Assistants (AIVA) is a segment of artificial intelligence that is rapidly developing. However, its utilization to address patients' frequently asked questions remains unexplored. METHODS: We developed an AIVA to answer questions related to 10 frequent topics asked by plastic surgery patients in our institution. Between July 27, 2018, and August 10 of 2018, we recruited subjects with administrative positions at our health care institution to chat with the virtual assistant. They asked, with their own words, 1 question for each topic and filled out a satisfaction questionnaire. Postsurvey analysis of questions and answers allowed assessment of the virtual assistant's accuracy. RESULTS: Thirty participants completed the survey. The majority was female (70%), and the mean age was 27.76 years (SD, 8.68 [19-51] years). The overall accuracy of the plastic surgery AIVA was 92.3% (277/294 questions), and participants considered the answer correct in 83.3% of the time (250/294 answers). Most of the participants considered the AIVA easy to use, answered adequately, and could be helpful for patients. However, when asked if this technology could replace a human assistant, they stayed neutral.

The Multifactorial Contribution of Publications in Plastic Surgery Journals in Microsurgery Education.

BACKGROUND: Microsurgery is one of the most complex operative skills. Recent restrictions on residents' working hours challenge residency program directors to ensure skill acquisition with scant time dedicated to microsurgery practice. We aimed to summarize the contribution of plastic surgery journals in microsurgical education. METHODS: A comprehensive literature search was performed. RESULTS: We observed an increasing number of publications on microsurgery education over the years. This could be due to the adoption of new technologies developed in the last 2 decades, the concerns about quality of resident training in the context of reduced work hours, the well-described benefit of medical simulations in other specialties, and the pressure on trainees to be proficient before operating on patients. The variety of aspects addressed in plastic surgery publications is broad: simulators, courses, skills assessment, national surveys, and technology trends. CONCLUSION: There is an upward trend in the number of publications and plastic surgery journals, demonstrating a remarkable contribution to microsurgery training.

Use of the subscapular system by maintaining unilateral decubitus placement without repositioning in microvascular free tissue transplantation.

BACKGROUND: In microvascular free-tissue harvest and transfer, the need for repositioning from lateral decubitus position and the inability to use a two-team approach are major drawbacks of the subscapular system. We present our experience with the subscapular system for upper and lower extremity reconstruction using a two-team approach without need for repositioning. METHODS: We conducted a retrospective chart review for all patients undergoing free flap transplant based on the subscapular system to the upper or lower extremity at our microsurgical facility from January 1, 2007 to December 31, 2011. Only cases not requiring intraoperative repositioning were included. Sixty-four patients underwent the two-team approach (37 upper extremity and 27 lower extremity transplants). Flap types included latissimus dorsi musculocutaneous, partial superior latissimus, dorsal thoracic fascia, serratus, scapular bone, and thoracodorsal artery perforator, either alone or as chimeric flaps. All patients were placed in the lateral decubitus position for the duration of the surgery. RESULTS: The ipsilateral subscapular system was used in 16% of cases for lower extremity defects, where the anterior tibial vessels served as recipient vessels. The contralateral subscapular system was used in all remaining cases for upper extremity or the vast majority for lower extremity (84%) defects, where either the superficial femoral, genicular, popliteal, sural, or posterior tibial vessels served as recipient vessels. With the exception of one partial flap loss secondary to infection, all flaps survived. CONCLUSIONS: Proper lateral decubitus positioning allows for a two-team approach without compromising safety or outcomes.

Alloplastic Auricular Reconstruction: Review of Implant Types, Adverse Events, and Aesthetic Outcomes.

IMPORTANCE: Alloplastic implants have been applied successfully in reconstruction of the external ear, either for congenital microtia or traumatic injury. OBJECTIVE: The objective of this study was to conduct a comprehensive systematic review of alloplastic implant materials utilized in the reconstruction of the external ear stratified by indication, specific implant type, postoperative complications, and aesthetic outcomes. EVIDENCE REVIEW: A comprehensive systematic review of published literature on alloplastic external ear reconstruction data was conducted utilizing Medline/PubMed database without timeframe limitations in June 2019. Articles were stratified by (1) indication (microtia versus trauma reconstruction) and (2) implant material type. All postoperative complications were recorded and comparatively analyzed between implant types. Aesthetic outcomes were also identified and compared between implant types. FINDINGS: A total of 755 patients (14 case series; follow-up range = 3 months--10 years) met the criteria for this study. Overall complication rate was 12.05% across all indications and materials used. The most frequent complications reported were graft exposure (7.8%), graft explantation (1.72%), and wound dehiscence (0.8%). Of the patients requiring graft explantation (n = 13), 7 (53.85%) received Medpor implants, and the other 6 (46.15%) were identified in silicone implants. Infection was only reported in Medpor implants. The overall rate of an acceptable aesthetic outcome was 99.34%. CONCLUSIONS AND RELEVANCE: Alloplastic implants are a reliable means of achieving an acceptable complication profile in external ear reconstruction. While there was an overall high rate of acceptable aesthetic outcomes, the studies evaluated in this systematic review differed in their criteria for final evaluation of aesthetic outcomes.

Using Digital Profileplasty for Surgical Planning.

This paper describes a method for setting up an automated and reliable digital profileplasty technique for use in Adobe Photoshop. Digital imaging software can be used to extrapolate more exact measurements during profileplasty. The digital profileplasty technique is helpful to provide intraoperative guidance during surgery.

Allogeneic and Alloplastic Augmentation Grafts in Nipple-Areola Complex Reconstruction: A Systematic Review and Pooled Outcomes Analysis of Complications and Aesthetic Outcomes.

BACKGROUND: With advancements in materials engineering, many plastic surgeons have looked to allogeneic tissue and alloplastic materials as a possible source of structure for long-lasting nipple-areola complex reconstruction. Furthermore, in light of the recent mandate from the Food and Drug Administration restricting the marketing and direct indication of acellular dermal matrices (ADMs) in breast reconstruction, we sought to highlight the overall safety and efficacy demonstrated in the existing literature surrounding all alloplastic materials in nipple-areola complex reconstruction. In this study, the authors conduct a systematic review and pooled outcomes analysis on allogenic and alloplastic implant materials utilized to achieve long-lasting nipple projection stratified by specific material used and respective outcomes. METHODS: A comprehensive systematic review on allogenic and synthetic materials data utilized in nipple reconstruction was conducted utilizing Medline/PubMed database. Articles were stratified by (1) alloplastic material, as well as (2) objective and patient-reported outcomes. RESULTS: A total of 592 nipple-areola complexes on 482 patients were featured in 15 case series. In all studies, alloplastic or allograft material was utilized to achieve and maintain nipple projection. Subjective measurements revealed a patient satisfaction rate of 93.3% or higher with the majority of patients being very satisfied with their reconstruction. The alloplastic and allograft implants analyzed had an overall complication rate of 5.3% across all materials used. The most common complication reported was flap or graft necrosis with a pooled rate of 2.5%. Overall, the Ceratite implant presented with the highest complication rate (18%) including flap/graft necrosis (13%) and extrusion of the artificial bone (5%). Other rigid implants such as the biodesign nipple reconstruction cylinder reported complications of extrusion (3.6%), projection loss requiring revision (2.5%), wound dehiscence/drainage (1.5%), flap or graft necrosis (1.0%) and excessive bleeding (0.5%). ADM implants had reported complications of both insufficient projection (0.8%) and excessive projection (1.6%), which required surgical revision. Injectable materials had minimal reported complications of pain during injection (0.8%) with Radiesse and a false-positive PET scan result (0.8%) with DermaLive. CONCLUSIONS: Allogeneic and alloplastic grafts are a reliable means of achieving satisfactory nipple projection, with a relatively low overall complication profile. The use of Ceratite (artificial bone) led to the highest complication rates. Further clinical studies are necessary to better understand the feasibility and longer-term outcomes of the use of allogeneic and synthetic augmentation grafts to improve nipple projection. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Optimizing Postoperative Pain Control in Autologous Breast Reconstruction: A Systematic Review.

BACKGROUND: Pain management approaches in autologous breast reconstruction have become a topic of great interest in the era of enhanced recovery after surgery protocols, as well as the opioid epidemic. The management of postoperative pain is of critical importance for women undergoing breast reconstruction; however, these protocols have yet to be synthesized and compared in the primary literature. Herein, we present a systematic review of approaches to provide optimal pain control while minimizing narcotic use and its associated potential negative sequelae in autologous breast reconstruction. METHODS: A comprehensive systematic review of the published literature was conducted using Ovid Medline/PubMed database without timeframe limitations, in compliance with the guidelines outlined in the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Inclusion criteria were selected for studies reporting objective outcomes of pain modulation in autologous breast reconstruction. Articles for inclusion were stratified based on intervention. RESULTS: A total of 101 articles were identified on initial search query. After full-text review and final screening of all articles and review of included studies' references, 28 studies met the inclusion criteria and were analyzed. CONCLUSION: There continues to be a substantial need for evidence-based guidelines in the plastic surgery literature. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Given the increasing popularity of and access to autologous approaches to breast reconstruction, we hope this area of study continues to be a top priority for plastic surgeons to allow for optimized postoperative care.

Functioning Free Muscle Transfer for Brachial Plexus Injury: A Systematic Review and Pooled Analysis Comparing Functional Outcomes of Intercostal Nerve and Spinal Accessory Nerve Grafts.

BACKGROUND: The aim of this study was to compare postoperative elbow flexion outcomes in patients receiving functioning free muscle transplantation (FFMT) innervated by either intercostal nerve (ICN) or spinal accessory nerve (SAN) grafts. METHODS: A comprehensive systematic review on FFMT for brachial plexus reconstruction was conducted utilizing Medline/PubMed database. Analysis was designed to compare functional outcomes between (1) nerve graft type (ICN vs. SAN) and (2) different free muscle graft types to biceps tendon (gracilis vs. rectus femoris vs. latissimus dorsi). RESULTS: A total of 312 FFMTs innervated by ICNs (169) or the SAN (143) are featured in 10 case series. The mean patient age was 28 years. Patients had a mean injury to surgery time of 31.5 months and an average follow-up time of 39.1 months with 18 patients lost to follow-up. Muscles utilized included the gracilis (275), rectus femoris (28), and latissimus dorsi (8). After excluding those lost to follow-up or failures due to vascular compromise, the mean success rates of FFMTs innervated by ICNs and SAN were 64.1 and 65.4%, respectively. CONCLUSION: This analysis did not identify any difference in outcomes between FFMTs via ICN grafts and those innervated by SAN grafts in restoring elbow flexion in traumatic brachial plexus injury patients.

Outcomes analysis of Goldilocks mastectomy and breast reconstruction: A single institution experience of 96 cases.

BACKGROUND: The Goldilocks mastectomy procedure involves local contouring of completely autologous breast tissue created by preserving and de-epithelializing the residual mastectomy flaps. The purpose of this study was to provide outcomes data for 96-Goldilocks mastectomy procedures analyzing indications, complications, relevant comorbidities, and adjuvant cancer treatment impacting reconstructive and aesthetic outcomes. METHODS: Comprehensive review of every patient who underwent Goldilocks mastectomy from 2012 to 2018 included relevant medical and surgical comorbidities, as well as complication profiles. Aesthetic outcomes were also assessed in those with postoperative imaging available. RESULTS: A total of 53 patients (96 breasts) were included in this study. Bilateral cases consisted of 81.1% of the total cohort (n = 86 cases), and 18.9% (n = 10 cases) were unilateral procedures. Mean age at the time of reconstruction was 55.8 (33-77) years. Mean body mass index (BMI) at the time of reconstruction was 33.7 (19.2-54.6). The overall complication rate was 9.38% (seroma = 2, hematoma = 1, cellulitis = 2, wound dehiscence = 3, and operating room take back = 1). CONCLUSIONS: Goldilocks breast reconstruction is a safe, effective option in patients with higher than average BMI or excess local breast tissue, or in patients meeting these criteria preferring a single-stage reconstruction. This study qualifies its use in patients with higher than average risk factors for more extensive reconstructive modalities.

Alloplastic Cranioplasty Reconstruction: A Systematic Review Comparing Outcomes With Titanium Mesh, Polymethyl Methacrylate, Polyether Ether Ketone, and Norian Implants in 3591 Adult Patients.

BACKGROUND: Acquired defects of the cranium represent a reconstructive challenge in patients with calvarial bone loss due to trauma, infection, neoplasia, congenital malformations, or other etiologies. The objective of this study was to compare postoperative rates of infection, local complications, and allograft failures following cranioplasty reconstruction using titanium mesh (Ti), polymethyl methacrylate (PMMA), polyether ether ketone (PEEK), and Norian implants in adult patients. METHODS: This constitutes the first systematic review of available literature on 4 different methods of alloplastic cranioplasty reconstruction, including Ti, PMMA, PEEK, and Norian implants, using the Newcastle-Ottawa Quality Assessment Scale guidelines for article identification, screening, eligibility, and inclusion. Electronic literature search included Ovid MEDLINE/PubMed, EMBASE, Scopus, Google Scholar, and Cochrane Database. Pearson exact test was utilized at P < 0.05 level of significance (J.M.P. v11 Statistical Software). RESULTS: A total of 53 studies and 3591 patients (mean age, 40.1 years) were included (Ti = 1429, PMMA = 1459, PEEK = 221, Norian = 482). Polymethyl methacrylate implants were associated with a significantly higher infection rate (7.95%, P = 0.0266) compared with all other implant types (6.05%). Polyether ether ketone implants were associated with a significantly higher local complication rate (17.19%, P = 0.0307, compared with 12.23% in all others) and the highest ultimate graft failure rate (8.60%, P = 0.0450) compared with all other implant types (5.52%). CONCLUSIONS: This study qualifies as a preliminary analysis addressing the knowledge gap in rates of infection, local surgical complication, and graft failure in alloplastic cranioplasty reconstruction with different implant types in the adult population. Longer-term randomized trials are warranted to validate associations found in this study.

Primary Hand Leiomyoma: A Systematic Review.

BACKGROUND: Primary leiomyoma is a rare cause of a mass in the hand, with few reported cases to date. To our knowledge, this constitutes the most comprehensive and up-to-date systematic review of the literature of all cases of primary hand leiomyoma. We also provide an additional case recently managed in our practice of confirmed primary vascular leiomyoma of the hand in a 44-year-old woman to add to the current body of literature. METHODS: We performed a comprehensive literature review of all articles published on primary leiomyoma of the hand. The PubMed database was used, with search terms leiomyoma hand, angioleiomyoma hand, and angiomyoma hand. Articles were selected for their accuracy in anatomic localization in the hand and confirmed pathology of leiomyoma. RESULTS: Our initial search query resulted in 216 articles. After applying the inclusion criteria, we identified 50 individual articles with 108 cases of confirmed primary leiomyoma in the hand from January 1, 1954, to July 1, 2018. Common initial clinical impressions recorded for primary hand leiomyoma included ganglion cyst, giant-cell tumor, hemangioma, and glomus tumor. Patients presenting with leiomyoma of the hand frequently describe a painful lesion, which differs from most other benign tumors of the hand at presentation. CONCLUSIONS: Leiomyoma is an important consideration when developing a differential diagnosis for primary benign masses in the hand. We hope that this comprehensive review can provide increased awareness of this tumor type.

Salvage of Exposed Microtia Cartilage Framework in a Pediatric Patient With a Preauricular Perforator Cutaneous Flap.

An 8-year-old boy with oculo-auriculo-vertebral syndrome presented to the authors' clinic for multidisciplinary management of his condition. His congenital ear deformity included bilateral protrusion as well as atypical Microtia affecting the left side. He underwent bilateral otoplasty combined with left canaloplasty at the first stage to address prominent ears and canal atresia and. The patient underwent subsequent reconstruction of his constricted left ear with costochondral cartilage graft to address elsewhere. He presented to the authors' clinic 2 weeks postoperatively with wound dehiscence and cartilage exposure along the scapha surface. The authors present their management strategy utilizing a preauricular pedicled perforator cutaneous flap in a staged manner with emphasis on technical details and review of available flap options for management of such complications.

Macrophage Transplantation Fails to Improve Repair of Critical-Sized Calvarial Defects.

INTRODUCTION: Over 500,000 bone grafting procedures are performed every year in the United States for neoplastic and traumatic lesions of the craniofacial skeleton, costing $585 million in medical care. Current bone grafting procedures are limited, and full-thickness critical-sized defects (CSDs) of the adult human skull thus pose a substantial reconstructive challenge for the craniofacial surgeon. Cell-based strategies have been shown to safely and efficaciously accelerate the rate of bone formation in CSDs in animals. The authors recently demonstrated that supraphysiological transplantation of macrophages seeded in pullalan-collagen composite hydrogels significantly accelerated wound healing in wild type and diabetic mice, an effect mediated in part by enhancing angiogenesis. In this study, the authors investigated the bone healing effects of macrophage transplantation into CSDs of mice. METHODS: CD1 athymic nude mice (60 days of age) were anesthetized, and unilateral full-thickness critical-sized (4 mm in diameter) cranial defects were created in the right parietal bone, avoiding cranial sutures. Macrophages were isolated from FVB-L2G mice and seeded onto hydroxyapatite-poly (lactic-co-glycolic acid) (HA-PLGA) scaffolds (1.0 × 10 cells per CSD). Scaffolds were incubated for 24 hours before they were placed into the CSDs. Macrophage survival was assessed using three-dimensional in vivo imaging system (3D IVIS)/micro-CT. Micro-CT at 0, 2, 4, 6, and 8 weeks was performed to evaluate gross bone formation, which was quantified using Adobe Photoshop. Microscopic evidence of bone regeneration was assessed at 8 weeks by histology. Bone formation and macrophage survival were compared at each time point using independent samples t tests. RESULTS: Transplantation of macrophages at supraphysiological concentration had no effect on the formation of bones in CSDs as assessed by either micro-CT data at any time point analyzed (all P > 0.05). These results were corroborated by histology. 3D IVIS/micro-CT demonstrated survival of macrophages through 8 weeks. CONCLUSION: Supraphysiologic delivery of macrophages to CSDs of mice had no effect on bone formation despite survival of transplanted macrophages through to 8 weeks posttransplantation. Further research into the physiological effects of macrophages on bone regeneration is needed to assess whether recapitulation of these conditions in macrophage-based therapy can promote the healing of large cranial defects.

National Analysis of Patients With External Ear Melanoma in the United States.

BACKGROUND: External ear melanoma (EEM) is a rare condition with controversies in the literature. We analyzed patients with EEM in the United States compared to other head and neck melanomas (OHNMs). METHODS: The National Cancer Database (NCDB) was used to select patients with head and neck melanoma from January 1, 2004 to December 31, 2015. Mann-Whitney and χ tests were used to estimate statistical significance, and multivariate logistic regression to identify independent associations adjusted for confounders. RESULTS: A total of 137,233 patients met the study criteria. Among them, 16,991 (12.4%) had EEM and 120,242 (87.6%) had OHNM. For patients with EEM, the mean (standard deviation) age was 66.26 (15.798) years. Most of the patients with EEM were men (85.5%), insured by Medicare (52.4%), and treated in Academic/Research Programs (47.7%) or Comprehensive Community Cancer Programs (32.3%). Most of the EEM tumors had invasive behavior (68.0%) were Stages 0 (30.3%) or I (40.3%), and were without ulceration (76.9%). Mean time to receive any treatment was 14.1 days for EEM compared with 14.6 days for OHNM (P < 0.001). We noticed a greater proportion of EEM in men (14.8%; adjusted odds ratio [aOR] 2.72 [2.605-2.852]; P < 0.001) compared to women (6.22%; reference). EEM was an independent factor for tumor Stage I (14.47%; aOR 1.61 [1.101-1.224], P < 0.001) and invasive behavior (13.86%; aOR 1.268 [1.15-1.389]; P < 0.001) compared to OHNM. CONCLUSION: EEM was associated with higher odds of invasive behavior compared to OHNM. Furthermore, men were found to have a higher likelihood to develop EEM compared to women.

Eyelid Melanoma in the United States: A National Cancer Database Analysis.

BACKGROUND: Eyelid melanoma (EM) is a rare condition that accounts for <1% of all cutaneous melanomas. In this analysis, patients diagnosed with EM in the United States were compared to those with other melanomas in the head and neck. METHODS: The National Cancer Database was used to select patients with head and neck melanoma from 2004 to 2015. RESULTS: A total of 137,233 patients met the criteria of the study. Among them, 2694 were diagnosed with EM (2%) and 134,539 in other head and neck locations (98%). Regarding the patients with EM, the mean age was 68.56 years (standard deviation 14.04). A greater number of them were treated in Academic/Research Programs (53.6%), insured by Medicare (55.7%), tumor in situ (52.2%), stage 0 (49%), and without ulceration (75.9%). The mean time to treatment commencement was 18.96 days for EM compared to 14.4 days for other melanoma in the head and neck regions (P < 0.001). There was a greater proportion of EM in female patients (odds ratio [OR] 2.371 [2.191-2.566], P < 0.001), compared to male; age greater than 80 years (OR 1.622 [1.360-1.934], P < 0.001) compared to 0 to 49 years. Moreover, EM was an independent predictor for treatment in Academic/Research Programs (OR 1.258 [1.160-1.365], P < 0.001) and diagnosis at autopsy (OR 1.414 [1.083-1.847], P = 0.011) compared to other melanoma in the head and neck region. CONCLUSION: These novel findings have the potential to guide clinical decision making in head and neck melanoma management.

Alloplastic Facial Implants: A Systematic Review and Meta-Analysis on Outcomes and Uses in Aesthetic and Reconstructive Plastic Surgery.

BACKGROUND: Alloplastic materials in facial surgery have been used successfully for various applications in the reconstructive restoration or aesthetic augmentation of the facial skeleton. The objective of this study was to conduct a comprehensive systematic review of alloplastic implant materials utilized to augment the facial skeleton stratified by anatomical distribution, indication, specific material used, and respective outcomes. METHODS: A comprehensive systematic review on alloplastic facial implant data was conducted utilizing Medline/PubMed database. Articles were stratified by (1) anatomic localization in the face, as well as (2) alloplastic material. RESULTS: A total of 17 studies (n = 2100 patients, follow-up range = 1 month-27 years) were included. Overall, mersilene mesh implants were associated with the highest risk of infection (3.38%). Methyl methacrylate implants were associated with the highest rate of hematoma (5.98%). Implants placed in the malar region (2.67%) and frontal bones (2.50%) were associated with the highest rates of infection. Implants placed in the periorbital region were associated with the highest rate of inflammation (8.0%), explantation (8.0%), and poor cosmetic outcome (17.0%). Porous implants were shown to be more likely to potentiate infection than non-porous implant types. CONCLUSIONS: Alloplastic facial implants are a reliable means of restoring facial symmetry and achieving facial skeletal augmentation with a relatively low complication profile. It is important for plastic surgeons to understand the relative risks for each type of implant to develop postoperative complications or poor long-term cosmetic results. Interestingly, porous implants were shown to be more likely to potentiate infection than non-porous implant types. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Flap Reconstruction of Gastrointestinal-to-Genitourinary Fistulas: A 20-Year Experience.

BACKGROUND: Gastrointestinal-to-genitourinary fistulas may occur secondary to obstetric complications, radiation therapy, cancer without radiation, inflammatory bowel disease, or previous surgery. Flap reconstruction is useful for complex cases refractory to standard techniques, separating the fistula tracts to aid healing. The purpose of this study was to investigate outcomes and risk factors for complications in flap reconstruction of fistulas from several different etiologies performed over a 20-year period. METHODS: All patients who underwent flap reconstruction between January 1995 and December 2014 were reviewed. Patient demographics, prior treatment failures, surgical indications, and comorbidities were obtained. Operative and postoperative data were collected, including flap type, length of stay, early and late complications, recurrences, and follow-up time. Operative success was defined as definitive treatment of the fistula without recurrence within 6 months. RESULTS: There were 59 patients who underwent 66 reconstructions. The overall complication rate was 59.1%. Complications included infection (21%), dehiscence (17%), and partial flap loss (1.5%). Operative success rate was 51.5%. Smoking history (p = 0.021) and body mass index (BMI) > 35 (p = 0.003) were significantly associated with increased likelihood of postoperative complications following flap reconstruction in these patients. Additionally, fistulas due to cancer resections had a higher likelihood of postoperative complications compared with fistulas due to bowel disease or obstetric complications (p = 0.04). CONCLUSION: Flap reconstruction can be successfully used for complex or refractory gastrointestinal-to-genitourinary fistulas. However, considerable complication and recurrence rates were found in this population. Patients with a BMI > 35 and a history of smoking were at greatest risk in this cohort of experiencing postoperative complications.

Comparison of Outcomes in Oncoplastic Pelvic Reconstruction with VRAM versus Omental Flaps: A Large Cohort Analysis.

BACKGROUND: The purpose of this study is to describe our experience and outcomes in oncoplastic pelvic reconstruction for patients who underwent either vertical rectus abdominis musculocutaneous (VRAM) or omental flap following abdominoperineal resection (APR) at a single tertiary care institution. METHODS: All patients who underwent pelvic reconstruction following APR with either VRAM or omental flaps from January 1992 to January 2017 were retrospectively reviewed. Patient demographics and relevant comorbidities including chemotherapy and radiation therapy data were collected and analyzed. In addition, margin status at the time of oncologic resection was analyzed. Flap-specific data were collected for each approach. Oncologic data collected included cancer type, stage at time of APR, and rate of tumor recurrence within the flap. RESULTS: A total of 562 patients were identified who underwent pelvic reconstruction with either VRAM or omental pedicle flaps. Of these, 274 (48.8%) underwent VRAM reconstruction and 288 (51.2%) underwent omental flap reconstruction. All margins were negative at time of cancer ablation surgery. Complications data included: seroma (VRAM = 2 [0.36%]; omentum = 32 [5.69%], p < 0.0001), wound dehiscence (VRAM = 31 [5.52%]; omentum = 17 [3.02%], p = 0.022), abscess (VRAM = 4 [0.71%]; omentum = 27 [4.8%], p < 0.0001), cellulitis (VRAM = 2 [0.36%]; omentum = 10 [1.78%], p = 0.025). Statistical comparison of tumor recurrence between these two reconstructive approaches showed a significantly higher recurrence rate in omental flaps compared with VRAM flaps (p = 0.000127). CONCLUSION: The results of this study suggest a significantly higher tumor recurrence rate in omental flap pelvic reconstruction compared with VRAM flaps. This knowledge has the potential to influence surgical planning and flap selection in pelvic reconstruction.