Treatment Delay From Onset of Occipital Neuralgia Symptoms to Treatment with Nerve Decompression Surgery: A Prospective Cohort Study.

BACKGROUND: The aim of this study was to a) evaluate the time between onset of occipital neuralgia symptoms and nerve decompression surgery, b) perform a cost comparison analysis between surgical and non-surgical treatment of occipital neuralgia and c) report postoperative results of nerve decompression for occipital neuralgia. METHODS: 1,112 subjects who underwent screening for nerve decompression surgery were evaluated for occipital neuralgia. 367 (33%) patients met the inclusion criteria. Timing of occipital neuralgia symptom onset and pain characteristics were prospectively collected. Cost associated with the non-surgical treatment of occipital neuralgia was calculated for the period between onset of symptoms and surgery. RESULTS: 226 (73%) patients underwent occipital nerve decompression. The average time between onset of occipital neuralgia and surgery was 19 years (7.1-32). Postoperatively, the median number of pain days per month decreased by 17 (0-26, 57%) (p < 0.001), the median pain intensity decreased by 4 (2-8, 44%) (p < 0.001), and median pain duration in hours was reduced by 12 (2-23, 50%) (p < 0.001). The annual mean cost of non-surgical occipital neuralgia treatment was $28,728.82 ($16,419.42-$41,198.41) per patient. The mean cost during the 19-year timeframe prior to surgery was $545,847.75($311,968.90-$782,769.82). CONCLUSION: This study demonstrates that patients suffer from occipital neuralgia for an average of 19 years prior to undergoing surgery. Nerve decompression reduces symptom severity significantly and should be considered earlier in the treatment course of occipital neuralgia that is refractory to conservative treatment to prevent patient morbidity and decrease direct and indirect healthcare costs. IRB REGISTRATION NUMBER & NAME: Weill Cornell Medicine: 23-04025985, Prospective Cohort Study Investigating Long- Term Outcomes After Headache Surgery.The Massachusetts General Hospital: 2012P001527, Correlation of pre-operative pain self-efficacy and post-operative migraine-specific symptoms and disability.

Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery.

Importance: Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. Objective: To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Design, Setting, and Participants: Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. Exposures: California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Main Outcomes and Measures: Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. Results: A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Conclusions and Relevance: Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

Airway and Feeding Outcomes in Pierre Robin Sequence: A Comparison of Three Management Strategies.

BACKGROUND: Controversy remains regarding optimal management of Pierre Robin sequence (PRS). The goal of this study was to compare airway and feeding outcomes in infants with PRS who underwent surgical intervention, specifically mandibular distraction osteogenesis (MDO) or tongue-lip adhesion (TLA), or who had conservative management (CM) without surgery. METHODS: All consecutive patients treated for PRS at a pediatric academic medical center, with at least one year follow-up, were included. Patients who underwent tracheostomy as an index procedure were excluded. Patients were divided into those who underwent MDO, TLA or CM. Feeding status and data from initial and follow-up polysomnograms were collected. Comparisons between groups were made using the Kruskal-Wallis test, followed by Mann-Whitney pairwise comparison with a Bonferroni correction, when appropriate. RESULTS: 67 neonates were included. 19 underwent TLA, 29 underwent MDO and 19 underwent CM. The proportions of syndromic patients were similar between groups. Patients undergoing CM had the lowest baseline AHI (9.1), but there were no significant differences between TLA (20.1) and MDO (25.4). At follow-up, the three groups had similar mean AHI (MDO 1.3, TLA 4.2, CM 4.5). A similar proportion of patients achieved AHI 5 or less (TLA 89.5%, MDO 96.6%, CM 84.2%). At one year, there were no significant differences in weight percentiles or in risk of failure-to-thrive between groups. One patient from the TLA group required a tracheostomy. CONCLUSION: The three treatment modalities achieved high airway and feeding success rates. All three modalities should have a place in the armamentarium of the craniofacial surgeon.

Trends in the Geospatial Distribution of Inpatient Adult Surgical Services across the United States.

OBJECTIVE: The aim of this study was to define trends in the geographic distribution of surgical services in the United States to assess possible geographic barriers and disparities in access to surgical care. SUMMARY BACKGROUND DATA: Despite the increased need and utilization of surgical procedures, Americans often face challenges in gaining access to health care that may be exacerbated by the closure and consolidation of hospitals. Although access to surgical care has been evaluated relative to the role of insurance, race, and health literacy/education, the relationship of geography and travel distance to access has not been well studied. METHODS: The 2005 and 2015 American Hospital Association annual survey was used to identify hospitals with surgical capacity; the data were merged with 2010 Census Bureau data to identify the distribution of the US population relative to hospital location, and geospatial analysis tools were used to examine a service area of real driving time surrounding each hospital. RESULTS: Although the number of hospitals that provided surgical services slightly decreased over the time periods examined (2005, n = 3791; 2015, n = 3391; P<0.001), the number of major surgery hospitals increased from 2005 (n = 539) to 2015 (n = 749) (P<0.001). The geographic location of hospitals that provided surgical services changed over time. Specifically, although in 2005 852 hospitals were located in a rural area, that number had decreased to 679 by 2015 (P<0.001). Of particular note, from 2005 to 2015 there was an 82% increase in the number of people who lived further than 60 minutes from any hospital (P<0.001). However, the number of people who lived further than 60 minutes from a major surgery hospital decreased (P<0.001). CONCLUSIONS: Although the number of rural hospitals decreased over the last decade, the number of large, academic medical centers has increased; in turn, there has been an almost doubling in the number of people who live outside a 60-minute driving range to a hospital capable of performing surgery.

Complex hepato-pancreato-biliary caseload during general surgery residency training: are we adequately training the next generation?

BACKGROUND: Information on procedure volume of graduating chief residents (GCRs) for hepato-pancreato-biliary(HPB) surgical procedures may inform assessments of resident training. This study sought to characterize trends in operative volumes over a 19-year period to define the degree to which general surgery residents gain exposure to HPB procedures during training. METHODS: The ACGME was queried for all HPB operations performed by GCR between 2000-2018. Total procedures as well as means and fold change was calculated and reported for each year. RESULTS: Between 2000-2018, the number of general surgery residency programs varied between 240 and 254. A total of 411,383 HPB procedures (36.2% liver, 42.8% pancreas, 21% complex biliary) were performed by 22,229 GCR. Each year of the study, GCR had similar mean number total procedures:liver 7.4, pancreas 8.7, and complex biliary 4.4. For liver procedures there was no difference in the fold change over time, however for pancreas there was an increase in the fold change from 2.25 to 3.25. CONCLUSION: Most GCRs are graduating with a low number of HPB procedures and trends suggesting a decrease in the mean number of procedures per GCR and an increasing variability among residents.

The Impact of Surgeons on the Likelihood of Mastectomy in Breast Cancer.

OBJECTIVE: This study evaluates the impact of individual surgeons and institutions on the use of mastectomy or breast conserving surgery (BCS) among elderly women with breast cancer. SUMMARY OF BACKGROUND DATA: Current literature characterizes patient clinical and demographic factors that increase likelihood of mastectomy use. However, the impact of the individual provider or institution is not well understood, and could provide key insights to biases in the decision-making process. METHODS: A retrospective cohort study of 29,358 women 65 years or older derived from the SEER-Medicare linked database with localized breast cancer diagnosed from 2000 to 2009. Multilevel, multivariable logistic models were employed, with odds ratios (ORs) used to describe the impact of demographic or clinical covariates, and the median OR (MOR) used to describe the relative impact of the surgeon and institution. RESULTS: Six thousand five hundred ninety-four women (22.4%) underwent mastectomy. Unadjusted rates of mastectomy ranged from 0% in the bottom quintile of surgeons to 58.0% in the top quintile. On multivariable analysis, the individual surgeon (MOR 1.97) had a greater impact on mastectomy than did the institution (MOR 1.71) or all other clinical and demographic variables except tumor size (OR 3.06) and nodal status (OR 2.95). Surgeons with more years in practice, or those with a lower case volume were more likely to perform mastectomy (P < 0.05). CONCLUSION: The individual surgeon influences the likelihood of mastectomy for the treatment of localized breast cancer. Further research should focus on physician-related biases that influence this decision to ensure patient autonomy.

Description of Mexican Cleft Surgeons' Experience With Foreign Surgical Volunteer Missions in Mexico.

BACKGROUND AND PURPOSE: Mexican cleft surgeons provide multidisciplinary comprehensive cleft lip and palate care to children in Mexico. Many Mexican cleft surgeons have extensive experience with foreign, visiting surgeons. The purpose of this study was to characterize Mexican cleft surgeons' domestic and volunteer practice and to learn more about Mexican cleft surgeons' experience with visiting surgeons. METHODS: A cross-sectional validated e-mail survey tool was sent to Mexican cleft surgeons through 2 Mexican plastic surgery societies and the Asociación Mexicana de Labio y Paladar Hendido y Anomalías Craneofaciales, the national cleft palate society that includes plastic and maxillofacial surgeons who specialize in cleft surgery. We utilized validated survey methodology, including neutral fact-based questions and repeated e-mails to survey nonresponders to maximize validity of statistical data; response rate was 30.6% (n = 81). RESULTS: Mexican cleft surgeons performed, on average, 37.7 primary palate repairs per year with an overall complication rate of 2.5%; 34.6% (n = 28) of respondents had direct experience with patients operated on by visiting surgeons; 53.6% of these respondents performed corrective surgery because of complications from visiting surgeons. Respondents rated 48% of the functional outcomes of visiting surgeons as "acceptable," whereas 43% rated aesthetic outcomes of visiting surgeons as "poor"; 73.3% of respondents were never paid for the corrective surgeries they performed. Thirty-three percent of Mexican cleft surgeons believe that there is a role for educational collaboration with visiting surgeons. CONCLUSIONS: Mexican cleft surgeons have a high volume of primary cleft palate repairs in their domestic practice with good outcomes. Visiting surgeons may play an important role in Mexican cleft care through educational collaborations that complement the strengths of Mexican cleft surgeons.

Sustained Overcorrection After Autologous Facial Fat Grafting in the Pediatric Population: A Case Series.

INTRODUCTION: Autologous fat grafting is a valuable tool in the correction of facial soft tissue asymmetry and volume deficits. Pubertal growth and fluctuations in body mass present unique challenges to achieving satisfactory results after autologous fat transfer in the pediatric population. Few studies exist describing the outcomes and complications of pediatric facial fat grafting. The objective of this study is to identify the complication profile and outcomes after autologous fat grafting for the correction of facial asymmetry and volume deficits in the pediatric population. METHODS: Retrospective chart review was performed identifying 19 patients having undergone autologous fat grafting to the face for correction of facial volume deficits or asymmetry. Intraoperative variables were analyzed including blood loss, tumescent volume, lipoaspirate volume, graft volume transferred, donor fat processing technique, and donor site. Patient growth parameters were evaluated using body mass index (BMI) at the time of grafting and most recent follow up. Outcomes were evaluated based on adequacy of the graft, number of revisions or corrections, and complications. RESULTS: A total of 19 patients were identified. The median age at the time of primary fat graft was 17 years. The average change in BMI from preoperative to the latest recorded date was +0.60 ± 1.90. The average time from primary procedure to most recent follow up was 1.7 years. Abdomen was the most common donor site utilized. Adequate correction was achieved with an average of 1.4 graftings. Complications included contour irregularity (n = 1) and persistent overcorrection (n = 3). One patient required lipoaspiration for treatment of overcorrection. An unpaired t test demonstrated no significant difference in preoperative BMI (P = 0.58), postoperative BMI (P = 0.28), or change in BMI after grafting (P = 0.56) between adequately corrected and overcorrected patients. CONCLUSIONS: Fat transfer is a safe and viable method for the correction of facial asymmetry in the pediatric population. Repeat fat grafting procedures may be required to achieve adequate correction; however, postoperative overcorrection is unlikely to resolve spontaneously in the pediatric population and is unrelated to changes in BMI. Care should be taken to minimize the degree of primary overcorrection when treating facial asymmetry in the pediatric population.

Effect of Surgeon Volume and Craniofacial Fellowship Training on Cleft Palate Complication Rates.

BACKGROUND: Both the general and pediatric surgical literature have evidenced an inverse relationship between surgical case volume and complications. This study seeks to ascertain the relationship between case volume and fistula rates in cleft palate patients. We also seek to determine if craniofacial fellowship training impacts fistula rates. METHODS: Charts were reviewed at a multidisciplinary cleft center in San Diego, CA. We performed chart review on 207 nonsyndromic patients with cleft lip and palate who had surgery at our institution from 1988 to 2010. Data were analyzed using independent samples t test, χ test, and stepwise binary logistic regression to assess whether surgeon case volume and craniofacial fellowship training correlated with fistula repair rate. RESULTS: The surgeon with the highest volume had significantly fewer fistula repairs than lower volume surgeons (P = 0.044). Patients operated on by the craniofacial fellowship trained surgeon had significantly fewer fistulas compared with other plastic surgeons who performed cleft palate surgery (P = 0.005). CONCLUSIONS: Based on our retrospective review, it does appear that both high case volume and craniofacial fellowship training are associated with fewer postoperative fistulas.

Incidence of Le Fort Surgery in a Mature Cohort of Patients With Cleft Lip and Palate.

Primary repair of cleft lip and palate occurs early in life, but ideal timing of these interventions remains controversial. Prior research has indicated that a later palate repair may improve patients' midfacial growth long term, whereas optimal timing of lip repair to maximize midfacial growth has not been identified.The purpose of this study is to analyze a large, diverse cohort of patients with cleft lip and palate to determine whether timing of primary palate repair and primary lip repair contributed significantly to subsequent orthognathic surgery. METHODS: Seventy-one nonsyndromic patients with cleft lip and/or palate were followed until age 23 years, and data regarding original diagnosis, surgical procedures, and dates were collected. Within our patient cohort, 12 patients (16.9%) underwent orthognathic surgery. Binary logistic regressions, Fisher exact tests, and Mann-Whitney U tests were used to determine whether timing of primary palate repair and primary lip repair contributed significantly to subsequent orthognathic surgery. RESULTS: In our cohort, the association of early lip repair with later orthognathic surgery trended toward significance (P = 0.080). Timing of primary palate repair was not significantly associated with later orthognathic surgery (P= 0.291). When correcting for sex, race, diagnosis, location of care, incidence of lip adhesions, and incidence of lip revisions, patient age at primary lip procedure was a significant predictor of later orthognathic surgery (P = 0.041). CONCLUSIONS: Inconsistent with prior research, age at primary palate repair in our cohort was not correlated with incidence of orthognathic surgery. Delayed primary lip repair was associated with a significant decrease in the rate of subsequent orthognathic surgery.

Sexual Function in Post-surgical Transgender and Gender Diverse Individuals.

Surgical treatment for gender dysphoria consists of facial, chest, and genital surgery. Chest and genital gender affirmation surgeries alter the form and function of the native organs. This can have a profound impact on sexual function for transgender and gender- diverse individuals. In this article, the authors will discuss the impacts that chest and genital gender affirmation surgeries can have on sexual function.

The Use of Postoperative Compression Garments in Plastic Surgery-Necessary or Not? A Practical Review.

This practical review critically evaluates the evidence behind the widespread use of postoperative compression therapy intended to improve surgical outcomes, such as reduced edema, ecchymosis, pain, and seroma formation. A literature search of PubMed was conducted to identify relevant studies concerning the use of compression garments after aesthetic surgery, including rhinoplasty, facelift, neck lift, mammoplasty, abdominoplasty, limb contouring, and others. Additionally, reconstructive and therapeutic procedures closely related in anatomy or technique to these cosmetic operations, such as breast reconstruction, mastectomy, and hernia repair, were also considered to provide further perspective. After study extraction, the volume, quality, and agreement of the evidence found was highly heterogenous depending on the context of specific operations and outcomes evaluated. The most well-supported indications for the use of postoperative compression garments are to mitigate edema and ecchymosis after rhinoplasty and to reduce postoperative pain after breast and abdominal procedures, although no effect on seroma rate was demonstrated. Any potential benefit must be balanced against the associated costs and possible complications of compression, including patient discomfort, increased venous stasis, and skin defects. Thus, we encourage surgeons to critically reassess their use of compression garments. In many settings, such as brachioplasty, there is limited high-quality evidence to inform best practice, and we urge the community to continue researching this important topic so that more definitive and comprehensive guidelines may be established.

Another Day, Another 82 Cents: A National Survey Assessing Gender-based Wage Differences in Board-certified Plastic Surgeons.

Background: Of 7461 actively practicing United States American Board of Plastic Surgery certified plastic surgeons, only 17% are women. In relation to this small number, gender inequities within the field have been the source of national discussions. Our study assessed the status of the gender-based wage-gap in plastic surgery and sought to identify possible causes. Methods: An anonymous 43-question survey was distributed to 2981 members of the American Society of Plastic Surgeons in 2021. Male and female responses were compared; an analysis also considering board-certification year was performed. Chi-square and Fisher exact tests were used for bivariate analysis. Continuous variables were compared with two-sample t tests and Wilcoxon rank sum tests. Results: Ten percent of contacted American Society of Plastic Surgeons members responded to our survey. Of the 288 respondents, 111 (38.5%) were women, and 177 (61.5%) were men. Men were more likely to have salaries over $400K USD per year (P < 0.0001). Earlier certification year was associated with pay greater than $400K per year (P = 0.0235) but was insignificant once stratified by gender (women: P = 0.2392, men: P = 0.7268). Earlier certification year was associated with production-based and self-determined wages (P = 0.0097), whereas later board-certification year was associated with nonnegotiable salaries (P < 0.0001). Conclusions: Women are significantly less likely to make salaries comparable to those of male plastic surgeons, related to shorter careers on average. An increase in female representation and career duration within the field is needed to improve the current wage-gap.

Treatment Delay in Patients Undergoing Headache Surgery (Nerve Decompression Surgery).

Background: Although headache surgery has been shown to be an effective treatment option for refractory headache disorders, it has not been included as part of the headache disorder management algorithm by non-surgical providers. This study aims to evaluate the delay in surgical management of patients with headache disorders. In addition, a cost comparison analysis between conservative and operative treatment of headache disorders was performed, and the surgical outcomes of headache surgery were reported. Methods: Among 1112 patients who were screened, 271 (56%) patients underwent headache surgery. Data regarding the onset of headache disorder and pre- and postoperative pain characteristics were prospectively collected. To perform a cost comparison analysis, direct and indirect costs associated with the conservative treatment of headache disorders were calculated. Results: The median duration between onset of headache disorder symptoms and headache surgery was 20 (8.2-32) years. The annual mean cost of conservative treatment of headache disorders was $49,463.78 ($30,933.87-$66,553.70) per patient. Over the 20-year time period before surgery, the mean cost was $989,275.65 ($618,677.31-$1,331,073.99). In comparison, the mean cost of headache surgery was $11,000. The median pain days per month decreased by 16 (0-25) (p<0.001), the median pain intensity reduced by 4 (2-7) (p<0.001), and the median pain duration decreased by 11 hours (0-22) (p<0.001). Conclusion: This study shows that patients experience symptoms of headache disorders for an average of 20 years prior to undergoing headache surgery. Surgical treatment not only significantly improves headache pain but also reduces healthcare costs and should be implemented in the management algorithm of headache disorders.

Multimodal Analgesia in the Aesthetic Plastic Surgery: Concepts and Strategies.

Postoperative pain management is crucial for aesthetic plastic surgery procedures. Poorly controlled postoperative pain results in negative physiologic effects and can affect length of stay and patient satisfaction. In light of the growing opioid epidemic, plastic surgeons must be keenly familiar with opioid-sparing multimodal analgesia regimens to optimize postoperative pain control. Methods: A review study based on multimodal analgesia was conducted. Results: We present an overview of pain management strategies pertaining to aesthetic plastic surgery and offer a multimodal analgesia model for outpatient aesthetic surgery practices. Conclusion: This review article presents an evidence-based approach to multimodal pain management for aesthetic plastic surgery.

Ethical Dilemmas in Global Plastic Surgery: Divergent Perspectives of Local and Visiting Surgeons.

BACKGROUND: As more of the world's resources are directed toward improving patient access to safe surgical and anesthesia care, there is a growing concern that volunteer surgeons' "desire to help" has numerous unintended consequences. The purpose of this study was to ask in-country, local surgeons and visiting volunteer plastic surgeons about the frequency of ethical dilemmas for different types of global surgery collaborations and to assess their perception of compliance with the concepts of autonomy, beneficence, nonmaleficence, and justice. METHODS: A cross-sectional email survey tool was sent to a representative sample of domestic American Society of Plastic Surgeons members, all international members of the American Society of Plastic Surgeons, and international partners of the Volunteers in Plastic Surgery committee of the Plastic Surgery Foundation. The survey response rate was 7.7 percent, with 356 respondents from 65 countries. RESULTS: This survey data showed a statistically significant divergence of perspectives between local and visiting surgeons in regard to scope of practice, quality of patient care, impact on local health care systems, perception of the quality of care by local providers, the integrity of the informed consent process, and photography in global plastic surgery collaborations. Though the short-term mission trip model was particularly polarizing when comparing the responses of local and visiting surgeons, educational and research exchanges may also significantly interrupt local health care and incite ethical lapses. CONCLUSION: This survey provides quantitative insight into the impact of current global plastic surgery collaborations and highlights ethical areas of disagreement between local and visiting surgeons.

Analysis of Adverse Effects of Multimodal Gabapentin in Abdominal Wall Reconstruction.

BACKGROUND: Multimodal analgesia, a key component of enhanced recovery after surgery protocols, emphasizes the use of nonopioid analgesics. Preoperative and postoperative gabapentin is often included within multimodal analgesia because it has been shown to reduce postoperative opioid use. However, the role of gabapentin has been questioned because of concerns of adverse effects, particularly in the elderly. In an effort to better understand the specific role of gabapentin within the context of an established enhanced recovery after surgery protocol, the authors studied the prevalence of its adverse effects in patients undergoing abdominal wall reconstruction. METHODS: Following institutional review board approval, a retrospective review of a prospectively collected database of 267 consecutive patients who underwent abdominal wall reconstruction performed by a single surgeon was conducted. Demographic variables; operative details; postoperative analgesic use; the presence of dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; and postoperative falls were recorded and analyzed according to postoperative gabapentin administration. RESULTS: Two hundred thirteen patients (80 percent) met inclusion criteria, of which 138 (65 percent) received postoperative gabapentin. Postoperative gabapentin use was not associated with dizziness, lightheadedness, or altered mental status; hypotension; negative Richmond Agitation Sedation Scale scores; or falls. Furthermore, even among those aged 65 years or older, postoperative gabapentin use was not significantly associated with these adverse events. CONCLUSIONS: In patients undergoing abdominal wall reconstruction, postoperative gabapentin administration was not associated with an increase in adverse effects. Further prospective analysis may better allow the characterization of the adverse effects of perioperative gabapentin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain.

BACKGROUND: Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve. METHODS: Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer. RESULTS: The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound. CONCLUSIONS: This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).