Incision Location Predicts 30-Day Major Adverse Events after Cosmetic Breast Augmentation: An Analysis of the Tracking Outcomes and Operations for Plastic Surgeons Database.

BACKGROUND: Enhanced understanding of early postoperative adverse events will improve patient counseling and preoperative risk modification to decrease complications in implant-based breast augmentation. This study seeks to evaluate the early major adverse events following cosmetic breast augmentation. METHODS: A retrospective cohort analysis of the Tracking Outcomes and Operations for Plastic Surgeons database was performed to identify any women undergoing augmentation mammaplasty with an implant between 2008 and 2016. RESULTS: A total of 84,296 patients were studied. Major adverse events were identified in 0.37 percent. Seroma requiring drainage was observed in 0.08 percent, hematoma requiring drainage was observed in 0.15 percent, deep wound disruption was observed in 0.09 percent, and implant loss was observed in 0.11 percent. The authors identified multiple independent predictors of major adverse events, including body mass index greater than 30 kg/m2 (relative risk, 2.05; p < 0.001), tobacco use (relative risk, 2.25; p < 0.001), and diabetes mellitus (relative risk, 1.8; p < 0.05). Use of a periareolar incision significantly increased the risk of developing an early postoperative complication (relative risk, 1.77; p < 0.001). CONCLUSIONS: The findings of this study indicate an early major adverse event rate following cosmetic breast augmentation with implants of 0.37 percent. The authors identified multiple independent predictors of major adverse events, including body mass index greater than 30 kg/m2, tobacco use, and diabetes mellitus. In addition, when controlling for other factors, periareolar incision significantly increased the risk for major adverse events, when compared to an inframammary incision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Leveraging the Tracking Operations and Outcomes for Plastic Surgeons Database for Plastic Surgery Research: A "How-To" Guide.

SUMMARY: The Plastic Surgeries Registry Network supported by the American Society of Plastic Surgeons (ASPS) and the Plastic Surgery Foundation offers a variety of options for procedural data and outcomes assessment and research. The Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database is a registry created for and used by active members of ASPS to monitor all types of procedural outcomes. It functions as a way for individual or group practices to follow surgical outcomes and constitutes a huge research registry available to ASPS members to access for registry-based projects. The TOPS registry was launched in 2002 and has undergone several iterations and improvements over the years and now includes more than 1 million procedure records. Although ASPS member surgeons have proven valuable assets in contributing their data to the TOPS registry, fewer have leveraged the database for registry-based research. This article overviews the authors' experience using the TOPS registry for a database research project to demonstrate the process, usefulness, and accessibility of TOPS data for ASPS member surgeons to conduct registry-based research. This article pairs with the report of the authors' TOPS registry investigation related to 30-day adverse events associated with incision location for augmentation mammaplasty.

How to Review a Surgical Scientific Paper: A Guide for Critical Appraisal.

It is important for surgeons to participate in the peer-review process of scientific literature. As the number of published manuscripts continues to increase, there is a great need for volunteerism in this arena. However, there is little formal or informal training, which can help surgeons provide unbiased and meaningful reviews. Therefore, it is critical to provide more resources and guidelines to aid surgeons during the review process. The purpose of this paper is to provide a structured guide for a quality review of a surgical paper. This review represents the work of the Association of Women Surgeons Publications Committee.

Orofacial Manifestations of Stickler Syndrome: An Analysis of Speech Outcome and Facial Growth After Cleft Palate Repair.

PURPOSE: The purpose of this study was to characterize airway problems, speech outcomes, and facial growth in patients with Stickler syndrome undergoing cleft palate repair. METHODS: A retrospective, longitudinal study was performed at the Children's Hospital of Philadelphia on 25 patients with Stickler syndrome and 53 nonsyndromic patients with clefts of the secondary palate repaired between 1977 and 2000. Airway problems were characterized by the incidence of Pierre Robin Sequence (PRS) and the necessity for surgical airway management. Speech was analyzed using the Pittsburgh weighted values for speech symptoms associated with velopharyngeal incompetence (VPI). Longitudinal anthropometric measurements represented up to 12 years of longitudinal cephalofacial growth. RESULTS: Seventy-two percent of patients with Stickler syndrome were diagnosed with PRS, 55.6% of whom required surgical airway management. Conversely, 20.8% of nonsyndromic patients were diagnosed with PRS (P < 0.0001), 18% of whom required surgical intervention (P < 0.05). Speech outcomes were poorer in patients with Stickler syndrome with 40% demonstrating borderline VPI and 13.3% demonstrating VPI, compared with 21.8% and 9.1%, respectively, in the nonsyndromic group. Both groups exhibited significantly shallower upper and mid facial depths and wider upper facial breadths when compared with normal standards of facial growth. Although there was a tendency toward decreased facial depths in patients with Stickler syndrome relative to nonsyndromic patients, the differences were nonsignificant. CONCLUSIONS: Patients with Stickler syndrome show significant potential for early airway compromise and a poorer prognosis for speech outcome after cleft palate repair. Their cephalofacial growth does not differ significantly from that of nonsyndromic cleft palate patients.

Precision Dermal Fat Grafting for Vermillion Deficiencies in Patients With Unilateral and Bilateral Cleft Lip.

OBJECTIVE: Deficiencies of the upper lip vermilion occur with some frequency following repair of unilateral and bilateral clefts of the lip and can compromise the aesthetic outcome. The presence of dense scar tissue within the lip at the cleft site as well as intrinsic vermillion deficiencies can make long-lasting correction of this deformity challenging. We describe a technique to address vermillion deficiencies after cleft lip repair. DESIGN: A novel lip augmentation technique for correction of residual vermilion deficiencies after unilateral and bilateral cleft lip repair is presented. This technique combines precise placement of a contoured dermal fat graft with local tissue (V-Y) rearrangement. CONCLUSION: In our experience, this method of lip augmentation following either unilateral or bilateral cleft lip repair can restore upper lip vermillion symmetry and provide predictable and durable results in patients with mild to severe vermillion deficiency.

The conchal butterfly graft in secondary reconstruction of the bilateral cleft lip nasal deformity.

OBJECTIVES: The bilateral cleft nasal deformity is characterized by a short columella and a broad, flattened nasal tip. Secondary correction is challenging and often complicated by skin envelope scarring and hypoplastic alar cartilages. Adequate and durable tip projection requires a procedure that adequately augments the nasal tip and maximizes tip support. We describe a novel technique for secondary correction of this deformity in the immature pediatric population. METHODS: The conchal butterfly graft technique utilizes a folded cartilage construct to simultaneously increase tip projection and provide tip support. A retrospective review of 19 consecutive patients with bilateral cleft lip who underwent secondary tip rhinoplasty utilizing our technique over a 7-year period was conducted. Charts were reviewed for age at operation, length of follow-up and secondary revision procedures. Pre- and post-operative photographs were compared using two different methods to assess the degree of change and overall aesthetic result. Three plastic surgeons who previously were unfamiliar with the technique independently rated seven nasal tip characteristics. Nasal tip projection (NTP) was then measured objectively by two widely utilized methods: the Goode method and the Baum method-modified by Powell. RESULTS: Long lasting correction of the bilateral cleft nasal deformity was achieved utilizing this technique in 19 patients over a 7-year period with a mean length of follow-up of 5.4 years. We demonstrate augmented nasal tip projection that approaches ideal relationships from both relative measurement and survey data. CONCLUSION: The conchal butterfly graft technique is effective for reconstruction of the bilateral cleft nasal deformity, and in our experience, has resulted in long lasting nasal projection and overall improved facial balance.

Sternal wound reconstruction: management in different cardiac populations.

Poststernotomy mediastinitis is a feared complication for patients undergoing cardiac surgery associated with high rates of morbidity and mortality. Approximately 15% of patients will ultimately be readmitted for a recurrent sternal wound infection. The objective of this study is to review a large single surgeon experience with sternal wound patients managed with a variety of soft tissue flaps to assess mitigating factors, involved organisms, and treatment protocols as related to specific cardiac populations. Records for 136 sternal reconstruction patients treated from January 2000 to July 2007 were evaluated. Patients underwent a variety of cardiac surgeries including coronary artery bypass grafting (CABG), valve replacement, aortic reconstruction, heart transplantation, lung transplantation, and combinations of these procedures. A total of 39.2% of patients developed a sternal wound during the same admission as their cardiac surgery, at an average of 16.1 days. This rate was only 6% for CABG-only patients and rose to nearly 50% in heart transplant and CABG + valve patients. A total of 78.6% of heart transplant patients with a sternal wound had a history of ventricular assist device and 41% of all patients had at least 1 previous sternotomy. Thirteen patients (9.6%) had 1 or more recurrent infections requiring surgery; 50% occurring in transplant patients, most of whom had diabetes and/or renal insufficiency. The most common presenting symptom was drainage (n = 75, 55.6%) or wound dehiscence (n = 22, 16.3%). Twenty-five different organisms were identified; 26 patients (18.5%) had multiple organisms. Staphylococcus species were most common. Plastic surgery intervention occurred on average 109.2 days after cardiac surgery. CABG and CABG + valve patients most frequently received right pectoralis muscle turnover flaps or left pectoralis muscle advancement flaps. Ten heart transplant patients (37.0%) underwent omental flaps. The 30-day perioperative mortality rate was 13 patients (9.6%).

Pediatric dog bite injuries: a 5-year review of the experience at the Children's Hospital of Philadelphia.

BACKGROUND: The objective of this study was to characterize the nature of dog bite injuries treated over a 5-year period at a large tertiary pediatric hospital and to identify relevant parameters for public education and injury prevention. METHODS: Investigators performed a retrospective review of emergency room records of a single tertiary pediatric hospital. Records of all patients who were evaluated for dog bite injuries between April of 2001 and December of 2005 were reviewed. All demographic, patient, and injury details were recorded. RESULTS: Five hundred fifty-one patients aged 5 months to 18 years were treated in the emergency department after suffering dog bite injuries during the study period. The majority of injuries (62.8 percent) were sustained by male children. Dog bite injuries were most prevalent during the months of June and July (24.1 percent). Grade school-aged children (6 to 12 years) constituted the majority of victims (51 percent), followed by preschoolers (2 to 5 years; 24.0 percent), teenagers (13 to 18 years; 20.5 percent), and infants (birth to 1 year; 4.5 percent). Injuries sustained by infants and preschoolers often involved the face (53.5 percent), whereas older children sustained injuries to the extremities (60.7 percent). More than 30 different offending breeds were documented in the medical records. The most common breeds included pit bull terriers (50.9 percent), Rottweilers (8.9 percent), and mixed breeds of the two aforementioned breeds (6 percent). CONCLUSIONS: Pediatric dog bites are preventable injuries, yet they persist as a prevalent public health problem. Evaluation of data from high-volume tertiary pediatric health care institutions identifies predictable patterns of injury with respect to patient age and gender, animal breed, provocation, and seasonality.