Current Trends in Orthognathic Surgery.

Orthognathic surgery has evolved significantly over the past century. Osteotomies of the midface and mandible are contemporaneously used to perform independent or coordinated movements to address functional and aesthetic problems. Specific advances in the past twenty years include increasing fidelity with computer-assisted planning, the use of patient-specific fixation, expanding indications for management of upper airway obstruction, and shifts in orthodontic-surgical paradigms. This review article serves to highlight the contemporary practice of orthognathic surgery.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis.

INTRODUCTION: Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention. METHODS: Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention. RESULTS: Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75. CONCLUSIONS: Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

A Review on Variability in Treatment Protocols With Posterior Cranial Vault Distraction.

BACKGROUND: Prior studies have confirmed the ability of posterior cranial vault distraction osteogenesis (PVDO) to expand the intracranial volume in patients with craniosynostosis. To date, there is scant literature on the optimal distraction protocol for PVDO. The authors sought to review the literature and define a common protocol for posterior cranial vault distraction. METHODS: The authors performed a systematic review for published PVDO protocols. The data collected from these studies included age at the time of PVDO, number of distraction devices placed, time for latency, rate and rhythm of distraction, distraction length, time for consolidation, and surgical outcomes. RESULTS: A total of 286 patients were identified within 24 studies from 2011 to 2019. The mean age of patients identified was 25.34 months. After application of distractors, latency period ranged between 1 and 7 days, with most patients undergoing 5 to 7 days of latency. Once distraction was begun, the majority of patients (77.4%) underwent 1 mm of distraction daily. Total lengths of distraction ranged between 13 and 35 mm, with the largest cohort of patients undergoing 26 to 30 mm of total distraction. A total of 60 complications were reported for a total of 212 patients, yielding an overall complication rate of 28.3%. CONCLUSIONS: Although there is variability in reported PVDO protocols, the majority are similar to distraction osteogenesis protocols described for long bone sites. Increased patient age correlates with selection of a greater latency period and total distraction length, while frequency of complications is also increased.

Rotation of the Ipsilateral Supraorbital Rim Around the Horizontal Axis in Unilateral Coronal Synostosis: A Craniometric Analysis of the Emergence Profile.

INTRODUCTION: Unilateral coronal synostosis (UCS) results in well-defined dysmorphic changes including sphenoid malposition yielding posterior displacement of the supraorbital rim. Although variation in the ipsilateral supraorbital rim emergence profile has been suggested, it has not been previously investigated. The authors sought to characterize the emergence profile of the ipsilateral supraorbital rim in UCS through craniometric analysis. METHODS: Thirty-five nonsyndromic UCS patients (0-18 months) with CT images obtained before operative intervention and 16 control patients (0-24 months, 32 orbits) were included. Craniometric measurements were performed to quantify the emergence profile of the ipsilateral supraorbital rim and locate the likely apex of rotation. RESULTS: The ipsilateral supraorbital rim was significantly rotated around the horizontal axis when measured in reference to the 0° vertical in UCS versus control patients by an average difference of 7.3° to 11.3° across age groups (P < 0.05). No significant effect modification was detected between age and UCS on ipsilateral supraorbital rim emergence profile (P > 0.05). Additional angles with vertices around the superior orbital circumference were then measured to locate the likely apex of rotation and revealed a significant decrease in the posterior orbital roof to 0° horizontal in UCS patients by an average of 9.3° to 22.1° in children under 1 year old (P < 0.01). CONCLUSION: Variation in the emergence profile of the ipsilateral supraorbital rim in UCS is quantified, and the apex of this rotation likely lies at the posterior orbital roof. The novel quantification and characterization of this deformity will better direct the operative approach and enable a more accurate correction.

Cleft Care Readability: Can Patients Access Helpful Online Resources?

OBJECTIVE: The present study identifies and analyzes online patient resources for cleft lip with or without cleft palate to survey the online educational landscape relative to the recommended difficulty set by the National Institutes of Health (NIH) and American Medical Association (AMA). METHODS: An internet search of "cleft palate," "cleft lip," and 12 similar inputs were entered into a search engine. The first 50 links for each search term were identified, collected, and reviewed individually for relevance and accessibility. The content of the websites was analyzed with Readability Studio Version 2019.1. The following readability metrics were utilized in this study: (1) Coleman-Liau (grade levels), (2) New Dale-Chall, (3) Flesch-Kincaid, (4) Flesch Reading Ease, (5) FORCAST, (6) Fry, (7) Gunning Fog, (8) New Fog Count, (9) Raygor Readability Estimate, and (10) Simple Measure of Gobbledygook. RESULTS: In no combination of search terms did any collection of links provide information within the mid-seventh grade levels recommended by the NIH. The analysis of 143 unique websites in the "Cleft Palate" group showed a readability level appropriate to high school students. The analysis of 144 unique websites in the "Cleft Lip" group showed a readability level appropriate for eighth grade students with 6 months of class complete. CONCLUSIONS: The information presented to patients on cleft care is too complex and well above the recommended 7th-grade reading level target set forth by the NIH and AMA, which hinders functional health literacy.

The "RealSelf Effect": Can Patient Reviews on Social Media Impact Clinic Volume?

BACKGROUND: Whether patient driven or surgeon driven, social media can serve as a strong marketing tool to attract plastic surgery patients. At many training programs, chief residents have the opportunity to run an independent clinic, in which patients are evaluated for aesthetic and reconstructive procedures. In this study, the authors sought to investigate the downstream effect of a single positive review on a major social review site on cosmetic surgery volume. METHODS: A retrospective pre-post intervention study was performed. Operating room case logs at an urban training program were queried for purely aesthetic cases performed through the chief resident clinic in 2012 to 2018. Procedures performed by nonplastic surgery services were excluded. RESULTS: A total of 1734 cases met the inclusion criteria. Before the online review, aesthetic cases grew from 61 to 82 (10% compounded annual growth rate). However, after the review was posted, 107 aesthetic cases were performed in the 2016-2017 academic year, driving a 30% growth rate. A large portion of this increase in growth can be attributed to the growth in number of rhytidectomies performed. DISCUSSION: This study evaluated the impact of social media on the volume of aesthetic cases performed through an established chief resident clinic and its utility in patient recruitment. Chief residents had an increase in the number of aesthetic surgery cases they performed after their clinic was featured on an online social media physician review website. This further reinforces the impact social media and an online presence have on plastic surgery training.

Characterization of Bilateral Parietal Thinning.

BACKGROUND: Bilateral parietal thinning (BPT) of the calvarium is uncommon but can lead to significant morbidity, including pain or communication through the thinned bone. This study aimed to define and characterize a novel grading system for BPT. METHODS: Coronal CT scans of patients with BPT were retrospectively analyzed and anatomic measurements were taken including (1) thinning ratio, defined as calvarial thickness at the thinnest point divided by the average thickness of the surrounding bone and (2) width of the defect. In addition, patient demographics and comorbidities were collected. RESULTS: Forty-three patients were identified with BPT, with an average age of 73 ±â€Š16 years and 74% were female. The authors' novel grading scheme based on depth of calvarium involvement was found to be significantly correlated to thinning ratio (P < 0.001) and width (P < 0.001). When controlling for comorbidities, increasing age (P = 0.044) was the only significant independent risk factor associated with thinning ratio. With respect to defect size, when controlling for comorbidities, both hypertension (P = 0.025) and increasing age (P = 0.024) were found to be significant independent risk factors related to increasing defect size. Twenty patients (47%) had multiple CT scans (range 5 month-5 year interval). In this group, patients had an average of 0.66 ±â€Š0.11 mm decrease in parietal thickness per each year of increasing age, showing progressive parietal thinning with time. CONCLUSION: This study proposes a novel quantitatively-characterized grading scheme for BPT. The authors' results indicate that when controlling for comorbidities, BPT thinning is associated with increasing age, while defect width is associated with increasing age and hypertension. This grading scheme can help to diagnose, classify, and monitor patients with parietal bone thinning.

The Role of Precedex in Post-Operative Pain Management Following Craniosynostosis Repair.

The application of dexmedetomidine (precedex) in pediatric settings has increased due to its superior safety and efficacy profile and it has been specifically suggested as an adjunct to IV acetaminophen and a substitute for morphine in craniosynostosis repair. However, reports of its use in pediatrics, let alone in craniosynostosis repair, remain limited and to date there are no studies addressing its use after craniosynostosis repair in children. This study is an IRB-approved retrospective case review of the use of dexmedetomidine following pediatric craniosynostosis repair as a postoperative analgesic/sedative agent at one institution.

Postoperative Pain Management Following Craniosynostosis Repair: Current Practices and Future Directions.

BACKGROUND: Postoperative analgesia following craniosynostosis repair is a clinical challenge for plastic and reconstructive surgeons. There is a paucity of published data on the postoperative pain associated with craniosynostosis repair procedures and the prescribed analgesia varies with different unit protocols. The authors sought to summarize the current knowledge of the postoperative analgesia following craniosynostosis repair by reviewing the literature for existing regimens, clinical outcomes, and recommendations. METHODS: Two independent investigators conducted a literature search of the Pubmed, Cochrane, and Google Scholar databases for relevant clinical studies. Studies were abstracted for procedure type, postoperative pain management protocol, pain scores, side effects, complications, and clinical recommendations. RESULTS: Ten studies describing the use of analgesic agents in open craniosynostosis surgery from 2000 to 2018 were fully reviewed, comprising a total of 431 patients undergoing surgical procedures using a combination regimen of narcotic and nonnarcotic agents (n = 315) and nonnarcotic agents alone (n = 116). CONCLUSION: Multimodal analgesia is the primary regimen used following open craniosynostosis repair procedures. Opioids are a critical component in pain management regimens, relieving patient discomfort. However, due to the deleterious effects that come with their prolonged use, intravenous acetaminophen is currently used as an alternative in many centers. The preferred mode of pain medication administration in the pediatric population is increasingly via the intravenous route which ensures that a full dose of pain medication is given. The authors suggest the use of dexmedetomidine, both an adjunct to intravenous acetaminophen and as a substitute for morphine due to its superior safety and efficacy profile.

Ankylosis of the Temporomandibular Joint in Pediatric Patients.

INTRODUCTION: While surgical interventions for temporomandibular joint (TMJ) ankylosis are well-documented, there is lack of consensus regarding the ideal approach in pediatric patients. Surgical interventions include gap arthroplasty, interpositional arthroplasty, or total joint reconstruction. METHODS: A systematic review of PubMed (Jan 1, 1990-Jan 1, 2017) and Scopus (Jan 1, 1990-Jan 1, 2017) was performed and included studies in English with at least one patient under the age of 18 diagnosed with TMJ ankylosis who underwent surgical correction. Primary outcomes of interest included surgical modality, preoperative maximum interincisal opening (MIO) (MIOpreop), postoperative MIO (MIOpostop), ΔMIO (ΔMIO = MIOpostop - MIOpreop), and complications. RESULTS: Twenty-four case series/reports with 176 patients and 227 joints were included. By independent sample t tests MIOpostop (mm) was greater for gap arthroplasty (30.18) compared to reconstruction (27.47) (t = 4.9, P = 0.043), interpositional arthroplasty (32.87) compared to reconstruction (t = 3.25, P = 0.002), but not for gap compared to interpositional (t = -1.9, P = 0.054). ΔMIO (mm) was greater for gap arthroplasty (28.67) compared to reconstruction (22.24) (t = 4.2, P = 0.001), interpositional arthroplasty (28.33) compared to reconstruction (t = 3.27, P = 0.002), but not for interpositional compared to gap (t = 0.29, P = 0.33). Weighted-average follow-up time was 28.37 months (N = 164). 4 of 176 (2.27%) patients reported development of re-ankylosis. There was no significant difference in occurrence of re-ankylosis between interventions. CONCLUSIONS: Given the technical ease of gap arthroplasty and nonsignificant differences in ΔMIO, MIOpostop, or occurrence of re-ankylosis between gap and interpositional arthroplasty, gap arthroplasty should be considered for primary ankylosis repair in pediatric patients, with emphasis on postoperative physiotherapy to prevent recurrent-ankylosis.

Review of Endoscopic Repair of Mandible Fractures.

INTRODUCTION: Fractures of the mandibular condyle represent more than 30% of all mandible fractures. If required, reduction has been performed using either a closed or an open technique with similar outcomes. Endoscopic fracture repair is a minimally invasive approach for open reduction, but there is limited data regarding indications and outcomes. This study aims to systematically review the demographics, features, and outcomes following endoscopic repair of mandibular fractures in adult patients. METHODS: The following databases were searched from their inception to December 31, 2016: PubMed, Cochrane, Web of Science, and the WHO Global Health Library, using terms related to endoscopy and mandibular fractures. Articles were screened and data were extracted by 2 independent reviewers. Disagreements arbitrated by discussion or a 3rd reviewer. RESULTS: Twenty-two manuscripts were included, representing 509 adult patients who had endoscopic repair of a mandibular fracture over 18 years. All endoscopic repairs were of the mandibular condyle, including both subcondylar and condylar neck fractures. The sample-sized weighted mean age was 33.5 years with 74.5% males in the study population. Permanent facial nerve injury was reported once (0.24%) and occlusive complications reported in 31 patients (6.5%). CONCLUSION: This systematic review identifies a large cohort of patients who underwent endoscopic repair of their mandibular fractures. Complications were rare and usually temporary, with permanent complications occurring at a respectable rate. The demographics and outcomes identified in this study can be used as an epidemiologic baseline for future research on endoscopic repair of mandibular fractures.

Lingual Pressure During Dingman-Assisted Cleft Palate Repair: An Investigatory Case Series.

BACKGROUND: A variety of palatoplasty techniques are used for cleft palate repair, almost all involving a device called the Dingman-Grabb mouth gag ("Dingman") to push the tongue and cheeks out of the way of the operating field. There have been numerous case reports of complications hypothesized to be due to the gag, such as lingual edema and airway obstruction. The purpose of this study is to introduce a technique for monitoring lingual pressure during Dingman-assisted palatoplasty and present preliminary data from a small series. METHODS: Patients with a cleft palate who underwent palatoplasty with the assistance of a Dingman-Grabb retractor at the Mount Sinai Hospital were eligible. Patients underwent a palatoplasty while having their lingual pressure monitored using a 23-gauge needle inserted into the tongue and connected to a pressure monitor. RESULTS: Three patients were included. Patients 1 and 2 experienced a rapid rise in lingual pressure over the course of the first 45 minutes of the palatoplasty before plateauing until the conclusion of the operation when the Dingman was released. Patient 3 plateaued almost immediately by minute 1 and then had a rise in lingual pressure during the latter half of the operation, reaching a peak pressure immediately before the end of the operation. CONCLUSIONS: The present study describes an easy method to monitor lingual pressure that succeeded in measuring such changes throughout 3 palatoplasties and confirming the acute rise in lingual pressure and the potential danger posed to the tongue and the airway through the use of the Dingman.

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices.

BACKGROUND: The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. OBJECTIVES: The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. METHODS: A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. RESULTS: Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. CONCLUSIONS: The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.

Risk Factors Leading to Free Flap Failure: Analysis From the National Surgical Quality Improvement Program Database.

BACKGROUND: The objective of this study was to identify risk factors for free flap failure among various anatomically based free flap subgroups. METHODS: The 2005 to 2012 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing microvascular free tissue transfer based on current procedural terminology codes. Univariate analysis was performed to identify any association between flap failure and the following factors: age, gender, race, body mass index (BMI), diabetes, smoking, alcohol use, hypertension, intraoperative transfusion, functional health status, American Society of Anesthesiologists class, operative time, and flap location. Factors yielding a significance of P < 0.20 were included in multivariate logistic regression models in order to identify independent risk factor significance for flap failure. Furthermore, patients were stratified based on recipient site (breast, head and neck, trunk, or extremity), and analysis was repeated in order to identify risk factors specific to each location. RESULTS: A total of 1921 of 2103 patients who underwent microvascular free flap reconstruction met inclusion criteria. Multivariate logistic regression identified BMI (adjusted odds ratio [AOR] = 1.07, P = 0.004) and male gender (AOR = 2.16, P = 0.033) as independent risk factors for flap failure. Among the "breast flaps" subgroup, BMI (AOR = 1.075, P = 0.012) and smoking (AOR = 3.35, P = 0.02) were independent variables associated with flap failure. In "head and neck flaps," operative time (AOR = 1.003, P = 0.018) was an independent risk factor for flap failure. No independent risk factors were identified for the "extremity flaps" or "trunk flaps" subtypes. CONCLUSIONS: BMI, smoking, and operative time were identified as independent risk factors for free flap failure among all flaps or within flap subsets.

The Impact of Resident Participation in Outpatient Plastic Surgical Procedures.

INTRODUCTION: Ensuring patient safety along with a complete surgical experience for residents is of utmost importance in plastic surgical training. The effect of resident participation on the outcomes of outpatient plastic surgery procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a prospective, validated, national database. METHODS: We identified all outpatient procedures performed by plastic surgeons between 2007 and 2012 in the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate regression models assessed the impact of resident participation when compared to attendings alone on 30-day wound complications, overall complications, and return to the operating room (OR). RESULTS: A total of 18,641 patients were identified: 12,414 patients with an attending alone and 6227 with residents participating. The incidence of overall complications, wound complications, and return to OR was increased with resident participation. When confounding variables were controlled for in multivariate analysis, resident participation was no longer associated with increased risk of wound complications. When stratified by year, incidence of overall complications, wound complications, and return to OR in the resident participation group are trending down and fail to be significantly different in 2011 and 2012. Multivariate analysis shows a similar trend. CONCLUSIONS: Resident participation is no longer independently associated with increased complications in outpatient plastic surgery in recent years, suggesting that plastic surgical training is successfully continuing to improve in both outcomes and safety. Additional prospective studies that characterize patient outcomes with resident seniority and the degree of resident participation are warranted. LEVEL OF EVIDENCE II: 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 .

Surgical Treatment of Pediatric Craniofacial Fractures: A National Perspective.

INTRODUCTION: Head trauma is the most common cause of death because of injury in children, and trauma alone is the leading cause of morbidity and mortality in pediatrics. This study aimed to characterize the demographics and economic burden associated with the surgical and nonsurgical repair of craniofacial fractures in the pediatric inpatient population in the United States. METHODS: A retrospective cohort study was performed using the 2012 Kids' Inpatient Database which identified 20,070 patients who had a skull or facial fracture, of whom 6395 (31.9%) were treated surgically. Epidemiologic patient and hospital data were analyzed as potential determinants of surgical treatment, prolonged hospitalizations, and higher charges. RESULTS: Pediatric craniofacial fractures are estimated to represent $1.2 billion of national healthcare expenditures annually. The average patient charge for surgical treatment of a craniofacial fracture in the pediatric population is $84,849 compared with $52,490 for nonsurgical management (P < 0.001), and the average length of stay was longer for surgical repair when compared with nonsurgical management for craniofacial fractures (5.3 days versus 4.6 days, P < 0.001). Patients who were older, African American, had nonprivate insurance, whose fracture was caused by external trauma, and who were treated in an urban hospital had an independently increased likelihood of surgical repair of craniofacial fractures. Patients who were older, female, insured, of lower income brackets, whose fracture was caused by a motor vehicle accident, who had surgical treatment of their craniofacial fracture, and who were treated in hospitals in the South, Midwest, or West, teaching hospitals, and government-owned hospitals had an independent risk for a prolonged hospitalization. Patients who were older, Caucasian, insured, whose fracture was caused by a motor vehicle accident, and who were treated in hospitals in the South, teaching hospitals, pediatric hospitals, larger hospitals, and government-owned hospitals had an independent risk for increased patient charges. CONCLUSIONS: Craniofacial fractures in the pediatric population represent a large economic burden to the patient and family, as well as the healthcare system as a whole. The identified patient and hospital demographics that are associated with prolonged hospital stays and higher patient charges may represent potential barriers to care, and additional research to elucidate these factors is warranted.

Flap Failure and Wound Complications in Autologous Breast Reconstruction: A National Perspective.

PURPOSE: There are many options for breast reconstruction following a mastectomy, and data on outcomes are greatly needed for both the patient and the care provider. This study aims to identify the prevalence and predictors of adverse outcomes in autologous breast reconstruction in order to better inform patients and surgeons when choosing a surgical technique. METHODS: This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified each autologous breast reconstruction performed between 2005 and 2012. Of the 6855 autologous breast reconstructions, there were 2085 latissimus dorsi (LD) flap procedures, 2464 pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedures, and 2306 free flap procedures that met the inclusion criteria. The prevalence of complications in each of the three procedures was calculated and compared using χ(2) analysis for binomial categorical variables. Univariate and multivariate logistic regression analyses identified independent risk factors for adverse outcomes in autologous reconstruction as a whole. RESULTS: The prevalence of general complications was 10.8% in LD flaps, 20.6% in TRAM flaps, and 26.1% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of wound complications was 4.3% in LD flaps, 8.1% in TRAM flaps, and 6.2% in free flaps for autologous breast reconstruction (p < 0.001). The prevalence of flap failure was 1.1 % in LD flaps, 2.7% in TRAM flaps, and 2.4% in free flaps for autologous breast reconstruction (p < 0.001). Multivariate regression analysis showed that obesity [odds ratio (OR) 1.495, p = 0.024], hypertension (OR 1.633, p = 0.008), recent surgery (OR 3.431, p < 0.001), and prolonged operative times (OR 1.944, p < 0.001) were independently associated with flap failure in autologous breast reconstruction procedures. When controlling for confounding variables, TRAM flaps were twice as likely (OR 2.279, p = 0.001) and free flaps were three times as likely (OR 3.172, p < 0.001) to experience flap failure when compared to LD flaps. CONCLUSIONS: Latissimus dorsi flaps are associated with the fewest short-term general complications and free flaps are associated with the most short-term general complications in autologous breast reconstruction. Free flaps are the most likely to experience flap failure, though there is no significant difference when compared to pedicled TRAM flaps. Free and TRAM flaps remain as the widely acceptable forms of breast reconstruction in the patient without many risk factors for flap failure or wound complications. The identified risk factors will aid in surgical planning and risk adjustment for both the patient and the care provider. Though many other factors will be taken into consideration with surgical planning of autologous breast reconstruction, the presence of these identified risk factors may encourage the use of a surgical technique associated with fewer adverse outcomes, like the LD flap. 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.

Outcomes and Safety of the Combined Abdominoplasty-Hysterectomy: A Preliminary Study.

BACKGROUND: Abdominoplasty (ABP) at the time of hysterectomy (HYS) has been described in the literature since 1986 and is being increasingly requested by patients. However, outcomes of the combined procedure have not been thoroughly explored. METHODS: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database and identified each ABP, HYS, and combined ABP-HYS performed between 2005 and 2012. The incidence of complications in each of the three procedures was calculated, and a multiplicative-risk model was used to calculate the probability of a complication for a patient undergoing distinct HYS and ABP on different dates. One-sample binomial hypothesis tests were performed to determine statistical significance. RESULTS: There were 1325 ABP cases, 12,173 HYS cases, and 143 ABP-HYS cases identified. Surgical complications occurred in 7.7 % of patients undergoing an ABP-HYS, while the calculated risk of a surgical complication was 12.5 % (p = 0.0407) for patients undergoing separate ABP and HYS procedures. The mean operative time was significantly lower for an ABP-HYS at 238 vs. 270 min for separate ABP and HYS procedures (p < 0.0001), and the mean time under anesthesia was significantly lower at 295 vs. 364 min (p < 0.0001). CONCLUSIONS: A combined ABP-HYS has a lower incidence of surgical complications than separate ABP and HYS procedures performed on different dates. These data should not encourage all patients to elect a combined ABP-HYS, if only undergoing a HYS, as the combined procedure is associated with increased risks when compared to either isolated individual procedure. However, in patients who are planning on undergoing both procedures on separate dates, a combined ABP-HYS is a safe option that will result in fewer surgical complications, less operative time, less time under anesthesia, and a trend towards fewer days in the hospital. LEVEL OF EVIDENCE IV: 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 .

Prepectoral implant reconstruction in the setting of post-mastectomy radiation.

Prepectoral breast reconstruction after mastectomy is a more commonly performed technique in recent years due to its numerous advantages over subpectoral breast reconstruction. This study reviews the current state of clinical outcomes for patients undergoing postmastectomy radiation therapy (PMRT) after prepectoral breast reconstruction. A comprehensive search of the literature was performed using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify all relevant studies. Outcome measures included demographics, mean follow-up, and complication measures. Three studies for a total of 175 breasts were identified. Average age was 49.3 years and BMI was 27.7 kg/m2. Mean follow up was 18.1 months. A total of 3 (1.7%) hematomas and 4 (2%) seromas were reported. Surgical site infection was the most common complication reported with an overall reported 32 breasts with infections (18%). A total of 9 (5.1%) cases of wound dehiscence were reported. Mastectomy flap necrosis was found in 10 (5.7%) breasts. A total of 22 (12.6%) tissue expanders or implants required explantation. The review of the literature suggests that prepectoral breast reconstruction with acellular dermal matrices in the setting of post mastectomy radiation therapy is a safe and successful surgical option resulting in excellent clinical outcomes. Furthermore, there may be a reduction of capsular contracture and implant migration in this setting, relative to traditional submuscular techniques with PMRT.

Considerations for Payment Bundling in Cleft Care.

SUMMARY: Since the introduction of the Bundled Payments for Care Improvement initiative, progress has been made in piloting bundled payment models to improve care coordination and curtail health care expenditures. In light of improvements in patient outcomes and the concomitant reduction in health care spending for certain high-volume and high-cost procedures, such as total joint arthroplasty and breast reconstruction, the authors discuss theoretical considerations for bundling payments for the care of patients with orofacial clefts. The reasons for and against adopting such a payment model to consolidate cleft care, as well as the challenges to implementation, are discussed. The authors purport that bundled payments can centralize components of cleft care and offer financial incentives to reduce costs and improve the value of care provided, but that risk adjustment based on the longitudinal nature of care, disease severity, etiologic heterogeneity, variations in outcomes reporting, and varying definitions of the episode of care remain significant barriers to implementation.