Decision-Making in Cleft-Related Surgery: A Qualitative Analysis of Patients and Caregivers.

OBJECTIVE: Preference-sensitive surgical decisions merit shared decision-making, as decision engagement can reduce decisional conflict and regret. Elective cleft-related procedures are often preference sensitive, and therefore, we sought to better understand decision-making in this population. DESIGN: Semistructured interviews were conducted to elicit qualitative data. A hierarchical codebook was developed through an iterative process in preparation for thematic analysis. Thematic analysis was performed to examine differences between patients and caregivers. SETTING: Multidisciplinary cleft clinic at a tertiary care center. PARTICIPANTS: Patients with cleft lip aged 8 and older (n = 31) and their caregivers (n = 31) were purposively sampled. Inability to converse in English, intellectual disability, or syndromic diagnoses resulted in exclusion. MAIN OUTCOME MEASURES: Preferences surrounding surgical decision-making identified during thematic analysis. RESULTS: Mean patient age was 12.7 (standard deviation: 3.1). Most had unilateral cleft lip and palate (43.8%). Three themes emerged: Insufficient Understanding of Facial Difference and Treatment, Diversity of Surgical Indications, and Barriers to Patient Autonomy. Almost half of caregivers believed their children understood their clefts, but most of these children failed to provide information about their cleft. Although many patients and caregivers acknowledged that surgery addressed function and/or appearance, patients and caregivers exhibited differences regarding the necessity of surgery. Furthermore, a large proportion of patients believed their opinions mattered in decisions, but less than half of caregivers agreed. CONCLUSIONS: Patients with clefts desire to participate in surgical decisions but have limited understanding of their facial difference and surgical indications. Cleft surgeons must educate patients and facilitate shared decision-making.

The Impact of Medicaid Expansion on Utilization of Vascular Procedures and Rates of Amputation.

BACKGROUND: Although New York's Medicaid expansion increased coverage in 2001, little is known regarding changes in surgical care utilization among patients with vascular disease. We sought to measure the impact of expansion on the rates of both vascular procedures and amputations. MATERIALS AND METHODS: A retrospective analysis was performed using the State Inpatient Databases of New York and Arizona, 1998-2006. Patients aged 18-64 who underwent lower extremity vascular surgery procedures or amputations between 1998 and 2006 were included. Outcomes included rates of total vascular, open vascular, and endovascular procedures, in addition to rates of amputation. A difference-in-difference analysis measured changes in the rates of procedure types, while adjusting for temporal trends in both states. RESULTS: In this cohort (n = 112,624), Medicaid expansion was not associated with a change in mortality (odds ratio 0.92, P = 0.5). Expansion was associated with a lower incidence of total vascular procedures (incidence rate ratio [IRR] 0.65, P < 0.001) and open vascular procedures (IRR 0.92, P = 0.002), but a higher incidence of endovascular procedures (IRR 1.13, P < 0.001). There was no change in the rate of amputations (IRR 1.02, P = 0.58). In patients with chronic limb-threatening ischemia (n = 12,668), expansion was associated with a lower incidence of total procedures (IRR 0.59, P < 0.001) and endovascular procedures (IRR 0.59, P < 0.001) but a higher incidence of amputations (IRR 1.43, P = 0.001) and higher odds of mortality (odds ratio 2.21, P = 0.032). CONCLUSIONS: After Medicaid expansion, the rates of total vascular procedures decreased, with no impact on amputations rates. Furthermore, the utilization of limb-saving procedures in patients with chronic limb-threatening ischemia did not increase.

Short- and Long-Term Outcomes by Procedure Type for Nonsagittal Single-Suture Craniosynostosis.

BACKGROUND: Minimally invasive approaches for the treatment of single-suture craniosynostosis are sometimes touted as equivalent to cranial vault reconstruction. While techniques for sagittal synostosis have been reviewed previously, evidence regarding open and less invasive surgical techniques for metopic, coronal, and lambdoid synostosis has yet to be reviewed. METHODS: Systematic searches were performed using Embase.com and PubMed. Included studies reported short- or long-term outcomes, compared at least 2 standard techniques, discussed single-suture coronal, metopic, or lambdoid craniosynostosis, and enrolled at least 20 study participants. Two authors screened titles and abstracts, and also performed full text review and data extraction. Given heterogeneous outcomes, qualitative synthesis was performed after data extraction. RESULTS: The search strategy yielded 2348 articles. Of these, 313 were removed as duplicates, and 1935 were excluded during title/abstract review. After full text review of 100 articles, 19 were selected for data extraction. The heterogeneity of outcomes precluded meta-analysis and required qualitative synthesis. While short-term outcomes indicated decreased morbidity of minimally invasive techniques, only 2 articles presented long-term reoperation rates. One study reported higher reoperation rates in the less invasive technique, and the second reported no reoperations in the median follow-up period of 33 months. CONCLUSION: Studies comparing long-term outcomes between different surgical techniques for single-suture craniosynostosis remain deficient. The development of standardized outcome measures is essential, and prospective, multicenter studies are necessary to assess the long-term efficacy of these procedures.

Debunking a Surgical Myth: Do Not Touch the Temporalis.

BACKGROUND: A longstanding dictum exists to avoid surgical manipulation of the temporalis muscle out of concern for an exceedingly high rate of muscle atrophy and recurrent temporal hollowing. The authors challenge this surgical myth, considering such advice to be erroneous. The authors hypothesize that elevation of the temporalis muscle, if performed using standard muscle flap principles, will demonstrate excellent results. METHODS: To assess temporalis response to surgical manipulation, the authors reviewed patients who underwent calvarial vault remodeling by the senior author for craniosynostosis between 1988 and 2011. Nonsyndromic patients with single-suture synostosis and 5 years of follow-up were eligible for inclusion. The medical record was used to measure rates of reoperation, recurrent temporal hollowing, and persistent temporalis overcorrection. RESULTS: Of the cohort reviewed, 196 patients met inclusion criteria. Ten patients (5.1%) exhibited recurrent bitemporal constriction. One patient (0.5%) underwent a revision temporalis turnover flap, and 2 patients (1.0%) underwent soft tissue augmentation. The overall reoperation rate was 1.5%. Temporalis overcorrection, in an attempt to prophylactically rectify the expected atrophy after temporalis manipulation, persisted in 11 patients (5.6%). Three of these patients required treatment with steroid injections, Botox injections, or operative muscle debulking. The overall reoperation rate for temporalis overcorrection was 1.5%. CONCLUSIONS: The authors' low reoperation rates for recurrent deformity, in combination with persistent temporalis overcorrection in 5.6% of patients, should dispel the myth that manipulation of the temporalis invariably results in atrophy. The muscle may be surgically manipulated, as long as plastic surgery principles are followed.

Guidelines for the Ethical Publication of Facial Photographs and Review of the Literature.

Facial photography presents a unique ethical dilemma, as faces are difficult to deidentify for publication. We performed a review of the literature to examine current guidelines for the publication of facial photographs. We also reviewed societies' websites, journal requirements, and ethical and legal aspects of confidentiality. Most articles emphasized the importance of consent for photography and publication. Masking is not appropriate, but some journals continue to allow masking. Most legislation allows patients to restrict the uses of photographs. In the end, it is imperative to protect patient privacy by obtaining consent for photograph publication after full disclosure of risks, and specific recommendations are provided regarding a comprehensive consent process.

Surgical Hypercorrection of Trigonocephaly: Evaluation of Surgical Outcomes.

BACKGROUND: A lasting correction of trigonocephaly is difficult to achieve, as a durable correction requires significant expansion to overcome galeal restriction and soft tissue recoil of the scalp. High rates of relapse have been reported throughout the literature. The specific aim of this study was to determine if the senior author's method of "hypercorrection" decreases relapse and the need for subsequent revisional surgery. METHODS: Patients who underwent operative correction of metopic craniosynostosis between 1988 and 2011 were reviewed. All patients underwent the "hypercorrection" technique performed by the senior author. Hypercorrection consisted of a fronto-orbital advancement of 2.5 to 3.5 cm and a concomitant hyperexpansion of bitemporal projection. Split cranial bone grafting ensured adequate coverage of the significantly expanded cranial vault. Only patients who had at least 5 years of follow-up were included for review of outcomes. Relapse was defined as recurrence of bitemporal constriction or lateral orbital retrusion, requiring surgical correction. RESULTS: Fifty-eight patients met criteria. Mean age at the time of surgery was 11 months. Mean follow-up was 9.0 years. During this time, 2 patients exhibited relapse requiring camouflage procedures. Cranial bone defects were found in 4 patients (7%), 3 of whom underwent cranial bone grafting, while 1 underwent methylmethacrylate placement at an outside institution. One patient underwent fat grafting for areas of soft tissue irregularity. No patients exhibited persistent sequelae of hypercorrection significant enough to require repeat fronto-orbital advancement. CONCLUSION: Surgical hypercorrection of trigonocephaly seems to minimize relapse and the need for revision in long-term follow-up and is therefore an important technique to consider.

Persistent Opioid Use Among Children, Adolescents, and Young Adults After Common Cleft Operations.

BACKGROUND: Surgical care represents an important source of opioid prescribing and chronic use, but rates of prolonged opioid use following pediatric procedures remain unclear. The authors describe the rates and risk factors for new persistent opioid use in patients after common cleft operations. METHODS: The authors examined claims from the Truven Marketscan databases from January 1, 2010 to December 31, 2014. The authors included opioid-naive patients ages 8 to 25, who underwent 1 of 10 cleft-related procedures. Patients were considered opioid-naïve if they had no opioid prescription fills in the 11 months prior to the perioperative period. The authors obtained a random sample of age-matched, nonsurgical patients from the same dataset to be used as a control group. Included cleft patients had no procedural codes in the 6 months following surgery. All included patients filled an opioid prescription during the perioperative period, defined as 30 days before and 14 days after surgery. The primary outcome was new persistent opioid use, which is defined as continued opioid prescription fills between 90 and 180 days after the procedure. RESULTS: This cohort included 2039 cleft patients and 2100 control patients. The incidence of new persistent opioid use following surgery was 4.4% and 0.1% in the control group. Higher odds of opioid use 3 months beyond surgery were associated with distractor placement (OR 5.34, CI 2.00-14.24, P = 0.001). Increasing age (OR 1.11, CI 1.04-1.17, P = 0.001) and presence of a gastrointestinal comorbidity (OR 7.37, CI 1.49-36.54, P = 0.014) were also associated with new persistent use. CONCLUSIONS: New persistent opioid use occurs after cleft-related procedures and could lead to chronic use in children, adolescents, and young adults.

Treatment of Keloids With Excision and Adjuvant Radiation: A Single Center Experience and Review of the Literature.

BACKGROUND: Management of keloids has remained a conundrum, because an optimum treatment regimen has yet to be elucidated. Currently, treatment varies widely between more conservative measures, such as steroid injections, topical medications, and silicone sheeting, to more aggressive options, such as surgery and postoperative radiation. The latter combination has been touted to have superior results, with the lowest rates of pathologic scar recurrence. METHODS: We performed a retrospective review to critically evaluate the effectiveness of surgical excision and radiation treatment in patients with keloids. Surgical resection of surgeon-selected keloids, combined with state-of-the-art postoperative cutaneous radiation therapy, was used at a major tertiary referral center. For patients with poor follow-up, phone calls were made to determine recurrence. In addition, we present a review of the current literature to provide a comprehensive synopsis of current keloid treatment. RESULTS: A total of 69 patients' records were reviewed. There were a total of 84 keloids upon pathology review. The overall recurrence rate for all keloids was 27%, and in those followed greater than 1 year, recurrence for keloids was 74%. About half the patients with more than 1 year of follow-up experienced recurrence more than 1 year after treatment. CONCLUSIONS: At this time, the evidence supporting surgery and radiation for the treatment of keloids remains equivocal, and randomized controlled studies are needed to determine the efficacy of this treatment protocol. Most importantly, our data reinforce the need for long-term follow-up in this patient population.

The Teaching of Ethics and Professionalism in Plastic Surgery Residency: A Cross-Sectional Survey.

BACKGROUND: The ethical practice of medicine has always been of utmost importance, and plastic surgery is no exception. The literature is devoid of information on the teaching of ethics and professionalism in plastic surgery. In light of this, a survey was sent to ascertain the status of ethics training in plastic surgery residencies. METHODS: A 21-question survey was sent from the American Council of Academic Plastic Surgeons meeting to 180 plastic surgery program directors and coordinators via email. Survey questions inquired about practice environment, number of residents, presence of a formal ethics training program, among others. Binary regression was used to determine if any relationships existed between categorical variables, and Poisson linear regression was used to assess relationships between continuous variables. Statistical significance was set at a P value of 0.05. RESULTS: A total of 104 members responded to the survey (58% response rate). Sixty-three percent were program directors, and most (89%) practiced in academic settings. Sixty-two percent in academics reported having a formal training program, and 60% in private practice reported having one. Only 40% of programs with fewer than 10 residents had ethics training, whereas 78% of programs with more than 20 residents did. The odds of having a training program were slightly higher (odds ratio, 1.1) with more residents (P = 0.17). CONCLUSIONS: Despite the lack of information in the literature, formal ethics and professionalism training does exist in many plastic surgery residencies, although barriers to implementation do exist. Plastic surgery leadership should be involved in the development of standardized curricula to help overcome these barriers.

The Protruding Premaxilla: Is Our Current Approach the Right Answer?

BACKGROUND: In bilateral cleft patients, surgeons usually attempt to move the premaxillary segment posteriorly. These patients almost always develop maxillary hypoplasia, rendering our current algorithms questionable. The authors sought to determine if the lateral segments are in an appropriate position to serve as a target for movement of the premaxilla. METHODS: Bilateral cleft lip and palate patients treated at the University of Michigan from 1997 to 2015 were reviewed. Patients with skull radiographs or computed tomography (CT) imaging performed at age 3 or younger were included. Noncleft patients <3 years old seen in the craniofacial clinic during 2015 with negative imaging were included as comparative norms. Sella-nasion-A (SNA), sella-nasion-piriform (SNP), and sella-nasion-posterior nasal spine (SN-PNS) angles were determined in both the cleft patients and the comparative norms. Paired t tests assuming unequal variance were used to compare angles between normal and cleft patients. RESULTS: Eighty-six bilateral cleft patients were identified, and 16 had imaging. Only 7 patients had a CT or skull radiograph. Thirteen noncleft patients with negative imaging were included. The mean SNA angle was 100.8 in cleft patients and 86.1 in noncleft patients (P = 0.002). The mean SNP angle was 62.9 in cleft patients and 71.3 in noncleft patients (P = 0.02). The mean SN-PNS angle was 23.2 in cleft patients and 33.8 in noncleft patients (P = 0.005). CONCLUSIONS: Our results indicate that the maxilla is deficient early in life with posterior positioning of the lateral segments. Therefore, the lateral segments should not serve as a reference point when treating the premaxilla.

Velopharyngeal Dysfunction and Sleep Apnea-A Survey to Ascertain Surgical Practice Patterns.

OBJECTIVE: To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD). DESIGN: A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice. MAIN OUTCOME MEASURES: We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons' evaluation of OSA and their approaches to VPD. RESULTS: A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038). CONCLUSIONS: Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.

Metopic Craniosynostosis: A Demographic Analysis Outside an Urban Environment.

BACKGROUND: Metopic craniosynostosis has traditionally been cited as the third most common type of isolated synostosis, after sagittal and coronal craniosynostosis. Recently, several urban institutions have observed an increase in the incidence of metopic synostosis. The authors sought to determine if similar demographic changes have occurred in a more suburban setting and if so, what specific variables were associated with this change. METHODS: Patients who underwent operative correction of craniosynostosis between 1989 and 2014 were retrospectively reviewed. The type of craniosynostosis as well as sex, family history, birth history, and other demographic data were recorded. Kendall-Mann trend tests and multinomial logistic regressions were conducted, and marginal effects were calculated for all variables included in the model. RESULTS: Records of 493 patients were reviewed. Using Kendall-Mann trend tests, it was determined that metopic, sagittal, and lambdoid craniosynostoses all demonstrated an increase in incidence. Based on raw data, metopic synostosis was found to be the second most common type of craniosynostosis between 2004 and 2014. Male sex and multiple gestations were both associated with metopic craniosynostosis. CONCLUSIONS: This study demonstrated an increasing incidence of metopic craniosynostosis over time, which ascended to the second most common type of synostosis in an analysis outside of an urban environment. In our study, male sex and multiple gestation were positively associated with an increased risk of metopic craniosynostosis. Prospective studies are needed to further delineate the evolving characteristics of this patient population.

Age at Craniosynostosis Surgery and Its Impact on Ophthalmologic Diagnoses: A Single-Center Retrospective Review.

BACKGROUND: Ocular abnormalities in craniosynostosis are a persistent concern for patients and providers, and some surgeons feel that early surgical intervention for synostosis alleviates the progression of ophthalmologic abnormalities. In contradistinction, the authors hypothesize that operating early will have no bearing on postoperative ophthalmologic outcomes. METHODS: Single-suture craniosynostosis patients who underwent surgical correction between 1989 and 2015 were reviewed. Patients with multisuture craniosynostosis, syndromic diagnoses, no preoperative ophthalmology evaluation, and less than 2 years of follow-up were excluded. Logistic regression was used to determine odds of preoperative and postoperative ophthalmologic abnormalities by age, while controlling for patient-level covariates. RESULTS: One hundred seventy-two patients met inclusion criteria. The median age at surgery was 10 months (interquartile range, 7 to 12.9 months). Increasing age at the time of surgery was associated with increased odds of preoperative ophthalmologic diagnoses (OR, 1.06; p = 0.037) but not postoperative diagnoses (OR, 1.00; p = 0.91). Increasing age at surgery was also not associated with increased odds of ophthalmologic diagnoses, regardless of timing (OR, 1.04; p = 0.08). Patients with coronal synostosis (OR, 3.94; p = 0.036) had significantly higher odds of preoperative ophthalmologic diagnoses. Patients with metopic (OR, 5.60; p < 0.001) and coronal (OR, 7.13; p < 0.001) synostosis had significantly higher odds of postoperative ophthalmologic diagnoses. CONCLUSIONS: After reviewing an expansive cohort, associations of both overall and postoperative ophthalmologic diagnoses with age at surgery were not found. The authors' findings thus run counter to the theory that early surgical intervention lessens the likelihood of postoperative ophthalmologic diagnoses and improves ophthalmologic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Persistent Opioid Use and High-Risk Prescribing in Body Contouring Patients.

BACKGROUND: Opioid misuse occurs commonly among obese patients and after bariatric surgery. However, the risk of new persistent use following postbariatric body contouring procedures remains unknown. METHODS: The authors examined insurance claims from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minn.) between 2001 and 2015 for opioid-naive patients undergoing five body contouring procedures: abdominoplasty/panniculectomy, breast reduction, mastopexy, brachioplasty, and thighplasty (n = 11,257). Their primary outcomes included both new persistent opioid use, defined as continued prescription fills between 90 and 180 days after surgery, and the prevalence of high-risk prescribing. They used multilevel logistic regression to assess the risk of new persistent use, adjusting for relevant covariates. RESULTS: In this cohort, 6.1 percent of previously opioid-naive patients developed new persistent use, and 12.9 percent were exposed to high-risk prescribing. New persistent use was higher in patients with high-risk prescribing (9.2 percent). New persistent use was highest after thighplasty (17.7 percent; 95 percent CI, 0.03 to 0.33). Increasing Charlson comorbidity indices (OR, 1.11; 95 percent CI, 1.05 to 1.17), mood disorders (OR, 1.27; 95 percent CI, 1.05 to 1.54), anxiety (OR, 1.41; 95 percent CI, 1.16 to 1.73), tobacco use (OR, 1.22; 95 percent CI, 1.00 to 1.49), neck pain (OR, 1.23; 95 percent CI, 1.04 to 1.46), arthritis (OR, 1.30; 95 percent CI, 1.08 to 1.58), and other pain disorders (OR, 1.36; 95 percent CI, 1.16 to 1.60) were independently associated with persistent use. CONCLUSIONS: Similar to other elective procedures, 6 percent of opioid-naive patients developed persistent use, and 12 percent were exposed to high-risk prescribing practices. Plastic surgeons should remain aware of risk factors and offer opioid alternatives. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons.

BACKGROUND: Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision. METHODS: Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05. RESULTS: The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44). CONCLUSIONS: All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.

When Is Posting about Patients on Social Media Unethical "Medutainment"?

Social media is characterized by online spaces for rapid communication, advertising, professional development, and advocacy, and these platforms have revolutionized the way we interact with people and our culture. In plastic surgery, platforms like Facebook, Snapchat, and Instagram are especially attractive for practice promotion and instantaneous connection with potential patients. However, considerable risks and ethical dilemmas lie in wait for the plastic surgeon who attempts to use patient photographs and videos for advertising. It is critical for plastic surgeons who use patient images for this purpose to facilitate fully informed consent, consider both context of use and the patient-physician power differential, and put patients' interests ahead of their own.

Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction.

Importance: In breast reconstruction, it is critical for patients and surgeons to have comprehensive information on the relative risks of the available options. However, previous studies that evaluated complications were limited by single-center designs, inadequate follow-up, and confounding. Objective: To assess 2-year complication rates across common techniques for postmastectomy reconstruction in a multicenter patient population. Design, Setting, and Participants: This longitudinal, multicenter, prospective cohort study conducted from February 1, 2012, through July 31, 2015, took place at the 11 study sites associated with the Mastectomy Reconstruction Outcomes Consortium study. Eligible patients included women 18 years and older presenting for first-time breast reconstruction with at least 2 years of follow-up. Procedures evaluated included direct-to-implant (DTI) technique, expander-implant (EI) technique, latissimus dorsi (LD) flap, pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, free transverse rectus abdominis myocutaneous (fTRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. Interventions: Postmastectomy breast reconstruction. Main Outcomes and Measures: Development of complications, reoperative complications, and wound infections during 2-year follow-up. Mixed-effects logistic regression analysis controlled for variability among centers and for demographic and clinical variables. Results: A total of 2343 patients (mean [SD] age, 49.5 [10.1] years; mean [SD] body mass index, 26.6 [5.7]) met the inclusion criteria. A total of 1525 patients (65.1%) underwent EI reconstruction, with 112 (4.8%) receiving DTI reconstruction, 85 (3.6%) pTRAM flaps, 95 (4.1%) fTRAM flaps, 390 (16.6%) DIEP flaps, 71 (3.0%) LD flaps, and 65 (2.8%) SIEA flaps. Overall, complications were noted in 771 (32.9%), with reoperative complications in 453 (19.3%) and wound infections in 230 (9.8%). Two years postoperatively, patients undergoing any autologous reconstruction type had significantly higher odds of developing any complication compared with those undergoing EI reconstruction (pTRAM flap: odds ratio [OR], 1.91; 95% CI, 1.10-3.31; P = .02; fTRAM flap: OR, 2.05; 95% CI, 1.24-3.40; P = .005; DIEP flap: OR, 1.97; 95% CI, 1.41-2.76; P < .001; LD flaps: OR, 1.87; 95% CI, 1.03-3.40; P = .04; SIEA flap: OR, 4.71; 95% CI, 2.32-9.54; P < .001). With the exception of LD flap reconstructions, all flap procedures were associated with higher odds of reoperative complications (pTRAM flap: OR, 2.48; 95% CI, 1.33-4.64; P = .005; fTRAM flap: OR, 3.02; 95% CI, 1.73-5.29; P < .001; DIEP flap: OR, 2.76; 95% CI, 1.87-4.07; P < .001; SIEA flap: OR, 2.62; 95% CI, 1.24-5.53; P = .01) compared with EI techniques. Of the autologous reconstructions, only patients undergoing DIEP flaps had significantly lower odds of infection compared with those undergoing EI procedures (OR, 0.45; 95% CI, 0.25-0.29; P = .006). However, DTI and EI procedures had higher failure rates (EI and DTI techniques, 7.1%; pTRAM flap, 1.2%; fTRAM flap, 2.1%; DIEP flap, 1.3%; LD flap, 2.8%; and SIEA flap, 0%; P < .001). Conclusions and Relevance: Significant differences were noted across reconstructive procedure types for overall and reoperative complications, which is critically important information for women and surgeons making breast reconstruction decisions.

The Ethical and Professional Use of Social Media in Surgery: A Systematic Review of the Literature.

Although certain medical societies have released guidelines on the use of social media, plastic surgery, with its inherent visual nature and potential for sensationalism, could benefit from increasing direction regarding the ethical use of social media. The authors hypothesized that although general platitudes for use exist in the literature, guidelines articulating the boundaries of professional use are nonspecific. Systematic searches of MEDLINE, Embase.com, and Cochrane Central Register of Controlled Trials were completed on January 18, 2017. Searches consisted of a combination of Medical Subject Headings terms and title and abstract keywords for social media and professionalism concepts. In addition, the authors manually searched the three highest impact plastic surgery journals (ending in October of 2017). Two authors screened all titles and abstracts. Studies related to clinical medicine, patient care, and the physician-patient relationship were included for full-text review. Articles related to surgery merited final inclusion. The initial search strategy yielded 954 articles, with 28 selected for inclusion after final review. The authors' manual search yielded nine articles. Of the articles from the search strategy, 10 were published in the urology literature, eight were published in general surgery, six were published in plastic surgery, three were published in orthopedic surgery, and one was published in vascular surgery. Key ethical themes emerged across specialties, although practical recommendations for professional social media behavior were notably absent. In conclusion, social media continue to be a domain with potential professional pitfalls. Appropriate use of social media must extend beyond obtaining consent, and plastic surgeons must adhere to a standard of professionalism far surpassing that of today's media culture.

Postoperative Ketorolac in Breast and Body Contouring Procedures: A Nationwide Claims Analysis.

BACKGROUND: Nonsteroidal antiinflammatory drugs are useful alternatives to narcotics for analgesia. However, concerns remain regarding their safety. The authors evaluated ketorolac use and complications. We hypothesized that no association between ketorolac and morbidity exists in patients undergoing body contouring. METHODS: Truven MarketScan claims database was analyzed for patients undergoing breast and body contouring surgery. Patients selected received ketorolac and were enrolled a minimum of 90 days. The authors performed a multivariable logistic regression to calculate risk of morbidity, adjusting for clinical and sociodemographic factors. RESULTS: Among the 106,279 patients enrolled, 4924 (4.6 percent) received postoperative ketorolac. In multivariable regression analysis, ketorolac was not associated with hematoma (OR, 1.20; 95 percent CI, 0.99 to 1.46; p > 0.05). There was an increased rate of reoperation within 72 hours (OR, 1.22; 95 percent CI, 1.00 to 1.49; p < 0.05; number needed to harm, 262 patients). Ketorolac was associated with fewer readmissions (OR, 0.76; 95 percent CI, 0.62 to 0.93; p < 0.05; number needed to treat, 87 patients), with a reduction in the rate of pain as a readmission diagnosis (0.6 percent versus 4.3 percent; p = 0.021). Ketorolac was associated with seroma, but this association may not be causal (OR, 1.28; 95 percent CI, 1.05 to 1.57; p < 0.05; number needed to harm, 247 patients). Ketorolac provided an estimated savings of $157 per patient. CONCLUSIONS: The benefits of ketorolac likely outweigh the risks after surgery. Absolute differences in reoperation rates were low, and improved rates of hospital admission impact cost savings. The authors advocate postoperative ketorolac once the wound is hemostatic. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Caregiver-Reported Outcomes and Barriers to Care among Patients with Cleft Lip and Palate.

BACKGROUND: For children with cleft lip and/or palate, access to care is vital for optimizing speech, appearance, and psychosocial outcomes. The authors posited that inadequate access to care negatively impacts outcomes in this population. METHODS: Sixty caregivers of children with cleft lip and palate were surveyed to assess perceived barriers using the validated Barriers to Care questionnaire. The questionnaire includes 39 items divided into five subscales, with higher scores indicating fewer barriers. Caregiver-reported outcomes were assessed using the Cleft Evaluation Profile, which captures cleft-specific appearance- and speech-related outcomes. Higher scores correspond to less satisfactory outcomes. Desire for revision surgery was assessed as a binary outcome among caregivers. Multivariable regression was used to evaluate the relationship of barriers to care, caregiver-reported outcomes, and desire for revision, adjusting for clinical and demographic covariates. RESULTS: Sixty percent of caregivers perceived barriers to care, and caregivers who reported poorer access to care described poorer cleft-related outcomes (r = 0.19, p = 0.024). Caregivers with poorer skills (r = 0.17, p = 0.037), expectations (r = 0.17, p = 0.045), and pragmatics (r = 0.18, p = 0.026) subscale scores were associated with worse Cleft Evaluation Profile scores. Barriers were also negatively associated with aesthetic item scores (r = 0.11, p = 0.025). Finally, caregivers reporting fewer barriers were 21.2 percent less likely to express interest in revision surgery. CONCLUSIONS: Barriers to care were associated with poorer appearance-related outcomes and increased interest in revision among caregivers of cleft patients. Enhancing access to care is critical in order to effectively meet goals of care for these families.