Use of Absorbable Dermal Staples in Bilateral Breast Reduction Surgery: Effects on Operative Times, Surgical Outcomes, and Procedure Charges.

BACKGROUND: Use of the absorbable deep dermal stapler in wound closure has become more common in plastic surgery because of its possible reduction in operative times and subsequent decrease in operative room costs. In this study, we examine the effects of this stapler on operative times and postoperative complications in bilateral reduction mammaplasties. METHODS: A retrospective, observational cohort study was conducted via electronic chart review on patients who underwent bilateral reduction mammaplasties. Patients were stratified by wound closure method. One group was closed with sutures only, and in the other group, deep dermal staples were used during closure of the inframammary fold incision. Incidences of patient comorbidities and postoperative complications were compared. In addition, a financial cost analysis was performed. RESULTS: The final patient cohort included 62 patients. Operative time was reduced by an average of 21.8 minutes when using deep dermal staples during closure, compared with when closing solely with sutures (P = 0.032). When controlling for mass of breast tissue removed and type of pedicle, deep dermal staple closure still predicted a reduction of 26.5 (SE, 9.9) minutes in operative time (P = 0.010). Postoperative complications were not affected by wound closure method (odds ratio, 4.36; 95% confidence interval, 0.91-31.7, P = 0.087). Though not statistically significant, financial charge was decreased with usage of deep dermal staples (P = 0.34). CONCLUSIONS: Use of absorbable deep dermal staples produces a significant decrease in operative time for reduction mammaplasties with no increase in postoperative complication rates.

A Review of 559 Sternal Wound Reconstructions at a Single Institution: Indications and Outcomes for Combining an Omental Flap With Bilateral Pectoralis Major Flaps in a Subset of 17 Patients With Infections Extending Into the Deep Mediastinum.

BACKGROUND: Sternal wound infection (SWI) and dehiscence after median sternotomy for cardiac surgery remain challenging clinical problems with high morbidity. Bilateral pectoralis major myocutaneous flaps are excellent for most sternal wounds but do not reach deeper mediastinal recesses. The omental flap may be a useful adjunct for addressing these deeper mediastinal infections. METHODS: Records of 598 sternal wound reconstructions performed by a single surgeon (J.A.A.) from 1996 to 2022 were reviewed. At the time of surgery, patients underwent sternal hardware removal, debridement, and closure with bilateral pectoralis major myocutaneous flaps. Pedicled omental flaps were also mobilized when additional vascularized tissue was required within the deeper mediastinum. RESULTS: Complete data were available for 559 sternal wound reconstructions performed by the senior author during this period. Bilateral pectoralis and omental flaps were mobilized in 17 of 559 (3.04%) patients. Common indications for initial cardiac surgery included repair or replacement of diseased aortic roots (9/17; 52.94%), aortic valves (8/17; 47.06%), and mitral valves (6/17; 35.29). Mean American Society of Anesthesiologists score was 3.56. Preoperative morbidity included culture-positive wound infection (12/17; 70.59%), dehiscence (15/17; 88.24%), wound drainage (11/17; 64.71%), and inability to close the chest after the original sternotomy because of hemodynamic instability (6/17; 35.29%). Intraoperative deep mediastinal or bone cultures were positive in 8 of 17 (47.06%) patients. Postoperative complications included partial dehiscence (2/17; 11.76%), skin edge necrosis (1/17; 5.88%), seroma (1/17; 5.88%), abdominal hernia (1/17; 5.88%), and recurrent infection (2/17; 11.76%). Three patients (17.65%) died within 30 days of the reconstruction surgery. CONCLUSIONS: Patients undergoing combined pectoralis major and omental flap closure frequently had a history of aortic root and valve disease, and other significant preoperative morbidities. However, postoperative complication rates after combined flap closure were relatively low. Combined pectoralis major and omental flap reconstruction thus appears to be an effective intervention in patients with sternal wounds extending into the deep mediastinum.

Open Repair Versus Closed Repair: A Cost-Analysis of the Two Surgical Approaches for the Treatment of Craniosynostoses.

PURPOSE: The purpose of this study was to quantify the hospitalization charges of the 2 general surgical approaches in the treatment of craniosynostosis and determine if there was a significant difference between the 2. Several studies compared them side-by-side according to specific variables, such as success rates, postoperative complications, blood loss, and length of stay, but were limited by small sample sizes. METHODS: This is a retrospective cohort study that was conducted using the Kids' Inpatient Database (KID). All patients diagnosed with craniosynostosis (Q75.0) were identified. The procedures were grouped according to the approach taken, whether it was a traditional, open approach, or a closed, minimally invasive approach. The primary predictor variable was the surgical approach (open vs closed). The outcome variables were the hospital charges (US dollars) and length of stay (days). Statistical analyses were based on the univariate and multivariate linear regression models, and P value less than .05 marked the significance level. RESULTS: Among a sample of 2,585 cases, an open approach was employed in 2,353 cases and a closed approach in 232 cases. Race, payer information, hospital region, admission status (elective vs not elective), patient location, and surgical approach (open vs closed) were all significant predictors (P < .15) of increased hospitalization charges. Relative to white patients, being in the 'other' racial class added $10,987 in hospital charges (P < .05). Relative to the Northeast, being a patient in the West added $33,459 in hospital charges (P < .01). Not being admitted electively added $72,572 (P < .01) relative to elective admissions. Finally, open repair added $59,539 (P < .01) in charges relative to closed repair. CONCLUSIONS: The traditional open approach added nearly $60,000 to the cost of the procedure when compared with the closed, endoscopic approach. The scope and invasiveness of the open approach demand greater surgical services, hospital services, supplies, and equipment, ultimately contributing to this increased cost.

What Are the Risk Factors for Epilepsy Among Patients With Craniosynostosis?

PURPOSE: The purpose of this study was to determine the risk factors for epilepsy among patients with craniosynostosis. METHODS: This is a retrospective cohort study that was completed with the Kids' Inpatient Database. All patients diagnosed with craniosynostosis between the years 2000 and 2012 were included. The primary predictor variables were obstructive sleep apnea (OSA), hydrocephalus, brain compression (BC), cerebral edema, papilledema, dolichocephaly, and plagiocephaly. The outcome variable was epilepsy. Logistic regression analysis was used to determine odds ratios (ORs) for the outcome (epilepsy). RESULTS: Our final sample had 4,709 patients with craniosynostosis, of whom 244 patients exhibited epilepsy (5.2%). The mean age of the patients was 1.43 years (range: 0-20). Relative to Asian patients, Black patients were 4 times more likely to have epilepsy (P < .05). Relative to patients in fringe counties of metro areas with a population of at least 1 million, patients in metro areas of 50,000 to 249,999 population were almost 2 times more likely to have epilepsy (P < .01). Hydrocephalus (OR, 6.6; P < .001), BC (OR, 2.4; P < .01), and OSA (OR, 3.0; P < .001) were independent risk factors for epilepsy among our sample of patients with craniosynostosis. CONCLUSIONS: Hydrocephalus, OSA, and BC increase the risk of epilepsy in patients with craniosynostosis. Black patients with craniosynostosis are also at increased risk for epilepsy. With regard to location, patients in areas with a population of 50,000 to 250,000 were at increased risk for epilepsy.

An Analysis of 400 Sternal Wound Reconstructions at a Single Institution: Bacterial Pathogens Vary With Time.

BACKGROUND: Sternal wound (SW) infection and dehiscence after median sternotomy from cardiac surgery remain challenging complications with high morbidity. Knowledge of common pathogen types and variance with time from cardiac surgery can simplify the choice of antibiotics while awaiting definitive culture results. METHODS: Records of 505 patients undergoing SW reconstruction by the senior author from 1996 to 2018 at a high-volume cardiac surgery center were reviewed. The most common indications for reconstruction were SW infection and dehiscence. At surgery, all patients underwent removal of sternal hardware, thorough debridement, and closure with bilateral pectoralis major myocutaneous advancement flaps. Deep tissue and bone cultures were sent in nearly all cases. Patients were split into group 1 or group 2 based on timing of flap reconstruction after initial cardiac surgery: 0 to 30 days and longer than 30 days, respectively. RESULTS: Complete data were available for 400 SW procedures performed during this period. Group 1 included 203 patients, and group 2 had 197 patients, with a mean time to SW surgery of 16.3 and 138.1 days, respectively. Intraoperative cultures were positive in 147 of 203 (72.4%), and 122 of 197 (61.9%) patients, respectively. Forty-four patients grew polymicrobial cultures. There was a significant difference in culture positivity rates in the 2 groups (P = 0.0004). The most common bacteria cultured in group 1 was Staphylococcus epidermidis (54 of 203 vs 21 of 197; P < 0.0001), whereas methicillin-sensitive Staphylococcus aureus was most common in group 2 (15 of 203 vs 22 of 197; P = 0.23). Methicillin-resistant S. aureus was relatively common in both groups (17 of 203 vs 21 of 197; P = 0.50). Although not statistically significant, Pseudomonas, Klebsiella, and Candida were all found in a higher percentage of patients in group 2 (p = 0.11, 0.20, 0.20). CONCLUSIONS: Microbial species cultured in SW flap reconstruction vary over time. Staphylococcus epidermidis is the most common infectious agent in patients having reconstruction within 30 days of cardiac surgery, whereas methicillin-sensitive S. aureus is most common after 30 days. The trend toward a higher incidence of Gram-negative and fungal organisms after 30 days may indicate a need for broader initial anti-infective coverage in this patient group. Awareness of these pathogen patterns can better inform antibiotic selection while awaiting culture data.

Primary Cleft Rhinoplasty: Long-Term Outcomes of a Single Technique Used Over 2 Decades.

BACKGROUND: Primary cleft rhinoplasty has become widely accepted owing to evidence of improved outcomes and need for fewer revisions. Several techniques have been described, but few surgeons have reported long-term outcomes of repairs performed via a single method. The present study examines long-term outcomes of a single surgeon's experience over 22 years using the same primary cleft rhinoplasty technique. METHODS: All consecutive cases of primary cleft rhinoplasty performed by the senior author at the time of unilateral cleft lip repair from 1996 to 2018 were selected for retrospective review. Patients older than 3 years or lacking documented follow-up were excluded. The primary outcome was the need for secondary rhinoplasty at age 15 years or later. RESULTS: Fifty-six patients met inclusion criteria. Median follow-up time was 7.52 years (interquartile range, 1.38-14.82). Twelve patients required minor long-term lip revision. No school-aged patients required additional correction of the nasal deformity before beginning school. Fifteen patients had follow-up beyond 14 years of age, 5 of whom had undergone definitive rhinoplasties as adolescents (8.9% of cohort; 33.3% of patients with follow-up beyond 14 years). Of the remaining 10 patients older than 14 years at last follow-up, none were seeking additional rhinoplasty. CONCLUSIONS: This series represents one of the longest-running published experiences of primary cleft rhinoplasty. Using a technique that requires no nasal incisions, the senior author has had excellent long-term results, with no need for any elementary school age rhinoplasties and with the majority of patients with follow-up older than 14 years not requiring a rhinoplasty in adolescence.

Is It Worth the Risk? Contralateral Prophylactic Mastectomy With Immediate Bilateral Breast Reconstruction.

BACKGROUND: An increasing number of women are choosing to undergo contralateral prophylactic mastectomy with immediate bilateral breast reconstruction. Operating on the contralateral noncancer side is not without its own set of risks. We sought to compare complication rates between the cancerous and contralateral prophylactic breasts. METHODS: A retrospective review was conducted of all patients undergoing immediate postmastectomy bilateral breast reconstruction for unilateral breast cancer between January 2008 and January 2019 at a single institution. Data were collected on patient demographics, cancer and adjuvant/neoadjuvant treatments, tumor, reconstruction, hospital stay, and complications. Complications were compared between the cancerous and the noncancerous breasts. RESULTS: One hundred sixty patients met the inclusion criteria of this study. Of these 160 patients, 33 (20.6%) had complications (major and minor) only to the cancerous breast, 7 (4.4%) had complications only to the noncancerous breast, and 7 (4.4%) had bilateral complications. Most patients underwent tissue expander/implant reconstruction (93.8%) with the rest (6.2%) undergoing abdominally based flap or latissimus dorsi flap reconstruction. Patients with complications were more likely to have hypertension, diabetes, exposure to radiation, and neoadjuvant chemotherapy. Complications included wound dehiscence, hematoma, cellulitis, seroma, capsular contracture, infected implant, and skin necrosis. Overall, there were significantly more complications to the cancerous breasts than the noncancerous breasts (P < 0.001). In addition, although exposure to radiation to the affected side significantly increased the likelihood of complications to that side (P < 0.0001), patients who were not exposed to any radiation were also more likely to have complications to the cancer side than to the noncancer side (P = 0.00065). However, after controlling for the effects of radiation, there was no significant difference in complications between the cancer side and the prophylactic side when stratifying by specific complications. CONCLUSIONS: Although contralateral prophylactic mastectomy with immediate bilateral reconstruction is not without added risk when compared with a unilateral procedure, this study shows that the incidence of complications to the noncancerous breast is less than that to the cancerous breast. This information can be used to help counsel patients with unilateral breast cancer on their treatment options and associated risks.

Creation of a Rat Lower Limb Lymphedema Model.

BACKGROUND: Lymphedema is a frequent complication after surgical treatments of cancer involving lymph node resection. However, research of lymphedema treatments, such as vascularized lymph node transfer, is limited by the absence of an adequate lymphedema animal model. The purpose of this study was to determine if we could create sustainable lower limb lymphedema in the rat with a combination of inguinal lymphadenectomy, circumferential skin and subcutaneous tissue excision, and radiotherapy. METHODS: Inguinal lymphadenectomies were completed in 15 Sprague-Dawley rats. In cohort A, 5 rats received a 0.5- to 1.0-cm wide excision of proximal thigh skin and subcutaneous tissue. This step was omitted for the 10 rats in cohort B. Cohort A then received a single radiation dose of 22.7 Gy, whereas cohort B received a cumulative dose of 40.5 Gy. Bioimpedance measurements were obtained monthly to assess lymphedema progression, and lymphatic drainage at 6 months postradiation was visualized via indocyanine green (ICG) lymphangiography. RESULTS: Two rats in cohort A developed visually appreciable lymphedema in the lower limb, with bioimpedance ratios of 0.684 and 0.542 and ankle circumference ratios of 1.294 and 1.061, respectively, consistent with lymphedema. Furthermore, ICG lymphangiography in these cohort A rats revealed impaired lower limb lymphatic drainage. In cohort B, however, bioimpedance and circumference ratios, and ICG lymphangiography, did not reveal abnormal lymphatic drainage. CONCLUSIONS: The combination of inguinal lymphadenectomy, circumferential skin and subcutaneous tissue excision, and radiotherapy can successfully create lower limb lymphedema in the rat. When soft tissue excision is omitted, lymphedema does not develop.

Extraocular sebaceous carcinoma as a rapidly growing back mass: a case report.

Sebaceous carcinoma is a rare cutaneous malignancy that frequently mimics other dermatologic conditions. Extraocular subtypes are uncommon, but when present are frequently located in the head and neck region. Herein, we present a patient with a rapidly growing upper back mass eventually diagnosed as sebaceous carcinoma and managed with wide surgical excision. Currently, sparse literature exists to guide management of such patients. This case highlights not only the diagnostic challenges of sebaceous carcinoma, but also the need for further studies to investigate therapeutic interventions and long-term outcomes.

Twenty-Year Outcome Experience With Open Craniosynostosis Repairs: An Analysis of Reoperation and Complication Rates.

BACKGROUND: Surgical intervention during infancy for both syndromic and nonsyndromic patients with craniosynostosis remains the criterion standard of treatment with the 2 main options being open vault remodeling versus minimally invasive surgery. Although open cranial vault remodeling was initially considered a high-risk procedure, many advances have improved its safety. Despite this, there is a paucity of literature on the long-term outcomes of contemporary open craniosynostosis repair. METHODS: A retrospective review of all patients who underwent primary open cranial vault repair for craniosynostosis by a single surgeon (J.A.A.) at New York-Presbyterian Hospital from 1995 to 2015 was performed. RESULTS: For primary open repair, 81 patients (46 males, 35 females) were analyzed, and affected sutures included unicoronal (28), bicoronal (7), metopic (24), sagittal (11), lambdoid (2), and multisuture (9). Fourteen patients (17.3%) were syndromic. Mean (SD) operative patient age was 13.81 (16.24) months: 34 (42%) were 0 to 6 months; 26 (32%), 7 to 12 months; and 21 (26%), 12 months of age or older. There were no intraoperative complications. Mean (SD) estimated blood loss for the plastic surgery portion of all cases was 74.53 (72.34) mL, and total estimated blood loss was 174.93 (182.23) mL. Mean (SD) hospital length of stay was 4.31 (1.59) days. One syndromic patient was readmitted for a wound infection (1.2%) that was successfully treated with antibiotics, and 2 syndromic patients (2.5%) had reoperation for fronto-orbital readvancement. CONCLUSIONS: This 20-year experience demonstrates the safety of modern open craniosynostosis repairs at a large academic medical center with low rates of mortality (0%), complications (1.2%), and reoperations (2.5%).

Financial Implications of Atypical Mycobacterial Infections After Cosmetic Tourism: Is It Worth the Risk?

BACKGROUND: Cosmetic tourism has become increasingly popular despite many associated risks. The economic impact of atypical mycobacterial infections in cosmetic tourism is poorly defined in the literature. We sought to investigate the costs and clinical course of patients with these infections. METHODS: A retrospective review of all patients managed by the Plastic Surgery Division at Columbia University Medical Center from 2013 to 2014 with atypical mycobacterial surgical site infections after cosmetic surgery outside the United States was performed. Data including patient demographics, procedure costs, clinical course, impact on daily life, and costs associated with complications were collected using hospital billing information, patient questionnaires, telephone interviews, and clinical charts. Cost analysis was done to identify the personal and societal costs of these complications. RESULTS: Data from 10 patients were collected and analyzed. Management of mycobacterial infections cost an average of $98,835.09 in medical charges. The indirect cost of these infections was $24,401 with a mean return to work time of 6.7 months. Total patient savings from cosmetic tourism was $3419. The total cost of a mycobacterial infection was greater than $123,236.47. Although the incidence of mycobacterial infection abroad is unknown, the potential cost of an infection alone outweighs the financial benefits of cosmetic tourism if the risk exceeds 2.77%. CONCLUSIONS: Atypical mycobacterial infections as a result of cosmetic tourism come at considerable cost to patients and the health care system. When our results are taken into consideration with other risks of cosmetic tourism, the financial risks likely far outweigh the benefits.

IGF1 Promotes Adipogenesis by a Lineage Bias of Endogenous Adipose Stem/Progenitor Cells.

Adipogenesis is essential for soft tissue reconstruction following trauma or tumor resection. We demonstrate that CD31(-)/34(+)/146(-) cells, a subpopulation of the stromal vascular fraction (SVF) of human adipose tissue, were robustly adipogenic. Insulin growth factor-1 (IGF1) promoted a lineage bias towards CD31(-)/34(+)/146(-) cells at the expense of CD31(-)/34(+)/146(+) cells. IGF1 was microencapsulated in poly(lactic-co-glycolic acid) scaffolds and implanted in the inguinal fat pad of C57Bl6 mice. Control-released IGF1 induced remarkable adipogenesis in vivo by recruiting endogenous cells. In comparison with the CD31(-)/34(+)/146(+) cells, CD31(-)/34(+)/146(-) cells had a weaker Wnt/ß-catenin signal. IGF1 attenuated Wnt/ß-catenin signaling by activating Axin2/PPARγ pathways in SVF cells, suggesting IGF1 promotes CD31(-)/34(+)/146(-) bias through tuning Wnt signal. PPARγ response element (PPRE) in Axin2 promoter was crucial for Axin2 upregulation, suggesting that PPARγ transcriptionally activates Axin2. Together, these findings illustrate an Axin2/PPARγ axis in adipogenesis that is particularly attributable to a lineage bias towards CD31(-)/34(+)/146(-) cells, with implications in adipose regeneration.

Risk factors of infected sternal wounds versus sterile wound dehiscence.

BACKGROUND: Sterile sternal dehiscence (SSD) and sternal wound infections (SWIs) are two complications of median sternotomy with high rates of morbidity. Sternal wound complications also carry significant economic burden, almost tripling patients' hospital costs and are considered a nonreimbursable "never event" for Medicare. Historically, SDD and SWI have been recognized as discrete entities, but nonetheless continue to be categorized as a singular complication in literature. The purpose of this study was to determine specific patient demographic and perioperative predictors of SSD and SWI. MATERIALS AND METHODS: An institutional review board-approved, retrospective study of 8098 consecutive patients who underwent cardiac surgery at Columbia University Medical Center between January 2008 and December 2013 was conducted. Patients were categorized into three groups: no sternal wound complication, SSD, or SWI. Statistical analysis was performed using univariate and multivariate logistic regression analysis. RESULTS: Of 8098 patients, there were 73 patients (0.9%) with SSD and 40 (0.5%) with SWI who required plastic surgical consultation, debridement, and flap closure. In univariate analysis of SSD, positive predictors (i.e., "risk" factors) were age >42 years, prior surgery this admission, ≥2 arterial conduits, internal mammary artery (IMA) grafting with or without previous IMA grafting, body mass index (BMI) >30 (obese), CHF, diabetes requiring medication, respiratory failure, and unplanned cardiac reoperation; negative predictors (i.e., "protective" factors) were no arterial conduits and extubation within 24 h. In univariate analysis of SWI, positive predictors were IMA grafting with or without previous IMA grafting, postoperative hematocrit urgent/emergent surgical priority, BMI >30 (obese), cardiac ejection fraction <40%, and respiratory failure; negative predictors were no arterial conduits and elective surgical priority. In multivariate regression, BMI >30, diabetes requiring medication, and respiratory failure were determined to be significant positive predictors of SSD, and IMA grafting with or without prior IMA grafting and respiratory failure were significant positive predictors for SWI; no significant negative predictors were identified. CONCLUSIONS: This study found that SSD and SWI have many common significant predictors consistent with findings that increased BMI, use of IMA grafts, poor cardiac reserve, and postoperative respiratory failure confer increased risk of sternal wound complications. Additionally, this study also found that there were predictors unique to each entity supporting that SSD and SWI may be related but are not a singular entity. Recognition and prevention of significant positive and negative predictors of SSD and SWI may be valuable in preoperative counseling, operative planning, and postoperative management. Although sternal wound complications can be successfully managed by plastic surgical intervention, preventing the development of median sternotomy complications may curb costs incurred by both patients and health care systems.

Single Institution Experience with Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for the Primary Prevention of Lymphedema.

BACKGROUND: As many as 40 % of breast cancer patients undergoing axillary lymph node dissection (ALND) and radiotherapy develop lymphedema. We report our experience performing lymphatic-venous anastomosis using the lymphatic microsurgical preventive healing approach (LYMPHA) at the time of ALND. This technique was described by Boccardo, Campisi in 2009. METHODS: LYMPHA was offered to node-positive women with breast cancer requiring ALND. Afferent lymphatic vessels, identified by injection of blue dye in the ipsilateral arm, were sutured into a branch of the axillary vein distal to a competent valve. Follow-up was with pre- and postoperative lymphoscintigraphy, arm measurements, and (L-Dex®) bioimpedance spectroscopy. RESULTS: Over 26 months, 37 women underwent attempted LYMPHA, with successful completion in 27. Unsuccessful attempts were due to lack of a suitable vein (n = 3) and lymphatic (n = 5) or extensive axillary disease (n = 1). There were no LYMPHA-related complications. Mean follow-up time was 6 months (range 3-24 months). Among completed patients, 10 (37%) had a body mass index of ≥30 kg/m(2) (mean 27.9 ± 6.8 kg/m(2), range 17.4-47.6 kg/m(2)), and 17 (63%) received axillary radiotherapy. Excluding two patients with preoperative lymphedema and those with less than 3-month follow-up, the lymphedema rate was 3 (12.5%) of 24 in successfully completed and 4 (50 %) of 8 in unsuccessfully treated patients. CONCLUSIONS: Our transient lymphedema rate in this high-risk cohort of patients was 12.5%. Early data show that LYMPHA is feasible, safe, and effective for the primary prevention of breast cancer-related lymphedema.

Management of sternal wounds by limited debridement and partial bilateral pectoralis major myocutaneous advancement flaps in 25 patients: a less invasive approach.

PURPOSE: Because sternal wound complications after sternotomy can be life threatening and often occur in very sick patients, optimal management of these complications remains an important topic. To decrease postoperative morbidity and shorten the recovery period, the senior author (J.A.A.) sought a less invasive approach to sternal debridement and flap closure in carefully selected patients. The purpose of this study was to evaluate the effectiveness of this approach by obtaining specific outcomes data from a series of patients treated with this less invasive method. MATERIALS AND METHODS: Of the most recent 174 sternal wounds treated by the senior author, 25 underwent limited debridement and partial bilateral pectoralis major advancement flaps. The charts of these 25 patients were reviewed and analyzed. RESULTS: In the 25 patients who underwent limited debridement, there were no mortalities intraoperatively or during the 30-day postoperative period. Six patients (24%) experienced complications after debridement, including 1 recurrent sternal wound infection, 1 partial wound dehiscence, 1 seroma, 1 hematoma, and 1 wound edge necrosis requiring revision. Mean length of hospitalization after the procedure was 10 days, compared with 30 days (P = 0.0001) as previously reported with full debridement (Plast Reconstr Surg 2004; 114:676). Mean estimated intraoperative blood loss was reduced from 331 mL during full debridement to 93 mL (P < 0.0001) with limited debridement (Plast Reconstr Surg 2004; 114:676). There was no increase in postoperative morbidity (24 % vs 13 %, P = 0.2117). CONCLUSIONS: The authors advocate limited sternal debridement and partial bilateral pectoralis major myocutaneous advancement flaps in patients with limited wounds and partially or fully healed sternums. We demonstrate that the procedure is effective but less invasive than complete debridement, reduces operative time and blood loss, and shortens length of hospitalization.

AeroForm patient controlled tissue expansion and saline tissue expansion for breast reconstruction: a randomized controlled trial.

BACKGROUND: Prosthetic reconstruction of the breast, as a 2-staged procedure using tissue expanders followed by placement of permanent implants, offers favorable aesthetic results with minimal additional surgical intervention. However, the current outpatient process to fill saline expanders can be lengthy and onerous, involving months of office visits and discomfort from the bolus saline expansions. We present a new technology (AeroForm Tissue Expansion System), which has the potential to improve the process of breast tissue expansion by providing a method for low-volume incremental filling, eliminating the need for injections and directly involving the patient by allowing her some control over the expansion process. METHODS: The described study is a 2:1 randomized controlled trial of the investigational CO2 expansion system and saline expanders. Of the 82 women receiving expanders, 58 (39 bilateral and 19 unilateral; bilateral rate, 67%) were implanted with CO2 tissue expanders and 24 subjects (15 bilateral and 9 unilateral; bilateral rate, 63%) were implanted with saline expanders. RESULTS: Preliminary validated expansion results were available for 55 women. Available mean time for active expansion in the CO2 group was 18.2 (9.2) days (median, 14.0; range, 5-39; number of expanders, 53), which was less than the mean time for active expansion in the saline group: 57.4 (33.6) days (median, 55; range, 5-137; number of expanders, 33). Available mean time from implant placement to exchange for a permanent prosthesis in the CO2 group was shorter [106.3 (42.9) days; median, 99; range, 42-237; number of expanders, 53] than for the women in the control group [151.7 (62.6) days; median, 140; range, 69-433; number of expanders, 33]. After 2 events--underexpansion (n=1) and erosion (n=1)--in the CO2 group, the internal membrane was redesigned and the expander bulk was decreased to minimize the risk of underexpansion and erosion in subsequent patients. CONCLUSIONS: Preliminary evidence indicates that the CO2-based tissue expansion system performs the same function as saline expansion devices without significantly altering the risk to the patient and that the device has the potential to make the expansion process faster and more convenient for both the patient and the physician.

Impact of Sociodemographic and Hospital Factors on Inpatient Bilateral Reduction Mammaplasty: A National Inpatient Sample Analysis.

Background: Although reduction mammaplasty remains a common procedure in plastic surgery, its interaction with sociodemographic and economic disparities has remained relatively uncharacterized on a nationwide scale. Methods: Patients who underwent reduction mammaplasty were identified within the 2016-2018 National Inpatient Sample databases. In addition to clinical comorbidities, sociodemographic characteristics, hospital-level variables, and postoperative outcomes of each patient were collected for analysis. Statistical analyses, including univariate comparison and multivariate logistic regression, were applied to the cohort to determine significant predictors of adverse outcomes, described as extended length of stay, higher financial cost, and postoperative complications. Results: The final patient cohort included 414 patients who underwent inpatient reduction mammaplasty. The average age was 45.2 ±â€…14.5 years. The average length of stay was 1.6 ±â€…1.5 days, and the average hospital charge was $53,873.81 ± $36,014.50. Sixty (14.5%) patients experienced at least one postoperative complication. Black race and treatment within a nonmetropolitan or rural county predicted postoperative complications (P < 0.01). Black race, lower relative income, and concurrent abdominal contouring procedures also predicted occurrence of extended length of stay (P < 0.01). Hospital factors, including larger bed capacity and for-profit ownership, predicted high hospital charges (P < 0.05). Severity of comorbidities, measured by a clinical index, also predicted all three outcomes (P < 0.001). Conclusion: In addition to well-described clinical variables, multiple sociodemographic and economic disparities affect outcomes in inpatient reduction mammaplasty.

Predictors of extended length of stay following outpatient reduction mammaplasty.

PURPOSE: Reduction mammaplasty has transitioned into a largely outpatient procedure in the United States. Following planned outpatient procedures, patients may still be admitted for additional inpatient care, incurring clinical and economic burden. Prior literature has not explored the preoperative and perioperative determinants of extended lengths of stay (LOS) after breast reduction surgery. METHODS: Patients who underwent scheduled outpatient reduction mammaplasty were identified via current procedural terminology code from the 2013 to 2021 National Surgical Quality Improvement Program databases. The primary outcome was extended LOS, defined as an LOS greater than 1 day. The most significant predictor variables were identified through bivariate association, and a binary logistic regression model was used to characterize predictive associations (p < 0.05). RESULTS: In this study, 33,924 patients were included in the final cohort of planned outpatient reduction mammaplasty cases. Among them 325 (1.0%) patients had extended LOS. Concurrent liposuction, body contouring, and increased operative time were the most significant predictors of extended LOS (p < 0.001), followed by older age, higher body mass index, bleeding disorder, history of diabetes, higher American Society of Anesthesiologists class, and White race (p < 0.05). When adjusted for other confounding variables, extended LOS was also a significant predictor of increased risk of postoperative complications after discharge (OR: 1.85, 95% confidence intervals: 1.27-2.69, p = 0.0012). CONCLUSION: Extended LOS after planned outpatient reduction mammaplasty is associated with specific comorbidities, and is a significant predictor of postoperative complications following hospital discharge. DATA AVAILABILITY STATEMENT: The data that support the findings of this study are publicly available.

Contralateral prophylactic mastectomy: Weighing the risks of delayed chemotherapy, radiotherapy, and hormonal therapy.

BACKGROUND: Many patients with unilateral breast cancer opt for contralateral prophylactic mastectomy (CPM) at the time of therapeutic mastectomy (immediate CPM) or following completion of adjuvant therapy. Studies show that immediate CPM increases the risk of surgical complications related to unilateral mastectomy (UM) alone, which may lead to delays in adjuvant therapy initiation. However, it is unclear if these complications cause clinically significant delays in initiating adjuvant chemotherapy, radiotherapy, or hormonal therapy. METHODS: A retrospective chart review was conducted on patients with breast cancer who underwent immediate CPM versus UM alone at Columbia University Medical Center from January 2000 to December 2020. Patient demographic and oncologic characteristics; complications; and timing of adjuvant chemotherapy, radiotherapy, and/or hormonal therapy relative to therapeutic mastectomy were collected. RESULTS: In this study, 239 UM alone patients were propensity score matched to 239 immediate CPM patients. No significant difference in complication rates was found between the index and contralateral breasts in CPM patients. A similar percentage of CPM and UM patients experienced postoperative complications (19% vs. 17%, p = 0.64). No significant difference in time to adjuvant chemotherapy, radiotherapy, or hormonal therapy was found between CPM patients with complications and all CPM patients or all UM patients. CONCLUSIONS: There is a lack of clear guidance for clinical decision-making regarding timing of CPM relative to adjuvant therapy. Our study suggests that immediate CPM does not significantly increase the risks of postoperative complications or complication-related delays in the initiation of adjuvant chemotherapy, radiotherapy, or hormonal therapy. This information may help patients and providers to plan, select, and schedule breast cancer treatment options.

Are Patients with Syndromic Craniosynostosis at Greater Risk for Epilepsy than Patients with Nonsyndromic Craniosynostosis?

OBJECTIVE: The aim of this study was to determine whether patients with syndromic craniosynostosis (SCS) are at increased risk for epilepsy relative to patients with nonsyndromic craniosynostosis (NSCS). METHODS: A retrospective cohort study was completed using the Kids' Inpatient Database (KID). All patients diagnosed with craniosynostosis (CS) were included. The primary predictor variable was study grouping (SCS vs. NSCS). The primary outcome variable was a diagnosis of epilepsy. Descriptive statistics, univariate analyses and multivariate logistic regression were performed to identify independent risk factors for epilepsy. RESULTS: The final study sample included a total of 10,089 patients (mean age, 1.78 years ± 3.70; 37.7% female). 9278 patients (92.0%) had NSCS, and the remaining 811 patients (8.0%) had SCS. A total of 577 patients (5.7%) had epilepsy. Not controlling for other variables, patients with SCS were at increased risk for epilepsy relative to patients with NSCS (OR 2.1, P < 0.001). After controlling for all significant variables, patients with SCS were no longer at increased risk for epilepsy relative to patients with NSCS (OR 0.73, P = 0.063). Hydrocephalus, Chiari malformation (CM), obstructive sleep apnea (OSA), atrial septal defect (ASD), gastro-esophageal reflux disease (GERD) were all independent risk factors (P < 0.05) for epilepsy. CONCLUSIONS: Syndromic craniosynostosis (SCS) in itself is not a risk factor for epilepsy relative to NSCS. The greater prevalence of hydrocephalus, CM, OSA, ASD, and GERD, all of which were risk factors for epilepsy, in patients with SCS relative to patients with NSCS likely explains the greater prevalence of epilepsy in SCS relative to NSCS.