ABSTRACT
BACKGROUND: A comprehensive comparison of surgical, aesthetic, and quality of life outcomes by reduction mammaplasty technique does not exist. We sought to ascertain the effect of technique on clinical, aesthetic, and patient-reported outcomes. METHODS: Patients with symptomatic macromastia undergoing a superomedial or inferior pedicle reduction mammoplasty by a single surgeon were identified. BREAST-Q surveys were administered. Postoperative breast aesthetics were assessed in 50 matched-patients. Patient characteristics, complications, quality of life, and aesthetic scores were analyzed. RESULTS: Overall, 101 patients underwent reductions; 60.3% had a superomedial pedicle. Superomedial pedicle patients were more likely to have grade 3 ptosis (P < 0.01) and had significantly shorter procedure time (P < 0.01). Only the inferior pedicle technique resulted in wound dehiscence (P = 0.03) and reoperations from complications (P < 0.01). Those who underwent an inferior pedicle reduction were 4.3 times more likely to experience a postoperative complication (P = 0.03). No differences in quality of life existed between cohorts (P > 0.05). Superomedial pedicle patients received significantly better scarring scores (P = 0.03). CONCLUSIONS: The superomedial pedicle reduction mammoplasty technique provides clinical and aesthetic benefits compared with the inferior pedicle technique.
Subject(s)
Mammaplasty , Quality of Life , Female , Humans , Treatment Outcome , Retrospective Studies , Surgical Flaps/surgery , Mammaplasty/methods , Breast/surgery , Hypertrophy/surgery , Postoperative Complications/surgery , Esthetics , Patient Reported Outcome MeasuresABSTRACT
BACKGROUND: Optimal reduction mammoplasty techniques to treat patients with gigantomastia have been debated and can involve extended pedicles (EP) or free nipple grafts (FNG). OBJECTIVES: The authors compared clinical, patient-reported, and aesthetic outcomes associated with reduction mammoplasty employing EP vs FNG. METHODS: A multi-institutional, retrospective study of adult patients with gigantomastia who underwent reduction mammoplasty at 2 tertiary care centers from 2017 to 2020 was performed. Gigantomastia was defined as reduction weight >1500 g per breast or sternal notch-to-nipple distance ≥40 cm. Surgeons at 1 institution employed the EP technique, whereas those at the other utilized FNG. Baseline characteristics, preoperative and postoperative BREAST-Q, and clinical outcomes were collected. Aesthetic outcomes were assessed in 1:1 propensity score-matched cases across techniques. Preoperative and postoperative photographs were provided to reviewers across the academic plastic surgery continuum (students to faculty) and non-medical individuals to evaluate aesthetic outcomes. RESULTS: Fifty-two patients met the inclusion criteria (21 FNG, 31 EP). FNG patients had a higher incidence of postoperative cellulitis (23% vs 0%, P < 0.05) but no other differences in surgical or medical complications. Baseline BREAST-Q scores did not differ between groups. Postoperative BREAST-Q scores revealed greater satisfaction with the EP technique (P < 0.01). The aesthetic assessment of outcomes in 14 matched pairs of patients found significantly better aesthetic outcomes in all domains with the EP procedure (P < 0.05), independent of institution or surgical experience. CONCLUSIONS: This multi-institutional study suggests that, compared with FNG, the EP technique for reduction mammoplasty provides superior clinical, patient-reported, and aesthetic outcomes for patients with gigantomastia.
Subject(s)
Mammaplasty , Nipples , Adult , Humans , Nipples/surgery , Retrospective Studies , Treatment Outcome , Surgical Flaps/transplantation , Breast/surgery , Mammaplasty/adverse effects , Mammaplasty/methods , Hypertrophy/surgery , Hypertrophy/etiologyABSTRACT
OBJECTIVE: This study assesses the user burden, reliability, and longitudinal validity of the AHQ, a novel VH patient-reported outcomes measure (PROM). BACKGROUND: We developed and psychometrically validated the AHQ as the first VH-specific, stakeholder-informed PROM. Yet, there remains a need to assess the AHQ's clinical applicability and further validate its psychometric properties. METHODS: To assess patient burden, pre- and postoperative patients were timed while completing the corresponding AHQ form. To measure test-retest reliability, a subset of patients completed the AHQ within a week of initial completion, and consecutive responses were correlated. Lastly, patients undergoing VH repair were prospectively administered the pre- and postoperative AHQ forms, the Hernia-Related Quality of Life Survey and the Short Form-12 both preoperatively and at postoperative intervals, up to over a year after surgery. Quality-of-Life scores were correlated from the 3 PROMs and effect sizes were compared using analysis of normal variance. RESULTS: Median response times for the pre- and postoperative AHQ were 1.1 and 2.7 minutes, respectively. The AHQ demonstrates high test-retest reliability coefficients for pre- and postoperative instruments ( r = 0.91, 0.89). The AHQ appropriately and proportionally measures expected changes following surgery and significantly correlates with all times points of theHernia-Related Quality of Life Survey and Short Form-12 MS and 4/5 (80%) SF12-PS. CONCLUSION: The AHQ is a patient-informed, psychometrically-validated, clinical instrument for measuring, quantifying, and tracking PROMs in VH patients. The AHQ exhibits low response burden, excellent reliability, and effectively measures hernia-specific changes in quality-of-Life following ventral hernia repair.
Subject(s)
Hernia, Ventral , Herniorrhaphy , Incisional Hernia , Patient Reported Outcome Measures , Quality of Life , Humans , Hernia, Ventral/surgery , Incisional Hernia/surgery , Prospective Studies , Reproducibility of Results , Surveys and Questionnaires , Treatment Outcome , Cost of IllnessABSTRACT
INTRODUCTION: Although there are many patient-reported outcome measures used for ventral hernia (VH), disease-specific instruments, such as the Hernia-related Quality-of-Life (QoL) Survey (HerQLes) and Abdominal Hernia-Q (AHQ), have shown greater accuracy in capturing all VH-related QoL. We present a novel calibration that allows providers to convert scores between the AHQ and HerQLes, enabling better unification of QoL data. METHODS: Patients with VH were prospectively identified and simultaneously administered both the AHQ and HerQLes pre- and post-operatively. To ensure the validity of the calibration, responses were excluded if patients answered instruments on different dates or if the responses were discordant on corresponding questions within each instrument. The calibration was estimated using a linear mixed effects model, including linear and quadratic scores, timing of survey relative to surgery and their interactions as fixed effects, and patients as random effects to account for multiple surveys from the same patient. RESULTS: In total, 109 patients were included, responding to 300 pairs of surveys (112 preoperative and 188 postoperative), of which 17 (5.6%) were excluded because of discordant responses. Conversion of the HerQLes to AHQ was most accurate when including whether the survey was completed pre- or post-operatively, with a mean squared error of 0.0091. Similarly, converting the AHQ to HerQLes was most accurate when factoring in the timing of survey administration, with a mean squared error of 0.016. CONCLUSIONS: We present a novel and accurate method to convert scores between the AHQ and HerQLes. Being able to unify QoL data from different PROMs supports efforts to more broadly integrate PROMs in surgery and to understand patient-defined measures of success.
Subject(s)
Hernia, Ventral , Herniorrhaphy , Calibration , Hernia, Ventral/surgery , Herniorrhaphy/methods , Humans , Patient Reported Outcome Measures , Quality of LifeABSTRACT
BACKGROUND: Two-stage (TS) implant-based reconstruction is the most commonly performed method of reconstruction after mastectomy. A growing number of surgeons are offering patients direct-to-implant (DTI) reconstruction, which has the potential to minimize the number of surgeries needed and time to complete reconstruction, as well as improve health care utilization. However, there are conflicting data regarding the outcomes and complications of DTI, and studies comparing the 2 methods exclusively are lacking. METHODS: Patients undergoing implant-based reconstruction after mastectomy within a large interstate health system between 2015 and 2019 were retrospectively identified and grouped by reconstruction technique (TS and DTI). The primary outcomes were a composite of complications (surgical site occurrences), health care utilization (reoperations, unplanned emergency department visits, and readmissions), and time to reconstruction completion. Risk-adjusted logistic and generalized linear models were used to compare outcomes between TS and DTI. RESULTS: Of 104 patients, 42 underwent DTI (40.4%) and 62 underwent TS (59.6%) reconstruction. Most demographic characteristics, and oncologic and surgical details were comparable between groups ( P > 0.05). However, patients undergoing TS reconstruction were more likely to be publicly insured, have a smoking history, and undergo skin-sparing instead of nipple-sparing mastectomy. The composite outcome of complications, reoperations, and health care utilization was higher for DTI reconstruction within univariate (81.0% vs 59.7%, P = 0.03) and risk-adjusted analyses (odds ratio, 3.78 [95% confidence interval [CI], 1.09-13.9]; P < 0.04). Individual outcome assessment showed increased mastectomy flap necrosis (16.7% vs 1.6%, P < 0.01) and reoperations due to a complication (33.3% vs 16.1%; P = 0.04) in the DTI cohort. Although DTI patients completed their aesthetic revisions sooner than TS patients (median, 256 days vs 479 [ P < 0.01]; predicted mean difference for TS [reference DTI], 298 days [95% CI, 71-525 days]; P < 0.01), the time to complete reconstruction (first to last surgery) did not differ between groups (median days, DTI vs TS, 173 vs 146 [ P = 0.25]; predicted mean difference [reference, DTI], -98 days [95% CI, -222 to 25.14 days]; P = 0.11). CONCLUSIONS: In this cohort of patients, DTI reconstruction was associated with higher complications, reoperations, and health care utilization with no difference in time to complete reconstruction compared with TS reconstruction. Further studies are warranted to investigate patient-reported outcomes and cost analysis between TS and DTI reconstruction.
Subject(s)
Breast Implantation , Breast Implants , Breast Neoplasms , Mammaplasty , Breast Implantation/methods , Breast Implants/adverse effects , Breast Neoplasms/complications , Breast Neoplasms/surgery , Female , Humans , Mammaplasty/methods , Mastectomy/methods , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Retrospective Studies , Treatment OutcomeABSTRACT
ABSTRACT: It is unknown if craniofacial trauma services are inequitably distributed throughout the US. The authors aimed to describe the geographical distribution of craniofacial trauma, surgeons, and training positions nationwide. State-level data were obtained on craniofacial trauma admissions, surgeons, training positions, population, and income for 2016 to 2017. Normalized densities (per million population [PMP]) were ascertained. State/ regional-level densities were compared between highest/lowest. Risk-adjusted generalized linear models were used to determine independent associations. There were 790,415 craniofacial trauma admissions (x?â=â2330.6 PMP), 28,004 surgeons (x?â=â83.5 PMP), and 746 training positions (x?â=â1.9 PMP) nationwide. There was significant state-level variation in the density PMP of trauma (median 1999.5 versus 2983.5, P â < â0.01), surgeon (70.8 versus 98.8, P â<â0.01), training positions (0 versus 3.4, P â<â0.01) between lowest/highest quartiles. Surgeon distribution was positively associated with income and training positions density ( P â<â0.01). Subanalysis revealed that there was an increase of 6.7 plastic and reconstructive surgeons/PMP for every increase of 1000 trauma admissions/PMP ( P â<â0.01). There is an uneven state-level distribution of facial trauma surgeons across the US associated with income. Plastic surgeon distribution corresponded closer to craniofacial trauma care need than that of ENT and OMF surgeons. Further work to close the gap between workforce availability and clinical need is necessary.
Subject(s)
Facial Injuries , Health Services Accessibility , Surgeons , Cross-Sectional Studies , Facial Injuries/epidemiology , Facial Injuries/surgery , Health Services Accessibility/statistics & numerical data , Humans , Income , Surgeons/supply & distribution , Trauma Centers/supply & distribution , WorkforceABSTRACT
INTRODUCTION: Consensus on the safety and efficacy of various types of mesh in reconstructing the abdomen has yet to be reached. Hybrid mesh products have been designed to address the need for a cost-effective mesh leveraging the tensile strength of a synthetic mesh while minimizing the prosthetic footprint within the abdominal wall through resorbable materials. In this study we evaluate early clinical outcomes and health related quality of life (HR-QOL) of a new Hybrid mesh, SynecorTM, for Ventral Hernia Repair (VHR). METHODS: Adult (>18 y old) patients undergoing VHR with SynecorTM mesh by a single surgeon between 2017-2019 with ≥1-y follow-up were identified. We analyzed a composite of postoperative outcomes as well as the incidence of hernia recurrence, readmissions, mortality, and HR-QOL. RESULTS: Thirty-five patients were included in our analysis with a median follow up of 2.1 y. The median age and BMI were 54.1 y and 33.2 kg/m2, respectively. The rate of surgical site occurrences was 37.1%, with only one patient (2.9%) requiring surgical intervention. No patients developed a hernia recurrence. Overall HR-QOL improved significantly (preoperative mean 2.5 [SD 0.7] versus postoperative 3.4 [0.4]; P< 0.01), particularly in regards to pain, functional status, self-esteem and body image (all P < 0.05). CONCLUSIONS: Abdominal reinforcement with SynecorTM mesh at the time of VHR results in promising early recurrence rates, an acceptable safety risk profile, and an improvement in overall HR-QOL.
Subject(s)
Hernia, Ventral/surgery , Herniorrhaphy/instrumentation , Postoperative Complications/epidemiology , Surgical Mesh , Adult , Female , Herniorrhaphy/statistics & numerical data , Humans , Male , Middle Aged , Patient Reported Outcome Measures , Pennsylvania/epidemiology , Quality of Life , Recurrence , Retrospective StudiesABSTRACT
PURPOSE: Poor health literacy and awareness are thought to be some of the major contributors to existing racial/ethnic disparities in access to breast reconstruction after mastectomy. This study aimed to determine whether physician led, community-based educational symposium improves understanding of breast cancer care and breast reconstruction in underserved populations. METHODS: Annual educational symposiums were held between 2017 and 2019 in underserved communities in the greater Philadelphia area. The symposium consisted of a series of short lectures on breast health, cancer screening, surgical management and reconstruction, patient testimonials, a Q&A panel, and an exhibitor fair. Attendees were given pre- and post-symposium surveys that evaluated knowledge of breast cancer care and reconstruction on a 0-100 scale based on percentage of correct answers. RESULTS: Of 169 individuals, 92%, 91%, and 83% completed pre-symposium, post-symposium, and both surveys, respectively. Median age was 60 years, and 92% were Black. Knowledge/understanding survey scores significantly improved after the symposium (50 vs. 87, p < 0.01). Of all respondents, 92% found the symposium to be useful, 89% were introduced to resources that they were not previously aware of, 90% would recommend the symposium to others, and 91% would pass along the information they learned. CONCLUSION: This study presents an effective and reproducible strategy to increase community awareness and understanding of general breast cancer concepts and breast reconstruction options. Through community outreach and education, physicians can help underserved populations have a better understanding of their potential options for breast reconstruction and ultimately reduce this well documented but inadequately addressed disparity in cancer care.
Subject(s)
Breast Neoplasms/surgery , Mammaplasty/education , Mammaplasty/methods , Mastectomy/methods , Adult , Early Detection of Cancer , Female , Healthcare Disparities , Humans , Middle Aged , Surveys and Questionnaires , Vulnerable PopulationsABSTRACT
BACKGROUND: Most data on health care utilization after incisional hernia (IH) repair are limited to 30-days and are not nationally representative. We sought to describe nationwide 1-year readmission burden after IH repair (IHR). METHODS: Patients undergoing elective IHR discharged alive were identified using the 2010-2014 Nationwide Readmission Database. Transfers and incomplete follow-up were excluded. Descriptive statistics were used to describe rates of 1-year readmission, IH recurrence, and bowel obstruction. Cox regression allowed identification of factors associated with 1-year readmissions. Generalized linear models were used to estimate predicted mean difference in cumulative costs/year, which allowed estimation of IHR readmission costs/year nationwide. RESULTS: Of 15,935 identified patients, 19.35% were readmitted within 1 y. Patients who were readmitted differed by insurance, Charlson index, illness severity, smoking status, disposition, and surgical approach compared with those who were not (P < 0.05). Of readmitted patients, 39.3% returned within 30 d; 50.9% and 25.6% were due to any and infectious complications, respectively; 25.6% presented to a different hospital; 35.4% required reoperation; 5.4% experienced bowel obstruction; and 5% had IHR revision. Factors associated with readmissions included Medicare (hazard ratio [HR] 1.46 [95% confidence interval 1.19-1.8]; P < 0.01) or Medicaid (HR 1.42 [1.12-1.8], P < 0.01); chronic pulmonary disease (1.38 [1.17-1.64], P < 0.01), and anemia (1.36, [1.05-1.75], P = 0.02). Readmitted patients had higher 1-year cumulative costs (predicted mean difference $12,190 [95% CI: 10,941-13,438]; P < 0.01). Nationwide cost related to readmissions totaled $90,196,248/y. CONCLUSIONS: One-year readmissions after IHR are prevalent and most commonly due to postoperative complications, especially infections. One-third of readmitted patients require a subsequent operation, and 5% experience IH recurrence, intensifying the burden to patients and on the health care system.
Subject(s)
Incisional Hernia/surgery , Patient Readmission/statistics & numerical data , Adolescent , Adult , Aged , Female , Humans , Incisional Hernia/economics , Male , Middle Aged , Patient Acceptance of Health Care , Patient Readmission/economics , Recurrence , Retrospective Studies , United States , Young AdultABSTRACT
Background: Coronavirus disease 2019 (COVID-19) pandemic-related changes may have led to changes in immediate breast reconstruction (IBR) rates. We aimed to evaluate these changes before, during, and after the initial wave of COVID-19. Methods: We retrospectively reviewed women who underwent mastectomy with or without IBR from January 1 to September 30, 2019 and from January 1 to September 30, 2020, and compared demographic, clinical, and surgical variables between defined time periods. Results: A total of 202 mastectomies were included. Fewer patients underwent IBR during the initial surge of COVID-19 (surge period) compared with the months before (presurge period; 38.46% versus 70.97%, P = 0.0433). When comparing the postsurge period with a year before (postsurge control), fewer patients underwent reconstruction even after the initial surge had passed (53.13% versus 81.25%, P = 0.0007). Those who underwent IBR were older than the year before (59.34 versus 53.06, P = 0.0181). The median number of postoperative visits in the postsurge period was 8.50 (interquartile range: 6-12) compared with 14 (interquartile range: 8-20.50) in the year before (P = 0.0017). The overall incidences of complications and unanticipated resource utilization were also significantly lower in the postsurge period compared with the year before [5.88% versus 30.77% (P = 0.0055), and 14.71% versus 28.85% (P = 0.0103), respectively]. Conclusions: IBR rates were lower even after the initial surge than at the year before. Furthermore, during the pandemic, IBR patients were older, had fewer follow-up visits, and fewer reported complications.
ABSTRACT
BACKGROUND: Implementation of patient-reported outcomes (PROs) represents a critical barrier to their widespread use and poses challenges to workflow and patient satisfaction. The authors sought to implement PRO surveys into surgical practice and identify principles for successful and broader implementation. METHODS: Outpatient surgical encounters from 2016 through 2019 related to hernia, breast surgery, or postbariatric body contouring were assessed with the Abdominal Hernia-Q, BREAST-Q, or BODY-Q surveys, respectively. Outcomes were implementation rates per quarter and time to optimal implementation (≥80%). Successful implementation principles were identified during the first implemented PRO instrument and applied to subsequent ones. Logistic regression models were used to estimate increase in rate of implementation per quarter by instrument controlling for clinic volume. Risk-adjusted generalized linear models determined predicted mean differences in total clinic time and patient satisfaction. RESULTS: A total of 1206 encounters were identified. The overall survey implementation rate increased from 15% in the first quarter to 90% in the last quarter ( P < 0.01). Abdominal Hernia-Q optimal implementation was reached by 15 months. Principles for successful implementation of PROs were workflow optimization, appropriate patient selection, staff engagement, and electronic survey integration. Consistent application of these principles optimized time to optimal implementation for BREAST-Q [9 months; 18.1% increase in implementation per quarter (95% CI, 1.5 to 37.5); P < 0.01] and BODY-Q [3 months; 56.3% increase in implementation per quarter (95% CI, 26.8 to 92.6); P = 0.03]. Neither patient clinic time ( P = 0.16) nor patient satisfaction differed during the implementation of PROs process ( P = 0.98). CONCLUSIONS: Prospective implementation of PROs can be achieved in surgical practice without an adverse effect on patient satisfaction or workflow. The proposed principles of implementation may be used to optimize efficiency for implementation of PROs.
Subject(s)
Patient Reported Outcome Measures , Quality Improvement , Humans , Prospective Studies , Surveys and Questionnaires , Patient SatisfactionABSTRACT
BACKGROUND: Massive weight loss after bariatric surgery can lead to excess skin associated with functional and aesthetic sequelae. Access to the benefit provided by body contouring procedures may be limited by insurance approval, which does not consider health-related quality of life. The aim of this study was to quantify the benefit in health-related quality of life for patients who undergo body contouring procedures after massive weight loss. METHODS: Patients evaluated for postbariatric body contouring procedures were systematically identified and prospectively surveyed using the BODY-Q. Health-related quality-of-life change for each functional scale was compared between those who underwent body contouring procedures (operative group, preoperatively versus postoperatively) and those who did not (nonoperative group, preoperatively versus resurvey) using t tests. Propensity score matching allowed the authors to balance baseline demographics, comorbidities, physical symptoms, and risk factors between cohorts. RESULTS: Fifty-seven matched patients were analyzed (34 operative versus 23 nonoperative). No significant difference in age, body mass index, time between surveys, or preoperative BODY-Q scores existed between cohorts. The surgical group demonstrated a significant improvement in 10 out of 11 BODY-Q functional scales. The nonoperative group realized no improvements and, in the interim, had a significant deterioration in four BODY-Q scales. CONCLUSIONS: Postbariatric body contouring procedures represent a critical and final step in the surgical weight loss journey for patients and are associated with significant improvements in health-related quality of life. Further deterioration in psychosocial and sexual health-related quality of life occurs in patients who do not undergo body contouring procedures following bariatric surgery. This study provides prospective comparative data that validate the field's standard intervention and justification for insurance approval. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.
Subject(s)
Bariatric Surgery , Body Contouring , Obesity, Morbid , Bariatric Surgery/methods , Humans , Obesity, Morbid/surgery , Prospective Studies , Quality of Life/psychology , Weight LossABSTRACT
BACKGROUND: Various medical specialties have demonstrated gender disparities involving industry-supported payments. The authors sought to determine whether such disparities exist within plastic surgery. METHODS: Industry contributions to plastic surgeons practicing in the United States were extracted from the Centers for Medicare and Medicaid Services Open Payments 2013 to 2017 databases. Specialists' gender was obtained through online searches. Kruskal-Wallis tests compared payments (in U.S. dollars) by gender (overall and by payment category). Linear regression estimated the independent association of female gender with increased/reduced payments while controlling for state-level variations. RESULTS: Of 1518 plastic surgeons, 13.4 percent were female. Of $44.4 million total payments from the industry, $3.35 million were made to female plastic surgeons (p < 0.01). During the study period, female plastic surgeons received lower overall payments than male plastic surgeons [median, $3500 (interquartile range, $800 to $9500) versus $4160.60 (interquartile range, $1000 to $19,728.20); p < 0.01]. This trend persisted nationwide after normalizing for year [$2562.50/year (interquartile range, $770 to $5916.25/year) versus $3200/year (interquartile range, $955 to $8715.15/year); p = 0.02] and at the state level in all 38 states where there was female representation. Analysis of payment categories revealed that honoraria payments were significantly higher for male plastic surgeons [$4738 (interquartile range, $1648 to $16,100) versus $1750 (interquartile range, $750 to $4100); p = 0.02]. Within risk-adjusted analysis, female plastic surgeons received $3473.21/year (95 percent CI, $671.61 to $6274.81; p = 0.02) less than male plastic surgeons. CONCLUSIONS: Gender disparities involving industry payments exist in plastic surgery at both national and state levels. Factors contributing to this phenomenon must be explored to understand implications of this gap.
Subject(s)
Surgeons , Surgery, Plastic , Aged , Centers for Medicare and Medicaid Services, U.S. , Conflict of Interest , Databases, Factual , Female , Humans , Industry , Male , Medicare , United StatesABSTRACT
BACKGROUND: Panniculectomy and abdominoplasty are uptrending procedures to address excess skin after weight loss which affects patient-reported quality of life. The authors aimed to identify factors associated with low preoperative quality of life, quantify the benefit of these procedures, and evaluate benefits across grades of obesity. METHODS: Patients seeking panniculectomy and abdominoplasty between 2018 and 2019 with a completed preoperative BODY-Q questionnaire were identified. Stratification by quality of life in tertiles for each BODY-Q domain allowed identification of characteristics associated with low quality of life using chi-square tests. Wilcoxon signed-rank tests were used to compare preoperative to postoperative change in quality of life. Differences in quality of life by obesity class (1-2 vs. 3) were ascertained using chi-square tests. RESULTS: A total of 183 patients completed preoperative quality-of-life questionnaires. Preoperative factors associated with low quality of life included age older than 40 years, Black race, public insurance, hypertension, and American Society of Anesthesiologists class (all p < 0.05). Of patients who completed a preoperative BODY-Q and underwent surgery, 46 (63 percent) completed both surveys. Quality of life improved postoperatively across all domains ( p < 0.01). The presence of a surgical site occurrence (e.g., infection, delayed healing, hematoma, seroma) did not impact postoperative quality of life in any domain ( p > 0.05). Obesity classification did not affect change in quality of life preoperatively to postoperatively ( p > 0.05). CONCLUSION: Quality of life is significantly lower at baseline in older, Black, publicly insured patients, and multimorbid patients, but improves dramatically after panniculectomy and abdominoplasty regardless of incidence of complications or degree of obesity. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
Subject(s)
Abdominoplasty , Quality of Life , Abdominoplasty/methods , Adult , Aged , Cohort Studies , Humans , Obesity/complications , Obesity/surgery , Patient Reported Outcome Measures , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Postoperative Complications/surgery , Retrospective StudiesABSTRACT
Importance: Prosthetic reinforcement of critically sized incisional hernias is necessary to decrease hernia recurrence, but long-term prosthetic-mesh footprint may increase complication risk during subsequent abdominal operations. Objective: To investigate the association of prior incisional hernia repair with mesh (IHRWM) with postoperative outcomes and health care utilization after common abdominal operations. Design, Setting, and Participants: This was a population-based, retrospective cohort study of patients undergoing inpatient abdominal surgical procedures during the period of January 2009 to December 2016, with at least 1 year of follow-up within 5 geographically diverse statewide inpatient/ambulatory databases (Florida, Iowa, Nebraska, New York, Utah). History of an abdominal operation was ascertained within the 3-year period preceding the index operation. Patients admitted to the hospital with a history of an abdominal operation (ie, bariatric, cholecystectomy, small- or large-bowel resection, prostatectomy, gynecologic) were identified using the International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification procedure codes. Patients with prior IHRWM were propensity score matched (1:1) to controls both with and without a history of an abdominal surgical procedure based on clinical and operative characteristics. Data analysis was conducted from March 1 to November 27, 2021. Main Outcomes and Measures: The primary outcome was a composite of adverse postoperative outcomes (surgical and nonsurgical). Secondary outcomes included health care utilization determined by length of hospital stay, hospital charges, and 1-year readmissions. Logistic and Cox regression determined the association of prior IHRWM with the outcomes of interest. Additional subanalyses matched and compared patients with prior IHR without mesh (IHRWOM) to those with a history of an abdominal operation. Results: Of the 914â¯105 patients undergoing common abdominal surgical procedures (81â¯123 bariatric [8.9%], 284â¯450 small- or large-bowel resection [31.1%], 223â¯768 cholecystectomy [24.5%], 33â¯183 prostatectomy [3.6%], and 291â¯581 gynecologic [31.9%]), all 3517 patients (age group: 46-55 years, 1547 [44.0%]; 2396 majority sex [68.1%]) with prior IHRWM were matched to patients without a history of abdominal surgical procedures. After matching, prior IHRWM was associated with increased overall complications (odds ratio [OR], 1.43; 95% CI, 1.27-1.60), surgical complications (OR, 1.51; 95% CI, 1.34-1.70), length of hospital stay (mean increase of 1.03 days; 95% CI, 0.56-1.49 days; P < .001), index admission charges (predicted mean difference of $11â¯896.10; 95% CI, $6096.80-$17â¯695.40; P < .001), and 1-year unplanned readmissions (hazard ratio, 1.14; 95% CI, 1.05-1.25; P = .002). This trend persisted even when comparing matched patients with prior IHRWM to patients with a history of abdominal surgical procedures, and the treatment outcome disappeared when comparing patients with prior IHRWOM to those without a previous abdominal operation. Conclusions and Relevance: Reoperation through a previously prosthetic-reinforced abdominal wall was associated with increased surgical complications and health care utilization. This risk appeared to be independent of a history of abdominal surgical procedures and was magnified by the presence of a prosthetic-mesh footprint in the abdominal wall.
Subject(s)
Abdominal Wall , Hernia, Ventral , Incisional Hernia , Abdominal Wall/surgery , Female , Hernia, Ventral/surgery , Humans , Incisional Hernia/surgery , Male , Middle Aged , Patient Acceptance of Health Care , Reoperation , Retrospective Studies , Surgical Mesh/adverse effectsABSTRACT
BACKGROUND: Repeated ventral hernia repair is associated with increased risk of complications and recurrence. The authors present the first study looking at how repeated ventral hernia repair affects quality of life, and whether there is a relationship between the number of prior repairs and quality-of-life improvement after surgery. METHODS: A retrospective chart review was conducted of patients undergoing ventral hernia repair between August of 2017 and August of 2019, who completed at least one preoperative and postoperative Abdominal Hernia-Q. Patients were split into four cohorts based on number of prior repairs (zero, one, two, or three or more). Categorical data were compared using chi-square and Fisher's exact tests, and continuous data were analyzed using Kruskal-Wallis tests. RESULTS: Ninety-three patients met inclusion criteria, with 19 (20 percent), 45 (48 percent), 15 (16 percent), and 14 patients (15 percent) in each cohort, ranging from zero to three or more prior repairs. Patients with more prior repairs were significantly more likely to be readmitted and undergo reoperation (p = 0.04 and p = 0.01, respectively), in addition to significantly higher cost of care (p = 0.004). Patients with three or more prior repairs had significantly lower preoperative quality of life when compared to patients with two or fewer prior repairs (p = 0.04). However, all patients reported a similar absolute level of quality of life postoperatively, irrespective of prior repairs (p = 0.34). CONCLUSIONS: Treatment of recurrent hernia remains a challenge because of poor clinical outcomes and higher risk of recurrence. This study shows that patients with multiple prior ventral hernia repairs report similar postoperative quality of life as patients undergoing primary repair. This information is valuable in determining appropriate surgical candidates and improving preoperative counseling. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.
Subject(s)
Hernia, Ventral , Herniorrhaphy , Hernia, Ventral/surgery , Herniorrhaphy/adverse effects , Humans , Incisional Hernia/epidemiology , Postoperative Complications/epidemiology , Quality of Life , Recurrence , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND: Breast reduction surgery has consistently fallen within the top 10 surgical procedures performed by plastic surgeons. This is because of its capability to relieve the physical and psychological impact of macromastia. Although numerous women pursue consultation, many never undergo the procedure. The authors aim to quantify the impact of breast reduction surgery on quality of life by comparing patients who underwent breast reduction surgery with those who did not. METHODS: Patients seeking breast reduction surgery between 2016 and 2019 were identified. As standard-of-care, patients are surveyed during the consultation visit and postoperative visits using the BREAST-Q. The preoperative survey was readministered a second time for those who did not undergo breast reduction surgery. Propensity score matching, based on patient demographics, comorbidities, and breast examination, was used to balance baseline characteristics. RESULTS: A total of 100 propensity-matched patients were identified (operative, n = 78; nonoperative, n = 22). Mean participant age was 39.5 ± 25 years and mean body mass index was 31.1 ± 7.4 kg/m2. Quality of life significantly improved in each domain for those in the operative group (p < 0.05). Those who did not undergo breast reduction surgery realized no improvement in quality of life and had a downward trend in quality of life across two of the four domains. CONCLUSIONS: Breast reduction surgery offers a significant improvement in quality of life for macromastia. This matched study demonstrates that patients who are able to undergo breast reduction surgery have a statistically significant improvement in all aspects of quality of life, whereas nonsurgical patients experience no benefit with time, with a trend toward deterioration in specific domains.
Subject(s)
Breast/abnormalities , Hypertrophy/surgery , Mammaplasty/statistics & numerical data , Patient Satisfaction/statistics & numerical data , Quality of Life , Adolescent , Adult , Breast/surgery , Female , Humans , Hypertrophy/psychology , Middle Aged , Treatment Outcome , Young AdultABSTRACT
Importance: The evidence provided supports routine and systematic capture of long-term outcomes after trauma, lengthening the follow-up for patients at risk for incisional hernia (IH) after trauma laparotomy (TL), counseling on the risk of IH during the postdischarge period, and consideration of preventive strategies before future abdominal operations to lessen IH prevalence as well as the patient and health care burden. Objective: To determine burden of and factors associated with IH formation following TL at a population-based level across health care settings. Design, Setting, and Participants: This population-based cohort study included adult patients who were admitted with traumatic injuries and underwent laparotomy with follow-up of 2 or more years. The study used 18 statewide databases containing data collected from January 2006 through December 2016 and corresponding to 6 states in diverse regions of the US. Longitudinal outcomes were identified within the Statewide Inpatient, Ambulatory, and Emergency Department Databases. Patients admitted with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for traumatic injuries with 1 or more concurrent open abdominal operations were included. Data analysis was conducted from March 2020 through June 2020. Main Outcomes and Measures: The primary outcome was IH after TL. Risk-adjusted Cox regression allowed identification of patient-level, operative, and postoperative factors associated with IH. Results: Of 35â¯666 patients undergoing TL, 3127 (8.8%) developed IH (median [interquartile range] follow-up, 5.6 [3.4-8.6] years). Patients had a median age of 49 (interquartile range, 31-67) years, and most were male (21â¯014 [58.9%]), White (21â¯584 [60.5%]), and admitted for nonpenetrating trauma (28â¯909 [81.1%]). The 10-year IH rate and annual incidence were 11.1% (95% CI, 10.7%-11.5%) and 15.6 (95% CI, 15.1-16.2) cases per 1000 people, respectively. Within risk-adjusted analyses, reoperation (adjusted hazard ratio [aHR], 1.28 [95% CI, 1.2-1.37]) and subsequent abdominal surgeries (aHR, 1.71 [95% CI, 1.56-1.88]), as well as obesity (aHR, 1.88 [95% CI, 1.69-2.10]), intestinal procedures (aHR, 1.47 [95% CI, 1.36-1.59]), and public insurance (aHRs: Medicare, 1.38 [95% CI, 1.20-1.57]; Medicaid, 1.35 [95% CI, 1.21-1.51]) were among the variables most strongly associated with IH. Every additional reoperation at the index admission and subsequently resulted in a 28% (95% CI, 20%-37%) and 71% (95% CI, 56%-88%) increased risk for IH, respectively. Repair of IH represented an additional $36.1 million in aggregate costs (39.9%) relative to all index TL admissions. Conclusions and Relevance: Incisional hernia after TL mirrors the epidemiology and patient profile characteristics seen in the elective setting. We identified patient-level, perioperative, and novel postoperative factors associated with IH, with obesity, intestinal procedures, and repeated disruption of the abdominal wall among the factors most strongly associated with this outcome. These data support preemptive strategies at the time of reoperation to lessen IH incidence. Longer follow-up may be considered after TL for patients at high risk for IH.
Subject(s)
Incisional Hernia/epidemiology , Laparotomy , Postoperative Complications/epidemiology , Wounds and Injuries/surgery , Adult , Aged , Databases, Factual , Female , Health Care Costs , Humans , Incidence , Male , Middle Aged , United States/epidemiologyABSTRACT
BACKGROUND: Sternoclavicular joint (SCJ) osteomyelitis is a rare pathology requiring urgent intervention. Several operative approaches have been described with conflicting reports. Here, we present a multi-institutional study utilizing multiple surgical pathways for SCJ reconstruction. METHODS: A multi-institutional retrospective cohort study was conducted to identify patients who underwent surgical repair for sternoclavicular osteomyelitis between 2008 and 2019. Patients were stratified according to reconstruction approach: single-stage reconstruction with advancement flap and delayed-reconstruction with flap following initial debridement. Demographics, operative approach, type of reconstruction, and postoperative outcomes were analyzed. RESULTS: Thirty-two patients were identified. Mean patient age was 56.2±13.8 years and 68.8% were male. The average body mass index (BMI) was 30.0±8.8 kg/m2. The most common infection etiologies were intravenous drug use and bacteremia (both 25%). Fourteen patients (43.8%) underwent one-stage reconstruction and 18 (56.2%) underwent delayed twostaged reconstruction. Both single and delayed-stage groups had comparable rates of reinfection (7.1% vs. 11.1%, respectively), surgical site complications (21.4% vs. 27.8%), readmissions (7.1% vs. 16.6%), and reoperations (7.1% vs. 5.6%; all P>0.05). The single-stage reconstruction group had a significantly lower BMI (26.2±5.7 kg/m2 vs. 32.9±9.1 kg/m2; P<0.05) and trended towards shorter hospital length of stay (11.3 days vs. 17.9 days; P=0.01). CONCLUSIONS: Both single and delayed-stage approaches are appropriate methods with comparable outcomes for reconstruction for SCJ osteomyelitis. When clinically indicated, a single-stage reconstruction approach may be preferable in order to avoid a second operation as associated with the delayed phase, and possibly shortening total hospital length of stay.