Treatment of Surgical Scars With Combination Pulsed Dye and Fractional Nonablative Laser: A Randomized Controlled Trial.

OBJECTIVE: To assess the effectiveness and safety of combined pulsed-dye laser (PDL) and NAFL for treatment of surgical scars. SUMMARY BACKGROUND DATA: PDL and NAFL have not been compared to healing by time alone. METHODS: Randomized controlled, single-blinded clinical trial at an urban, university hospital. Healthy adults' status post skin surgery with primary closure were randomized to either 3 sessions of combination PDL and NAFL every 2 to 8 weeks, or control of no treatment. At baseline and 36-week follow-up, Patient and observer Scar Assessment Scale and Scar Cosmesis Assessment and Rating were completed by participants and blinded physicians. The primary outcome was scar improvement, as measured by the score difference over time. RESULTS: Of 76 participants, 52 completed the study (July 2017 to June 2019). No severe adverse events were reported. Patient and observer Scar Assessment Scale assessments demonstrated improvement in total score in the laser group compared to controls, as reported by patients [mean difference (standard deviation), laser: 12.86 (6.91) vs control: 7.25 (6.34); P = 0.004] and blinded physicians [18.32 (8.69) vs 13.08 (9.63); P = 0.044]. Patients observed a greater improvement in scar thickness [3.68 (2.04) vs 1.88 (1.85); P = 0.002] and stiffness [3.57 (2.78) vs 1.50 (2.11); P = 0.004] with lasers, and physicians reported greater improvement in vascularity [3.71 (1.98) vs 1.71 (1.52); P = 0.0002]. The live Scar Cosmesis Assessment and Rating subscore for erythema improved significantly with lasers [1.04 (0.79) vs 0.42 (0.50); P = 0.001]. CONCLUSIONS AND RELEVANCE: Combined PDL and NAFL resulted in scar improvement. Scar thickness, stiffness, and erythema were improved. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03057964).

Development of a core outcome set for basal cell carcinoma.

BACKGROUND: There is variation in the outcomes reported in clinical studies of basal cell carcinoma. This can prevent effective meta-analyses from answering important clinical questions. OBJECTIVE: To identify a recommended minimum set of core outcomes for basal cell carcinoma clinical trials. METHODS: Patient and professional Delphi process to cull a long list, culminating in a consensus meeting. To be provisionally accepted, outcomes needed to be deemed important (score, 7-9, with 9 being the maximum) by 70% of each stakeholder group. RESULTS: Two hundred thirty-five candidate outcomes identified via a systematic literature review and survey of key stakeholders were reduced to 74 that were rated by 100 health care professionals and patients in 2 Delphi rounds. Twenty-seven outcomes were provisionally accepted. The final core set of 5 agreed-upon outcomes after the consensus meeting included complete response; persistent or serious adverse events; recurrence-free survival; quality of life; and patient satisfaction, including cosmetic outcome. LIMITATIONS: English-speaking patients and professionals rated outcomes extracted from English language studies. CONCLUSION: A core outcome set for basal cell carcinoma has been developed. The use of relevant measures may improve the utility of clinical research and the quality of therapeutic guidance available to clinicians.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting.

BACKGROUND: Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. OBJECTIVES: The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. METHODS: Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. RESULTS: The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. CONCLUSIONS: The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

Guidelines of care for the management of basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common form of human cancer, with a continually increasing annual incidence in the United States. When diagnosed early, the majority of BCCs are readily treated with office-based therapy, which is highly curative. In these evidence-based guidelines of care, we provide recommendations for the management of patients with BCC, as well as an in-depth review of the best available literature in support of these recommendations. We discuss biopsy techniques for a clinically suspicious lesion and offer recommendations for the histopathologic interpretation of BCC. In the absence of a formal staging system, the best available stratification based on risk for recurrence is reviewed. With regard to treatment, we provide recommendations on treatment modalities along a broad therapeutic spectrum, ranging from topical agents and superficially destructive modalities to surgical techniques and systemic therapy. Finally, we review the available literature and provide recommendations on prevention and the most appropriate follow-up for patients in whom BCC has been diagnosed.

Guidelines of care for the management of cutaneous squamous cell carcinoma.

Cutaneous squamous cell carcinoma (cSCC) is the second most common form of human cancer and has an increasing annual incidence. Although most cSCC is cured with office-based therapy, advanced cSCC poses a significant risk for morbidity, impact on quality of life, and death. This document provides evidence-based recommendations for the management of patients with cSCC. Topics addressed include biopsy techniques and histopathologic assessment, tumor staging, surgical and nonsurgical management, follow-up and prevention of recurrence, and management of advanced disease. The primary focus of these recommendations is on evaluation and management of primary cSCC and localized disease, but where relevant, applicability to recurrent cSCC is noted, as is general information on the management of patients with metastatic disease.

Surgical Duration Impacts Venous Thromboembolism Risk in Microsurgical Breast Reconstruction.

BACKGROUND: Increased surgical duration can impact patient outcomes and operative efficiency metrics. In particular, there are studies suggesting that increased surgical duration can increase the risk of venous thromboembolism (VTE). One of the longer duration plastic surgery procedures commonly performed is microsurgical breast reconstruction. With the widening indications for multiple and "stacked" free flaps to reconstruct breasts, we endeavored to assess (1) the relationship between duration of microsurgical breast reconstruction and VTE; and (2) determine if a threshold operative time exists that connotes VTE higher risk. METHODS: Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2014 who underwent microsurgical breast reconstruction were identified by Current Procedural Terminology code. Three models of multivariate logistic regression were used to characterize the adjusted risk for VTE by operative duration, bilaterality, the length of stay, and patient demographics. RESULTS: A total of 4,782 patients who underwent microsurgical breast reconstruction were identified. Overall VTE incidence was 1.13%. The mean operative duration was 8:31 hours:minutes (standard deviation: 2:59). Operative duration was statistically associated with VTE in continuous, quintile, and dichotomized risk models. Beyond an operative duration of 11 hours, adjusted VTE risk increases fourfold corresponding to a number needed to harm of 45.8. CONCLUSIONS: Increasing surgical duration heightens the risk of VTE in microsurgical breast reconstruction. Increasing body mass index and age enhances this VTE risk. Moreover, limiting surgical duration to 11 hours or less can decrease VTE risk by fourfold vis-à-vis baseline. LEVEL OF EVIDENCE: Risk, II.

Demystifying the "July Effect" in Plastic Surgery: A Multi-Institutional Study.

BACKGROUND: The "July Effect" refers to a theoretical increase in complications that may occur with the influx of inexperienced interns and residents at the beginning of each academic year in July. OBJECTIVES: We endeavored to determine if a July Effect occurs in plastic surgery. METHODS: Plastic surgery procedures were isolated from the National Surgical Quality Improvement Program registry. Cases involving residents were grouped as either having occurred within the first academic quarter (AQ1) or remaining year (AQ2-4). Groups were propensity matched using patient/operative factors and procedure type to account for baseline differences. Univariate and multivariate regression analyses assessed differences in overall complications, surgical and medical complications, individual complications, length of hospital stay, and operative time. A comparison group comprised of procedures without resident involvement was also analyzed. RESULTS: There were 5967 cases with resident involvement, 5156 of which successfully matched. Both univariate and multivariate regression analyses revealed no significant differences between AQ1 and AQ2-4 in terms of overall, surgical, medical and individual complications, or length of hospital stay. There was a statistically significant, albeit not clinically significant, increase in operative time by 10 minutes per procedure during AQ1 in comparison to AQ2-4 (P = 0.001). For procedures lacking resident participation, there were no differences between AQ1 and AQ2-4 in terms of these outcomes. CONCLUSIONS: A July Effect was not observed for plastic surgery procedures in our study, conceivably due to enhanced resident oversight and infrastructural safeguards. Patients electing to undergo plastic surgery early in the academic year can be reassured of their safety during this period.

ASDS Guidelines Task Force: Consensus Recommendations Regarding the Safety of Lasers, Dermabrasion, Chemical Peels, Energy Devices, and Skin Surgery During and After Isotretinoin Use.

BACKGROUND: Currently, the isotretinoin (13-cis-retinoic acid) package insert contains language advising the discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. It is common practice to follow this standard because of concerns regarding reports of sporadic adverse events and increased risk of scarring. OBJECTIVE: To develop expert consensus regarding the safety of skin procedures, including resurfacing, energy device treatments, and incisional and excisional procedures, in the setting of concurrent or recent isotretinoin use. MATERIALS AND METHODS: The American Society for Dermatologic Surgery authorized a task force of content experts to review the evidence and provide guidance. First, data were extracted from the literature. This was followed by a clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS: The task force concluded that there is insufficient evidence to justify delaying treatment with superficial chemical peels and nonablative lasers, including hair removal lasers and lights, vascular lasers, and nonablative fractional devices for patients currently or recently exposed to isotretinoin. Superficial and focal dermabrasion may also be safe when performed by a well-trained clinician.

Outcomes After Elevation of Serratus Anterior Fascia During Prosthetic Breast Reconstruction.

BACKGROUND: Achieving optimal inferolateral coverage is critical to successful prosthetic breast reconstruction. Serratus anterior fascia (SF) elevation, a promising alternative to muscle flaps and acellular dermis (ADM), has not been rigorously studied. This study evaluates complication rates after mastectomy and immediate tissue expander (TE) coverage using SF, relative to other existing methods of reconstruction. METHODS: Retrospective review of consecutive patients undergoing mastectomy with immediate TE reconstruction over 10 years at 1 institution was performed. Patients with serratus muscle (SM) or SF elevation were analyzed. ADM reconstructions were used for comparative analysis only. Relevant demographic and clinical data were recorded. Complications were categorized by type and end outcome, including nonoperative (no further surgery), operative (surgery except explantation), and explantation. RESULTS: The SM and SF elevation was performed in 375 (487 breasts) and 177 (255 breasts) patients, respectively. Mean follow-up was 43.8 months. The SM and SF patients were demographically similar, but SF had higher intraoperative fill volumes (P < 0.0001) and required fewer postoperative expansions (P < 0.0001). There were no differences in complications between SM and SF patients. Regression analysis, adjusted for several variables, revealed that SF was not an independent risk factor for complications. The ADM- and SF-assisted reconstruction also showed no differences in outcomes. CONCLUSIONS: Our review demonstrates that SF elevation is a safe, feasible alternative for achieving inferolateral coverage during prosthetic breast reconstruction. Furthermore, this technique allows for greater fill volumes and less expansions than SM. As a readily available alternative to muscle flaps and ADM, SF elevation should be considered integral to any prosthetic breast reconstruction algorithm.

Impact of Postoperative Antibiotic Prophylaxis Duration on Surgical Site Infections in Autologous Breast Reconstruction.

BACKGROUND: Although some surgeons prescribe prolonged postoperative antibiotics after autologous breast reconstruction, evidence is lacking to support this practice. We used the Tracking Operations and Outcomes for Plastic Surgeons database to evaluate the association between postoperative antibiotic duration and the rate of surgical site infection (SSI) in autologous breast reconstruction. STUDY DESIGN: The intervention of interest for this study was postoperative duration of antibiotic prophylaxis: either discontinued 24 hours after surgery or continued beyond 24 hours. The primary outcome variable of interest for this study was the presence of SSI within 30 days of autologous breast reconstruction. Cohort characteristics and 30-day outcomes were compared using χ² and Fischer exact tests for categorical variables and Student t tests for continuous variables. Multivariate logistic regression was used to control for confounders. RESULTS: A total of 1036 patients met inclusion criteria for our study. Six hundred fifty-nine patients (63.6%) received antibiotics for 24 hours postoperatively, and 377 patients (36.4%) received antibiotics for greater than 24 hours. The rate of SSI did not differ significantly between patients given antibiotics for only 24 hours and those continued on antibiotics beyond the 24-hour postoperative time period (5.01% vs 2.92%, P = 0.109). Furthermore, antibiotic duration was not predictive of SSI in multivariate regression modeling. CONCLUSIONS: We did not find a statistically significant difference in the rate of SSI in patients who received 24 hours of postoperative antibiotics compared to those that received antibiotics for greater than 24 hours. These findings held for both purely autologous reconstruction as well as latissimus dorsi reconstruction in conjunction with an implant. Thus, our study does not support continuation of postoperative antibiotics beyond 24 hours after autologous breast reconstruction.

Assessing Outcomes and Safety of Inpatient Versus Outpatient Tissue Expander Immediate Breast Reconstruction.

BACKGROUND: With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database. METHODS: NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications. RESULTS: Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16). CONCLUSIONS: Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.

Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients.

BACKGROUND: With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking. METHODS: The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts. RESULTS: In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication. CONCLUSIONS: Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.

Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications.

STUDY OBJECTIVE: The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications after laparoscopic and robotic hysterectomy. DESIGN: Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by Current Procedural Terminology code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses using χ(2), Fisher's exact, and one-way analysis of variance tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications. DESIGN CLASSIFICATION: Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than 1 center or research group). SETTING: American College of Surgeons NSQIP. PATIENTS: Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP. INTERVENTIONS: None, retrospective database study. MEASUREMENTS AND MAIN RESULTS: Of the 7630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (1.0%), and blood transfusion (1.0%). Return to the operating room was required in 97 patients (1.3%), and there were 4 deaths, for a mortality rate of .05%. Complications increased steadily with longer operative time. Operative time ≥ 240 minutes was associated with increased overall complications (13.8% vs 4.6%, p < .001), surgical complications (5.4% vs 1.5%, p < .001), medical complications (10.4% vs 3.2%, p < .001), return to the operating room (2.7% vs 1.2%, p = .002), deep venous thrombosis (.5% vs .06%, p = .011), pulmonary embolism (.7% vs .1%, p = .012), and blood transfusion (3.4% vs .8%, p < .001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.28-1.54; p < .001), medical complications (OR, 1.42; 95% CI, 1.28-1.57; p < .001), surgical complications (OR, 1.32; 95% CI, 1.17-1.49; p < .001), venous thromboembolism (OR, 1.47; 95% CI, 1.12-1.92; p = .005), UTI (OR, 1.20; 95% CI, 1.05-1.36; p = .006), blood transfusion (OR, 1.42; 95% CI, 1.18-1.71; p < .001), and return to the operating room (OR, 1.25; 95% CI, 1.08-1.45; p = .003). CONCLUSION: We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.

Predictors of adverse events after parotidectomy: a review of 2919 cases.

OBJECTIVE: There is a current paucity of large-scale, multi-institutional studies that explore the risk factors for major complications following parotidectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program participant use file was reviewed to identify all patients who had undergone parotidectomy between 2006 and 2011. Risk factors that predicted adverse events were estimated by using multivariate logistic regression. RESULTS: Of 2919 included patients, 202 patients experienced adverse outcomes within the first 30 days of surgery. These included surgical complications in 76 (2.6%) patients; medical complications in 90 (3.1%) patients; death in 7 (0.2%) patients; and reoperation in 77 (2.6%) patients. Predictors of any complication included disseminated cancer (odds ratio [OR] = 2.28; 95% confidence interval [CI], 1.05-4.95; P = .036) and increasing total relative value units (OR = 1.01; 95% CI, 1.00-1.02; P = .027). Active smoking was a major risk factor for surgical complications (OR = 1.81; 95% CI, 1.08-3.05; P = .025). Dyspnea (OR = 2.93; 95% CI, 1.37-6.27; P = .006) significantly predicted medical complications. CONCLUSION: Although complication rates after parotidectomy are generally low, avoidance of specific and nonspecific postoperative complications still remains an area for improvement. Future outcomes databases should include procedure-specific complications, including facial nerve injury.

Preoperative Albumin Alone is Not a Predictor of 30-Day Outcomes in Pressure Ulcer Patients: A Matched Propensity-Score Analysis of the 2006-2011 NSQIP Datasets.

BACKGROUND: While there has been a great deal of literature describing the relationship between nutritional status and development of pressure ulcers, statistically rigorous studies analyzing the relationship between hypoalbuminemia and outcomes are lacking. METHODS: The American College of Surgeons' multicenter, prospective, National Surgical Quality Improvement Program database was used to identify patients who underwent surgery for treatment of pressure ulcers between 2006 and 2011. Matched propensity-score analysis was performed to match experimental groups with regard to preoperative comorbidities. Outcomes of interest included overall/surgical/medical complications and 30-day mortality. Multivariable logistic regression models were used to assess the independent association between hypoalbuminemia and outcomes. RESULTS: Over the 6-year study period, 551 patients met criteria for study inclusion. Median albumin level was 2.8 g/dL. Before propensity matching, multiple adverse outcomes were significantly elevated in patients with albumin levels below the median value (very-low albumin, or VLA), compared to control patients. However, after matching preoperative comorbidities, the differences in 30-day outcomes were eliminated. In both analyses, there was no significant difference in 30-day surgical complications. CONCLUSIONS: It is generally understood that hypoalbuminemic patients have elevated risks for surgical procedures. In pressure ulcer patients, it appears that these risks are not due to hypoalbuminemia alone, but rather a long list of attendant comorbidities. Consequently, hypoalbuminemia alone should not be used to determine the timing of a procedure for pressure ulcer surgery. Knowledge of these risks is necessary for patient counseling and surgical planning in this population.

Comparison of Delayed and Immediate Tissue Expander Breast Reconstruction in the Setting of Postmastectomy Radiation Therapy.

BACKGROUND: Despite the continued demand for immediate prosthetic breast reconstruction, some suggest that delayed reconstruction may reduce complications. However, with limited comparative data available, the extent of this benefit is unclear, particularly in the setting of postmastectomy radiation therapy (PMRT). This study evaluates outcomes after mastectomy and delayed tissue expander reconstruction (DTER) or immediate tissue expander reconstruction (ITER). METHODS: A retrospective review of 893 consecutive patients (1201 breasts) who underwent mastectomy with DTER or ITER at one institution during a 10-year period was performed. Relevant patient factors, including the use of PMRT and complication rates, were recorded. Complications were categorized by type and end-outcome, including nonoperative (no further surgery), operative (further surgery except explantation), and explantation. Statistics were done using Student t test and Fisher exact test. RESULTS: There were no differences in clinical risk factors between ITER (n = 1127 breasts) and DTER (n = 74 breasts) patients. Delayed tissue expander reconstruction breasts had lower rates of mastectomy flap necrosis (P = 0.003), and nonoperative (P = 0.01) and operative (P = 0.001) complications relative to ITER. In ITER breasts, PMRT increased operative complications (P = 0.02) and explantation (P = 0.0005), resulting in a decrease in overall, 2-stage success rate (P < 0.0001). In contrast, there were no differences in outcomes between PMRT and non-PMRT DTER breasts. CONCLUSIONS: This comparative study, the largest to date, suggests that DTER is a viable reconstructive alternative that may minimize certain complications over ITER, including in patients needing PMRT. However, unlike with ITER, surgeons can evaluate patients' potential for success with DTER based on skin flap appearance after both mastectomy and PMRT (when present). As a result, the benefits of DTER may also be due to a careful patient selection process preoperatively. The choice of DTER should, therefore, be balanced against both individual patient risk factors and the psychological appeal of immediate reconstruction.

Risk Factors for Complications Differ Between Stages of Tissue-Expander Breast Reconstruction.

BACKGROUND: Tissue-expander (TE) placement followed by implant exchange is currently the most popular method of breast reconstruction. There is a relative paucity of data demonstrating patient factors that predict complications specifically by stage of surgery. The present study attempts to determine what complications are most likely to occur at each stage and how the risk factors for complications vary by stage of reconstruction. METHODS: A retrospective chart review was performed on all 1275 patients who had TEs placed by the 2 senior authors between 2004 and 2013. Complication rates were determined at each stage of reconstruction, and these rates were further compared between patients who had pre-stage I radiation, post-stage I radiation, and no radiation exposure. Multivariate logistic regression was used to identify independent predictors of complications at each stage of reconstruction. RESULTS: A total of 1639 consecutive TEs were placed by the senior authors during the study period. The overall rate for experiencing a complication at any stage of surgery was 17%. Complications occurred at uniformly higher rates during stage I for all complications (92% stage I vs 7% stage II vs 1% stage III, P < 0.001). Predictors of stage I complications included increased body mass index [odds ratio (OR), 1.04; 95% confidence interval (CI), 1.01-1.07], current smoking status (OR, 3.0; 95% CI, 1.7-4.8), and higher intraoperative percent fill (OR, 3.3; 95% CI, 1.7-6.3). Post-stage I radiation was the only independent risk factor for a stage II complication (OR, 4.5; 95% CI, 1.4-15.2). CONCLUSIONS: Complications occur at higher rates after stage I than after stage II, and as expected, stage III complications are exceedingly rare. Risk factors for stage I complications are different from risk factors for stage II complications. Body mass index and smoking are associated with complications at stage I, but do not predict complications at stage II surgery. The stratification of risk factors by stage of surgery will help surgeons and patients better manage both risk and expectations.

The use of patient registries in breast surgery: a comparison of the tracking operations and outcomes for plastic surgeons and national surgical quality improvement program data sets.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) and the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) registries gather outcomes for plastic surgery procedures. The NSQIP collects hospital data using trained nurses, and the TOPS relies on self-reported data. We endeavored to compare the TOPS and NSQIP data sets with respect to cohort characteristics and outcomes to better understand the strengths and weakness of each registry as afforded by their distinct data collection methods. STUDY DESIGN: The 2008 to 2011 TOPS and NSQIP databases were queried for breast reductions and breast reconstructions. Propensity score matching identified similar cohorts from the TOPS and NSQIP databases. Shared 30-day surgical and medical complications rates were compared across matched cohorts. RESULTS: The TOPS captured a significantly greater number of wound dehiscence occurrences (4.77%-5.47% vs 0.69%-1.17%, all P<0.001), as well as more reconstructive failures after prosthetic reconstruction (2.82% vs 0.26%, P<0.001). Medical complications were greater in NSQIP (P<0.05). Other complication rates did not differ across any procedure (all P>0.05). CONCLUSIONS: The TOPS and NSQIP capture significantly different patient populations, with TOPS' self-reported data allowing for the inclusion of private practices. This self-reporting limits TOPS' ability to identify medical complications; surgical complications and readmissions, however, were not underreported. Many surgical complications are captured by TOPS at a higher rate due to its broader definitions, and others are not captured by NSQIP at all. The TOPS and NSQIP provide complementary information with different strengths and weakness that together can guide evidence-based decision making in plastic surgery.

Predictors of 61 unplanned readmission cases in microvascular free tissue transfer patients: multi-institutional analysis of 774 patients.

BACKGROUND: Unplanned readmissions serve as a marker for health care quality. Risk factors associated with unplanned readmission after microvascular free tissue transfer have never been examined. In this study, we sought to identify perioperative predictors of 30-day unplanned readmission in free flap patients. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed to identify all patients who underwent microvascular free tissue transfer in 2011. Multivariate logistic regression models were used to estimate independent predictors of unplanned readmission. RESULTS: Among free flap patients, unplanned readmission rate was 7.9%. In multivariate analysis, the only factor that significantly predicted unplanned readmission (P < 0.05) was open wound/wound infection (odds ratio [OR] 2.71). Postoperative variables significantly associated with unplanned readmission included surgical complications (OR 5.43), medical complications (OR 5.62), and unplanned reoperation (OR 3.94). Flap failure was not associated with unplanned readmission. CONCLUSIONS: In our study, the presence of either open wound/wound infection, development of surgical complications, medical complications, and unplanned reoperations were associated with unplanned readmissions. Further research in predictive factors is suggested to avoid costly, unnecessary, and preventable readmissions.