Mandible Fractures Undergoing Transfer Rarely Require Acute Intervention.

Study Design: A retrospective review was conducted of all patients with mandibular fractures who were evaluated by plastic surgery at a Level I trauma center between January 1, 2017 and May 1, 2020. Data including demographic characteristics, mechanism of injury, type of presentation (e.g., primary or transfer), treatment plan, and time to intervention were recorded. Objective: Mandibular fractures are common traumatic injuries. Because these injuries are managed by surgical specialists, these patients are often emergently transferred to tertiary care hospitals. This study aims to assess the benefits of emergent transfer in this patient group. Methods: Variables were summarized using descriptive statistics. The relationship with initial disposition was assessed via tests of association, including Student's t-test, Fisher's exact test, or chi-square tests. Significance was set to p values less than 0.05. Multivariate regression analysis was conducted to determine predictors of presentation to outside hospital followed by transfer to our institution. Results: Records from 406 patients with isolated mandibular fractures were evaluated. 145 (36%) were transferred from an outside hospital specifically for specialty evaluation. One patient required intervention in the Emergency Department (ED). Of the 145 patients that were transferred to our facility, eight (5.5%) were admitted for operative management. Patients with open injuries and pediatric patients showed benefit from transfer. Conclusions: Patients are frequently transferred to tertiary care facilities for specialty service evaluation and treatment. However, when isolated mandible fractures were evaluated, only one patient required intervention in the ED. Patients with grossly open fractures and pediatric patients were more frequently admitted specifically for operative management. This practice of acute interfacility transfer represents an unnecessary cost to our health system as isolated mandible fractures can be managed on an outpatient basis. We suggest that pediatric patients and patients with open fractures be transferred for urgent evaluation and management, whereas most patients would be appropriate for outpatient evaluation.

A Systematic Review and Meta-Analysis Comparing the Clinical Outcomes of Profunda Artery Perforator Versus Gracilis Thigh Flap as a Second Choice for Autologous Breast Reconstruction.

PURPOSE: Autologous breast reconstruction remains a versatile option to produce a natural appearing breast after mastectomy. The deep inferior epigastric perforator remains the most commonly used flap choice, but when this donor site is unsuitable or unavailable, the transverse upper gracilis (TUG) or profunda artery perforator (PAP) flaps are popular secondary alternatives. We conduct a meta-analysis to better understand patient outcomes and adverse events in secondary flap selection in breast reconstruction. METHODS: A systematic search was conducted on MEDLINE and Embase for all articles published on TUG and/or PAP flaps for oncological breast reconstruction in postmastectomy patients. A proportional meta-analysis was conducted to statistically compare outcomes between PAP and TUG flaps. RESULTS: The TUG and PAP flaps were noted to have similar reported rates of success and incidences of hematoma, flap loss, and flap healing (P > 0.05). The TUG flap was noted to have significantly more vascular complications (venous thrombosis, venous congestion, and arterial thrombosis) than the PAP flap (5.0% vs 0.6%, P < 0.01) and significantly greater rates of unplanned reoperations in the acute postoperative period (4.4% vs 1.8%, P = 0.04). Infection, seroma, fat necrosis, donor healing complications, and rates of additional procedures all exhibited high degree of heterogeneity precluding mathematical synthesis of outcomes across studies. CONCLUSIONS: Compared with TUG flaps, PAP flaps have fewer vascular complications and fewer unplanned reoperations in the acute postoperative period. There is need for greater homogeneity in reported outcomes between studies to enable for synthesis of other variables important in determining flap success.

Alpha Defensin-1 Biomarker Outperforms Culture in Diagnosing Breast Implant-Related Infection: Results from a Multicenter Prospective Study.

BACKGROUND: Prompt diagnosis of breast implant infection is critical to reducing morbidity. A high incidence of false-negative microbial culture mandates superior testing modalities. Alpha defensin-1 (AD-1), an infection biomarker, has outperformed culture in diagnosing periprosthetic joint infection with sensitivity/specificity of 97%. After previously demonstrating its feasibility in breast implant-related infection (BIRI), this case-control study compares the accuracy of AD-1 to microbial culture in suspected BIRI. METHODS: An institutional review board-approved, prospective, multicenter study was conducted of adults with prior breast implant reconstruction undergoing surgery for suspected infection (cases) or prosthetic exchange/revision (controls). Demographics, perioperative characteristics, antibiotic exposure, and implant pocket fluid were collected. Fluid samples underwent microbial culture, AD-1 assay, and adjunctive markers (C-reactive protein, lactate, cell differential); diagnostic performance was assessed by means of sensitivity, specificity, and accuracy from receiver operating characteristic curve analysis, with values of P < 0.05 considered significant. RESULTS: Fifty-three implant pocket samples were included (cases, n = 20; controls, n = 33). All 20 patients with suspected BIRI exhibited cellulitis, 65% had abnormal drainage, and 55% were febrile. All suspected BIRIs were AD-1 positive (sensitivity, 100%). Microbial culture failed to grow any microorganisms in four BIRIs (sensitivity, 80%; P = 0.046); Gram stain was least accurate (sensitivity, 25%; P < 0.001). All tests demonstrated 100% specificity. Receiver operating characteristic curve analyses yielded the following areas under the curve: AD-1, 1.0; microbial culture, 0.90 ( P = 0.029); and Gram stain, 0.62 ( P < 0.001). Adjunctive markers were significantly higher among infections versus controls ( P < 0.001). CONCLUSIONS: Study findings confirm the accuracy of AD-1 in diagnosing BIRI and indicate superiority to microbial culture. Although further study is warranted, AD-1 may facilitate perioperative decision-making in BIRI management in a resource-efficient manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Quantifying the Effective Lift of Skin-Only, SMAS Plication, and Extended SMAS Face-Lift Techniques in a Cadaveric Study.

BACKGROUND: Rhytidectomies are performed to rejuvenate the aging face. Various techniques exist to achieve soft-tissue elevation and skin tightening. This study analyzes three common face-lift techniques: skin-only, superficial musculoaponeurotic system (SMAS) plication, and extended SMAS lifts. The authors characterize effective facial changes with each procedure in a cadaver model. METHODS: The authors performed face-lift procedures on 18 cadaver hemifaces. Each face was measured along horizontal and vertical vectors. The primary outcome was change along these vectors. Skin-only, SMAS plication, and extended SMAS lifts were performed sequentially on each hemiface. SMAS plication was used to approximate a lateral SMASectomy procedure. Parameter measurements were compared. RESULTS: All three procedures exhibited a significant tightening along horizontal vectors. SMAS procedures provided a significant lift along all vertical vectors, whereas the skin-only lift failed to demonstrate significant vertical elevation. SMAS procedures achieved significantly greater composite horizontal and vertical lifts compared to the skin-only operation. There was only an incremental increase in lift between the SMAS plication and extended SMAS procedures in the upper and midface regions. The extended SMAS led to the greatest lift in the lower face. CONCLUSIONS: SMAS procedures provided a greater lift along both horizontal and vertical vectors than the skin lift alone. The increased dissection in the extended SMAS technique resulted in only a modest increase in lift compared to SMAS plication. The extended SMAS approach appears to offer the most benefit at the lower face and may be the best choice for targeting this region.

Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Updated Systematic Review and Analysis of Treatment Strategies.

BACKGROUND: Although guidelines have been published on treatment of breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL), there has been no comprehensive analysis of BIA-ALCL treatment variation based on the available literature. The authors sought to assess current treatment strategies of BIA-ALCL relative to current guidelines. METHODS: Database searches were conducted in June of 2020. Included articles were case reports and case series with patient-level data. Collected variables included clinicopathologic features, implant characteristics, diagnostic tests, ALCL characteristics, treatment, and details of follow-up and outcome. Treatment data from before and after 2017 were compared with National Cancer Center Network guidelines. RESULTS: A total of 89 publications were included and 178 cases of BIA-ALCL were identified. Most patients presented with seroma ( n = 114, 70.4 percent), followed by a mass ( n = 14, 8.6 percent), or both ( n = 23, 14.2 percent). Treatment included en bloc capsulectomy of the affected implant in 122 out of 126 cases with treatment details provided (96.8 percent). Radiation therapy was given in 38 cases (30.2 percent) and chemotherapy was given in 71 cases (56.3 percent). Practitioners used less chemotherapy for local disease after treatment guideline publication in 2017 ( p < 0.001), whereas treatment for advanced disease remained unchanged ( p = 0.3). There were 10 recurrences and eight fatalities attributable to BIA-ALCL, which were associated with advanced presentation (29 versus 2.1 percent; OR, 19.4; 95 percent CI, 3.9 to 96.3; p < 0.001). CONCLUSIONS: BIA-ALCL remains a morbid but treatable condition. Current guidelines focus treatment for local disease and reduce nonsurgical interventions with radiation or chemotherapy. Patients presenting with advanced BIA-ALCL experience higher rates of recurrence and mortality.

Evaluating the Inaccuracy of the National Surgical Quality Improvement Project Surgical Risk Calculator in Plastic Surgery: A Meta-analysis of Short-Term Predicted Complications.

BACKGROUND: Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC's ability to predict complications among patients having plastic surgery. METHODS: OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I2 statistic, indicating heterogeneity, was judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex). RESULTS: Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48-0.87], cardiac AUC = 0.66 [0.20-0.99], venous thromboembolism AUC = 0.55 [0.47-0.63]), (surgical: surgical site infection AUC = 0.55 [0.46-0.63], reoperation AUC = 0.54 [0.49-0.58], serious complication AUC = 0.58 [0.43-0.73], and any complication AUC = 0.60 [0.57-0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54-0.99]), heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes. CONCLUSIONS: The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.

Symptomatic hernia of the thigh musculature requiring reconstruction: A rare late presenting sequela after fascial release for compartment syndrome.

Acute compartment syndrome (ACS) of the lower extremity is a surgical emergency, often secondary to severe crush injury, and requires immediate fascial release. In treatment of ACS, the underlying fascia is left unrepaired and the subsequent fascial defect does not generally cause negative consequences. Here, we present a 24-year-old man who developed symptomatic muscle herniation 3-years after undergoing fascial release secondary to ACS of the anterior thigh. Given the size of the defect, reconstruction was performed using Acellular Dermal Matrix (ADM). The patient did well, with no complications 6 months postoperatively. Symptomatic muscle herniation following fasciotomy can be treated with hernia reduction and fascial repair. When primary closure is not possible, Acelluar Dermal Matrix (ADM) is an option for successful fascial reconstruction.

Refining Indications for Orbital Floor Fracture Reconstruction: A Risk-Stratification Tool Predicting Symptom Development and Need for Surgery.

BACKGROUND: Challenges in orbital floor fracture management include delayed symptom onset and controversial surgical indications based on radiographic findings. This study assessed which imaging characteristics most reliably predict symptomatology to generate a tool quantifying individual need for surgery on initial presentation. METHODS: The clinical course for all patients with isolated orbital fractures at a single institution from 2015 to 2017 were reviewed. Trauma mechanism, computed tomographic scan findings, and symptoms necessitating surgery (diplopia, enophthalmos) were noted. Univariable and multivariable regression modeling was used to generate a predictive risk model for operative fractures. RESULTS: One hundred twenty-one patients with isolated orbital fractures were identified. Mechanism of injury included falls (41 percent), assault (37 percent), and vehicular trauma (17 percent). Patient follow-up averaged 4.4 ± 4.8 months. Average orbital floor fracture area was 2.4 cm2 (range, 0.36 to 6.18 cm2), and orbital volume herniation averaged 0.70 cm3 (range, 0.01 to 4.23 cm3). Twenty-one patients (17.3 percent) required surgical intervention for symptomatic fractures. The strongest predictors of symptoms were orbital volume increase greater than 1.3 cm3 (OR, 10.5; p = 0.001) and inferior rectus displacement within/below the fracture line (OR, 3.7; p = 0.049). Mechanical fall was risk-reducing (OR, 0.08; p = 0.005). Symptom risk was stratified from low (3.6 percent) to high risk (71 percent) (C-statistic = 0.90). The volume of herniated orbital contents was significantly more predictive of symptoms than fracture area (C-statistic = 0.81 versus C-statistic = 0.66; p = 0.02). CONCLUSIONS: The proposed risk tool allows highly accurate, early prediction of symptomatic orbital floor fractures. Findings suggest that orbital volume change, not fracture area, more reliably informs operative indications, along with inferior rectus muscle caudal malposition. A simplified stepwise decision algorithm demonstrates the potential utility of this risk-assessment tool. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Machine Learning and Surgical Outcomes Prediction: A Systematic Review.

BACKGROUND: Machine learning (ML) has garnered increasing attention as a means to quantitatively analyze the growing and complex medical data to improve individualized patient care. We herein aim to critically examine the current state of ML in predicting surgical outcomes, evaluate the quality of currently available research, and propose areas of improvement for future uses of ML in surgery. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "machine learning" and "surgery" for papers published between 2015 and 2020. RESULTS: Of the initial 2677 studies, 45 papers met inclusion and exclusion criteria. Fourteen different subspecialties were represented with neurosurgery being most common. The most frequently used ML algorithms were random forest (n = 19), artificial neural network (n = 17), and logistic regression (n = 17). Common outcomes included postoperative mortality, complications, patient reported quality of life and pain improvement. All studies which compared ML algorithms to conventional studies which used area under the curve (AUC) to measure accuracy found improved outcome prediction with ML models. CONCLUSIONS: While still in its early stages, ML models offer surgeons an opportunity to capitalize on the myriad of clinical data available and improve individualized patient care. Limitations included heterogeneous outcome and imperfect quality of some of the papers. We therefore urge future research to agree upon methods of outcome reporting and require basic quality standards.

Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients.

BACKGROUND: Many plastic surgeons avoid the administration of venous thromboembolism (VTE) chemoprophylaxis out of concern for surgical bleeding in abdominoplasty. Although previous studies have attempted to address the relationship between abdominoplasty and bleeding or VTE, poor reporting techniques remain a challenge. As a result, there has been a lack of reliable data to guide clinical practice. OBJECTIVES: The authors sought to determine the prevalence of bleeding and VTE in abdominoplasty with and without chemoprophylaxis. METHODS: A systematic review was performed following PRISMA guidelines utilizing PubMed, CINAHL, and Cochrane Central. Patient demographics, comorbidities, risk category (if available), bleeding events, VTE events, and chemoprophylaxis information were recorded. RESULTS: Across 10 articles, 691 patients received chemoprophylaxis in the setting of abdominoplasty: 68 preoperatively, 588 postoperatively, and 35 received both; 905 patients did not receive chemoprophylaxis. A total of 96.8% of patients were female, 73% underwent concomitant liposuction, and none were clearly risk stratified. The overall incidence of VTE and bleeding was 0.56% (9/1596) and 1.6% (25/1596), respectively. Compared with no chemoprophylaxis, chemoprophylaxis was not associated with increased incidence of bleeding (1.3% [9/671] vs 0.91% [8/881], P = 0.417) or decreased incidence of VTE (0.87% [6/691] vs 0.33% [3/901], P = 0.187). CONCLUSIONS: The prevalence of bleeding in abdominoplasty was low. Chemoprophylaxis was not associated with increased risk of bleeding or decreased risk of VTE, though the lack of risk stratification and heterogeneity of the cohort precludes firm conclusions. This study underscores the importance of utilizing validated risk-stratification tools to guide perioperative decision-making.

Natural Language Processing in Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim of this study was to systematically assess the application and potential benefits of natural language processing (NLP) in surgical outcomes research. SUMMARY BACKGROUND DATA: Widespread implementation of electronic health records (EHRs) has generated a massive patient data source. Traditional methods of data capture, such as billing codes and/or manual review of free-text narratives in EHRs, are highly labor-intensive, costly, subjective, and potentially prone to bias. METHODS: A literature search of PubMed, MEDLINE, Web of Science, and Embase identified all articles published starting in 2000 that used NLP models to assess perioperative surgical outcomes. Evaluation metrics of NLP systems were assessed by means of pooled analysis and meta-analysis. Qualitative synthesis was carried out to assess the results and risk of bias on outcomes. RESULTS: The present study included 29 articles, with over half (n = 15) published after 2018. The most common outcome identified using NLP was postoperative complications (n = 14). Compared to traditional non-NLP models, NLP models identified postoperative complications with higher sensitivity [0.92 (0.87-0.95) vs 0.58 (0.33-0.79), P < 0.001]. The specificities were comparable at 0.99 (0.96-1.00) and 0.98 (0.95-0.99), respectively. Using summary of likelihood ratio matrices, traditional non-NLP models have clinical utility for confirming documentation of outcomes/diagnoses, whereas NLP models may be reliably utilized for both confirming and ruling out documentation of outcomes/diagnoses. CONCLUSIONS: NLP usage to extract a range of surgical outcomes, particularly postoperative complications, is accelerating across disciplines and areas of clinical outcomes research. NLP and traditional non-NLP approaches demonstrate similar performance measures, but NLP is superior in ruling out documentation of surgical outcomes.

Underdiagnosis of Nasoorbitoethmoid Fractures in Patients with Zygoma Injury.

BACKGROUND: Nasoorbitoethmoid fractures commonly accompany midface fractures and may be underdiagnosed, resulting in incomplete reconstruction or inadequate treatment following facial trauma. To better understand the nasoorbitoethmoid fracture diagnosis and treatment tendencies, the authors analyzed concomitant nasoorbitoethmoid injuries in the setting of zygoma fractures. METHODS: The facial trauma database at a level I trauma center was evaluated. All patients with diagnosed zygoma fractures from June of 2011 to March of 2016 were assessed for a concomitant nasoorbitoethmoid injury. Documentation of these fractures in radiology, plastic surgery, and operative notes was recorded, as was the rate of nasoorbitoethmoid fracture surgical repair. RESULTS: The authors identified 339 eligible patients and completed retrospective analysis of computed tomographic images for their 356 zygoma fractures. The incidence of concomitant nasoorbitoethmoid fractures was 30.6 percent (109 of 356). Documentation rates of nasoorbitoethmoid fractures were 0 percent, 3.7 percent, and 8.3 percent in radiology, plastic surgery, and operative notes, respectively. The rate of surgical correction of nasoorbitoethmoid injuries was 22.9 percent (25 of 109). Of those fractures identified, 44.9 percent (49 of 109) were minimally displaced or nondisplaced. Subset analysis of only significantly displaced fractures yielded an incidence of 16.8 percent (60 of 356). Of significantly displaced fractures, documentation rates were 0 percent, 6.7 percent, and 16.8 percent in radiology, plastic surgery, and operative notes, respectively. The surgical repair rate of significantly displaced fractures was 31.7 percent (19 of 60). CONCLUSIONS: These findings suggest a high concomitance rate of nasoorbitoethmoid fractures with zygoma fractures and identify a tendency to underdocument and undertreat this injury pattern. Clinicians managing patients with midface trauma should have a high suspicion for nasoorbitoethmoid trauma. Plastic surgeons and radiologists should be better trained in identifying the nasoorbitoethmoid fracture pattern.

Outcomes of Poly-4-hydroxybutyrate Mesh in Ventral Hernia Repair: A Systematic Review and Pooled Analysis.

Within the past decade, poly-4-hydroxybutyrate (P4HB) biosynthetic mesh has been introduced as a potential alternative to traditional biologic and synthetic mesh in ventral hernia repair (VHR). The aim of this study was to systematically assess clinical outcomes with the P4HB in VHR. METHODS: A literature search identified all articles published in 2000 involving the use of P4HB in VHR. Descriptive statistics were used to synthesize collective data points, including postoperative outcomes. A pooled analysis of postoperative outcomes was performed using chi-square test and Fisher exact test. RESULTS: Across 7 studies, the P4HB was used in 453 patients. The mean rate of surgical site infection (SSI) was 6.8% (31/453), reoperation 10.7% (30/281), and recurrence 9.1% (41/453). At an average follow-up of 26.8 months, the incidence of recurrence was 10.4% (28/270). Onlay was significantly associated with increased recurrence (14.2% versus 4.4%, P = 0.001). Among sublay placements, there was no difference in recurrence in clean (Center for Disease Control [CDC] 1) or contaminated (CDC >1) wounds (2.7% versus 6.1%, P = 0.585), but contaminated wounds were associated with increased SSI (2.7% versus 15.2%, P = 0.028). Ventral Hernia Working Group grade 2 and 3 did not have different incidences of recurrence (8.0% versus 5.1%, P = 0.526) nor SSI (5.1% versus 14.6%, P = 0.265). CONCLUSIONS: Overall, clinical outcomes of the P4HB mesh in VHR are acceptable. The P4HB mesh serves as a reliable alternative to traditional synthetic and biologic mesh across a range of defect characteristics and patient health conditions. Further research is needed to better understand the conditions in which it may provide a clinical benefit over traditional mesh types.

Computed Tomography Image Analysis in Abdominal Wall Reconstruction: A Systematic Review.

Ventral hernias are a complex and costly burden to the health care system. Although preoperative radiologic imaging is commonly performed, the plethora of anatomic features present and available in routine imaging are seldomly quantified and integrated into patient selection, preoperative risk stratification, and perioperative planning. We herein aimed to critically examine the current state of computed tomography feature application in predicting surgical outcomes. METHODS: A systematic review was conducted in accordance with the Preferred Reporting Items for a Systematic Review and Meta-Analysis (PRISMA) checklist. PubMed, MEDLINE, and Embase databases were reviewed under search syntax "computed tomography imaging" and "abdominal hernia" for papers published between 2000 and 2020. RESULTS: Of the initial 1922 studies, 12 papers met inclusion and exclusion criteria. The most frequently used radiologic features were hernia volume (n = 9), subcutaneous fat volume (n = 5), and defect size (n = 8). Outcomes included both complications and need for surgical intervention. Median area under the curve (AUC) and odds ratio were 0.68 (±0.16) and 1.12 (±0.39), respectively. The best predictive feature was hernia neck ratio > 2.5 (AUC 0.903). CONCLUSIONS: Computed tomography feature selection offers hernia surgeons an opportunity to identify, quantify, and integrate routinely available morphologic tissue features into preoperative decision-making. Despite being in its early stages, future surgeons and researchers will soon be able to integrate 3D volumetric analysis and complex machine learning and neural network models to improvement patient care.

Can We Predict Incisional Hernia?: Development of a Surgery-specific Decision-Support Interface.

OBJECTIVE: The aim of this study was to identify procedure-specific risk factors independently associated with incisional hernia (IH) and demonstrate the feasibility of preoperative risk stratification through the use of an IH risk calculator app and decision-support interface. SUMMARY BACKGROUND DATA: IH occurs after 10% to 15% of all abdominal surgeries (AS) and remains among the most challenging, seemingly unavoidable complications. However, there is a paucity of readily available, actionable tools capable of predicting IH occurrence at the point-of-care. METHODS: Patients (n = 29,739) undergoing AS from 2005 to 2016 were retrospectively identified within inpatient and ambulatory databases at our institution. Surgically treated IH, complications, and costs were assessed. Predictive models were generated using regression analysis and corroborated using a validation group. RESULTS: The incidence of operative IH was 3.8% (N = 1127) at an average follow-up of 57.9 months. All variables were weighted according to ß-coefficients generating 8 surgery-specific predictive models for IH occurrence, all of which demonstrated excellent risk discrimination (C-statistic = 0.76-0.89). IH occurred most frequently after colorectal (7.7%) and vascular (5.2%) surgery. The most common occurring risk factors that increased the likelihood of developing IH were history of AS (87.5%) and smoking history (75%). An integrated, surgeon-facing, point-of-care risk prediction instrument was created in an app for preoperative estimation of hernia after AS. CONCLUSIONS: Operative IH occurred in 3.8% of patients after nearly 5 years of follow-up in a predictable manner. Using a bioinformatics approach, risk models were transformed into 8 unique surgery-specific models. A risk calculator app was developed which stakeholders can access to identify high-risk IH patients at the point-of-care.

A Cross-Sectional Survey Study among Hand Surgeons in the United States on Standardizing Microsurgery Training.

Although microsurgery plays a more expansive role in hand surgery, microsurgery training systems may not have followed the same evolution, as have other operative techniques. A cross-sectional survey study with 13 multiple choice questions was administered to the members of the American Society for Surgery of the Hand; 503 out of 3,395 responded to the survey (14.8% response rate), and 58% did not have a microsurgical laboratory in their institution, whereas 42% did. Of the institutions that had a microsurgical laboratory, 32.4% also had a microsurgical rat laboratory. Of all respondents, 78% agreed or strongly agreed that their training program should have microsurgery training outside of the operating room, and 53% agreed or strongly agreed that their curriculum needed improvement; 65.6% agreed or strongly agreed that training should be standardized across the nation. Our results indicate that the training needs standardization and that institutional training curriculum needs to be improved. This is a Level III study.

Improved Diagnostic Accuracy of Periprosthetic Breast Infection: Novel Application of the Alpha Defensin-1 Biomarker.

Prompt, accurate diagnosis of breast implant infection is critical to minimizing patient morbidity. Bacterial culture false negative rate approaches 25%-30%, and better costeffective testing modalities are needed. Alpha defensin-1 (AD-1) is a neutrophil-mediated biomarker for microbial infection. With sensitivity/specificity of 97% and 96%, it has replaced culture as the preferred diagnostic modality for orthopedic periprosthetic infection, but has yet to be investigated in breast reconstruction. This pilot study compares the diagnostic performance of AD-1 to bacterial culture in suspected periprosthetic breast infection. METHODS: Patients with prosthetic breast reconstruction and suspected periprosthetic infection were prospectively studied. Implant pocket fluid was analyzed with gram stain and culture, AD-1 assay, and adjunctive markers. Demographics, operative history, prosthetic characteristics, and antibiotic exposure were collected, and diagnostic performance of each test was compared. RESULTS: Fifteen breasts with suspected periprosthetic breast infection were included, 10 (66.7%) of which were acutely infected. Gram stain correctly identified only 1 of 10 infections, whereas culture failed to identify 1 infection and reported equivocal/false-positives in 2 noninfected samples. AD-1, however, correctly classified all 15 samples. AD-1 exhibited 100% sensitivity and specificity, comparing favorably to culture (sensitivity: 90%, specificity: 60%), although this did not reach significance (P=0.22). Infected breasts also demonstrated significantly higher adjunctive marker levels compared to noninfected breasts. CONCLUSIONS: This study demonstrates the utility of AD-1 in diagnosing periprosthetic breast infection. Combining AD-1 with adjunctive inflammatory markers may allow more accurate, prompt detection of implant infection which may reduce morbidity and reconstructive failures.

Predicting Adverse Perioperative Events in Patients Undergoing Primary Cleft Palate Repair.

OBJECTIVE: This study aimed to identify risk factors for adverse perioperative events (APEs) after cleft palatoplasty to develop an individualized risk assessment tool. DESIGN: Retrospective cohort. SETTING: Tertiary institutional. PATIENTS: Patients younger than 2 years with cleft palate. INTERVENTIONS: Primary Furlow palatoplasty between 2008 and 2011. MAIN OUTCOME MEASURE(S): Adverse perioperative event, defined as laryngo- or bronchospasm, accidental extubation, reintubation, obstruction, hypoxia, or unplanned intensive care unit admission. RESULTS: Three hundred patients averaging 12.3 months old were included. Cleft distribution included submucous, 1%; Veau 1, 17.3%; Veau 2, 38.3%; Veau 3, 30.3%; and Veau 4, 13.0%. Pierre Robin (n = 43) was the most prevalent syndrome/anomaly. Eighty-three percent of patients received reversal of neuromuscular blockade, and total morphine equivalent narcotic dose averaged 0.19 mg/kg. Sixty-nine patients (23.0%) had an APE, most commonly hypoventilation (10%) and airway obstruction (8%). Other APEs included reintubation (4.7%) and laryngobronchospasm (3.3%). APE was associated with multiple intubation attempts (odds ratio [OR] = 6.6, P = .001), structural or functional airway anomaly (OR = 4.5, P < .001), operation >160 minutes (OR = 2.2, P = .04), narcotic dose >0.3 mg/kg (OR = 2.3, P = .03), inexperienced provider (OR = 2.1, P = .02), and no paralytic reversal administration (OR = 2.0, P = .049); weight between 9 and 13 kg was protective (OR = 0.5, P = .04). Patients were risk-stratified according to individual profiles as low, average, high, or extreme risk (APE 2.5%-91.7%) with excellent risk discrimination (C-statistic = 0.79). CONCLUSIONS: APE incidence was 23.0% after palatoplasty, with a 37-fold higher incidence in extreme-risk patients. Individualized risk assessment tools may enhance perioperative clinical decision making to mitigate complications.

Managing Groin Wounds after Infrainguinal Vascular Procedures: Examining the Reoperative Events and Complication Profile of Muscle Flap Reconstruction.

BACKGROUND: The literature has been void of large outcome studies detailing the efficacy and complication profile of muscle flap reconstruction of complex groin wounds. Furthermore, a first-line choice for muscle flap selection remains unclear. The aim of this study is 2-fold: (1) to examine the complication profile and associated risk factors following muscle flap coverage and (2) to provide a compared efficacy analysis of the sartorius muscle flap (SMF) versus the rectus femoris flap (RFF) in the treatment of wounds following an infrainguinal vascular procedure. METHODS: A retrospective review of records was performed on all patients undergoing complex groin wound reconstruction from January 2005 to September 2014. RESULTS: A total of 201 flaps were performed on 184 patients. There were no sentinel bleeding events through the course of graft salvage or perioperative morbidity beyond local wound complications. Coronary artery disease (P = 0.049), dyslipidemia (P < 0.001), diabetes (P = 0.047), and history of multiple prior infrainguinal procedures (P = 0.029) were associated with increased complications following groin wound reconstruction. There was no statistically significant difference in complications in comparing the RFF versus the SMF (27.9% vs. 38.9% respectively; P = 0.109). There was no significant difference in the rates of graft salvage in comparing the RFF versus the SMF (21.6% vs. 16.1%, respectively; P = 0.459). CONCLUSIONS: Muscle flap coverage can be safely employed for vascular graft salvage. Medical comorbidities and multiple prior infrainguinal procedures are predictive of perioperative complications. The SMF and RFF demonstrated equivocal rates of complications and graft salvage. Given that the RFF risks increased functional morbidity and necessitates a second donor site, the SMF may be considered as an effective first-line approach for reconstruction of complex groin wounds.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction.

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.