Abdominal donor-site complications following autologous breast reconstruction: A multi-institutional multisurgeon study.

BACKGROUND: The deep inferior epigastric perforator (DIEP) free flap is the gold standard procedure for autologous breast reconstruction. Although breast-related complications have been well described, donor-site complications and contributing patient risk factors are poorly understood. METHODS: We examined a multi-institutional, prospectively maintained database of patients undergoing DIEP free flap breast reconstruction between 2015 and 2020. We evaluated patient demographics, operative details, and abdominal donor-site complications. Logistic regression modeling was used to predict donor-site outcomes based on patient characteristics. RESULTS: A total of 661 patients were identified who underwent DIEP free flap breast reconstruction across multiple institutions. Using logistic regression modeling, we found that body mass index (BMI) was an independent risk factor for umbilical complications (odds ratio [OR] 1.11, confidence interval [CI] 1.04-1.18, p = 0.001), seroma (OR 1.07, CI 1.01-1.13, p = 0.003), wound dehiscence (OR 1.10, CI 1.06-1.15, p = 0.001), and surgical site infection (OR 1.10, CI 1.05-1.15, p = 0.001) following DIEP free flap breast reconstruction. Further, immediate reconstruction decreases the risk of abdominal bulge formation (OR 0.22, CI 0.108-0.429, p = 0.001). Perforator selection was not associated with abdominal morbidity in our study population. CONCLUSIONS: Higher BMI is associated with increased abdominal donor-site complications following DIEP free flap breast reconstruction. Efforts to lower preoperative BMI may help decrease donor-site complications.

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures.

BACKGROUND: Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed. METHODS: An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor. RESULTS: A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression. CONCLUSION: Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

The heart of it all: Body dysmorphic disorder in cosmetic surgery.

BACKGROUND: Body Dysmorphic Disorder (BDD) represents a prevalent mental health condition characterized by distress arising from self-perceived physical imperfections. BDD serves as a contraindication to aesthetic surgery. Recognizing BDD holds paramount importance for plastic surgeons, as it is instrumental in averting the exacerbation of this condition while ensuring appropriate referrals. OBJECTIVE: This study aimed to investigate the prevalence of BDD in cosmetic surgery patients and to pinpoint key characteristics associated with BDD. This information provides plastic surgeons with specific factors to consider during preoperative evaluations. METHODS: We employed TriNetX database to identify patients with BDD who underwent cosmetic surgery identified by Current Procedural Terminology codes. Demographics and patient characteristics were identified using the International Classification of Diseases 10 codes. We calculated odds ratios (OR) by using chi-squared tests to assess risk factors among patients with BDD. RESULTS: Of 226,374 patients who underwent plastic surgery between August 2002 and August 2022, fewer than 0.1% were diagnosed with BDD. Of the BDD patients, 52.1% were diagnosed after cosmetic surgery. Compared with the control group, BDD patients were more likely to undergo rhinoplasty (OR=1.784, p = 0.004) and nonlocalized lipectomy (OR=1.448, p = 0.021) and less likely to undergo blepharoplasty (OR=0.451, p = 0.002). Findings indicated a strong association between BDD patients undergoing cosmetic procedures and comorbid psychiatric conditions such as depression (OR=4.279, p < 0.05), anxiety (OR=5.490, p < 0.05), and Attention-Deficit Hyperactivity Disorder (OR=3.993, p < 0.05). CONCLUSIONS: These findings underscore the ongoing significance of BDD in the context of cosmetic surgery, potentially indicating a lower surgery rate among BDD patients compared with previous estimates. Nevertheless, avenues for further improvement persist. Our data affirm the noteworthy occurrence of postsurgery BDD development, thereby highlighting the ongoing necessity for psychiatric evaluation in surgical patients.

Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions.

Purpose: Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density. Methods: A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications. Results: A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P = .05) and patients with osteoporosis (P = .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P = .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P = .01), surgical site infection (P < .0001), and malunion (P < .0001). Conclusions: We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients. Type of study/level of evidence: Prognostic III.

Targeted muscle reinnervation in upper extremity amputations.

PURPOSE: Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation.

Risk factors associated with pressure ulcer recurrence after reconstruction: Analysis of a national database.

In this study, we sought to clarify the patient traits and comorbidities that are associated with pressure injury recurrence following pressure injury reconstruction. An insurance claims database, PearlDiver, was used to conduct a retrospective cohort study. The two cohorts included patients who underwent pressure injury reconstruction without recurrence and patients who experienced recurrence with subsequent reconstruction. Multiple logistic regression analysis was used to identify risk factors for recurrence after reconstruction. Recurrence was associated with hypoalbuminemia (p < 0.05), paraplegia (p < 0.05), and osteomyelitis (p < 0.05). In patients with osteomyelitis, primary closure was associated with recurrence (p < 0.05) while flap reconstruction was not (p > 0.05). Osteomyelitis was not associated with recurrence after flap reconstruction. Prior to reconstruction, patients with osteomyelitis and hypoalbuminemia should have their nutrition and infection optimised.

Venous Thromboembolism after Deep Inferior Epigastric Perforator Flap Breast Reconstruction: Review of Outcomes After a Postoperative Prophylaxis Protocol.

BACKGROUND: Deep inferior epigastric perforator (DIEP) flap breast reconstruction is among the higher-risk patient groups for venous thromboembolism (VTE) in plastic surgery. Surgeons often opt for a patient-specific approach to postoperative anticoagulation, and the field has yet to come to a consensus on VTE chemoprophylaxis regimens. METHODS: A new chemoprophylaxis protocol was introduced starting March 2019 that involved two weeks of treatment with enoxaparin, regardless of patient risk factors. A retrospective chart review was conducted on all patients who underwent DIEP flap breast reconstruction at our institution between January 2014 and March 2020. Patients were grouped based on whether they enrolled in the new VTE protocol in the postoperative period or not. Patient demographics, prophylaxis type, and outcomes data were recorded, retrospectively. The primary outcome measure was postoperative VTE incidence. RESULTS: Risk of VTE was significantly higher in patients discharged without VTE prophylaxis compared to patients discharged with prophylaxis (3.7% vs. 0%, p = 0.03). Notably, zero patients in the VTE prophylaxis group developed a DVT or PE. Additionally, the risk of a VTE event was 25 times greater in patients with a Caprini score greater than or equal to 6 (p=0.0002). CONCLUSIONS: We demonstrate the successful implementation of a two-week VTE chemoprophylaxis protocol in DIEP flap breast reconstruction patients that significantly reduces the rate of VTE while not affecting the rate of hematoma complications.

Analysis of a National Database Investigating Development of Trigger Finger after Treatment of Dupuytren Disease.

Dupuytren disease is associated with inflammation and myofibroblast overgrowth, as is stenosing tenosynovitis (trigger finger). Both are linked with fibroblast proliferation, but a potential associative link between the diseases is unknown. The purpose of this study was to evaluate the progression of trigger finger following treatment for Dupuytren contracture in a large database. Methods: A commercial database encompassing 53 million patients was utilized from January 1, 2010 to March 31, 2020. The study cohort included patients diagnosed with either Dupuytren disease or trigger finger utilizing International Classification Codes 9 and 10. Terminology codes were used to identify common Dupuytren procedures, as well as trigger finger release. Logistic regression analysis was used to define independent risk factors for developing trigger finger. Results: A total of 593,606 patients were diagnosed with trigger finger. Of these patients, 15,416 (2.6%) were diagnosed with trigger finger after diagnosis of Dupuytren disease, whereas 2603 (0.4%) patients were diagnosed with trigger finger after treatment of Dupuytren contracture. Independent risk factors for trigger finger included age 65 years or older (OR 1.00, P < 0.05), diabetes (OR 1.12, P < 0.05) and obesity (OR 1.20, P < 0.005). Patients who received collagenase clostridium histolyticum treatment (OR 0.34, P < 0.005) for Dupuytren contracture were significantly less likely to develop trigger finger. Conclusions: Dupuytren contracture is associated with inflammation and subsequent trigger finger development at a higher rate than the background population frequency. Collagenase clostridium histolyticum injection may lead to a decreased risk of trigger finger requiring surgical intervention in patients with risk factors.

Analysis of Time Between Skin Lesion and Lymph Node Biopsies and Lymph Node Metastasis in Patients With Melanoma.

This cohort study assesses whether increasing time to surgery is associated with sentinel lymph node status in patients with cutaneous melanoma stage T1b or higher.

Patterns of Opioid Demand after Operative Treatment of Distal Radius Fractures.

The purpose of this study was to evaluate opioid demand after open reduction and internal fixation of distal radius fractures in patients with and without a diagnosis of cannabis use. Methods: The PearlDiver database was queried for all patients who underwent open reduction and internal fixation of distal radius fractures between 2010 and 2020. Patients were categorized into two groups: (1) those with an active diagnosis of cannabis use (case) and (2) those without (control). The primary outcome measure was morphine milligram equivalents per prescription filled within 30 days after surgery. A logistic regression was used to determine potential risk factors associated with increased opioid filling patterns. Results: The rates of prescription refills before and after surgery were congruent in both the case and control populations and did not show significant differences (P > 0.05). The average morphine milligram equivalents of patients' first opioid prescription was significantly reduced in the case population compared with the control (352.26 versus 480.61 morphine milligram equivalents/prescription, P = 0.005). A history of chronic opioid use was the strongest predictor of prolonged opioid prescription refills after surgery. Conclusions: This study found a significant reduction in opioid volume in patients with a diagnosis of cannabis use who filled an opioid prescription after open reduction and internal fixation of distal radius fractures. Mental health diagnoses, specifically depression, showed an increased risk of multiple opioid prescription refills in patients without a diagnosis of cannabis use.

Extended Venous Thromboembolism Chemoprophylaxis following Microsurgical Breast Reconstruction: Analysis of Trends in Postoperative Anticoagulation.

BACKGROUND: Microsurgical breast reconstruction following mastectomy represents a high-risk patient group for venous thromboembolism (VTE), but there is limited consensus on postoperative prophylaxis duration. The aim of this study was to characterize the risk of VTE after microsurgical breast reconstruction, the risk reduction associated with postoperative outpatient VTE prophylaxis, the clinical factors associated with VTE events, and surgeon prescribing patterns regarding outpatient VTE prophylaxis. METHODS: A commercially available database of 53 million unique patients, PearlDiver, was used to identify patients with breast cancer who underwent microsurgical breast reconstruction. Patients were grouped into those receiving any form of outpatient VTE prophylaxis at discharge and those who did not. Probability of VTE within 90 days was calculated for each group followed by absolute risk reduction and number needed to treat. A logistic regression, assuming binomial distribution, was performed to determine clinical factors associated with VTE events after surgery. RESULTS: A total of 22,606 patients underwent microsurgical breast reconstruction from 2010 to 2020. Of these patients, 356 (1.6%) were discharged with VTE prophylaxis and 22,250 (98.4%) were discharged without. No patients developed a VTE in the prophylaxis group, and 403 (1.8%) developed a VTE in the group without prophylaxis. The number needed to prevent one VTE was 55.25 patients. Most VTE events occurred after postoperative day 10 (71.3%). CONCLUSIONS: Outpatient chemoprophylaxis following breast reconstruction is underused despite the majority of VTE events occurring after the acute postoperative period. Breast microsurgeons should consider routine outpatient chemoprophylaxis as part of their postoperative care pathway to optimize VTE prevention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An Evaluation of the Impact of Mental Illness on Postoperative Breast Reconstruction Revision Surgery.

Breast cancer impacts millions of people yearly affecting various aspects of their lives-including but not limited to mental health. Patients with a known psychiatric history, specifically generalized anxiety disorder (GAD) and/or depression, have previously been shown to have an increased number of revisions after breast reconstruction. Methods: A commercially available database of 91 million unique patients, PearlDiver, was used to identify patients with breast cancer who underwent autologous free flap breast reconstruction. An average number of revisions were calculated from each group of patients-those with a history of anxiety and/or depression and patients without a history of anxiety and/or depression. A logistic regression was performed to determine risk factors associated with patients undergoing revision surgery. Results: A total of 39,683 patients with a history of breast cancer underwent autologous breast reconstruction between 2010 and 2020, of which 6308 (15.9%) patients had a history of GAD and/or depression before autologous reconstruction. A total of 13,422 (33.8%) patients received at least one revision surgery. Patients with GAD only, depression only, and concomitant GAD and depression received 1.40 revisions each with no significant differences between the control and any of the study groups (P = 0.956). Logistic regression did not find psychiatric history to be associated with patients undergoing revision surgery (OR, 0.94; 95% CI, 0.89-1.00). Conclusion: Patients who underwent autologous reconstruction for breast cancer demonstrated no difference in rates of secondary surgical revision, regardless of a concurrent mental health history.

Risk Factors for Infection After Distal Radius Fracture Fixation: Analysis of Impact on Cost of Care.

Purpose: Infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased costs. This study aimed to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on cost. Methods: This study used the PearlDiver national database, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020. The cohort included patients undergoing distal radius fracture fixation. The endpoint was postoperative infection within 180 days of fixation. Two-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. A propensity-matched cohort was created using patient age, gender, and open fracture. Logistic regression analyses defined independent risk factors for developing a postoperative infection among all patients and within the matched cohorts. A Mann-Whitney U test was used to compare costs of care with and without infection. Results: The database included 87,169 patients who underwent distal radius fracture fixation. Postoperative infections were identified in 781 patients (0.9%). There was a significant difference in rates of postoperative infection with percutaneous fixation (1.3%) versus open fixation (0.8%). Logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco to be independent risk factors for developing a postoperative infection. Logistic regression analysis of the propensity-matched cohorts identified tobacco use as a significant risk factor. The average cost of care for patients undergoing fracture fixation without an infection was $6,383, versus $23,355 for those with an infection, which was significantly different. Conclusions: Multiple risk factors for postoperative infection were identified. Cost is significantly increased after postoperative infection, by almost 4-fold. Attempts to correct or optimize modifiable risk factors may lead to substantial cost savings, and potentially decreased rates of infection. Type of study/level of evidence: Prognostic III.

Measuring intraoperative surgical instrument use with radio-frequency identification.

OBJECTIVE: Surgical instrument oversupply drives cost, confusion, and workload in the operating room. With an estimated 78%-87% of instruments being unused, many health systems have recognized the need for supply refinement. By manually recording instrument use and tasking surgeons to review instrument trays, previous quality improvement initiatives have achieved an average 52% reduction in supply. While demonstrating the degree of instrument oversupply, previous methods for identifying required instruments are qualitative, expensive, lack scalability and sustainability, and are prone to human error. In this work, we aim to develop and evaluate an automated system for measuring surgical instrument use. MATERIALS AND METHODS: We present the first system to our knowledge that automates the collection of real-time instrument use data with radio-frequency identification (RFID). Over 15 breast surgeries, 10 carpometacarpal (CMC) arthroplasties, and 4 craniotomies, instrument use was tracked by both a trained observer manually recording instrument use and the RFID system. RESULTS: The average Cohen's Kappa agreement between the system and the observer was 0.81 (near perfect agreement), and the system enabled a supply reduction of 50.8% in breast and orthopedic surgery. Over 10 monitored breast surgeries and 1 CMC arthroplasty with reduced trays, no eliminated instruments were requested, and both trays continue to be used as the supplied standard. Setup time in breast surgery decreased from 23 min to 17 min with the reduced supply. CONCLUSION: The RFID system presented herein achieves a novel data stream that enables accurate instrument supply optimization.

Addressing Surgical Instrument Oversupply: A Focused Literature Review and Case-Study in Orthopedic Hand Surgery.

BACKGROUND: Instrument oversupply drives cost in the operating room (OR). We review previously reported methodologies for surgical instrument reduction and report a pilot methodology for optimizing instrument supply via ethnographic instrument tracking of thumb carpometacarpal (CMC) arthroplasties. Additionally, we report a cost analysis of instrument oversupply and potential savings of tray optimization methods. METHODS: Instrument utilization was tracked over 8 CMC arthroplasties conducted by 2 surgeons at an ambulatory surgery center of a large academic hospital. An optimized supply methodology was designed. A cost analysis was conducted using health-system-specific data and previously published research. RESULTS: After tracking instrument use in 8 CMC arthroplasties, a cumulative total of 59 out of the 120 instruments in the Hand & Foot (H&F) tray were used in at least 1 case. Two instruments were used in all cases, and another 20 instruments were used in at least 50% of the cases. Using a reduced tray with 59 instruments, potential cost savings for tray reduction in 60 cases were estimated to be $2086 without peel-packing and $2356 with peel-packing. The estimated cost savings were lower than those reported in literature due to a reduced scope and exclusion of OR time cost in the analysis. CONCLUSIONS: Instrument oversupply drives cost at our institution's ambulatory surgery center. Ethnography is a cost-effective method to track instrument utilization and determine optimal tray composition for small services but is not scalable to large health systems. The time and cost required to observe sufficient surgeries to enable supply reduction to motivate the need for more efficient methods to determine instrument utility.

A Comparison of Surgical Complications in Patients Undergoing Delayed versus Staged Tissue-Expander and Free-Flap Breast Reconstruction.

BACKGROUND: Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear. METHODS: The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications. RESULTS: Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875). CONCLUSIONS: The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Time-Driven, Activity-Based Costing of Presurgical Infant Orthopedics: A Critical Component of Establishing Value of Latham Appliance and Nasoalveolar Molding.

BACKGROUND: Value-based health-care reform requires assessment of outcomes and costs of medical interventions. In cleft care, presurgical infant orthopedics is still being evaluated for clinical benefits and risks; however, the cost of these procedures has been largely ignored. This study uses robust accounting methods to quantify the cost of providing two types of presurgical infant orthopedics: Latham appliance treatment and nasoalveolar molding. METHODS: This is a prospective study of patients with nonsyndromic cleft lip and/or palate who underwent treatment with presurgical infant orthopedics from 2017 to 2019 at two academic centers. Costs were measured using time-driven activity-based costing. Personnel costs, facility costs (operating room, clinic, and inpatient ward), and equipment costs were included. Travel expenses were incorporated as an estimate of direct costs borne by the family, but indirect costs (e.g., time off from work) were not considered. RESULTS: Twenty-three patients were treated with Latham appliance treatment and 14 were treated with nasoalveolar molding. For Latham appliance treatment, average total cost was $7553 per patient ($1041 for personnel, $637 for equipment, $4871 for facility, and $1004 for travel over 6.5 visits). Unilateral and bilateral costs were $6891 and $8860, respectively. For nasoalveolar molding, average cost totaled $2541 ($364 for personnel, $151 for equipment, $300 for facility, and $1726 for travel over 13 visits); $2120 for unilateral and $3048 for bilateral treatment. CONCLUSIONS: The major difference in cost is attributable to operative placement of the Latham device. Travel cost for nasoalveolar molding is often higher because of frequent clinical encounters required. Future investigation should focus on whether outcomes achieved by presurgical infant orthopedics justify the $2100 to $8900 expenditure for these adjunctive procedures.

The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial.

BACKGROUND: Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS: This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS: Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION: In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis.

BACKGROUND: Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction. METHODS: Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. RESULTS: A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. CONCLUSIONS: Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Implications of Training Pathways on Future Academic Plastic Surgeon Employment.

BACKGROUND: The limited supply of academic plastic surgery positions has led to increased demand and strong competition for these desired positions. Residents and students now seek out academic opportunities earlier in their training to account for this employment shortage. Training pathways and locations play an extremely important role in obtaining an academic position at most institutions. This study aimed to evaluate the training patterns of academic plastic surgeons in an attempt to elucidate its value and role for trainees interested in pursuing future academic careers. METHODS: All full-time faculty members at currently accredited integrated and independent plastic surgery programs were included in the study; clinical affiliates were excluded. These institutions' websites were then queried to obtain the training history of the surgeons meeting inclusion criteria. Data were entered into a centralized database from which descriptive statistics were obtained. RESULTS: In the 741 surgeons included in the study, 514 (69.4%) completed the independent plastic surgery track and 227 (30.6%) completed the integrated pathway. Residents completing the independent track had 20.8% and 31.7% employment at the same institution where they finished their general and plastic surgery residency, respectively. Of those completing the integrated pathway, 33.9% are employed at the same institution where they graduated from residency. In addition, 47.9% of the surgeons included in the study completed medical school, residency, or fellowship at the current institution at which they are employed. Lastly, 512 surgeons (69.4%) completed at least 1 postresidency fellowship. CONCLUSIONS: Academic surgeons commonly complete a postresidency fellowship and are often employed at institutions where they have formerly trained. Trainees considering an academic career should consider these patterns when planning their future careers.