Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research. METHODS: A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication. RESULTS: A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery. CONCLUSION: This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

HISTORIQUE: Le Programme national d'amélioration de la qualité des soins chirurgicaux (PNAQC) est une base de données des résultats chirurgicaux à la fois solide et de qualité, qui mesure les résultats des interventions chirurgicales rajustées au risque au bout de 30 jours. La présente étude exploratoire vise à décrire le mode d'utilisation du PNAQC dans la recherche en chirurgie plastique. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse bibliographique électronique fouillée dans PubMed, Embase, MEDLINE et CINAHL. À l'aide de critères d'inclusion prédéfinis, deux analystes ont examiné des articles de manière indépendante pour en déterminer la pertinence. Ils ont inclus les articles qui utilisaient les données du PNAQC pour mener des recherches dans un domaine de la chirurgie plastique ou analyser les interventions chirurgicales effectuées par des plasticiens. L'information extraite incluait le domaine de la chirurgie plastique, le pays d'origine, la revue scientifique et l'année de publication. RÉSULTATS: Au total, 106 articles respectaient les critères d'inclusion. Le principal domaine de chirurgie plastique était la reconstruction mammaire, qui représentait 35 % des articles. Des 106 articles, 95 % avaient été publiés au cours des cinq années précédentes. La revue Plastic and Reconstructive Surgery avait publié la plupart des articles liés au PNAQC (59 %). Toutes les études étaient rétrospectives. Il est à souligner que, pour ce qui est du domaine de la chirurgie plastique, une seule étude portait sur les brûlures et aucune, sur les traumatismes. CONCLUSION: La présente étude exploratoire décrit le mode d'utilisation des données du PNAQC pour analyser les interventions en chirurgie plastique et leurs résultats pour orienter les améliorations de la qualité dans de 106 articles. Elle démontre l'utilité du PNAQC dans les publications, mais fait également ressortir certaines limites de ce dansgramme en chirurgie plastique.

Adjunctive Dorsal Scapular Nerve Transfer to Suprascapular Nerve for Brachial Plexus Birth Injuries: Case Series.

PURPOSE: Brachial plexus birth injury (BPBI) may result in permanent functional deficits. Brachial plexus birth injury involving the suprascapular nerve (SSN) is conventionally treated using accessory nerve transfer or excision and nerve grafting. This study analyzed shoulder function in patients with BPBI undergoing dorsal scapular nerve (DSN) to SSN transfer. METHODS: We performed a retrospective review of all infants referred to the McMaster University Children's Hospital for BPBI between 1999 and 2012. Patients were included if they underwent SSN reconstruction with DSN transfer and functional outcomes were recorded as measured by the active movement scale (AMS). RESULTS: Of the 266 patients referred, 16 met inclusion criteria. From the initial assessment to final follow-up, average AMS scores improved by 4.1 and 4.4 points for shoulder abduction and external rotation, respectively. In addition, 50% of patients had shoulder abduction greater than half of full range of motion and 43% had external rotation greater than half of full range of motion (AMS scores of 6 or greater). No patient had a secondary surgery; however, 9 of 16 had subsequent botulinum toxin injections. CONCLUSIONS: Although DSN to SSN nerve transfers were combined with other interventions and the outcomes cannot be attributed solely to this nerve transfer alone, it presents an alternative approach to SSN reinnervation under circumstances in which the accessory nerve is unavailable, damaged, or suboptimal. Successful results were achieved; thus, further exploration and study are warranted. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Brachial Plexus Birth Injury in Elective Versus Emergent Caesarean Section: A Cohort Study.

OBJECTIVE: Although Caesarean section (CS) is protective for brachial plexus birth injury (BPBI), the incidence is not zero. A trial of labour with unfavourable intrauterine positioning is hypothesized to result in excessive force on the brachial plexus. The purpose of this study was to determine the risk of BPBI in emergent CS versus elective CS. METHODS: This was a retrospective cohort study. The authors used a nationwide demographic sample of all infants born in Canada from 2004 to 2012. BPBI diagnoses, risk factors, and national incidence data were obtained from the Canadian Institute for Health Information Discharge Abstract Database and Hospital Morbidity Database. The primary outcome was risk of BPBI in emergent CS versus elective CS. RESULTS: BPBI incidence was 1.24 per 1000 live births. Known biases may have underestimated the incidence. CS (elective and emergent) was protective for BPBI as compared with vaginal delivery (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.13-0.18, P < 0.0001). Emergent CS was a moderately strong risk factor for BPBI versus elective CS (OR 3.14; 95% CI 1.79-5.10, P = 0.0001). CONCLUSION: Emergent CS is a moderate risk factor for BPBI compared with elective CS. Intrauterine positioning with a trial of labour may provide an antenatal etiology in these distinct cases.

Functional Outcomes of Late Posttraumatic Enophthalmos Correction.

BACKGROUND: Posttraumatic enophthalmos has debilitating functional consequences, resulting in restriction of ocular motility and diplopia. Surgical correction aims to restore the globe position and ultimately improve function. This study evaluates the functional outcome of posttraumatic enophthalmos repair. METHODS: Patients included in this study had posttraumatic enophthalmos and diplopia requiring enophthalmos repair. Diplopia was graded from 0 (no diplopia) to 4 (constant diplopia) based on the Functional Diplopia Grading Scale. Limitations of eye movements were recorded in the vertical, horizontal, and torsional directions. Data were gathered prospectively at preoperative assessment, postenophthalmos repair, and final follow-up. RESULTS: Between 2002 and 2014, 41 patients fulfilled inclusion criteria. Substantial functional improvement, defined as a decrease of greater than or equal to 1 grade of diplopia, was achieved in 65.9 percent of patients (27 of 41) after all surgical interventions. Patients with residual diplopia (34 of 41) after enophthalmos surgery were managed with secondary strabismus surgery (10 of 34) and/or prism glasses (four of 34). After all interventions, vertical restrictions improved from -1.95 ± 1.13 to -1.06 ± 0.98. Horizontal restrictions improved from -0.88 ± 0.62 to 0.59 ± 0.6. Adequate clinical correction of enophthalmos to within 2 mm of the contralateral globe was achieved in 37 of 41. CONCLUSIONS: This is the largest case series evaluating functional outcomes of patients undergoing posttraumatic delayed enophthalmos repair. A multidisciplinary care approach resulted in improved globe position and eye movement, and improvement of diplopia. Further studies with larger sample sizes are needed to better understand and treat this important and challenging problem. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Aggressive Combined Medical and Surgical Management of Mucormycosis Results in Disease Eradication in 2 Pediatric Patients.

Rhinocerebral mucormycosis is an acute, rapidly fatal, fungal infection, classically involving the nasal mucosa and paranasal sinuses. It is an aggressive, opportunistic infection that frequently progresses to involve the orbit and cerebrum. Cerebral extension in immunocompromised patients is almost universally fatal. There are limited data on mucormycosis in pediatric immunocompromised patients in the literature, with only few reports on rhinocerebral involvement. The immunocompromised patients described in this report presented with suspected periorbital and nasal cellulitis, progressing rapidly to necrotic changes in nasal tissue and oral palatal mucosa. In these patients, the surgical resection of mucormycosis-infected tissue followed by flap reconstruction combined with medical treatment effectively treated the infection, allowed for the rapid resumption of chemotherapy and dramatically improved the quality of life for both the patient and their family.

La mucormycose rhinocérébrale est une infection fongique aiguë qui devient vite fatale et qui touche généralement les muqueuses nasales et les sinus paranasaux. C'est une infection agressive et opportuniste qui évolue souvent pour toucher l'orbite et le cerveau. Chez les patients immunodéprimés, l'atteinte cérébrale est presque toujours fatale. Les données sur la mucormycose chez les patients immunodéprimés d'âge pédiatrique sont limitées dans les publications, et seulement quelques articles traitent de l'atteinte rhinocérébrale. Les patients immunodéprimés décrits dans le présent rapport ont consulté à cause d'une présomption de cellulite périorbitale et nasale qui a évolué rapidement vers une nécrose des tissus nasaux et de la muqueuse oropalatine. Chez ces patients, la résection chirurgicale des tissus infectés par la mucormycose suivie d'une reconstruction par lambeau combinée à un traitement médical, a favorisé la résolution de l'infection, ce qui a permis une reprise rapide de la chimiothérapie et a considérablement amélioré la qualité de vie du patient et de sa famille.