Follow-Up Study: One-Step Salvage of Infected Prosthetic Breast Reconstructions Using Antibiotic-Impregnated Polymethylmethacrylate Plates and Concurrent Tissue Expander Exchange.

BACKGROUND: Periprosthetic infections represent major complications in breast reconstruction, frequently leading to expander-implant loss. No consensus regarding a management algorithm for attempted salvage currently exists. This study assessed outcomes of the authors' salvage protocol using an antibiotic-impregnated polymethylmethacrylate implant with expander device exchange. METHODS: A retrospective chart review identified infected implant-based breast reconstruction cases treated between 2009 and 2017. Of 626 cases initially identified, a total of 62 cases had severe prosthetic infections, and underwent either prosthetic salvage (n = 45) or immediate explantation (n = 17). All the prosthetic salvage patients received intravenous antibiotics followed by surgical débridement, insertion of polymethylmethacrylate plates, device exchange, and postoperative antibiotics. After clinical resolution of infection, tissue expansion was performed, with the polymethylmethacrylate plates remaining in situ until exchanged for permanent implants. RESULTS: The authors' study demonstrated a primary infection clearance rate of 82.2 percent (n = 37). Compared to the traditional explantation group, a significantly higher percentage of the salvage patients completed final reconstruction (84.4 percent versus 35.3 percent; p < 0.001). Fewer patients abandoned reconstruction efforts after infection clearance (2.2 percent versus 58.8 percent; p < 0.001). The majority of cases (78.8 percent) that succeeded the salvage protocol ultimately received implant-based reconstruction; 62.5 percent that failed the salvage protocol still went on to receive autologous tissue reconstruction. CONCLUSIONS: Sustained local antibiotic delivery using polymethylmethacrylate implants and expander device exchange can successfully salvage an infected breast expander/implant. Compared with the traditional explantation approach, more patients complete final reconstruction. Other benefits include preserved skin envelope integrity and possibly improved long-term aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate Soft-Tissue Reconstruction for Chronic Infected Tibia Nonunions Treated with an Ilizarov Frame.

There are multiple options available for the management of large tibial defects. The Ilizarov frame is one of the most widely used techniques due to the physiological bone growth and the symmetrical distribution of axial forces permitting adequate bone distribution. However, disadvantages still remain including obtaining additional soft-tissue access for defect coverage. We present our experience with soft-tissue reconstruction for chronic infected tibial nonunions using free tissue transfers simultaneously with Ilizarov device placement. A retrospective review was performed from 2014 to 2016 of patients presenting with a chronically infected tibia nonunion and treated by our senior orthopedic and plastic surgeons. Demographic data, comorbidities, intraoperative details and postoperative outcomes were collected. A total of 6 patients were identified with a mean age of 46.2 ± 11.6 years. Complete flap survival and resolved active infection were achieved in 5 of our patients, 4 demonstrated body union on imaging, and all of them reached complete ambulance. Flap revisions with allografting for partial flap loss were performed in 1 patient. Preoperative planning is critical for immediate lower extremity reconstruction in the setting of an Ilizarov frame. From our institutional experience, free tissue transfer can safely be placed after frame placement.

Morbidity of First Rib Resection in the Surgical Repair of Thoracic Outlet Syndrome.

Background: Thoracic outlet syndrome (TOS) is a complex entity resulting in neurogenic or vascular manifestations. A wide array of procedures has evolved, each with its own benefits and drawbacks. The authors hypothesized that treatment of TOS with first rib resection (FRR) may lead to increased complication rates. Methods: A retrospective case control study was performed on the basis of the National Surgical Quality Improvement Program database from 2005 to 2014. All cases involving the operative treatment of TOS were extracted. Primary outcomes included surgical and medical complications. Analyses were primarily stratified by FRR and secondarily by other procedure types. Results: A total of 1853 patients met inclusion criteria. The most common procedures were FRR (64.0%), anterior scalenectomy with cervical rib resection (32.9%), brachial plexus decompression (27.2%), and anterior scalenectomy without cervical rib resection (AS, 8.9%). Factors associated with increased medical complications included American Society of Anesthesiologists (ASA) classification of 3 or greater and increased operative time. The presence or absence of FRR did not influence complication rates. Conclusions: FRR is not associated with an increased risk of medical or surgical complications. Medical complications are associated with increased ASA scores and longer operative time.

Management of Microsurgical Patients using Intraoperative Unfractionated Heparin and Thromboelastography.

BACKGROUND: Maintaining optimal coagulation is vital for successful microvascular tissue transfer. The viscoelastic thromboelastography (TEG) is a modern and dynamic method to assess a patient's coagulation status. The aim of this study was to evaluate its diagnostic capabilities of identifying microvascular complications. METHODS: A retrospective chart review was conducted for the most recent 100 cases of abdominal free flap breast reconstruction of a single surgeon. Patient demographics, medical history, clinical, and operative details were documented. Thrombocyte counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), and various TEG parameters were gathered for preoperative, intraoperative, and two postoperative time points. RESULTS: A total of hundred patients were identified, who underwent 172 abdominal-based free flaps for breast reconstruction. TEG was more dynamic compared with PT or aPTT and demonstrated borderline hypocoagulate values intraoperatively upon unfractionated heparin administration and hypercoagulate values postoperatively. In contrast, PT and aPTT demonstrated a continuously hypocoagulable state. Complications included five thrombotic events and three hematomas. The thrombotic cases had much steeper increases of TEG-G between surgery and postoperative day 2 (p = 0.049), while PT and aPTT failed to identify these patients. Of those, two resulted in flap loss (1.2%) that both occurred in patients with abdominal scars from previous surgery. CONCLUSION: The TEG is a useful adjunct for monitoring coagulation status in microsurgical breast reconstruction. When thrombosis at the anastomosis occurs, TEG correlates with a more rapid rebound from an intraoperative hypocoagulable state to a postoperative hypercoagulable state, when using the TEG. The TEG is a valuable tool for a more dynamic assessment of the patients' changing coagulation status.

Multi-institutional Analysis of Surgical Management and Outcomes of Mandibular Fracture Repair in Adults.

Mandibular fractures are rare, most commonly occurring in young male patients who present with facial trauma. The etiology, incidence, and presentation vary among previous publications depending on cultural and socioeconomic factors of the region of origin. This multi-institutional study aims to present demographic characteristics, surgical treatment, and clinical outcomes of surgical repair of mandible fractures in the United States. An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) adult databases of the years 2006 through 2014 was performed identifying 940 patients with an International Classification of Diseases, version 9 (ICD-9) diagnosis of either closed or open fracture of the mandible. Preoperative, perioperative, and postoperative details were categorized and evaluated for these two cohorts. Multivariate analysis was performed to detect risk factors related to any complications. Patients were predominantly male (85.7%), young with a mean age of 34.0 ± 14.8 years, and relatively healthy with body mass index of 23.6 ± 8.2 and an American Society of Anesthesiologists (ASA) class of 1 or 2 (84.4%). However, more than half were regular smokers (51.1%). The top five most frequent procedures performed for mandibular repair were exclusively open surgical approaches with internal, external, or interdental fixation in both cohorts. Patients with open fractures were more often admitted as emergencies, treated inpatient, required longer operative times, and presented with more contaminated wounds ( p < 0.05). Overall, medical (1.7%) and surgical complications (3.7%) were low. A high ASA class 3 or above and emergency operations were identified as risk factors for medical adverse events. Despite frequent concomitant injuries after trauma and a diverse array of mandibular injury types, our patient sample demonstrated favorable outcomes and low complication rates. Open surgical techniques were the most common procedures in this study representing the American population.

Breast reconstruction with DIEP and SIEA flaps in patients with prior abdominal liposuction.

INTRODUCTION: Suction-assisted lipectomy (SAL) has been considered a relative contraindication for autologous breast reconstruction due to reservations about size and integrity of perforator vessels. Such patients are often not considered ideal candidates for breast reconstruction utilizing deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. The aim of this article is to describe our experience with these flaps after SAL. METHODS: Retrospectively, patient charts from 2005 to 2015 were analyzed and 9 patients (13 flaps) were identified who received breast reconstruction after prior donor-site SAL. Eight patients underwent DIEP and 1 patient an SIEA flap breast reconstruction. The patients' average age was 47.7 (ranging 33-64) years and their BMI 26.0 (ranging 21.1-36.5). Preoperative radiologic studies were obtained for all patients via either Doppler ultrasound or cross-sectional imaging to assess abdominal perforators. Abdominal SAL took place between 2 and 20 years before reconstruction. RESULTS: On average, 2.4 (ranging 1-4) perforators with a mean diameter of 0.68 mm (ranging 0.2-2.5 mm) were included per DIEP flap and anastomosed to the internal mammary arteries. Median follow-up period was 1.2 (ranging 0.5-9.6) years without any flap loss, flap necrosis, hematoma, or unplanned reoperation. One breast seroma and one fat necrosis occurred. All patients had a successful reconstruction and finished treatment at our institution. CONCLUSION: Our results show that DIEP and SIEA flaps are safe and effective options for breast reconstruction in patients with previous abdominal SAL. Extensive preoperative patient evaluation and perforator imaging is important in identifying suitable candidates within this patient population.

Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes.

BACKGROUND: Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS. METHODS: Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (= N) ultimately filled out both parts of the questionnaire sets: 1 day before the first stage (T0) and 6 months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality. RESULTS: Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0-10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p < 0.01). All but one patient (97.5%) reported no regrets about having undergone surgery, and the majority recommended it to other patients with gender dysphoria. Femininity and sexual activity increased significantly postoperatively (p < 0.01). Satisfaction with intercourse and orgasm was high: 6.70 and 8.21, respectively, on a 0-10 scale. CONCLUSION: Satisfaction with the cosmetic outcome, as well as the functional and sexual outcomes, reveal positive effects of SRS using the combined technique on transgender patient lives. Nevertheless, standardized and validated SRS-specific questionnaires are lacking. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Safety of open ventral hernia repair in high-risk patients with metabolic syndrome: a multi-institutional analysis of 39,118 cases.

BACKGROUND: Metabolic syndrome (MetS) entails the simultaneous presence of a constellation of dangerous risk factors including obesity, diabetes, hypertension, and dyslipidemia. The prevalence of MetS in Western society continues to rise and implies an elevated risk for surgical complications and/or poor surgical outcomes within the affected population. OBJECTIVE: To assess the risks and outcomes of multi-morbid patients with MetS undergoing open ventral hernia repair. SETTING: Multi-institutional case-control study in the United States. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was sampled for patients undergoing initial open ventral hernia repair from 2012 through 2014 and then stratified into 2 cohorts based on the presence or absence of MetS. Statistical analyses were performed to evaluate preoperative co-morbidities, intraoperative details, and postoperative morbidity and mortality to identify risk factors for adverse outcomes. RESULTS: Mean age (61.0 versus 56.0 yr, P<.001), body mass index (39.2 versus 31.1, P<.001), and prevalence of co-morbidities of multiple organ systems were significantly higher (P<.001) in the MetS cohort compared to control. Patients with MetS received higher American Society of Anesthesiologists classifications (81.0% versus 43.1% class 3 or higher, P<.001), were more likely to require operation as emergency cases (11.4% versus 7.2%, P<.001), required longer operative times (103 versus 87 min, P<.001), had longer hospitalizations (3.5 versus 2.4 d, P<.001), and had more contaminated wounds (15.9% versus 12.0% class 2 or higher, P<.001). Overall, they had more medical (7.5% versus 4.2%, P<.001), and surgical complications (9.7% versus 5.4%, P<.001), experienced more readmissions (8.3% versus 5.7%, P<.001) and reoperations (3.4% versus 2.5%, P<.001), and were at higher risk for eventual death (.8% versus .5%, P=.008). CONCLUSIONS: The presence of MetS is related to a multitude of unfavorable outcomes and increased mortality after open ventral hernia repair compared with a non-MetS control group. MetS is a useful marker for high operative risk in a population that is generally prone to obesity and its associated diseases.

Comment to: "Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database".

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optimizing Exposure for the Occipital Nerve in Migraine Surgery while Maintaining Hair Length.

Surgical decompression of the greater occipital nerve is used in the treatment of migraine headaches. Generally, hair is removed from the posterior scalp to aid with exposure and minimize interference. The securing of occipital hair with surgical tape and rubber bands instead of preoperative hair removal is a viable alternative. The preservation of hair length can lead to better patient satisfaction by avoiding the hair length discrepancies and has demonstrated a low risk of surgical-site infection.

Comparing Plastic Surgery and Otolaryngology Management in Cleft Care: An Analysis of 4,999 Cases.

Care for patients with cleft lip and palate is best managed by a craniofacial team consisting of a variety of specialists, including surgeons, who are generally plastic surgeons or otolaryngologists trained in the United States. The goal of this study was to compare the surgical approaches and management algorithms of cleft lip, cleft palate, and nasal reconstruction between plastic surgeons and otolaryngologists. We performed a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program Pediatric database between 2012 and 2014 to identify patients undergoing primary repair of cleft lip, cleft palate, and associated rhinoplasty. Two cohorts based on primary specialty, plastic surgeons and otolaryngologists, were compared in relation to patient characteristics, 30-day postoperative outcomes, procedure type, and intraoperative variables. Plastic surgeons performed the majority of surgical repairs, with 85.5% ( n = 1,472) of cleft lip, 79.3% ( n = 2,179) of cleft palate, and 87.9% ( n = 465) of rhinoplasty procedures. There was no difference in the age of primary cleft lip repair or rhinoplasty. However, plastic surgeons performed primary cleft palate repair earlier than otolaryngologists ( p = 0.03). Procedure type varied between the specialties. In rhinoplasty, otolaryngologists were more likely to use septal or ear cartilage, whereas plastic surgeons preferred rib cartilage. Results were similar, with no statistically significant difference in terms of mortality, reoperation, readmission, or complications. Significant variation exists in the treatment of cleft lip and palate based on specialty service with regard to procedure timing and type. However, short-term rates of mortality, wound occurrence, reoperation, readmission, and surgical or medical complications remain similar.

A comparison of medical education in Germany and the United States: from applying to medical school to the beginnings of residency.

Both Germany and the United States of America have a long tradition of science and medical excellence reaching back as far as the nineteenth century. The same tribute must be paid to the medical educational system in both countries. Despite significant initial similarities and cross-inspiration, the paths from enrolling in a medical university to graduating as a medical doctor in Germany and the US seem to have become much different. To fill a void in literature, the authors' objective therefore is to delineate both structures of medical education in an up-to-date review and examine their current differences and similarities. Recent medical publications, legal guidelines of governmental or official organizations, articles in media, as well as the authors' personal experiences are used as sources of this report. Tuition loans of over $200,000 are not uncommon for students in the US after graduating from medical schools, which are often private institutions. In Germany, however, the vast majority of medical universities are tax-funded and, for this reason, free of tuition. Significant differences and surprisingly multiple similarities exist between these two systems, despite one depending on government and the other on private organizations. Germany currently employs an integrated medical curriculum that typically begins right after high school and consists of a 2-year long pre-clinical segment teaching basic sciences and a 4-year clinical segment leading medical students to the practical aspects of medicine. On the other hand, the US education is a two-stage process. After successful completion of a Bachelor's degree in college, an American student goes through a 4-year medical program encompassing 2 years of basic science and 2 years of clinical training. In this review, we will address some of these similarities and major differences.

Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy.

BACKGROUND: Metabolic syndrome (MetS) is defined as the concomitant disease process of obesity and at least two of the following variables: diabetes, hypertension, hypertriglyceridemia, or reduced high-density lipoprotein. These entities are well established as risk factors for complications following surgery. Obese patients are particularly prone to the development of MetS. The authors therefore aimed at elucidating the impact of MetS on the perioperative panniculectomy outcomes. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was analyzed for all primary procedures of panniculectomy from 2010 through 2015. The cases were stratified based on the presence or absence of MetS and evaluated for demographic data, intraoperative details, and their morbidity and mortality within 30 days after surgery. RESULTS: A total of 7030 cases were included in this study. Patients with MetS (6.2%) were of significantly worse health, required more emergency admissions (p = 0.022), longer hospitalization (p < 0.001), and more frequently inpatient procedures (p < 0.001) compared to the control group without MetS (3.8%). Plastic surgery was the predominant specialty operating on 79.5% of all cases. Surgical (23.3 vs. 8.7%) complications, readmission (8.7 vs. 3.0%), and reoperations (6.9 vs. 3.1%) rates were all significantly higher in patients with MetS that those without (p < 0.001). One fatality occurred in each cohort (0.23 vs. 0.02%, p = 0.010). CONCLUSION: Comorbidities are not uncommon in patients undergoing panniculectomy, especially in those diagnosed with MetS. Health-care providers need to be aware of the increased morbidity and mortality in this high-risk subgroup and need to consider preoperative optimization and management before proceeding with surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Management of soft tissue tumors of the upper extremity: a review.

INTRODUCTION: Management of malignant tumors of the hand and wrist is challenging and is generally approached by limb salvage or amputation. With advances in care, amputation has been superseded by limb salvage as the treatment of choice. METHODS: A narrative literature review was performed to identify articles on the topic of management of soft tissue tumors of the upper extremity, including surgical management, adjuvant radiation therapy, and chemotherapy. RESULTS: A total of 29 articles were selected. Earlier reports favored radical tumor resection, which often led to amputation, whereas later articles demonstrated limb salvage as the preferential treatment modality. CONCLUSIONS: Given the detrimental effects on function and psychologic outcomes, amputation has been superseded by limb salvage in most cases, although it can occasionally be the only option. A variety of adjuvant therapies have been described, including radiation or brachytherapy, chemotherapy, and regional hyperthermia. Radiation treatment, and specifically brachytherapy, is beneficial to select patients. Controversy surrounds chemotherapy in certain subtypes, and regional hyperthermia requires further investigation.

Resident Involvement in Microsurgery: An American College of Surgeons National Surgical Quality Improvement Program Analysis.

OBJECTIVE: In the current healthcare climate, there is increased focus on medical errors, patient outcomes, and the influence of resident participation on these metrics. Other studies have examined the influence of resident involvement on surgical outcomes, but the arena of microsurgery, with added complexity and learning curve, has yet to be investigated. DESIGN: A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database was performed to find patients undergoing procedures with free tissue transfer by screening for Current Procedural Terminology codes. Primary outcomes measured include flap failure, wound, infectious, and major and minor complications. SETTING: This study was conducted at the Methodist Hospital, an academic hospital located in Houston, Texas. PARTICIPANTS: Patients in the National Surgical Quality Improvement Program database between the years 2005 and 2012 undergoing microsurgical procedures were included in this analysis. RESULTS: A total of 1466 patients met inclusion criteria. There was a statistically significant association of major complications with age, peripheral vascular disease, American Society of Anesthesiologists (ASA) classification of 3 or greater, total operative time, and year of operation. Multivariate analysis on minor complications demonstrated significant association with ASA class of 3 or 4. Resident involvement was not a significant factor among any outcome measures including major complications, minor complications, flap failure, wound complications, infectious complications, bleeding requiring transfusion, and unexpected reoperation rates within 30 days. CONCLUSIONS: This study provides further evidence in support of the claim that resident involvement in microsurgery is safe and effective, with similar rates of major complications, minor complications, flap failure, and unexpected reoperation. High ASA classification and history of peripheral vascular disease were strong predictors of major complications and should be optimized preoperatively before free tissue transfer. Later years were associated with decreased major complication rates, which may be reflective of enhanced supervision standards.

The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases.

BACKGROUND: The growing elderly population necessitates a greater number of aging patients requiring complex reconstructive surgery involving free tissue transfer. The purpose of this study was to assess the safety, efficacy, and outcomes of microsurgical free tissue transfer in elderly patients using a national multi-institutional database. METHODS: We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients undergoing free tissue transfer. We stratified cohorts based on ages 18-49, 50-59, 60-69, 70-79, and 80+ years and analyzed primary outcomes of surgical complications, medical complications, mortality, and flap failure. RESULTS: A total of 5,951 patients were identified for inclusion in the analysis. Univariate analysis demonstrated progressively increasing surgical (P = .001) and medical (P < .001) complication rates with increasing age. After controlling for confounding variables, age was not significantly associated with rates of surgical (OR 1.00, 95% CI 0.99-1.01, P = .737) or medical (OR 1.01, 95% CI 0.99-1.03, P = .209) complications, flap failure (OR 1.00, 95% CI 1.00-1.02, P = .689), or reoperation (OR 1.01, 95% CI 1.00-1.03, P = 0.165). Factors associated with surgical complications included BMI (OR 1.03, 95% CI 1.00-1.05, P = .031), prolonged operative time (OR 1.001, 95% CI 1.000-1.002, P = .002), American Society of Anesthesiologists (ASA) classification of 3 or greater (OR 1.62, 95% CI 1.17-2.23, P = .003), and prolonged hospitalization (OR 1.03, 95% CI 1.02-1.04, P < .001). ASA classification of 3 or greater (OR 2.57, 95% CI 1.48-4.45, P = .001), renal history (OR 10.13, 95% CI 1.57-65.55, P = .015), and prolonged hospitalization (OR 1.06, 95% CI 1.04-1.08, P < .001) were associated with medical complications. Age was associated with increased mortality (OR 1.06, 95% CI 1.00-1.13, P = .048). CONCLUSION: Age alone should not be used as an absolute or even relative contraindication in patient assessment. Rather, preoperative assessment should focus on comorbidities and assessment of physiologic age instead of chronologic age. Optimization of these comorbidities is key to sustaining favorable outcomes in microsurgical free flap reconstruction in the elderly population.

Analysis of risk factors associated with unplanned reoperations following pediatric plastic surgery.

BACKGROUND/PURPOSE: Unplanned reoperation (UR) is an outcome measure with multiple advantages that can be used as a standardized tool to assess an institution's quality and safety of medical care. This study aimed to identify parameters associated with an increased likelihood of UR following plastic surgery in patients less than 18 years of age by using a large validated national multicenter database. METHODS/DESCRIPTION: We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database between 2012 and 2014 to identify pediatric patients undergoing primary plastic surgery procedures. Two cohorts were compared: patients who experienced UR and those who did not. Multiple logistic regression analysis was utilized to identify independent risk factors associated with UR. RESULTS: A total of 18,106 patients were identified in this analysis, with an overall UR rate of 0.8% (n = 137) within 30 days after surgery. Patients were on average 5.59 ± 5.27 years of age with 9522 boys (52.6%) and 8584 girls (47.4%). The procedures most commonly associated with UR were excision of skin and subcutaneous tissue for hidradenitis (UR = 10.3%), forehead, and/or supraorbital rim reconstruction with grafts (allograft or prosthetic material, UR = 6.1%), use of multiplane external fixators (UR = 5.6%), mastectomy for gynecomastia (UR = 4.4%), and forehead and/or supraorbital rim reconstruction with autograft (3.3%). The average number of relative value units per case was 10.01 ± 7.91. Independent risk factors for UR include inpatient procedure (p < 0.001), ASA class 3 or higher (p = 0.03), prolonged operative time (p < 0.001), and prior open wound or wound infection (p = 0.05). The most significant predictors of UR were postoperative medical and surgical complications (OR, 18.92 and 39.98, respectively, p < 0.001). CONCLUSIONS: With increasing focus on outcomes-driven healthcare, unplanned reoperation may be useful for monitoring quality across hospitals and identifying opportunities for quality improvement. This study provides the first analysis of risk factors associated with 30-day unplanned reoperations in pediatric plastic surgery. These results may aid in the informed consent process, improve patient risk assessment, counseling, and surgical planning.

The impact of resident involvement in breast reconstruction surgery outcomes by modality: An analysis of 4,500 cases.

BACKGROUND: The goal of this study was to determine the impact of resident involvement on various methods of breast reconstruction via an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) retrospective analysis. METHODS: We performed a retrospective analysis of the ACS NSQIP database to identify patients undergoing breast reconstruction by free flap, implant, latissimus dorsi (LD), and transverse rectus abdominis myocutaneous (TRAM) flap reconstruction modalities. Primary outcomes measured include major and wound complications. RESULTS: A total of 4,500 cases were included in this analysis, of which residents participated in 1,743 (38.7%). Major complications occurred in 7.2% of all cases, and wound complications occurred in 3.3% of all cases. BMI was positively correlated with major complications in free flap, implant, and TRAM reconstruction groups. Wound complications were associated with BMI in free flap, implant, and TRAM reconstruction, with steroid use in implant and TRAM reconstruction, and with a history of bleeding disorder in LD reconstruction. Resident involvement did not reach significance in any reconstruction group as an independent factor for major or wound complications. CONCLUSIONS: Resident involvement is safe and effective across implant, free flap, LD, and TRAM based methods of breast reconstruction with similar major and wound complication rates. Participation of trainees in these surgical cases is imperative for future patient care.

Orbital Decompression for Thyroid Eye Disease.

Although most cases of thyroid eye disease (TED) can be managed medically, some refractory or severe cases are treated surgically with orbital decompression. Due to a lack of randomized controlled trials comparing surgical techniques for orbital decompression, none have been deemed superior. Thus, each case of TED is managed based on patient characteristics and surgeon experience. Surgical considerations include the extent of bony wall removal, the surgical approach, the choice of incision, and the use of fat decompression. Outcomes vary based on surgical indications and techniques; hence, vision can improve or worsen after the surgery.