Inpatient versus Outpatient Immediate Alloplastic Breast Reconstruction: Recent Trends, Outcomes, and Safety.

Background: Immediate alloplastic breast reconstruction was traditionally performed as an inpatient procedure. Despite several reports in the literature demonstrating comparable safety outcomes, there remains hesitancy to accept breast reconstruction performed as an outpatient procedure. Methods: A retrospective review of National Surgical Quality Improvement Program data from 2014 to 2018 was utilized to evaluate recent trends and 30-day postoperative complication rates for inpatient versus outpatient immediate prosthetic-based breast reconstruction. Propensity score matching was used to obtain comparable groups. Results: During the study period, 33,587 patients underwent immediate alloplastic breast reconstruction. Of those, 67.5% of patients were discharged within 24 hours, and 32.4% of patients had a hospital stay of more than 24 hours. Immediate alloplastic reconstruction had an overall growth rate of 16.9% from 2014 to 2018. After propensity score matching, intraoperative variables that correlated with significantly increased inpatient status included increased work relative value units (16.3 ± 2.3 versus 16.2 ± 2.6; P < 0.001), longer operative times (228 ± 86 versus 206 ± 77; P < 0.001), and bilateral procedure (44.0% versus 43.5%; P < 0.001). There were higher rates of pulmonary embolism, wound dehiscence, urinary tract infection, transfusions, sepsis, readmissions, and reoperations in the group with the longer hospital stay. Conclusion: Based on increased complication rates and costs in the inpatient setting, we propose outpatient reconstructive surgery as a safe and cost-effective alternative for immediate alloplastic breast reconstruction.

Management of Dog Bite Injuries: Procedural Sedation, Infection, and Operative Indications at a Single-Institution Level I Pediatric Trauma Hospital.

BACKGROUND: Dog bite injuries are common within the pediatric population. Currently, there are inconclusive data on best sedation practice, antibiotic regimen, and need for plastic surgery referrals for treatment of dog bite injuries in the emergency department (ED) versus operating room (OR). This study set out to determine sedation practice, infection management, and necessity for plastic surgery referral at a level I pediatric trauma center. METHODS: A retrospective review of all pediatric (0-18 years old) dog bites documented in electronic medical records from January 1, 2010, to December 31, 2019, was performed. Bitten by dog encounters were identified by International Classification of Diseases, Ninth Revision and Tenth Revision codes E906.0 and W54.0, W54.0XXA, and W54, respectively. Data gathered included age, gender, month of injury, circumstance of injury, injury characteristics, location of repair, person performing repair, sedation (if used, then length of sedation), inpatient admission, antibiotics prescribed, dog characteristics (breed, size, sex, age, relationship to patient), and complications. Summary statistics were calculated as mean ± SD. Comparisons for nominal variables were performed using the χ2 test. All analyses were performed using Stata v.16. 1. RESULTS: A total of 1438 pediatric patients were included in this study over a 10-year period. Of injuries requiring repair (n = 846), most repairs were performed in the ED (97.1% [822/846]), whereas 24 (2.8%) required repair in the OR. Of the bites that required repair (n = 846), 81.1% (686/846) were performed by an emergency medicine physician and 147 (17.4%) by plastic surgeons. Procedural sedation in the ED was performed in 146 repairs (17.3%). Documented sedation time ranged from 10 to 96 minutes. Most patients received a prescription for antibiotics (80.5%), usually amoxicillin/clavulanate (90.8%). Infection was the most common sequela (9.5%). There was no significant difference in infection rates between repairs performed in the ED versus those in the OR. CONCLUSION: Our study indicates that pediatric patient dog bite injuries can be successfully managed in an ED. Procedural sedation has demonstrated no increased safety risks compared with the OR. Rates of infection are also not demonstrated to be significantly higher in repairs done in the ED versus those taken to operating theater.

The Role of Premastectomy Mastopexy and Breast Reduction in the Reconstruction of the Enlarged or Ptotic Breast.

BACKGROUND: The indications for nipple-sparing mastectomy have broadened over time. Patients undergoing nipple-sparing mastectomy who have enlarged or ptotic breasts are at risk for skin flap and/or nipple-areola complex necrosis. Premastectomy mastopexy or breast reduction may reduce the risk for these complications. METHODS: A retrospective review was undertaken in a series of patients who underwent premastectomy reduction mammaplasty or mastopexy followed by nipple-sparing mastectomy and immediate staged tissue expander/implant-based breast reconstruction. In each case, a subnipple biopsy was performed at the premastectomy procedure to clear it of any potential malignant involvement. In addition, the area under the areola was undermined to maximize the effect of the delay phenomenon on the eventual survival of the nipple-areola complex. Final reconstruction involved tissue expander exchange for a permanent implant with associated fat grafting. Data regarding surgical timing and selected postoperative complications were recorded. RESULTS: In total, 39 implant-based reconstructions were performed in 20 patients. There were no cases of mastectomy flap necrosis, and partial necrosis of the nipple-areola complex with delayed wound healing was seen in two breasts in the same patient. All patients eventually completed the reconstructive process successfully. CONCLUSION: Premastectomy mastopexy or breast reduction may afford a protective effect against mastectomy flap or nipple-areola complex necrosis in patients with large or ptotic breasts who subsequently undergo nipple-sparing mastectomy with immediate breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Transgender Surgery: Perspectives Across Levels of Training in Medical and Surgical Specialties.

Purpose: Approximately 1.4 million adults identify as transgender in the United States. Transgender patients face societal, legal, and medical discrimination that can lead to health disparities. The objective of this study was to evaluate knowledge and perceptions of transgender health care across various levels of medical training and specialties. Methods: Between April 1, 2019 and May 1, 2019, an anonymous survey was distributed to residents and attendings, in both medical and surgical specialties, at a university-affiliated hospital. Participants were recruited into the study with survey distribution by email to residency program directors, residents, and residency-affiliated attendings. Results: There was a response rate of 29.5% (118/400). Across all respondents, 34.7%, 31.4%, and 39% knew where to refer transgender patients for hormone replacement, psychotherapy, or surgery, respectively. Only 37.9% of residents and 46.2% of attendings reported that they were confident of providing care for a transgender patient (p=0.130). In addition, less than one-third of surgical respondents reported sufficient knowledge to describe transgender surgery. The most common reasons affecting comfort level when caring for transgender patients were lack of exposure (53.4%) and lack of formal education (47.6%), with other reasons being personal, moral, and religious reasons (11%, 8.5%, and 6.8%, respectively). Conclusion: Despite literature demonstrating the effectiveness of formal didactics and education in transgender health, there remain disparities in the knowledge and comfort of residents and attendings across all specialties. To deliver competent health care to transgender patients, efforts must focus on improving the availability of system-wide resources and educational opportunities for all specialties.

Chronic Persisting Hematoma: Report of a Case and Literature Review.

The authors present a unique case of chronic persisting hematoma formation at the site of a remote congenital melanocytic nevus excision with tissue expander reconstruction. Similarities between chronic persisting hematoma and chronic encapsulated seroma are addressed to provide guidance on the appropriate workup and management for the plastic surgeon. 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 .

A Cost-Minimization Analysis Evaluating the Use of Liposomal Bupivacaine in Reconstructive Plastic Surgery Procedures.

BACKGROUND: Postsurgical pain management is critical to patient satisfaction and value. Several studies have evaluated liposomal bupivacaine in postoperative pain management protocols; however, its economic feasibility remains undefined. This study analyzes the economic impact of liposomal bupivacaine using a national claims database to assess postoperative clinical and financial outcomes in plastic and reconstructive procedures. METHODS: The Vizient Clinical Data Base/Resource Manager electronic database was reviewed for plastic surgery procedures (i.e., abdominoplasty, abdominal wall reconstruction, mastectomy with immediate tissue expander placement, mastectomy with direct-to-implant reconstruction, autologous breast reconstruction, and augmentation mammaplasty) at participating hospitals from July 1, 2016, to July 1, 2017. The main outcome measures were the length of stay; 7-, 14-, and 30-day readmission rates; and direct and total costs observed. RESULTS: During the study period, 958 total cases met inclusion criteria. Liposomal bupivacaine was used in 239 cases (25 percent). Compared with cases that did not use liposomal bupivacaine, liposomal bupivacaine cases had a decreased length of stay (9.2 days versus 5.8 days), decreased cost (total cost, $39,531 versus $28,021; direct cost, $23,960 versus $17,561), and lower 30-day readmission rates (4 percent versus 0 percent). The 14- and 7-day readmission rates were similar between the two groups. CONCLUSIONS: The use of liposomal bupivacaine may contribute to a reduction in length of stay, hospital costs, and 30-day readmission rates for abdominal and breast reconstructive procedures, which could contribute to a favorable economic profile from a system view. Focusing on the measurement and improvement of value in the context of whole, definable, patient processes will be important as we transition to value-based payments.

Flap-Mastopexy in Autologous Breast Reconstruction: Timing and Technique.

BACKGROUND: Techniques in breast reconstruction have significantly advanced the possibility to create more natural and aesthetically appealing breasts. Despite thorough preoperative planning and vigilant operative technique, symmetry remains a concern for select patients who have undergone autologous breast reconstruction. Although symmetry procedures of the contralateral breast have been well described in the literature, little has been published regarding secondary revision in the autologous reconstructed breast, leaving uncertainty as to the appropriate timing and technique for revision procedures that will not hinder the viability of the flap. In this article, we provide an effective, reproducible and safe method of mastopexy after autologous breast reconstruction. METHODS: A retrospective review of all patients undergoing autologous breast reconstruction by a single surgeon between 2007 and 2014 was performed. Patients who underwent mastopexy after autologous breast reconstruction were included. Patient characteristics, type of reconstruction, staging of procedures, secondary operations, and complications were recorded. RESULTS: Ten patients with asymmetric autologous breast reconstruction underwent flap mastopexy in 1 or both breasts. Indications for mastopexy included asymmetry resulting from immediate loss of autologous flaps, unilateral fat necrosis, scarring after mastectomy flap necrosis, excess ptosis, and volume asymmetries. No flap loss, fat necrosis, or nipple loss occurred after flap mastopexy. CONCLUSIONS: The autologous mastopexy technique is a useful option in secondary refinement procedures for breast reconstruction. It provides a reliable and predictable method to adjust the inframammary fold, increase projection, and address excess ptosis. It has a low complication rate and can be safely and reliably performed as early as 3 months after initial reconstruction.