Randomized Controlled Trial Comparing Liposomal to Plain Bupivacaine in the Transversus Abdominis Plane for DIEP Flap Breast Reconstruction.

BACKGROUND: Pain control after autologous breast reconstruction is important for patient satisfaction and early recovery. Transversus abdominis plane (TAP) blocks are commonly used as part of an enhanced recovery after surgery (ERAS) pathway for breast reconstruction. It is uncertain whether liposomal bupivacaine used in TAP blocks offers additional advantages. This study aimed to compare the efficacy of liposomal bupivacaine versus plain bupivacaine for patients undergoing deep inferior epigastric perforator flap reconstruction. METHODS: This double-blinded randomized controlled trial studied patients undergoing abdominally based autologous breast reconstruction between June of 2019 and August of 2020. Subjects were randomly assigned liposomal or plain bupivacaine, performed using ultrasound-guided TAP block technique. All patients were managed according to an ERAS protocol. Primary outcomes were postoperative narcotic analgesia required, measured in oral morphine equivalents from postoperative days 1 to 7. Secondary outcomes included numeric pain scale score on postoperative days 1 to 7, nonnarcotic pain medication use, time to first narcotic use, return of bowel function, and length of stay. RESULTS: Sixty patients were enrolled: 30 received liposomal bupivacaine and 30 received plain bupivacaine. There were no significant differences in demographics, daily oral morphine equivalent narcotic use, nonnarcotic pain medication use, time to narcotic use, numeric pain scale score, time to bowel function, or length of stay. CONCLUSION: Liposomal bupivacaine does not confer advantages over plain bupivacaine when used in TAP blocks for abdominally based microvascular breast reconstruction in patients under ERAS protocols and multimodal approaches for pain control. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Patient Perspectives on Resident Involvement in Plastic Surgery.

OBJECTIVE: The objective of this study is to understand how patients at a large academic hospital perceive the training levels of residents and attendings and their perspectives on resident involvement in surgery. DESIGN: This is a cross-sectional survey-based study. SETTING: Patients who received care at Vanderbilt University Medical Center were asked to respond to our anonymous electronic survey via email. PARTICIPANTS: There were 3370 patients who underwent plastic surgery within the last 3 years at Vanderbilt University Medical Center were asked to participate. Eight hundred thirty-seven surveys were returned, representing a 24.8% response rate. RESULTS: There were 58.7% of the patients that were confident that a resident has completed medical school. There were 58.4% that report that they usually know if a resident will be assisting their surgeon in the OR, but 86.3% agree that they would like to know if a resident will be involved in their surgery. There were 76.3% that are comfortable with a resident performing parts of their surgery as long as their surgeon is ready to take over if needed. CONCLUSIONS: Patient understanding of a resident physician's education and abilities remains low. There is a discrepancy between the number of patients who would like to know if a resident will be involved in their surgery versus the number who are actually told if a resident will be involved.

The Flexible Care Pathway: An Alternative Paradigm for Post-Operative Care.

INTRODUCTION: Telehealth has demonstrated reduced cost and increased satisfaction post-operatively compared to Conventional Follow-up (CFU). However, a Flexible Care Pathway (FCP), which involves only "as-needed" follow-up, has never been formally evaluated. We hypothesize that the FCP is a safe and satisfactory for patients who undergo carpal (CTR)/ cubital tunnel release (CuTR). MATERIALS AND METHODS: Preoperatively, veterans were given the option to enroll in the FCP, in which post-operative follow-up visits were "as-needed" only. Patients who chose CFU were evaluated within 2 weeks post-operatively. Preoperatively, detailed post-operative instructions were given to both groups. Both groups were contacted by phone 30 days post-operatively with a questionnaire. The main outcomes were the number of FCP to CFU conversions, complications, time and distance of patient travel, and patient satisfaction. RESULTS: 105 patients were enrolled in the study, 60.2% chose FCP. One quarter (23.7%) of patients in the FCP group returned for in-person clinic evaluation. On average, the CFU group travelled a roundtrip distance of 102.9 miles and expended 3.51 h for their follow-up visits. CFU patients ranked their satisfaction at an average of 8.6/10, FCP patients ranked an average of 9.5/10 (p < 0.05). CONCLUSIONS: The FCP can be used in ambulatory hand surgeries with a high degree of safety and satisfaction, studied up to 30 days post-operatively. The FCP demonstrated higher patient satisfaction and a decrease in patient travel than CFU. This is particularly relevant in geographically broad areas, in populations with less access to specialty care, and in a pandemic where contact is limited.

Preoperative Risk Factors and Complication Rates of Breast Augmentation With Fat Grafting.

BACKGROUND: The current literature on the complications and risk factors of autologous fat grafting (AFG) for breast augmentation is scant and inconclusive. OBJECTIVES: The aim of this study was to use a large, multicenter database to determine the major complications and risk factors of patients undergoing breast augmentation with AFG in comparison to breast augmentation with implants. METHODS: Patients undergoing breast augmentation with AFG as well as with implants between January 2, 2017 and July 31, 2019 were identified from the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 45 days postoperatively. Age, gender, BMI, smoking, diabetes, facility, ASA class, and anesthetic type were evaluated as risk factors. RESULTS: Among the 76,128 patients enrolled in CosmetAssure, 789 (1.0%) underwent breast augmentation with AFG, in comparison to 18,544 (24.3%) patients with implants. The incidence of any major complication in the AFG cohort and implant cohort was 3.2% and 2.3%, respectively. Infection was significantly higher in the AFG cohort (1.1% vs 0.5%). Tobacco users were more likely to have any complication, infection, and pulmonary dysfunction/hypoxia on univariate analysis. ASA Class III/IV was more likely to have any complication and infection. On multivariate analysis, smoking was an independent risk factor for any complication (relative risk = 17.1) and infection (relative risk = 20.2). CONCLUSIONS: Infection and hematoma are the most common major complications in breast augmentation with AFG. Tobacco use is the only independent risk factor for overall complications and infection. Breast augmentation with AFG has a higher infection rate than augmentation with implants.

Incidence and Preoperative Risk Factors for Major Complications After Capsulectomy: Analysis of 3048 Patients.

BACKGROUND: Although there are many indications for periprosthetic breast capsulectomy, heightened public attention surrounding breast implant illness has resulted in increased rates of capsulectomy. OBJECTIVES: This study aimed to identify the incidence of major complications and risk factors associated with capsulectomy. METHODS: From an examination of a prospectively enrolled cosmetic surgery insurance database, CosmetAssure (Birmingham, AL), patients undergoing capsulectomy between January 2, 2017 and July 31, 2019 were identified. Outcomes measured included the occurrence of and risk factors for major complication(s) necessitating an emergency department visit, hospitalization, or reoperation within 45 postoperative days. RESULTS: Among 76,128 patients evaluated, 3048 (4.0%) underwent capsulectomy. There was a significant increase in number of capsulectomies following January 6, 2019 (2.7/day vs 5.2/day, P < 0.05). Capsulectomy patients were more likely to have any complication and specifically hematoma than those undergoing breast implant removal or replacement without capsulectomy (2.8% vs 1.9% and 1.6% vs 0.9%, respectively, P < 0.05). Eighty-four (2.8%) developed at least 1 complication. The most common complications included hematoma (1.6%) followed by infection (0.5%). American Society of Anesthesiologists Class III/IV was an independent risk factor for any complication and BMI ≥30 kg/m2 and office-based surgical suites were risk factors for infection. CONCLUSIONS: A growing number of capsulectomies are being performed. The most common major complication is hematoma. Patients undergoing capsulectomy experience a higher complication rate than those undergoing breast implant removal or replacement without capsulectomy. Patients should be counseled regarding the potential for major complications.

Post-Mastectomy Surgical Pocket Irrigation With Triple Antibiotic Solution vs Chlorhexidine Gluconate: A Randomized Controlled Trial Assessing Surgical Site Infections in Immediate Tissue Expander Breast Reconstruction.

BACKGROUND: Post-mastectomy pocket irrigation solution choice is debated and primarily surgeon dependent. We compare triple antibiotic solution (TAS) with 0.05% chlorhexidine gluconate (CHG). OBJECTIVES: The purpose of this study was to determine surgical site infection (SSI) rates after utilizing TAS vs CHG for breast pocket irrigation in immediate tissue expander (TE) breast reconstruction. METHODS: A prospective, blinded, randomized controlled trial was performed in patients (18-81 years old) who underwent bilateral mastectomy with TE reconstruction. In each patient, 1 mastectomy pocket was randomized to TAS and the other to CHG. Both the TE and the pocket were irrigated in the respective solution. The primary outcome was the incidence of SSI. Secondary outcomes were rates of mastectomy flap necrosis, hematoma, and seroma. RESULTS: A total of 88 patients who underwent bilateral immediate breast reconstruction were enrolled. Demographic and operative characteristics were equivalent because each patient served as their own control. Between the TAS and CHG groups, the incidence of SSI did not differ (5 [4.5%] vs 7 [8.0%], P = 0.35), including minor infections (2 [2.3%] vs 1 [1.1%], P = 0.56), major infections (2 [2.3%] vs 6 [6.8%], P = 0.15), and those resulting in explantation (2 [2.3%] vs 5 [4.5%], P = 0.25). Necrosis, hematoma, or seroma formation also did not differ. No patients who developed SSI received radiation. CONCLUSIONS: This study does not demonstrate a statistically significant difference in SSI between TAS and CHG irrigation, though TAS approached statistical significance for lower rates of infectious complications.

The Effective Duration of Antimicrobial Activity of Mafenide Acetate After Reconstitution.

Mafenide acetate is an effective but costly antimicrobial solution used for burn wounds. The package insert instructs the user to discard unused solution within 48 hours of opening. The purpose of this study is to evaluate the antimicrobial activity of mafenide acetate beyond 48 hours after reconstitution, to possibly reduce cost by eliminating product waste. Staphylococcus aureus and Pseudomonas aeruginosa isolates were used to seed Mueller-Hinton agar plates. Filter paper disks were then saturated with 5% mafenide acetate at 0, 2, 7, 14, 30, and 60 days after reconstitution. Disks were then placed on the seeded agar plates and incubated. After incubation, the zone of inhibition around each plate was measured. A zone of inhibition of 2 mm or greater was indicative of susceptibility. Mafenide acetate remained efficacious, with a zone of inhibition of >2 mm to both organisms at 0, 2, 7, 14, 30, and 60 days after mafenide acetate reconstitution. This in vitro study demonstrates that the antimicrobial activity of mafenide acetate remains present for at least 60 days after reconstitution. Unused mafenide may not need to be discarded at 48 hours after opening. Reducing wasted product has the potential to translate into cost savings.

Assessment of the Effect of Autograft Orientation on Peripheral Nerve Regeneration Using Diffusion Tensor Imaging.

PURPOSE: Given no definite consensus on the accepted autograft orientation during peripheral nerve injury repair, we compare outcomes between reverse and normally oriented autografts using an advanced magnetic resonance imaging technique, diffusion tensor imaging. METHODS: Thirty-six female Sprague-Dawley rats were divided into 3 groups: sham-left sciatic nerve isolation without injury, reverse autograft-10-mm cut left sciatic nerve segment reoriented 180° and used to coapt the proximal and distal stumps, or normally oriented autograft-10-mm cut nerve segment kept in its normal orientation for coaptation. Animals underwent sciatic functional index and foot fault behavior studies at 72 hours, and then weekly. At 6 weeks, axons proximal, within, and distal to the autograft were evaluated using diffusion tensor imaging and choline acetyltransferase motor staining for immunohistochemistry. Toluidine blue staining of 1-µm sections was used to assess axon count, density, and diameter. Bilateral gastrocnemius/soleus muscle weights were compared to obtain a net wet weight. Comparison of the groups was performed using Mann-Whiney U or Kruskal-Wallis H tests to determine significance. RESULTS: Diffusion tensor imaging findings including fractional anisotropy, radial diffusivity, and axial diffusivity were similar between reverse and normally oriented autografts. Diffusion tensor imaging tractography demonstrated proximodistal nerve regeneration in both autograft groups. Motor axon counts proximal, within, and distal to the autografts were similar. Likewise, axon count, density, and diameter were similar between the autograft groups. Muscle net weight at 6 weeks and behavioral outcomes (sciatic functional index and foot fault) at any tested time point were also similar between reverse and normally oriented autografts. CONCLUSIONS: Diffusion tensor imaging may be a useful assessment tool for peripheral nerve regeneration. Reversing nerve autograft polarity did not demonstrate to have an influence on functional or regenerative outcomes.

A novel conduit-based coaptation device for primary nerve repair.

BACKGROUND: Conduit-based nerve repairs are commonly used for small nerve gaps, whereas primary repair may be performed if there is no tension on nerve endings. We hypothesize that a conduit-based nerve coaptation device will improve nerve repair outcomes by avoiding sutures at the nerve repair site and utilizing the advantages of a conduit-based repair. METHODS: The left sciatic nerves of female Sprague-Dawley rats were transected and repaired using a novel conduit-based device. The conduit-based device group was compared to a control group of rats that underwent a standard end-to-end microsurgical repair of the sciatic nerve. Animals underwent behavioral assessments at weekly intervals post-operatively using the sciatic functional index (SFI) test. Animals were sacrificed at four weeks to obtain motor axon counts from immunohistochemistry. A sub-group of animals were sacrificed immediately post repair to obtain MRI images. RESULTS: SFI scores were superior in rats which received conduit-based repairs compared to the control group. Motor axon counts distal to the injury in the device group at four weeks were statistically superior to the control group. MRI tractography was used to demonstrate repair of two nerves using the novel conduit device. CONCLUSIONS: A conduit-based nerve coaptation device avoids sutures at the nerve repair site and leads to improved outcomes in a rat model. Conduit-based nerve repair devices have the potential to standardize nerve repairs while improving outcomes.

Bridging the Gap: Engineered Porcine-derived Urinary Bladder Matrix Conduits as a Novel Scaffold for Peripheral Nerve Regeneration.

PURPOSE: This study aims to compare engineered nerve conduits constructed from porcine-derived urinary bladder matrix (UBM) with the criterion-standard nerve autografts, for segmental loss peripheral nerve repairs. METHODS: Forty-eight Sprague-Dawley rats were divided into 2 groups. All underwent a 10-mm sciatic nerve gap injury. This was repaired using either (1) reverse autograft-the 10-mm cut segment was oriented 180 degrees and used to coapt the proximal and distal stumps or (2) UBM conduit-the 10-mm nerve gap was bridged with UBM conduit. Behavior assessments such as sciatic function index and foot fault asymmetry scores were performed weekly. At 3- or 6-week time endpoints, the repaired nerves and bilateral gastrocnemius/soleus muscles were harvested from each animal. Nerves were evaluated using immunohistochemistry for motor and sensory axon staining and with diffusion tensor imaging. The net wet muscle weights were calculated to assess the degree of muscle atrophy. RESULTS: The UBM group demonstrated significantly improved foot fault asymmetry scores at 2 and 4 weeks, whereas there was no difference in sciatic function index. The net muscle weights were similar between both groups. Motor axon counts proximal/inside/distal to the conduit/graft were similar between UBM conduits and reverse autografts, whereas sensory axon counts within and distal to the conduit were significantly higher than those of the autograft at 6 weeks. Sensory axonal regeneration seemed to be adherent to the inner surface of the UBM conduit, whereas it had a scattered appearance in autografts. Diffusion tensor imaging parameters between groups were similar. CONCLUSIONS: Urinary bladder matrix conduits prove to be at least similar to nerve autografts for the repair of peripheral nerve injuries with a short gap. The matrix perhaps serves as a scaffold to augment sensory nerve growth. CLINICAL RELEVANCE: In a clinical setting, UBM may eliminate the donor site morbidity and increased operative time associated with nerve autografting.

Utility and outcomes of hydroxocobalamin use in smoke inhalation patients.

INTRODUCTION: Hydroxocobalamin has been available for use for suspected cyanide toxicity in smoke inhalation patients in the United States since 2006. Our study compares outcomes of patients who received hydroxocobalamin to historical controls who did not. METHODS: In this retrospective review, patients administered hydroxocobalamin (2008-2014) were compared to historical controls (2002-2008). Patients <18 years, patients who received an alternate antidote, and patients without suspicion of smoke inhalation injury were excluded. Mortality was the primary outcome. Secondary outcomes evaluated were 7-day change in creatinine, culture-proven pneumonia, days on mechanical ventilation, ventilator- free days (VFD), ICU length of stay (ICU LOS), and hospital length of stay (HLOS). RESULTS: A total of 138 patients in the hydroxocobalamin group and 135 in the control group were identified. Mortality rate was similar between both groups (29% vs. 28%, p=0.90). Hydroxocobalamin was associated with lower pneumonia rate (23% vs. 49%, p<0.01), less ventilator days (4 days vs. 7 days, p<0.01), and increased VFD (20 days vs. 11 days, p=0.01) compared to controls. Shorter ICU LOS (6 days vs. 10 days, p=0.03) and a trend toward lower HLOS (7 day vs. 11 days, p=0.06) were also found in patients who received hydroxocobalamin. CONCLUSIONS: Routine administration was associated with lower rate of pneumonia, faster liberation from the ventilator, and reductions in intensive care unit stay. Burn centers should consider its empiric use in suspected smoke inhalation patients.

Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities.

BACKGROUND: There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned. OBJECTIVES: This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals. METHODS: A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed. RESULTS: Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01). CONCLUSIONS: Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3.

2.5% Mafenide Acetate: A Cost-Effective Alternative to the 5% Solution for Burn Wounds.

Mafenide acetate is an antimicrobial agent used to decrease the bacterial load for burn wounds. The 5% solution is more commonly used yet double the cost of its 2.5% counterpart. This study aims to evaluate outcomes and cost associated with the use of 2.5 vs 5% mafenide acetate formulation in the adult burn population. Adult patients (≥18 years) receiving 2.5% mafenide acetate during an 11-month period between 2014 and 2015, corresponding to a policy change in favor of the use of 2.5% mafenide acetate, were queried. Historical controls, patients receiving 5% mafenide acetate, were also reviewed during an 11-month period between 2013 and 2014. A retrospective review was performed comparing wound infection rate, bacteremia, sepsis, pneumonia, duration of mafenide therapy, length of hospital stay, mortality, and cost. A total of 54 and 65 patients received 2.5 and 5% mafenide acetate, respectively. There was no difference in wound infection, bacteremia, sepsis, pneumonia, duration of treatment, and mortality between the two groups. No adverse events occurred in either group directly related to mafenide. Candida and Staph species were the two most common isolates in the 2.5% group, whereas Pseudomonas and Staph species were the most common in the 5% arm. The mean cost of 2.5% mafenide therapy was $1494.92 compared with $3741.39 for 5% mafenide acetate. The 2.5% concentration demonstrates to be an equally efficacious and cost-effective alternative to the 5% concentration. Burn centers should consider the use of the more dilute preparation for burn wound infection prophylaxis as it may reduce the cost without compromising patient safety.

Hydrofiber Dressing Saturated With Mafenide Acetate Extends the Duration of Antimicrobial Activity.

Mafenide acetate is used in some burn wounds for its ability to penetrate eschar but requires frequent uncomfortable dressing changes for its application. The authors hypothesize that hydrofiber dressings will hold mafenide acetate solution for an extended period of time and maintain antimicrobial activity longer than traditional gauze, thus possibly obviating the need for frequent dressing changes. Four experimental arms included: 1) hydrofiber, stored on a dry well plate as control, 2) gauze saturated with 2.5% mafenide acetate, stored on nonsterile porcine skin, 3) hydrofiber saturated with mafenide acetate, stored on dry well plate, and 4) hydrofiber saturated with mafenide acetate, stored on nonsterile porcine skin. At 0, 24, 48, and 72 hours, a 1-cm disk was cut from the dressing sheet of each study arm, placed on agar plates seeded with Staphylococcus aureus and Pseudomonas aeruginosa, and incubated for 24 hours, and the zone of inhibition was measured. A zone of 2 mm or greater was indicative of susceptibility. Each arm of the experiment was performed four times to demonstrate reproducibility. Plain hydrofiber (control) demonstrated no zone of inhibition at any time point, thereby possessing no antimicrobial activity alone. Gauze saturated with mafenide acetate did not reliably demonstrate antimicrobial activity beyond 0 hours. Hydrofiber saturated with mafenide acetate, whether stored on a dry well plate or nonsterile porcine skin, consistently possessed sustained antimicrobial activity as demonstrated by zones of inhibition greater than 2 mm to both S. aureus and P. aeruginosa. Mafenide acetate-soaked hydrofiber dressings stay moist and maintain antimicrobial activity against S. aureus and P. aeruginosa for at least 72 hours without repeated soaks.

Preoperative Risk Factors and Complication Rates of Thighplasty: Analysis of 1,493 Patients.

BACKGROUND: Despite a rise in thighplasties, outcomes and risk factors have not been well described. OBJECTIVES: This study investigated the incidence and risk factors of major complications following thighplasty in a large, prospective, multicenter database. It further evaluated the safety of combined procedures. METHODS: Patients undergoing thighplasty between 2008 and 2013 were identified within the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 30 days postoperatively. Age, gender, body mass index, smoking, diabetes, type of facility, and combination procedures were evaluated as risk factors. RESULTS: Among the 129,007 patients enrolled in CosmetAssure, 1493 (0.8%) underwent thighplasty. One thousand and eighty-eight (72.9%) thighplasties were combined with other procedures. Ninety-nine (6.6%) developed at least one complication. The most common complications were infection (2.7%), hematoma (2.1%), suspected venous thromboembolism (VTE) (1.1%), fluid overload (0.5%), and confirmed VTE (0.3%). Thighplasties performed in a hospital had higher complications (8.1%) than ambulatory surgical center (6.2%) and office-based surgical suite (3.1%). When thighplasty was performed alone, smoking was an independent risk factor to develop at least one complication (RR = 9.51) and hematoma (RR = 13.48). Compared to thighplasty alone, complication rate did not increase with the addition of concomitant procedures (4.7% vs 7.4%, P = .079). CONCLUSION: Infection and hematoma are the most common major complications. In thighplasty alone, smoking is the only independent risk factor for overall complications and hematoma formation. The addition of concomitant cosmetic procedures does not increase complication rates. LEVEL OF EVIDENCE: 2 Risk.

Incidence and Risk Factors of Major Complications in Brachioplasty: Analysis of 2,294 Patients.

BACKGROUND: Brachioplasty is a popular procedure to correct upper arm ptosis. However, current literature on complications and risk factors is scant and inconclusive. OBJECTIVES: Using a large, prospective, multicenter database, we report the incidence of major complications and risk factors in patients undergoing brachioplasty. METHODS: Patients who underwent brachioplasty between 2008 and 2013 were identified from the CosmetAssure (Birmingham, AL) database. The primary outcome was the occurrence of major complication(s), defined as complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Risk factors including age, gender, body mass index (BMI), smoking, diabetes, combined procedures, and type of surgical facility were evaluated using univariate and multivariate analysis. RESULTS: Within the 129,007 patients enrolled in CosmetAssure, 2294 (1.8%) underwent brachioplasty. Brachioplasty patients were more likely to be older than 50 years (50.1%), obese (36.3%), diabetic (5.5%), but less likely smokers (5.5%). Major complications occurred in 3.4% brachioplasties with infection (1.7%) and hematoma (1.1%) being most common. Combined procedures, performed in 66.8% cases, had a complication rate of 4.4%, in comparison to 1.3% for brachioplasties performed alone. Combined procedures (RR = 3.58), males (RR = 3.44), and BMI ≥ 30 kg/m(2) (RR = 1.92) were identified as independent risk factors for the occurrence of any complication. Combined procedures (RR = 12.42), and the male gender (RR = 8.89) increased the risk of hematoma formation. CONCLUSIONS: Complication rates from brachioplasty are much lower than previously reported. Hematoma and infection are the most common major complications. Combined procedures, male gender, and BMI ≥ 30 kg/m(2) are independent risk factors for complications. LEVEL OF EVIDENCE 2: Risk.