Using the modified frailty index to predict negative outcomes in free-flap breast reconstruction: A National Surgical Quality Improvement Project-based study.

BACKGROUND: Post-mastectomy free-flap breast reconstruction is becoming increasingly common in the United States. However, predicting which patients may suffer complications remains challenging. We sought to apply the validated modified frailty index (mFI) to free-flap breast reconstruction in breast cancer patients and determine its utility in predicting negative outcomes. METHODS: We conducted a retrospective study using National Surgical Quality Improvement Project (NSQIP). All patients who had a CPT code of 19364, indicative of free tissue transfer for breast cancer reconstruction, were included. Data on preoperative characteristics and postoperative outcomes were collected. Patients were separated based on the number of mFI factors present into three categories: 0, 1, and > 2 factors. Preoperative demographics, clinical status, and other comorbidities were also studied. Negative outcomes were compared using multivariate logistic regression. RESULTS: 11,852 patients (mean age 50.9 ± 9.5) were found; 24.2% had complications, comparable to previous literature. mFI is predictive of all types of negative outcomes. 22.5% of all patients with 0 mFI, 27.7% of patients with 1 mFI and 34.2% of patients with at least two mFI had a negative outcome. The most common factors contributing to the mFI were history of hypertension (24.8%) and diabetes (6.1%). mFI was found to be an isolated risk factor for negative outcomes, along with steroid use, American Society of Anesthesiology (ASA) classification, body mass index, and immediate, and bilateral operations. CONCLUSIONS: This NSQIP-based study for patients undergoing free flap breast reconstruction shows that the mFI holds predictive value regarding negative outcomes. This provides more information to properly counsel patients before free flap breast reconstruction surgery.

Multidisciplinary surgical treatment approach for dermatofibrosarcoma protuberans: an update.

Dermatofibrosarcoma protuberans (DFSP) is a cutaneous sarcoma that has remained a challenge for oncologic and reconstructive surgeons due to a high rate of local recurrence. The objective of this study is to investigate the oncologic and reconstructive benefits of employing a multidisciplinary two-step approach to the treatment of DFSP. A retrospective review was conducted using a prospectively collected database of all patients who underwent resection and reconstruction of large DFSPs by a multidisciplinary team, including a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic and reconstructive surgeon, at one academic institution from 1998-2018. Each patient underwent Mohs micrographic surgery for peripheral margin clearance (Step 1) followed by wide local excision (WLE) of the deep margin by surgical oncology and immediate reconstruction by plastic surgery (Step 2). 57 patients met inclusion criteria. Average defect size after WLE (Step 2): 87.3 cm2 (range 8.5-1073.5 cm2). Mean follow-up time was 37 months (range 0-138 months). There were no cases of recurrence. A two-step multidisciplinary surgical treatment approach for DFSP minimizes risk of recurrence, decreases patient discomfort, and allows immediate reconstruction after deep margin clearance.

Innovative Bioactive Glass Fiber Technology Accelerates Wound Healing and Minimizes Costs: A Case Series.

OBJECTIVE: To evaluate the efficacy and value of a novel borate-based bioactive glass fiber (BBGF) advanced wound matrix in the treatment of chronic wounds. METHODS: Four patients with chronic wounds that had failed multiple prior treatments were identified and treated with the BBGF technology. Patient demographics, wound characteristics, and prior treatment history were obtained. Costs associated with prior treatments were estimated and recorded using available cost data. RESULTS: The average wound duration prior to initiation of BBGF treatment was 391 days. All of the patients had a history of multiple failed interventions, including operative procedures, negative-pressure wound therapy, cellular and/or tissue-based products, dermal grafts, and synthetic wound matrices. Prior interventions resulted in an average estimated cost of $87,750 per patient. All of the patients achieved complete wound closure in an average of 55 days using BBGF treatment. Patients were treated with 3.3 applications of the BBGF product on average, with an average cost of $3,564. The use of the BBGF advanced wound matrix on initial presentation could have saved the healthcare system an average of $84,186 per patient and reduced wound duration by an average of 336 days. CONCLUSIONS: The BBGF advanced wound matrix resulted in the healing of chronic wounds that had failed multiple prior interventions. In this series of challenging cases, BBGF accelerated healing while minimizing costs and improving patient outcomes. By offering an effective therapy at a low cost, BBGF has the potential to add significant value for both the healthcare system and the patient.

Lending a Hand to Health Care Disparities: A Cross-sectional Study of Variations in Reimbursement for Common Hand Procedures.

Background: Despite the role of one's hands in human function and quality of life, financial disincentives to perform common hand procedures in patients with government-sponsored insurance plans may lead to longer wait times and decreased access to care. Here, we identify the variations in reimbursement for 4 common hand procedures as a step toward understanding these financial implications to develop safeguards to minimize effects on access to care. Methods: Billing data were collected over a 10-year period for patients undergoing carpal tunnel release (open, Current Procedural Terminology 64721; endoscopic, 29848), cubital tunnel release (64718), ganglion cyst excision (25111), and interposition arthroplasty (25447). Patients were placed into cohorts according to insurance type-private insurance, Medicare, Medicaid, or worker's compensation-and these were directly compared. Results: A total of 3489 procedures between 2005 and 2015 were identified in this study (carpal tunnel 65.8%, cubital tunnel 28.7%, ganglion cyst excision 4.1%, and interposition arthroplasty 13.8%). In all, 54.7% of patients had private insurance; 26.3%, Medicare; 10.5%, worker's compensation; and 8.5%, Medicaid. Reimbursement, as a percentage of charge, differed significantly by payor type for all cases and by procedure. On average, worker's compensation plans reimbursed 65.5% of submitted charges; private insurance, 50.6%; Medicare, 25.1%; and Medicaid, 24.6%. Conclusions: We found that wide variations in reimbursement for common hand procedures exist and may preclude some surgeons from offering certain procedures to a subset of patients. Understanding these discrepancies is a key first step in minimizing a potential care delivery disparity for this patient population.

Five Financial Pearls for Medical Students, Residents, and Young Surgeons.

BACKGROUND: Finances impact every aspect of our daily lives. Despite this, they are rarely discussed in medical school or surgical training. Consequently, more than half the medical students we interview report no formal teaching about personal finance. The purpose of this article was to present 5 topics every graduating medical student, resident, and young surgeon should understand to start the path to financial independence. METHODS: We synthesized recommendations and data from several books on financial literacy, blogs on the topic, and the personal experiences of the 4 authors. RESULTS: The following 5 topics were identified as critical for young surgeons: learn about and manage your own finances, consider the financial implications of your career choices, make a plan to pay off your student loans, make a budget and stick to it, and think carefully before buying property. Central to these 5 lessons is the idea that starting to invest and save early is essential to taking advantage of interest and capital gains. We also demonstrate pay and cost differences in 5 regions of the country and outline the 2 main pathways one can take to repaying their student loans. CONCLUSIONS: Financial literacy is an important aspect of being an effective surgeon. With minimal effort, you can take these 5 steps now toward financial freedom. Doing so will improve your sense of control over your financial life and decrease anxiety about the unknown.

The "Butterfly" Wrap: A Simplified Technique for Consistent Prosthesis Coverage in Prepectoral Breast Reconstruction.

BACKGROUND: Here, we describe our simple, systematic, reproducible, and effective method for prosthesis coverage in prepectoral breast reconstruction. METHODS: Our Butterfly Wrap is a simple technique, which provides prosthesis coverage with a single sheet of acellular dermal matrix (ADM) in a reproducible and elegant manner. The wrap design creates an anatomic tear-shaped pocket to guide expansion and encourage lower pole fullness, without ADM folding or bunching for optimal incorporation and minimal overlap. Further, it minimizes waste, allowing for smaller sheets of ADM to be used per breast, and can easily be performed in minimal time on the back table while the mastectomies are being performed, as a means of minimizing cost. RESULTS: Our technique can be applied to effectively cover all shapes and sizes of expanders and implants, both teardrop and round. As a result, the surgeon need only focus on the critical nuances of prosthesis-based prepectoral breast reconstruction, without the anxiety of how to wrap the prosthesis and what size of ADM to use. CONCLUSIONS: The Butterfly Wrap is a simple, systematic, reproducible, and effective method for prosthesis coverage in prepectoral reconstruction.

Are Residents Prepared for Surgical Cases? Implications in Patient Safety and Education.

OBJECTIVE: In surgical education, the areas of focus and evaluation are skewed toward technical skill and operative knowledge; less emphasized is familiarity with the patient's medical history. The purposes of this study were to characterize how surgical trainees prepare for cases and to determine the comprehensiveness of their preparation. DESIGN: A 27-question survey was created through a web-based software program and distributed to all resident physicians and fellows in the Departments of Surgery, Neurosurgery, and Otolaryngology at our institution. Survey responses were collected anonymously and analyzed. Institutional review board exemption was obtained. SETTING: This study was performed at Washington University in St. Louis, Missouri, at an institutional hospital setting. PARTICIPANTS: The survey was distributed to current surgical trainees at Washington University in St. Louis in the Departments of Surgery, Neurosurgery, and Otolaryngology. Further, 130 of 169 surgical residents and fellows completed the survey. RESULTS: Most respondents (96%) taught themselves case preparation. Only 57% of respondents reviewed the patients medical record before every surgery. Although most respondents (83%) felt they were prepared or very prepared from a patient-specific standpoint, only 24% felt that their handoff of a patient to on-call colleagues was comprehensive enough to include all pertinent aspects of a patient's history and expected perioperative course. From a technical perspective, most residents (63%) felt they were prepared or very prepared, and this level of comfort increased with postgraduate year; 76% of respondents would not feel comfortable telling their attending they were not adequately prepared. CONCLUSIONS: Although most trainees feel prepared or very prepared for cases from a patient-specific regard, only half review the patient's medical record before every surgery. Furthermore, almost all trainees have taught themselves how to prepare for surgery. This represents a critical gap in residency education and an opportunity to improve patient safety and quality of care.

A Cross-Sectional Study of Variations in Reimbursement for Breast Reconstruction: Is A Healthcare Disparity On the Horizon?

BACKGROUND: Despite growing demand for breast reconstruction, financial disincentives to perform breast reconstruction in patients with government-sponsored insurance plans may lead to longer wait times and decreased access to care. We identify the variation in reimbursement for implant and autologous reconstruction as a step toward understanding these financial implications, to develop safeguards to minimize effects on access to care. METHODS: Billing data were collected over a 10-year period for patients undergoing implant-based (19357) or free-flap (19364) breast reconstruction. Patients were placed into cohorts according to insurance type-Medicare, Medicaid, or private insurance, and these were directly compared. RESULTS: A total of 2691 women underwent breast reconstruction between 2003 and 2013; 71.2% had private insurance, 13.3% had Medicaid, and 14.49% had Medicare. For implant-based reconstructions, the average reimbursement of total charges was 16.3% for Medicaid, 28.3% for Medicare, and 67.2% for private insurance. For autologous reconstruction, average reimbursement was 12.37% for Medicaid, 22.9% for Medicare, and 35.35% for private insurance. Hourly reimbursement estimates for Medicaid patients undergoing autologous reconstruction were lowest. The highest hourly reimbursement estimate was for privately insured patients undergoing implant-based reconstruction. Over time, reimbursement for autologous reconstruction has declined significantly for all payor types, whereas implant-based reimbursement disparities are narrowing. CONCLUSIONS: We found that wide variations in reimbursement for breast reconstruction procedures exist and may preclude some surgeons from offering certain reconstructive options to a subset of patients. Understanding these discrepancies is a key first step in minimizing a potential care delivery disparity for this patient population.

A Retrospective Cohort Study on Payor Type and the Effect on Revisions in Breast Reconstruction.

BACKGROUND: Patients who are insured by Medicare and Medicaid are less likely to undergo breast reconstruction than their privately insured counterparts. Whether insurance type also affects subsequent revisions remains unknown. This study explores the relationship among payor type, revision procedures, and the completion of breast reconstruction. METHODS: A retrospective cohort study was created including patients who underwent breast reconstruction at the authors' institution from 1996 to 2016. Data collected included age, cancer stage, race, laterality, initial breast reconstruction type, total number of procedures, number of trips to the operating room, and subsequent revisions. Analysis of covariance and logistic regression were used to estimate the controlled mean number of revisions and probability of completion of reconstruction as a function of insurance type. RESULTS: A total of 3113 patients were included: 2271 (72.9 percent) with private insurance, 450 (14.5 percent) with Medicare, and 392 (12.6 percent) with Medicaid. On controlled analysis, there was no difference in total number of procedures, number of revisions, or number of trips to the operating room among the three insurance types. There was no difference in the proportion of patients undergoing symmetry procedures or nipple-areola reconstruction. CONCLUSIONS: To the authors' knowledge, this is the first study to evaluate discrepancies in number of procedures, revisions, and the proportion of patients completing breast reconstruction among insurance types. When controlling for other factors, the authors report no differences in care based solely on payor type. Instead, patient and surgeon variables may be responsible for the differences observed, and should be targeted in future research to improve equity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Adipose Tissue Drives Response to Ischemia-Reperfusion Injury in a Murine Pressure Sore Model.

BACKGROUND: Ischemia-reperfusion injury contributes significantly to the pathogenesis of chronic wounds such as pressure sores and diabetic foot ulcers. The authors' laboratory has previously developed a cyclical murine ischemia-reperfusion injury model. The authors here use this model to determine factors underlying tissue response to ischemia-reperfusion injury. METHODS: C57BL/6 mice were subjected to cycles of ischemia-reperfusion that varied in number (one to four cycles) and duration of ischemia (1 to 2 hours). For each ischemia-reperfusion condition, the following variables were analyzed: (1) digital photographs for area of necrosis; (2) hematoxylin and eosin staining and immunohistochemistry for inflammatory infiltrate; and (3) expression of inflammatory markers by quantitative polymerase chain reaction. In addition, human adipocytes and fibroblasts were cultured in vitro under conditions of hypoxia and reoxygenation, and expression of inflammatory markers was analyzed by quantitative polymerase chain reaction. RESULTS: Increases in both ischemia-reperfusion cycle number and ischemia duration correlated with increased areas of epithelial necrosis both grossly and histologically, and with an increase in cellularity and neutrophil density. This increased inflammatory infiltrate and a significant increase in the expression of proinflammatory markers (Hmox1, interleukin-6, interleukin-1, and monocyte chemoattractant protein-1) was observed in adipose tissue subjected to ischemia-reperfusion injury, but not in dermis. These results were mirrored in human adipose tissue. CONCLUSIONS: The authors further characterize a novel, reproducible murine model of ischemia-reperfusion injury. The results of their study indicate that adipose tissue is less tolerant of ischemia-reperfusion than dermal tissue. Rather than being an "innocent bystander," adipose tissue plays an active role in driving the inflammatory response to ischemia-reperfusion injury.

Lipedema: A Relatively Common Disease with Extremely Common Misconceptions.

Lipedema, or adiposis dolorosa, is a common adipose tissue disorder that is believed to affect nearly 11% of adult women worldwide. It is characterized most commonly by disproportionate adipocyte hypertrophy of the lower extremities, significant tenderness to palpation, and a failure to respond to extreme weight loss modalities. Women with lipedema report a rapid growth of the lipedema subcutaneous adipose tissue in the setting of stress, surgery, and/or hormonal changes. Women with later stages of lipedema have a classic "column leg" appearance, with masses of nodular fat, easy bruising, and pain. Despite this relatively common disease, there are few physicians who are aware of it. As a result, patients are often misdiagnosed with lifestyle-induced obesity, and/or lymphedema, and subjected to unnecessary medical interventions and fat-shaming. Diagnosis is largely clinical and based on criteria initially established in 1951. Treatment of lipedema is effective and includes lymphatic support, such as complete decongestive therapy, and specialized suction lipectomy to spare injury to lymphatic channels and remove the diseased lipedema fat. With an incidence that may affect nearly 1 in 9 adult women, it is important to generate appropriate awareness, conduct additional research, and identify better diagnostic and treatment modalities for lipedema so these women can obtain the care that they need and deserve.

Predictors of readmission after outpatient plastic surgery.

BACKGROUND: Hospital readmissions have become a topic of focus for quality care measures and cost-reduction efforts. However, no comparative multi-institutional data on plastic surgery outpatient readmission rates currently exist. The authors endeavored to investigate hospital readmission rates and predictors of readmission following outpatient plastic surgery. METHODS: The 2011 National Surgical Quality Improvement Program database was reviewed for all outpatient procedures. Unplanned readmission rates were calculated for all 10 tracked surgical specialties (i.e., general, thoracic, vascular, cardiac, orthopedics, otolaryngology, plastics, gynecology, urology, and neurosurgery). Multivariate logistic regression models were used to determine predictors of readmission for plastic surgery. RESULTS: A total of 7005 outpatient plastic surgery procedures were isolated. Outpatient plastic surgery had a low associated readmission rate (1.94 percent) compared with other specialties. Seventy-five patients were readmitted with a complication. Multivariate regression analysis revealed obesity (body mass index ≥ 30), wound infection within 30 days of the index surgery, and American Society of Anesthesiologists class 3 or 4 physical status as significant predictors for unplanned readmission. CONCLUSIONS: Unplanned readmission after outpatient plastic surgery is infrequent and compares favorably to rates of readmission among other specialties. Obesity, wound infection within 30 days of the index operation, and American Society of Anesthesiologists class 3 or 4 physical status are independent predictors of readmission. As procedures continue to transition into outpatient settings and the drive to improve patient care persists, these findings will serve to optimize outpatient surgery use.

A multivariate regression analysis of panniculectomy outcomes: does plastic surgery training matter?

BACKGROUND: Panniculectomy can improve quality of life in morbidly obese patients, but its functional benefits are counterbalanced by relatively high complication rates. The authors endeavored to determine the impact of plastic surgery training on panniculectomy outcomes. METHODS: A retrospective review was performed of the prospectively maintained American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing panniculectomy from 2006 to 2010. Patient demographic details, surgeon specialty training, and 30-day outcomes were assessed. RESULTS: A total of 954 panniculectomies meeting inclusion criteria were identified. Plastic surgeons performed 694 (72.7 percent) of the procedures, and 260 (27.3 percent) were performed by nonplastic surgeons. Nonplastic surgeons had significantly higher rates of overall complications (23.08 percent versus 8.65 percent; p < 0.001) and wound infections (12.69 percent versus 5.33 percent; p < 0.001) than plastic surgeons. Average operative time for plastic surgeons was significantly longer than that for nonplastic surgeons (3.00 ± 1.48 hours versus 1.88 ± 0.93 hours; p < 0.001). Risk-adjusted multivariate regression showed that undergoing a panniculectomy by a nonplastic surgeon was a significant predictor of overall postoperative complications (odds ratio, 2.09; 95 percent CI, 1.35 to 3.23) and wound infection (odds ratio, 1.73; 95 percent CI, 1.004 to 2.98). Subgroup analysis of propensity-matched samples supported this finding. CONCLUSION: Multivariate regression analysis of National Surgical Quality Improvement Program data showed that panniculectomy performed by plastic surgeons results in lower rates of overall postoperative complications compared with that performed by nonplastic surgeons.

The incidence of methicillin-resistant Staphylococcus aureus in pressure ulcers.

Colonization of chronic wounds with methicillin-resistant Staphylococcus aureus continues to be an important healthcare concern. Aside from the morbidity associated with infections, colonization alone can contribute to outbreaks at long-term-care facilities and within hospitals. Despite the prevalence of pressure ulcers, the incidence of S aureus in these chronic wounds is unknown.

Bone biology and physiology: Part I. The fundamentals.

The principles of bone biology and physiology permeate all subspecialty practices in plastic and reconstructive surgery from hand surgery to aesthetic surgery. Despite its importance in our practices, the biology of bone healing and bone physiology rarely surfaces within textbooks, literature reviews, or residency curricula. In this article, the authors present the first of a two-part series reviewing the important concepts of bone biology and bone physiology relevant to plastic surgery in an effort to ameliorate this educational gap.