Branding a Plastic Surgery Group Practice: A Case Study.

BACKGROUND: You only get one opportunity to make a first impression. In today's era, that first impression is frequently a digital one. The authors' old digital brand "face" was stale and not a true representation of how they view themselves as a practice. In an evolving arena of competition and surgical scope, the authors felt compelled to engage in rebranding their practice. METHODS: This article details the steps the authors took to launch a new website, generate collateral branded material, and execute a social media marketing plan. The authors attempt to keep the outline general enough to be applicable to the range of practice types of the Journal 's readership, and present relevant results of the process. RESULTS: Samples of "creative" products are shown. Quantifiable outcomes were direct website traffic (91% increase), website sessions (82% increase), unique users (55% increase), page views (118% increase), and time spent browsing (100% increase). The authors experienced a 21% increase in new patient volume and a similar increase in total cases performed. CONCLUSIONS: This article outlines steps the authors took to rebrand their practice in the face of current challenges in the plastic surgery landscape and how prospective patients seek surgeons. Benchmarking the steps of a successful branding process is crucial and informative to developing and executing a plan. Although there are many potential contributors to the growth of a practice, the impact of our branding appears to be a significant factor.

Umbilical Ablation During Deep Inferior Epigastric Perforator Flap Harvest Decreases Donor Site Complications.

BACKGROUND: Donor site complications are a significant source of morbidity for patients undergoing abdominal-based free flap breast reconstruction, but there is a paucity of data regarding minimizing these postoperative complications. We hypothesize that selective ablation of the umbilicus at the time of deep inferior epigastric perforator (DIEP) harvest decreases the incidence of umbilical and abdominal wall complications in high-risk patients. METHODS: A retrospective review was performed of all patients (n = 117) who underwent DIEP harvest with concomitant umbilical ablation from 2010 to 2015. This cohort was paired with 117 patients who underwent DIEP harvest without umbilical ablation. Preoperative risk factors, intraoperative factors, and postoperative complications were compared. RESULTS: The umbilical ablation group had significantly higher body mass index (30.9 vs 27.4 kg/m, P < 0.001), presence of umbilical scar (20.9% vs 5.3%, P < 0.001), umbilical hernia (82.9% vs 8.5% P < 0.001), ventral hernia (23.9% vs 1.7%, P < 0.001), and rectus diastasis (10.3% vs 2.6%, P = 0.016). There were no significant differences of smoking, diabetes mellitus, hypertension, prior abdominal surgery, or midline abdominal scar. The umbilical ablation group had a significantly lower rate of postoperative abdominal wound dehiscence and skin loss (11.1% vs 22.2%, P = 0.023) and overall donor site complications (24.8% vs 39.3%, P = 0.017). There was no significant difference in incidence of cellulitis, seroma, or abscess. Mean follow-up time was 1.8 years. CONCLUSIONS: Selective umbilical ablation in high-risk patients at the time of abdominal flap harvest can result in significantly fewer donor site wound complications, even in the setting of increased risk factors for poor wound healing. This is likely due to avoidance of umbilical incisions and decreased upper abdominal skin undermining. We conclude that umbilical ablation is a viable option to minimize donor site complications, especially in high-risk patients.

Neoumbilicoplasty With a Pedicled Deep Inferior Epigastric Perforator Island Flap.

Management of the umbilicus is a common dilemma at the time of abdominoplasty and abdominal wall reconstruction. It is not uncommon for underlying pathologies, such as hernias and surgical scars, to result in a disfigured or obliterated native umbilicus or make the blood supply to the umbilical stalk unreliable. In these scenarios, the umbilicus is often sacrificed. Staged neoumbilical reconstruction may be offered and typically utilizes a small skin flap and full-thickness skin graft (Ann Plast Surg 2009;63:358-360). Our technique, in contrast, permits reconstruction of the neoumbilicus in the immediate setting utilizing normally discarded skin with a robust blood supply from a deep inferior epigastric artery perforator. In this series of 13 consecutive neoumbilicoplasties, the pedicled deep inferior epigastric artery perforator island flap provided reliable results and favorable aesthetic outcomes.

Using a Single Internal Mammary Artery as Retrograde and Antegrade Flow for Bilateral Deep Inferior Epigastric Artery Perforator Reconstruction: A Case Report.

Deep inferior epigastric artery perforator (DIEP) flaps have become an attractive option for autologous breast reconstruction. The internal mammary artery (IMA) is the usual artery of choice for reconstruction. Unfortunately, there are certain situations when the IMA may not be suitable for usage as in previous radiation or diminutive size. Several options have been documented, such as using the thoracodorsal vessels. In this case report, we report usage of the distal and proximal ends of a contralateral single mammary artery to supply antegrade and retrograde flow to bilateral DIEP flaps. With increasing complexity of patient populations, the use of alternate approaches to recipient vessel in DIEP reconstruction becomes essential for effective outcomes.

Older adults' perceptions of recovery from mental illness: Impact of psychiatric hospitalization prior to 1990.

OBJECTIVE: We tested the hypothesis that older adults are more likely than younger adults to consider their current mental health status when estimating their own recovery from psychiatric illness because many older people were first hospitalized for psychiatric illness prior to the emergence of the recovery movement in the 1990s, before recovery was redefined to include life improvements other than symptom alleviation. METHOD: Seventy-one members of a rehabilitation program (age 23 to 69; M = 49) were asked to rate satisfaction with their own recovery and with their current mental and physical health. The study hypothesis was tested in two hierarchical regression analyses that examined variation in the correlation between mental health and recovery self-ratings first by age and then by year of first hospitalization. RESULTS: The correspondence between mental health and recovery self-ratings was twice as strong for adults age 50 and older compared with those younger than age 50 and this same age difference in self-ratings was also evident for participants first hospitalized for a psychiatric illness earlier versus later than 1990. The correlation between physical health and recovery self-ratings did not vary by age or year of first hospitalization. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Recovery-oriented interventions will be most effective for older individuals when service providers take into account their personal histories and the propensity of many older adults to associate recovery with symptom improvement even while embracing other life improvements.

The fleur-de-lis upper gracilis flap for breast reconstruction: flap design and outcome.

We evaluated a fleur-de-lis design for the gracilis myocutaneous flap to improve flap volume for breast reconstruction. Thirty-one flaps were used in 17 consecutive patients undergoing the procedure for either thin body habitus (23 flaps) or prior abdominal surgery (8 flaps). The flap success rate was 100%. The fleur-de-lis flap provided proportionate breast reconstructions in all patients. Complications included 6 (19.3%) donor-site dehiscence and 4 (12.9%) episodes of cellulitis. Applying a negative pressure dressing to the donor site (n=26) significantly reduced the initially high dehiscence rate to 7.7% (P<0.01). There was no incidence of lower extremity edema or sensory loss. The fleur-de-lis gracilis flap can be performed with a low flap related complication rate and acceptable donor-site morbidity. Because of its standardized flap design, improved volume, and favorable breast shaping, it may allow autologous breast reconstruction to be offered to a greater number of patients.

Cost effectiveness of chest computed tomography after lung cancer resection: a decision analysis model.

BACKGROUND: Postoperative surveillance with chest computed tomography (CT) is often performed in patients who have undergone resection of non-small cell lung cancer (NSCLC), despite lack of supporting data. This study involves the creation of a decision analysis model to predict the cost effectiveness of postoperative surveillance CT. METHODS: A decision analysis model was created in which a hypothetical cohort of patients underwent annual chest CT after resection of a stage IA NSCLC. The incidence of second primary lung cancer (SPLC), sensitivity and specificity of CT, as well as survival after resection of initial primary and SPLC were derived from published literature. The cost of CT and other procedures prompted by a positive finding on CT was calculated from Medicare reimbursement schedules. Cost effectiveness was defined as a cost of less than 60,000 dollars per quality-adjusted life-year gained in the cohort under surveillance compared with controls under no surveillance. RESULTS: In the initial (base case) analysis, the cost of surveillance CT was 47,676 dollars per quality-adjusted life-year gained, implying cost effectiveness. However, factors that rendered surveillance CT cost ineffective were (1) age at entry into the surveillance program greater than 65 years, (2) cost of CT greater than 700 dollars, (3) incidence of SPLC of less than 1.6% per patient per year of follow-up, and (4) a false positive rate of surveillance CT greater than 14%. CONCLUSIONS: Surveillance with postoperative CT may be a cost-effective intervention to detect SPLC in selected patients with previously resected stage IA NSCLC.

Is carotid angioplasty and stenting more cost effective than carotid endarterectomy?

OBJECTIVE: Carotid angioplasty and stenting (CAS) has been advocated as a minimally invasive and inexpensive alternative to carotid endarterectomy (CEA). However, a precise comparative analysis of the immediate and long-term costs associated with these two procedures has not been performed. To accomplish this, a Markov decision analysis model was created to evaluate the relative cost effectiveness of these two interventions. METHODS: Procedural morbidity/mortality rate for CEA and costs (not charges) were derived from a retrospective review of consecutive patients treated at New York Presbyterian Hospital/Cornell (n = 447). Data for CAS were obtained from the literature. We incorporated into this model both the immediate procedural costs and the long-term cost of morbidities, such as stroke (major stroke in the first year = $52,019; in subsequent years = $27,336/y; minor stroke = $9419). We determined long-term survival rate in quality-adjusted life years and lifetime costs for a hypothetic cohort of 70-year-old patients undergoing either CEA or CAS. Our measure of outcome was the cost-effectiveness ratio. RESULTS: The immediate procedural costs of CEA and CAS were $7871 and $10,133 respectively. We assumed major plus minor stroke rates for CEA and CAS of 0.9% and 5%, respectively. We assumed a 30-day mortality rate of 0% for CEA and 1.2% for CAS. In our base case analysis, CEA was cost saving (lifetime savings = $7017/patient; increase in quality-adjusted life years saved = 0.16). Sensitivity analysis revealed major stroke and death rates as the major contributors to this differential in cost effectiveness. Procedural costs were less important, and minor stroke rates were least important. CAS became cost effective only if its major stroke and mortality rates were made equivalent to those of CEA. CONCLUSION: CEA is cost saving compared with CAS. This is related to the higher rate of stroke with CAS and the high cost of stents and protection devices. To be economically competitive, the mortality and major stroke rates of CAS must be at least equivalent if not less than those of CEA.

The cost-effectiveness of a "quick-screen" program for abdominal aortic aneurysms.

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) is increasing, and the prognosis of ruptured AAA remains dismal. Early diagnosis and intervention are crucial. We designed this study to determine whether selected population screening with a brief "quick-screen" ultrasound could be cost-effective. METHODS: A series of 25 patients with risk factors for AAA were evaluated in a blinded fashion by a quick-screen ultrasound and a full conventional study. Times and accuracy for the 2 approaches were compared. An analysis of the cost-effectiveness of screening for AAA was then performed using a Markov model. We determined the long-term survival in quality-adjusted life years and lifetime costs for a hypothetical cohort of 70-year-old males undergoing either AAA screening or not. Our measure of outcome was the cost-effectiveness ratio (CER). RESULTS: The average time for a quick screen was one-sixth that of a conventional study (4 vs 24 minutes). The accuracy of the quick screen was 100%. In our base-case analysis, screening for AAA was cost-effective with a CER of $11,215. Society usually is willing to pay for interventions with CER of less than $60,000 (eg, CER for coronary artery bypass grafting, $9500; breast cancer screening, $16,000). In sensitivity analysis, reducing the cost of screening from $259 (approximate Medicare reimbursement) to $40 (the quick screen) improved the CER to $6850. Moreover, screening populations with increased prevalence of AAA (eg, male with family history [18%]) further improved the CER. CONCLUSIONS: Our analysis demonstrates that ultrasound screening for AAA should be offered to all males above the age of 60. Widespread screening for AAA should be adopted and reimbursed by Medicare and other insurers.

Quinaprilat during cardioplegic arrest in the rabbit to prevent ischemia-reperfusion injury.

OBJECTIVES: This study evaluated intracardiac angiotensin-converting enzyme inhibition as an adjuvant to cardioplegia and examined its effects on hemodynamic, metabolic, and ultrastructural postischemic outcomes. METHODS: The experiments were performed with an isolated, erythrocyte-perfused, rabbit working-heart model. The hearts excised from 29 adult New Zealand White rabbits (2950 +/- 200 g) were randomly assigned to four groups. Two groups received quinaprilat (1 microg/mL), initiated either with cardioplegia (n = 7) or during reperfusion (n = 7). The third group received l-arginine (2 mmol/L) initiated with cardioplegia (n = 7). Eight hearts served as a control group. Forty minutes of preischemic perfusion were followed by 60 minutes of hypothermic arrest and 40 minutes of reperfusion. RESULTS: All treatments substantially improved postischemic recovery of external heart work (62% +/- 6%, 69% +/- 3%, and 64% +/- 5% in quinaprilat during cardioplegia, quinaprilat during reperfusion, and l-arginine groups, respectively, vs 35% +/- 5% in control group, P <.001) with similarly increased external stroke work and cardiac output. When administered during ischemia, quinaprilat significantly improved recovery of coronary flow (70% +/- 8%, P =.028 vs quinaprilat during reperfusion [49% +/- 5%] and P =.023 vs control [48% +/- 6%]). l-Arginine (55% +/- 7%) showed no significant effect. Postischemic myocardial oxygen consumption remained low in treatment groups (4.6 +/- 1.2 mL. min(-1). 100 g(-1), 6.0 +/- 2.2 mL. min(-1). 100 g(-1), and 4.7 +/- 1.6 mL. min(-1). 100 g(-1) in quinaprilat during cardioplegia, quinaprilat during reperfusion, and l-arginine groups, respectively, vs 4.2 +/- 0.8 mL. min(-1). 100 g(-1) in control group), even though cardiac work was markedly increased. High-energy phosphates, which were consistently elevated in all treatment groups, showed a significant increase in adenosine triphosphate with quinaprilat during ischemia (2.24 +/- 0.14 micromol/g vs 1.81 +/- 0.12 micromol/g in control group, P =.040). Ultrastructural grading of mitochondrial damage revealed best preservation with quinaprilat during ischemia (100% [no damage], P =.001 vs control). CONCLUSION: These experimental findings have clinical relevance regarding prevention of postoperative myocardial stunning and low coronary reflow in patients undergoing heart surgery.

Why insurers should reimburse for compression stockings in patients with chronic venous stasis.

BACKGROUND: Chronic venous stasis ulcers produce substantial morbidity rates and result in a significant expense to society. Fortunately, compression stockings (CS) have been found to reduce the rate of recurrence in patients with previous ulceration. Surprisingly, Medicare and other insurers do not reimburse the expense associated with CS or with patient education (Ed), which is essential to ensure compliance. METHODS: A Markov decision analysis model was used for analysis of the cost-effectiveness of a strategy of reimbursement for CS and Ed (prophylaxis) versus one that does not supply these resources in a 55-year-old patient with prior venous stasis ulceration. The mean time to ulcer recurrence (53 months with CS+Ed; 18.7 months without prophylaxis), the mean time for ulcer healing (4.6 months), the probabilities of hospitalization (12%) and amputation (0.4%) after the development of an ulcer, and quality-adjustment factors (0.80 during ulcer treatment) were derived from the literature. The cost of CS ($300/year) and Ed ($93 for initial evaluation; $58/year; $40/recurrence) and the medical cost of ulcer treatment (average cost, $1621/recurrence) were calculated from our hospital cost accounting system. RESULTS: A strategy of CS and Ed was cost saving, with 0.37 quality-adjusted life years and $5904 saved, compared with a strategy that does not provide these resources. The inclusion of loss of revenue related to absence from work in the analysis increased cost savings to $17,080 during the patient's lifetime. With sensitivity analysis, CS and Ed remained cost-effective (lifetime cost per quality-adjusted life year saved, <$60,000) if amputations and the cost of ulcer treatment were eliminated or if the cost of prophylaxis was increased to 600% of the base-case. The mean time to recurrence in patients with CS and Ed needed to be reduced from 53 months to 21.1 months before this strategy was no longer cost-effective. CONCLUSION: Prophylactic CS and Ed in patients with prior venous stasis ulceration are cost saving, even with the most conservative of assumptions. Insurers should routinely reimburse for these interventions.