Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 50
Filtrar
1.
J Reconstr Microsurg ; 36(4): 289-293, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31994158

RESUMO

BACKGROUND: There are many different variables to consider in lower extremity microvascular soft tissue reconstruction including flap choice. Our aim is to objectively evaluate recipient complications related to lower extremity donor flap laterality. METHODS: A total of 77 lower extremity soft tissue reconstructions utilizing microvascular free tissue transfers for Gustilo type III between 1979 and 2016 were collected. We compared complication rates between ipsilateral and contralateral donor sites relative to the injured leg. The following parameters were analyzed: overall complications, total flap failure, partial flap failure, major complications, operative takebacks, and salvage rates. RESULTS: In this study, 25 ipsilateral reconstructions were performed, while 52 cases utilized the contralateral leg. Overall complication rates were higher in the ipsilateral group (40.0%) compared with the contralateral side (23.1%) but were not statistically significant (p = 0.12). The ipsilateral group was four times as likely to experience vascular compromise (24.0 vs. 5.8%; p = 0.05). However, there were no significant differences in complications, flap failures or flap survival. Mean operative time was significantly greater in the same side group as compared with the contralateral group (11.3 vs. 7.5 hours; p = 0.006). CONCLUSION: Although there is a higher risk of anastomotic thrombosis, particularly venous thrombosis, associated with ipsilateral donor-site group, there were no significant differences in complications or flap survival. Flaps can be harvested from a traumatized leg with acceptable complication rates while avoiding the morbidity of operating on an uninjured limb.

2.
Aesthet Surg J ; 40(2): 220-227, 2020 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-31119282

RESUMO

BACKGROUND: Improving the quality of research published in plastic surgery literature has been recognized as a difficult and time-intensive process. Despite significant progress over the last decade, leaders in the field continue to advocate for higher-quality studies to better inform clinical practice. OBJECTIVES: The aim of this study was to evaluate and analyze trends in the levels of evidence (LOEs) of the plastic surgery literature over the last decade in 4 major journals. METHODS: After systematic review of all articles published between 2008 and 2017 in Plastic and Reconstructive Surgery, Annals of Plastic Surgery, Journal of Plastic, Reconstructive, and Aesthetic Surgery, and Aesthetic Surgery Journal (ASJ), included articles were assigned an LOE and classified according to study design and category. RESULTS: In total, 8211 articles were included. Case series and reports represented 36.1% and 13.6% of studies, respectively. Additionally, 27.2% were retrospective cohort studies, 8.2% prospective cohort studies, 3.9% systematic reviews, and 2.9% randomized controlled trials (RCTs). Overall, the percentage of Level I/II studies has increased from 10.9% in 2008 to 17.3% in 2017. ASJ published the greatest proportion of Level I/II studies (23.2%) and RCTs (5.1%) of all the journals. There were significant differences in the distribution of Level I/II studies by journal (P < 0.001) and category (P < 0.001). CONCLUSIONS: Over the past decade, plastic surgery journals have published higher-quality research and a significantly greater proportion of Level I and II studies. The field must continue to strive for robust study designs, while also recognizing the importance of lower-LOE research.

3.
Plast Reconstr Surg ; 145(1): 184e-192e, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31609286

RESUMO

BACKGROUND: Simulation is a standard component of residency training in many surgical subspecialties, yet its impact on knowledge and skills acquisition in plastic surgery training remains poorly defined. The authors evaluated the potential benefits of simulation-based cleft surgery learning in plastic surgery resident education through a prospective, randomized, blinded trial. METHODS: Thirteen plastic surgery residents were randomized to a digital simulator or textbook demonstrating unilateral cleft lip repair. The following parameters were evaluated before and after randomization: knowledge of surgical steps, procedural confidence, markings performance on a three-dimensional stone model, and surgical performance using a hands-on/high-fidelity three-dimensional haptic model. Participant satisfaction with either educational tool was also assessed. Two expert reviewers blindly graded markings and surgical performance. Intraclass correlation coefficients were calculated. Wilcoxon signed rank and Mann-Whitney U tests were used. RESULTS: Interrater reliability was strong for preintervention and postintervention grading of markings [preintervention intraclass correlation coefficient, 0.97 (p < 0.001); postintervention intraclass correlation coefficient, 0.96 (p < 0.001)] and surgical [preintervention intraclass correlation coefficient, 0.83 (p = 0.002); postintervention intraclass correlation coefficient, 0.81 (p = 0.004)] performance. Postintervention surgical knowledge (40.3 ± 4.4 versus 33.5 ± 3.7; p = 0.03), procedural confidence (24.0 ± 7.0 versus 14.7 ± 2.3; p = 0.03), markings performance (8.0 ± 2.5 versus 2.9 ± 3.1; p = 0.03), and surgical performance (12.3 ± 2.5 versus 8.2 ± 2.3; p = 0.04) significantly improved in the digital simulation group compared with before intervention, but not in the textbook group. All participants were more satisfied with the digital simulator as an educational tool (27.7 ± 2.5 versus 14.4 ± 4.4; p < 0.001). CONCLUSION: The authors present evidence suggesting that digital cognitive simulators lead to significant improvement in surgical knowledge, procedural confidence, markings performance, and surgical performance.

4.
J Surg Res ; 245: 420-425, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31442745

RESUMO

BACKGROUND: Prolonged impairment of protective ocular functions can compromise vision and lead to blindness if uncorrected. Several facial transplants have incorporated periorbital structures with variable eyelid preservation, but objective assessment of post-transplant periorbital function has been limited. MATERIALS AND METHODS: Kinematic data were collected from a full-face recipient that included the fist total eyelid transplantation at 5 separate pre-transplant (PRE) and post-transplant time points (T1-T4). Using optical facial tracking, eyelid movements were tracked during involuntary blinking and compared with controls. RESULTS: There was significant improvement in right eye aperture from PRE to T1 (ß = 5.54, P < 0.001), with no change between T1 and T4. Aperture fluctuated in the left eye, with a temporary decrease between T2 and T3 corresponding with revision brow lift (ß = -4.57, P < 0.001). Although improved from the pre-transplantation, right and left eye apertures remained significantly smaller than controls at T1 and T4 (P < 0.001). Similarly, spatial coupling increased from PRE to T1 (ß = 0.63, P < 0.001) and remained high at T4, albeit significantly less than controls (P < 0.001). Temporal coupling improved from PRE to T2 (ß = 2.29, P < 0.02) and was sustained at subsequent time points, with no difference relative to controls at T4. Considerable improvement was observed on clinical examination, with full functional status. CONCLUSIONS: Application of a novel method for assessing functional eyelid recovery using facial tracking technology to the first total eyelid transplantation in the setting of a full facial transplant shows clear functional improvement after transplantation and suggests revisions can be performed safely to optimize aesthetic outcomes without permanent negative functional impact.


Assuntos
Pálpebras/transplante , Transplante de Face , Adulto , Fenômenos Biomecânicos , Pálpebras/fisiologia , Humanos , Masculino
5.
Plast Reconstr Surg Glob Open ; 7(8): e2368, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31592385

RESUMO

Despite promising short- and long-term results to date in vascularized composite allotransplantation (VCA), acute rejection remains the most common major complication in recipients. Currently, diagnosis of acute rejection relies on clinical inspection correlated with histopathological analysis. However, disagreement exists regarding the value of full-thickness skin and mucosal biopsies and histopathology remains semiquantitative, subject to sampling bias, and prone to intra- and inter-observer variabilities. Additionally, biopsies may cause infection, scarring, and/or potentially incite rejection through immune activation after injury. Noninvasive methods to diagnose rejection represent a critical unmet need for the emerging field of VCA. Here, we propose a novel technique utilizing skin stripping of the epidermis and subsequent molecular analysis to detect known markers of acute rejection. Using a small animal VCA model, we sought to validate our epidermal sampling technique as a noninvasive diagnostic test for acute rejection.

6.
Plast Reconstr Surg ; 144(3): 759-767, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31461042

RESUMO

BACKGROUND: Marko Godina, in his landmark paper in 1986, established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries. The aim of this study was to determine how timing influences outcomes in lower extremity traumatic free flap reconstruction based on Godina's original findings. METHODS: A retrospective review identified 358 soft-tissue free flaps from 1979 to 2016 for below knee trauma performed within 1 year of injury. Patients were stratified based on timing of coverage: 3 days or less (early), 4 to 90 days (delayed), and more than 90 days (late). The delayed group was further divided into two groups: 4 to 9 days and 10 to 90 days. Flap outcomes were examined based on timing of reconstruction. RESULTS: Flaps performed within 3 days after injury compared with between 4 to 90 days had decreased risk of major complications (OR, 0.40, p = 0.04). A receiver operating curve demonstrated day 10 to be the optimal day for predicting flap success. Flaps performed less than or equal to 3 days versus 4 to 9 days had no differences in any flap outcomes. In contrast, flaps performed within 4 to 9 days of injury compared to within 10 to 90 days were associated with significantly lower total flap failure rates (relative risk, 0.29, p = 0.025) and major complications (relative risk, 0.37, p = 0.002). CONCLUSIONS: Early free flap reconstruction performed within 3 days of injury had superior outcomes compared with the delayed (4 to 90 day) group, consistent with Godina's original findings. However, as an update to his paradigm, this ideal early period of reconstruction can be safely extended to within 10 days of injury without an adverse effect on outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Microcirurgia/métodos , Tratamento de Ferimentos com Pressão Negativa/métodos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Lesões dos Tecidos Moles/terapia , Tempo para o Tratamento , Adolescente , Adulto , Feminino , Retalhos de Tecido Biológico/transplante , História do Século XX , Humanos , Extremidade Inferior/lesões , Masculino , Microcirurgia/história , Microcirurgia/normas , Pessoa de Meia-Idade , Tratamento de Ferimentos com Pressão Negativa/história , Tratamento de Ferimentos com Pressão Negativa/normas , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Reconstrutivos/história , Procedimentos Cirúrgicos Reconstrutivos/normas , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
7.
J Surg Res ; 243: 509-514, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31377491

RESUMO

BACKGROUND: The goal of our study was to evaluate risk factors for wound complications in patients with diabetes mellitus undergoing transmetatarsal amputations (TMAs), given the paucity of research on this subject. MATERIALS AND METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program database. In this retrospective analysis, all surgical cases with a primary Current Procedural Terminology code for TMA from 2009 to 2015 were reviewed. RESULTS: A total of 2316 patients with diabetes mellitus who underwent TMA were identified. Overall wound complications occurred in 276 (11.9%) of patients. Univariate analysis showed that the operative time was significantly longer in patients who developed complications than those who did not (58.3 ± 39.5 versus 50.6 ± 39.4; P = 0.003). Furthermore, the rate of obesity was significantly higher among patients who developed wound complications than those who did not (47.1% versus 41.5%; P = 0.04). Multivariate analysis demonstrated that a longer operative time (odds ratio = 1.02; 95% confidence interval: 1.01-1.04; P = 0.01) and obesity (odds ratio = 1.60; 95% confidence interval: 1.06-2.40; P = 0.03) were independent risk factors for wound complications in our cohort. CONCLUSIONS: These findings emphasize the importance of having heightened clinical vigilance in obese patients with diabetes mellitus undergoing this procedure, close postoperative follow-up, and limiting operative time when possible.


Assuntos
Amputação/efeitos adversos , Pé Diabético/cirurgia , Ossos do Metatarso/cirurgia , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Pé Diabético/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Deiscência da Ferida Operatória/etiologia , Infecção da Ferida Cirúrgica/etiologia , Estados Unidos/epidemiologia
8.
Plast Reconstr Surg ; 2019 Jun 07.
Artigo em Inglês | MEDLINE | ID: mdl-31335794

RESUMO

BACKGROUND: Marko Godina in his landmark paper in 1986 established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries to minimize edema, fibrosis and infection while optimizing outcomes. However, with the evolution of microsurgery and wound management, recent studies have suggested that reconstruction can be performed beyond this window of 3 days with comparable outcomes. The aim of this study was to determine how timing influences perioperative outcomes in free flap reconstruction for lower extremity trauma. METHODS: A retrospective review of our institutional flap registry from 1979-2016 identified 806 lower extremity free flaps. 358 soft tissue free flaps for below knee trauma performed within one year of injury met inclusion criteria. Patients were stratified based on timing of coverage: ≤3 days (early), 4-90 days (delayed) and >90 days (late). A receiver operating curve (ROC) was generated and Youden index was used to determine the optimal time of reconstruction for predicting flap success. Based on this, the delayed group was further divided into two groups: 4-9 days and 10-90 days. Demographics, flap characteristics and outcomes were compared using Chi-square and one-way ANOVA. Multivariate logistic regression was performed to determine whether timing of reconstruction independently predicts complications and flap failures, controlling for injury-related and operative factors. RESULTS: The mean age was 38.8 years (range 18-83) and 76% of patients were male. Seventy-seven free flaps (21.5%) were performed ≤3 days after initial injury, 233 (65.1%) were performed within 4-90 days and 48 (13.4%) flaps were performed after 90 days. There was no significant difference in flap type (p=0.08), injury sublocation (p=0.15) or presence of arterial injury (p=0.167) between the cohorts. Reconstruction within 4-90 days was more commonly performed in the second era (between 1997-2016) while early reconstruction was more common in the initial era (1976-1996). Univariate analysis demonstrated no association between time to coverage and rates of partial flap failure (p=0.11), total flap failure (p=0.44), takebacks (p=0.79) or major complications (p=0.14). Multivariate logistic regression analysis demonstrated that flaps performed within 3 days after injury had decreased risk of major complications (OR 0.40, p=0.04) and a trend towards decreased risk of partial flap failures (OR 0.13, p=0.06) compared to flaps performed between 4-90 days. Our ROC curve demonstrated day 10 to be the optimal day for predicting flap success (AUC=0.56). Multivariate logistic regression analysis demonstrated that flaps performed ≤3 days vs. 4-9 days had no differences in major complications (p=0.08), partial flap failure (p=0.92) or total flap failure (p=0.35). In contrast, flaps performed within 4-9 days of injury compared to those performed within 10-90 days were associated with significantly lower total flap failure rates (RR 0.29, p=0.025) and major complications (RR 0.37, p=0.002). CONCLUSIONS: Early free flap reconstruction performed within 3 days of injury had superior outcomes compared to the delayed (4-90 day) group, consistent with Godina's original findings. However, as an update to his paradigm, this ideal early period of reconstruction can be safely extended to within 10 days of injury without an adverse effect on outcomes.

9.
Craniomaxillofac Trauma Reconstr ; 12(2): 150-155, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31073366

RESUMO

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.

10.
Plast Surg Nurs ; 39(2): 48-51, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31136558

RESUMO

Nasal trauma is a common complication of nasal continuous positive airway pressure (NCPAP) and may range from erythema, edema, and skin breakdown to columellar necrosis. Although rare, columellar necrosis can be a devastating complication following NCPAP, and surgical repair remains challenging due to contour and color-match difficulties, tenuous vascularity, and limited available adjacent skin. In addition, because operative site protection is critical to a successful repair, many surgeons opt to delay surgical intervention from infancy until a later age so that the patient does not inadvertently injure and compromise the graft during the early postoperative period. Here, we present a case of composite nasal reconstruction in an infant following columellar necrosis secondary to NCPAP, along with the design and implementation of a simple, inexpensive, and protective nasal splint that allows for early repair at the time of infancy.


Assuntos
Procedimentos Cirúrgicos Nasais/métodos , Contenções/tendências , Pressão Positiva Contínua nas Vias Aéreas/efeitos adversos , Pressão Positiva Contínua nas Vias Aéreas/métodos , Desenho de Equipamento , Feminino , Humanos , Lactente , Procedimentos Cirúrgicos Nasais/normas , Resultado do Tratamento
11.
Plast Reconstr Surg ; 143(4): 1165-1178, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30921141

RESUMO

BACKGROUND: Cleft deformities of the lip and palate affect nearly one in 500 to 700 births, and lead to increased morbidity and mortality if untreated. Nevertheless, significant global disparities in access to timely and appropriate care still exist. The relatively basic infrastructure required to surgically correct these deformities and large unmet disease burden have resulted in a significant number of foundation-based cleft care initiatives focused on developing countries. In this study, the authors evaluate the peer-reviewed literature generated by these foundations in an attempt to assess their clinical, scientific, educational, and economic impact. METHODS: A comprehensive review of the literature was performed using key search terms, and the level of evidence of identified articles was determined. Data were then analyzed to determine the different models of foundation-based cleft care in developing countries, and their clinical, scientific, educational, and economic impact. RESULTS: A total of 244 articles were identified through the authors' search and reviewed. Foundation-based cleft care initiatives in developing countries have significantly contributed to a better understanding of disease epidemiology, barriers to care, safety considerations, complications and outcomes, and international and local cleft surgery education. The cleft care center model is more cost-effective than the surgical mission model and provides more sustainable care. CONCLUSIONS: Foundation-based cleft care prevents significant morbidity in developing countries and has provided valuable resources for capacity building. The surgical mission model should be considered as a transitory conduit for establishing the more effective and sustainable cleft care center model of care.


Assuntos
Fenda Labial/cirurgia , Fissura Palatina/cirurgia , Fundações/organização & administração , Missões Médicas/organização & administração , Procedimentos Cirúrgicos Reconstrutivos , Países em Desenvolvimento , Acesso aos Serviços de Saúde/organização & administração , Humanos , Garantia da Qualidade dos Cuidados de Saúde/organização & administração
12.
Plast Reconstr Surg ; 143(6): 1290e-1297e, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30907812

RESUMO

BACKGROUND: Face transplant teams have an ethical responsibility to restore the donor's likeness after allograft procurement. This has been achieved with masks constructed from facial impressions and three-dimensional printing. The authors compare the accuracy of conventional impression and three-dimensional printing technology. METHODS: For three subjects, a three-dimensionally-printed mask was created using advanced three-dimensional imaging and PolyJet technology. Three silicone masks were made using an impression technique; a mold requiring direct contact with each subject's face was reinforced by plaster bands and filled with silicone. Digital models of the face and both masks of each subject were acquired with Vectra H1 Imaging or Artec scanners. Each digital mask model was overlaid onto its corresponding digital face model using a seven-landmark coregistration; part comparison was performed. The absolute deviation between each digital mask and digital face model was compared with the Mann-Whitney U test. RESULTS: The absolute deviation (in millimeters) of each digitally printed mask model relative to the digital face model was significantly smaller than that of the digital silicone mask model (subject 1, 0.61 versus 1.29, p < 0.001; subject 2, 2.59 versus 2.87, p < 0.001; subject 3, 1.77 versus 4.20, p < 0.001). Mean cost and production times were $720 and 40.2 hours for three-dimensionally printed masks, and $735 and 11 hours for silicone masks. CONCLUSIONS: Surface analysis shows that three-dimensionally-printed masks offer greater surface accuracy than silicone masks. Greater donor resemblance without additional risk to the allograft may make three-dimensionally-printed masks the superior choice for face transplant teams. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.


Assuntos
Transplante de Face/métodos , Impressão Tridimensional/normas , Custos e Análise de Custo , Transplante de Face/economia , Humanos , Doadores Vivos , Impressão Tridimensional/economia , Elastômeros de Silicone/economia , Sítio Doador de Transplante , Transplante Homólogo
14.
Plast Reconstr Surg ; 143(5): 906e-919e, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30789474

RESUMO

BACKGROUND: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed. RESULTS: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing mastectomies (37.2 percent)]. Meta-analysis revealed an overall partial nipple-areola complex necrosis rate of 4.62 percent (95 percent CI, 3.14 to 6.37 percent) and a total nipple-areola complex necrosis rate of 2.49 percent (95 percent CI, 1.87 to 3.21 percent). Information on overall nipple-areola complex necrosis rate by incision type was available for 30 of 51 studies (4645 nipple-sparing mastectomies). Periareolar incision had the highest nipple-areola complex necrosis rate (18.10 percent). Endoscopic and mastopexy/prior scar/reduction incisions had the lowest rates of necrosis at 4.90 percent and 5.79 percent, respectively, followed by the inframammary fold incision (6.82 percent). The rate of single-stage implant reconstruction increased during this period. CONCLUSIONS: For nipple-sparing mastectomy, the periareolar incision maintains the highest necrosis rate because of disruption of the nipple-areola complex blood supply. The inframammary fold incision has become the most popular incision, demonstrating an acceptable complication profile.


Assuntos
Neoplasias da Mama/cirurgia , Mastectomia Subcutânea/métodos , Mamilos/patologia , Tratamentos com Preservação do Órgão/métodos , Complicações Pós-Operatórias/epidemiologia , Implante Mamário/estatística & dados numéricos , Feminino , Humanos , Mastectomia Subcutânea/efeitos adversos , Necrose/epidemiologia , Necrose/etiologia , Mamilos/irrigação sanguínea , Mamilos/cirurgia , Tratamentos com Preservação do Órgão/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Estudos Retrospectivos , Ferida Cirúrgica/complicações
15.
Plast Reconstr Surg ; 143(3): 644e-654e, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30624340

RESUMO

BACKGROUND: Since the inception of the integrated model, educational leaders have predicted its ongoing evolution, as the optimal plastic surgery curriculum remains a source of debate. With the now complete elimination of the "coordinated" pathway, the total number of integrated programs has arguably reached a plateau. Accordingly, this study examines the current state of training in integrated residencies and reevaluates the variability in the first 3 years of training observed previously. METHODS: Program information was obtained for all 68 integrated plastic surgery programs, and rotation schedules were available for 59. Plastic, general, and subspecialty surgery exposures were quantified and compared. Inclusion of rotations "strongly suggested" by the Residency Review Committee was also examined. RESULTS: Plastic surgery exposure ranged from 3.5 to 25 months (mean, 13.9 ± 5.4 months). General surgery ranged from 5 to 22.5 months (mean, 12.8 ± 4.7 months). Subspecialty rotations ranged from 0 to 8 months (mean, 3.6 ± 1.8 months). There was no difference in mean plastic surgery exposure between programs based within departments versus divisions (15.4 months versus 13.3 months; p = 0.184). There remained significant variability in the inclusion of 18 non-plastic surgery rotations, including the "strongly suggested" rotations. CONCLUSIONS: Plastic surgery exposure remains highly variable with a greater than 7-fold difference between programs. This suggests that programs are still sorting out the ideal curriculum. However, there is an overall trend toward earlier and increased plastic surgery exposure, which now exceeds the average time spent on general surgery rotations.


Assuntos
Currículo/tendências , Cirurgia Geral/educação , Internato e Residência/tendências , Cirurgia Plástica/educação , Prestação Integrada de Cuidados de Saúde , Humanos , Avaliação de Programas e Projetos de Saúde
16.
J Craniofac Surg ; 30(2): 571-577, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30676448

RESUMO

BACKGROUND: Mandibular fractures are the most common isolated facial fractures in the United States. Various risk factors have been associated with increased rates of postoperative complications. However, national outcome reports are limited and data are conflicting. Using a national multi-institutional database, the authors sought to analyze 30-day outcomes after mandibular fracture repair and determine risk factors for complications, readmission, and reoperation. METHODS: Retrospective review of the American College of Surgeons National Surgical Quality Improvement database was performed to identify patients undergoing surgical treatment of mandibular fractures between 2010 and 2015 using current procedural terminology codes. Primary outcomes included: wound complications, overall complications, as well as readmission and reoperation rates. Multivariate regression analysis was performed to adjust for confounders. RESULTS: A total of 953 patients were eligible for analysis. Mean patient age was 34.5 years, 84% were males, and 50% were active smokers. Wound complications, overall complications, 30-day reoperation, and readmission occurred in 4.0%, 7.9%, 2.2%, and 33% of patients, respectively. Age was a significant risk factor for 30-day readmission (odds ratio [OR] = 1.06, P = 0.01), reoperation (OR = 1.05, P = 0.01), and overall complications (OR = 1.03, P = 0.02) on multivariate analysis, and smoking was a significant risk factor for 30-day reoperation (OR = 4.86, P = 0.03). CONCLUSION: The analysis identified age as an independent risk factor for readmission, reoperation, and overall complications. Smokers were also nearly 5 times as likely to undergo additional surgery. This is particularly important given that over half of patients were active smokers, highlighting the importance of perioperative patient education and smoking cessation within this population.


Assuntos
Fraturas Mandibulares , Complicações Pós-Operatórias/epidemiologia , Adulto , Feminino , Humanos , Masculino , Fraturas Mandibulares/epidemiologia , Fraturas Mandibulares/cirurgia , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Resultado do Tratamento
17.
Wound Repair Regen ; 27(3): 249-256, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30663823

RESUMO

The effect of diabetes on postoperative outcomes following surgical management of pressure ulcers is poorly defined despite evidence showing that patients with diabetes are at increased risk for developing pressure ulcers, as well as postoperative wound complications including delayed healing and infection. This study aimed to examine the impact of diabetes on postoperative outcomes following surgical management of pressure ulcers using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. In this retrospective analysis all CPT codes with ICD-9 diagnoses of pressure ulcers were reviewed. A total of 3,274 patients who underwent surgical management of pressure ulcers were identified, of which 1,040 (31.8%) had diabetes. Overall primary outcomes showed rates of superficial and deep incisional surgical site infection (SSI) were 2.0 and 4.2%, respectively, while the rate of wound dehiscence was 2.1%. Univariate analysis of primary outcomes stratified by diabetes status showed that patients with diabetes had significantly higher rates of superficial incisional SSI (3.9 vs. 2.3%; p = 0.01), deep incisional SSI (7.0 vs. 4.3%; p = 0.001), wound dehiscence (5.2 vs. 2.7%; p < 0.001), as well as significantly higher rates of readmission (12.8 vs. 8.9%; p = 0.001). Multivariate analysis for significant outcomes between groups on univariate analysis demonstrated that diabetes was an independent risk factor for superficial incisional SSI (OR = 2.7; 95% CI: 1.59-4.62; p < 0.001), deep incisional SSI (OR = 1.85; 95% CI: 1.26-2.70; p = 0.002), wound dehiscence (OR = 4.09; 95% CI: 2.49-6.74; p < 0.001), and readmission within 30 days (OR = 1.38; 95% CI: 1.05-1.82; p = 0.02). These findings emphasize the importance of preoperative prevention, and vigilant postoperative wound care and monitoring in patients with diabetes to minimize morbidity and optimize outcomes. Future prospective studies are needed to establish causality between diabetes and these outcomes.


Assuntos
Complicações do Diabetes/cirurgia , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 2/fisiopatologia , Lesão por Pressão/patologia , Infecção da Ferida Cirúrgica/patologia , Cicatrização/fisiologia , Adulto , Idoso , Complicações do Diabetes/fisiopatologia , Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Cuidados Pré-Operatórios/métodos , Lesão por Pressão/etiologia , Lesão por Pressão/cirurgia , Estudos Prospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/cirurgia
18.
J Surg Res ; 235: 148-159, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30691788

RESUMO

BACKGROUND: Diabetic patients are known to be at increased risk of postoperative complications after multiple types of surgery. However, conflicting evidence exists regarding the association between diabetes and wound complications in mastectomy and breast reconstruction. This study evaluates the impact of diabetes on surgical outcomes after mastectomy procedures and implant-based breast reconstruction. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database review from 2010 to 2015 identified patients undergoing total, partial, or subcutaneous mastectomy, as well as immediate or delayed implant reconstruction. Primary outcomes included postoperative wound complications and implant failure. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Multivariate regression was used to control for confounders. RESULTS: The following groups were identified: partial (n = 52,583), total (n = 41,540), and subcutaneous mastectomy (n = 3145), as well as immediate (n = 4663) and delayed (n = 4279) implant reconstruction. Diabetes was associated with higher rates of superficial incisional surgical site infection (SSI) in partial mastectomy (odds ratio [OR] = 8.66; P = 0.03). Diabetes was also associated with higher rates of deep incisional SSI (OR = 1.61; P = 0.01) in subcutaneous mastectomy and both superficial (OR = 1.56; P = 0.04) and deep incisional SSI (OR = 2.07; P = 0.04) in total mastectomy. Diabetes was not associated with any wound complications in immediate reconstruction but was associated with higher rates of superficial incisional SSI (OR = 17.46; P < 0.001) in the delayed reconstruction group. There was no association with implant failure in either group. CONCLUSIONS: Evaluation of the largest national cohort of mastectomy and implant reconstructive procedures suggests that diabetic patients are at significantly increased risk of 30-d postoperative infectious wound complications but present no difference in rates of early implant failure.


Assuntos
Complicações do Diabetes , Mamoplastia/efeitos adversos , Mastectomia/efeitos adversos , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Infecção da Ferida Cirúrgica/epidemiologia
19.
Obes Surg ; 29(2): 426-433, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30238217

RESUMO

BACKGROUND: Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated. METHODS: The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders. RESULTS: Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications. CONCLUSION: Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.


Assuntos
Abdominoplastia/efeitos adversos , Lipectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Abdominoplastia/métodos , Abdominoplastia/mortalidade , Abdominoplastia/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/mortalidade , Cirurgia Bariátrica/estatística & dados numéricos , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Lipectomia/métodos , Lipectomia/mortalidade , Lipectomia/estatística & dados numéricos , Masculino , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Qualidade de Vida , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco
20.
J Craniofac Surg ; 30(2): 352-357, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30531274

RESUMO

INTRODUCTION: Orthognathic surgery plays an important role in restoring aesthetic facial contour, correcting dental malocclusion, and the surgical treatment of obstructive sleep apnea. However, the rate of complications following bimaxillary as compared with single-jaw orthognathic surgery remains unclear. The authors therefore sought to evaluate complication rates following bimaxillary as compared with single-jaw orthognathic surgery MATERIALS AND METHODS:: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify comparison groups. Preoperative characteristics and postoperative outcomes were compared between groups. The listed procedures have different operating times and characteristics with longer time expected in the bimaxillary osteotomies group. Regression analyses were performed to control for potential confounders. RESULTS: The 3 groups of interest included patients who underwent mandibular osteotomies (n = 126), LeFort I osteotomy (n = 194), and bimaxillary osteotomies (n = 190). These procedures have different operating times, with a longer time expected with bimaxillary osteotomies. Patients undergoing bimaxillary osteotomies had significantly higher rates of early wound complications, overall complications, longer mean operative time, and mean hospital length of stay. Performing bimaxillary osteotomies in the outpatient setting was an independent risk factor for wound complications (OR = 12.58; 95% CI: 1.66-95.20; P = 0.01), while an ASA class of 3 or more was an independent risk factor for overall complications (OR = 3.61; 95% CI: 1.02-12.75; P = 0.04) and longer hospital length of stay (ß = 4.96; 95% CI: 2.64 - 7.29; P < 0.001). CONCLUSIONS: Surgery in the outpatient setting as well as patient American Society of Anesthesiology physical status class 3 or higher were independent factors for postoperative adverse events in patients undergoing bimaxillary surgery. Our findings highlight the importance of addressing modifiable risk factors preoperatively and the need for closer postoperative monitoring in this patient population for optimal outcomes.


Assuntos
Má Oclusão/cirurgia , Procedimentos Cirúrgicos Ortognáticos/efeitos adversos , Complicações Pós-Operatórias/etiologia , Adulto , Estética Dentária , Feminino , Humanos , Masculino , Má Oclusão/complicações , Osteotomia Mandibular/efeitos adversos , Osteotomia Mandibular/métodos , Análise Multivariada , Duração da Cirurgia , Procedimentos Cirúrgicos Ortognáticos/métodos , Osteotomia de Le Fort/efeitos adversos , Osteotomia de Le Fort/métodos , Complicações Pós-Operatórias/epidemiologia , Análise de Regressão , Risco , Apneia Obstrutiva do Sono/etiologia , Apneia Obstrutiva do Sono/cirurgia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA