Postoperative Complications of Panniculectomy and Abdominoplasty: A Retrospective Review.

BACKGROUND: Recent studies of panniculectomy outcomes have reported variable complication rates ranging from 8.65% to 56%. Meanwhile, reported abdominoplasty complication rates are considerably lower (~4%). This discrepancy may be attributable to inaccurate inclusion of abdominoplasty patients in panniculectomy cohorts. We performed the current study to better characterize panniculectomy complication rates at a large tertiary care center. METHODS: We performed a retrospective review of patients who underwent abdominoplasty or panniculectomy at the Johns Hopkins Hospitals between 2010 and 2017. Patients were identified by Common Procedural Terminology codes (15847/17999, 15830) confirmed via the operative note. We examined postoperative complication rates including surgical site infection, seroma formation, wound dehiscence, readmission/reoperation, and postoperative length of stay (LOS). We used parametric and nonparametric methods to determine differences between abdominoplasty and panniculectomy outcomes, as well as logistic regression analysis to evaluate factors associated with patient outcomes following panniculectomy. RESULTS: Of the 306 patients included, 103 underwent abdominoplasty while 203 underwent panniculectomy. Initial complication rates following abdominoplasty and panniculectomy were 1.94% and 12.8%, respectively (P = 0.002). Thirty-day complication rates were 9.7% for abdominoplasty and 21.2% for panniculectomy (P = 0.012). The median LOS was 1 day (interquartile range, 0-1 day) for abdominoplasty and 2 days (interquartile range, 1-4 days) for panniculectomy (P = 0.002). No statistically significant differences in complication rates at 6 months and 1 year were observed. CONCLUSIONS: Panniculectomy offers many functional benefits including improved hygiene and enhanced mobility. However, this study demonstrates that panniculectomy patients may have significantly higher complication rates initially and 30 days postoperatively and longer LOS than individuals undergoing abdominoplasty.

Online Patient Resources for Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Readability Analysis.

INTRODUCTION: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emerging issue facing the medical community. Government organizations such as the US Food and Drug Administration and specialty groups including the American Society of Plastic Surgeons have published online resources about BIA-ALCL for patients. Given the complexity of the diagnosis, it is important that patients can easily read these resources. In this study, we examined the readability levels of online BIA-ALCL patient resources using multiple verified reading scores. METHODS: "BIA-ALCL" and "breast implant-associated anaplastic large cell lymphoma" were entered into 3 Internet search engines. The top 20 results for each were filtered by resource type and intended audience (physician vs patient). Published scientific articles, online database physician resources, and Web sites requiring subscriptions or fees were excluded. We then examined the readability of each with multiple verified reading scores, including the Flesch-Kincaid, Gunning-Fog, Coleman-Liau, Simplified Measure of Gobbledygook, and Automated Readability Index indices. Obtained data were analyzed using descriptive statistics and t test for independent samples. RESULTS: Fifteen Web sites qualified for further analysis. For all texts, the average readability level was measured between 12 and 13 years of education on each readability index or approximately 18 to 19 years old. The Flesch-Kincaid Reading Ease average was 43.16 ±10.9 on a scale of 1 to 100, corresponding to a "difficult" designation. When compared by search criteria (spelled-out vs abbreviated), the results for the abbreviation "BIA-ALCL" had higher education requirements than those with the condition spelled out. However, these differences were not statistically significant. There was also great variation in word and sentence measurements. Twelve of the 15 Web sites contained more than 15% complex words, having more than 3 syllables, with breastcancer.org having the lowest (11%) and plasticsurgery.org the highest (20%). DISCUSSION: Since the initial announcement in 2014 by the National Cancer Comprehensive Network, the medical community has begun educating ourselves and our patients about BIA-ALCL. Unfortunately, this study suggests that online patient resources on BIA-ALCL may be too complex for most readers, exceeding that of the average US resident (eighth grade) and Medicare beneficiary (fifth grade). Although the goal of learning more about BIA-ALCL and counseling patients appropriately remains paramount, we should continue to improve patient education materials given their vital role in healthcare decision-making.

Malpractice Litigation in Plastic Surgery: Can We Identify Patterns?

BACKGROUND: Malpractice litigation has a significant impact on healthcare costs and important professional implications for healthcare providers. OBJECTIVES: The authors sought to comprehensively characterize the litigation landscape in plastic surgery across its different subspecialties. METHODS: The authors utilized the Westlaw legal database to conduct a comprehensive search of malpractice cases in the United States in the following categories: cosmetic, reconstructive, hand, craniofacial, and gender affirmation surgery. They conducted both a Boolean and a natural language search to identify cases in which a plastic surgeon was the defendant. Data were analyzed employing descriptive statistics, logistic regression, and relative risk calculations. RESULTS: In total, 165 cases were included. Most surgeons accused of malpractice worked in a private setting (148 [90%]). Among the 22 (13%) cases that contained information on board certification status, most surgeons were board certified (17 [77%]). Resident involvement was mentioned in only 5 (3%) cases. The majority of cases were successfully defended by surgeons (98 [60%] vs 65 [40%]), particularly in craniofacial surgery (risk ratio: 1.54; P = 0.03; 95% CI: 1.03-2.3). Surgeons who successfully defended a case were more likely to benefit from summary judgment (P = 0.005). CONCLUSIONS: Malpractice litigation is commonplace in medical practice, and no specialty is spared. Legal outcomes were in favor of plastic surgeons in the majority of cases, particularly those that proceeded to summary judgment. Surgeons can avoid litigation by maintaining detailed office and surgical notes, always obtaining informed consent, adequately following and monitoring patients after surgery, and ensuring compliance by communicating frequently and effectively.

The Role of Antifibrinolytics in Reducing Blood Loss During Craniofacial or Orthognathic Surgical Procedures: A Meta-Analysis.

PURPOSE: Use of antifibrinolytic drugs in craniofacial and orthognathic surgery seems quite promising and has strong advocates. However, supporting evidence is controversial and limited by a small sample of individual studies. We sought to systematically review and meta-analyze the available data regarding the role of preoperative or intraoperative antifibrinolytic drugs (eg, tranexamic acid, aprotinin, or aminocaproic acid) in craniofacial and orthognathic surgery. MATERIALS AND METHODS: We searched PubMed, Scopus, Embase, the Cochrane Library, and Web of Science through April 19, 2018, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes of interest included the volume of blood loss, volume of transfusions, and operative time. A meta-analysis was performed with a random-effects model using Review Manager (RevMan) software (The Cochrane Collaboration, Copenhagen, Denmark). RESULTS: We identified 32 eligible studies with 749 patients undergoing craniofacial surgery and 546 undergoing orthognathic surgery. Meta-analysis showed that antifibrinolytic use led to statistically significant decreases in blood loss and blood transfusions for craniofacial procedures in adult or pediatric patients and to significantly less blood loss during orthognathic surgical procedures. Operative time did not significantly differ for either type of surgery. CONCLUSIONS: Antifibrinolytics can significantly reduce blood loss in craniofacial surgical procedures including pediatric craniosynostosis and adult rhinoplasties and in orthognathic surgical procedures, as well as transfusion requirements in pediatric craniofacial surgical procedures. However, the clinical significance of the medications is still questionable because of the relative paucity of information on adverse effects and the usual small volume loss during those operations.

Association of preoperative opioid use and postoperative complications following breast reconstruction.

BACKGROUND: Previous studies in orthopedics and general surgery have linked negative patient outcomes with preoperative opioid use. In this study, we investigated the association of preoperative opioid use on breast reconstruction outcomes and quality of life (QoL). METHODS: We reviewed our prospective registry of patients who underwent breast reconstruction for documented preoperative opioid use. Postoperative complications were recorded at 60 days after the first reconstructive surgery and 60 days after the final staged reconstruction. We used a logistic regression model to assess the association between opioid use and postoperative complications, controlling for smoking, age, laterality, BMI, comorbidities, radiation, and previous breast surgery; linear regression to analyze RAND36 scores to evaluate the impact of preoperative opioid use on postoperative QoL, controlling for the same factors; and Pearson chi-squared test to assess factors that may be associated with opioid use. RESULTS: Of the 354 patients eligible for inclusion, 29 (8.2%) were prescribed preoperative opioids. There were no differences in opioid use by race, BMI, comorbidities, previous breast surgery, or laterality. Preoperative opioids were associated with increased odds of postoperative complications within 60 days after the first reconstructive surgery (OR: 6.28; 95% CI: 1.69-23.4; p = 0.006) and within 60 days after the final staged reconstruction (OR: 8.38; 95% CI: 1.17-59.4; p = 0.03). Among patients using opioids preoperatively, the RAND36 physical and mental scores decreased but were not statistically significant. CONCLUSION: We found that preoperative opioid use is associated with increased odds of postoperative complications among patients who underwent breast reconstruction and may contribute to clinically significant declines in postoperative QoL.

The Use of Alloderm® Coverage to Reinforce Tissues in Two-Stage Tissue Expansion Placement in the Subcutaneous (Prepectoral) Plane: A Prospective Pilot Study.

PURPOSE: Two-stage tissue expander (TE) to implant breast reconstruction is commonly performed by plastic surgeons. Prepectoral implant placement with acellular dermal matrix (ADM, e.g., AlloDerm®) reinforcement is evidenced by minimal postoperative pain. However, the same is not known for TE-based reconstruction. We performed this study to explore the use of complete AlloDerm® reinforcement of breast pocket tissues in women undergoing unilateral or bilateral mastectomies followed by immediate, two-stage tissue expansion in the prepectoral plane. METHODS: Patients (n = 20) aged 18-75 years were followed prospectively from their preoperative consult to 60 days post-TE insertion. The pain visual analog scale (VAS), Patient Pain Assessment Questionnaire, Subjective Pain Survey, Brief Pain Inventory-Short Form (BPI-SF), postoperative nausea and vomiting (PONV) survey, BREAST-Q Reconstruction Module, and short-form 36 (SF-36) questionnaires were administered. Demographic, intraoperative, and 30- and 60-day complications data were abstracted from medical records. After TE-to-implant exchange, patients were followed until 60 days postoperatively to assess for complications. RESULTS: Pain VAS and BPI-SF pain interference scores returned to preoperative values by 30 days post-TE insertion. Static and moving pain scores from the Patient Pain Assessment Questionnaire returned to preoperative baseline values by day 60. The mean subjective pain score was 3.0 (0.5 standard deviation) with seven patients scoring outside the standard deviation; none of these seven patients had a history of anxiety or depression. Median PONV scores remained at 0 from postoperative day 0 to day 7. Patient-reported opioid use dropped from 89.5% to 10.5% by postoperative day 30. BREAST-Q: Sexual well-being scores significantly increased from preoperative baseline to day 60 post-TE insertion. Changes in SF-36 physical functioning, physician limitations, emotional well-being, social functioning, and pain scores were significantly different from preoperative baseline to day 60 post-TE insertion. Five participants had complications within 60 days post-TE insertion. One participant experienced a complication within 60 days after TE-to-implant exchange. CONCLUSIONS: We describe pain scores, opioid usage, patient-reported outcomes data, and complication profiles of 20 consecutive patients undergoing mastectomy followed by immediate, two-stage tissue expansion in the prepectoral plane. We hope this study serves as a baseline for future research.

Trends of Medicare Reimbursement Rates for Common Plastic Surgery Procedures.

BACKGROUND: Knowledge of Medicare reimbursement is essential for plastic surgeons providing care to Medicare beneficiaries. The authors sought to evaluate changes in Medicare reimbursement for common plastic surgery procedures from 2010 to 2020. METHODS: The authors assessed the Physician Fee Schedule of the Centers for Medicare and Medicaid Services website. Rates of work-, facility-, or malpractice-related relative value units and total monetary units for 26 common plastic surgery procedures between 2010 and 2020 were evaluated. Descriptive statistics were used to calculate relative differences and to compare observed changes over time with the rate of inflation. RESULTS: For the selected procedures, the authors found an average relative difference in terms of monetary units of an increase by 2.02 percent. However, after adjusting for inflation, the average relative difference was a decrease by 14.31 percent. The authors' analysis indicates that, on average, there was a 1.55 percent decrease in physician relative value units between 2010 and 2020. CONCLUSIONS: Medicare reimbursement rates have changed significantly over the past decade. However, these changes did not keep pace with the rate of inflation. Plastic surgeons should be aware of these trends and advocate for more fair reimbursement rates.

Determinants of receiving immediate breast reconstruction: An analysis of patient characteristics at a tertiary care center in the US.

BACKGROUND: Breast reconstruction is an option for women undergoing mastectomy for breast cancer. Previous studies have reported underutilization of reconstructive surgery. This study aims to examine the role demographic, clinical and socio-economic factors may have on patients' decisions to undergo breast reconstruction. METHODS: We analyzed data from our institutional database. Using multivariable and multinomial logistic regression, we compared breast cancer patients who had undergone mastectomy-only to those who had immediate breast reconstruction (overall and by type of reconstruction). RESULTS: We analyzed data on 1459 women who underwent mastectomy during the period 2003-2015. Of these, 475 (32.6%) underwent mastectomy-only and 984 (67.4%) also underwent immediate breast reconstruction. After adjusting for potential confounders, older age (OR = 0.18, 95%CI:0.08-0.40), Asian race (OR = 0.29, 95%CI:0.19-0.45), bilateral mastectomy (OR = 0.71, 95%CI:0.56-0.90), and higher stage of disease (OR = 0.44, 95%CI:0.26-0.74) were independent risk factors for not receiving immediate breast reconstruction. Furthermore, patients with Medicare or Medicaid insurance were less likely than patients with private insurance to receive an autologous reconstruction. There was no evidence for changes over time in the way socio-demographic and clinical factors were related to receiving immediate breast reconstruction after mastectomy. CONCLUSIONS: Clinical characteristics, sociodemographic factors like age, race and insurance coverage affect the decision for reconstructive surgery following mastectomy.