Ari M. Wes

An evaluation of complications, revisions, and long-term aesthetic outcomes in nonsyndromic metopic craniosynostosis.

Background: The authors evaluated the complications, revisions, and long-term aesthetic outcomes of patients with isolated metopic synostosis. Methods: A retrospective chart review was performed on consecutive metopic craniosynostosis patients treated from June of 1987 to June of 2012 at The Children’s Hospital of Philadelphia. Patient demographics, operative details, and postoperative data were collected. Outcomes were reported as Whitaker classification and postoperative clinical characteristics assessed before additional interventions. Reoperation in patients with greater than 5 years of follow-up was noted. Appropriate statistical analyses were applied. Results: From 1987 to 2012, 178 patients underwent surgical correction of isolated metopic craniosynostosis, and 147 met inclusion criteria. Average age at surgery was 0.83 year (range, 0.3 to 4.7 years); average follow-up was 5.8 years (range, 1.0 to 17.8 years). There were 13 surgical complications (8.8 percent), three major (2.0 percent), and 10 minor (6.8 percent). At follow-up, 67 patients (56.8 percent) were classified as Whitaker class I, six (5.1 percent) as class II, 43 (36.4 percent) as class III, and two (1.7 percent) as class IV. Patients with greater than 5 years’ follow-up (n = 57) were more likely to have temporal hollowing (OR, 2.9; 95 percent CI, 1.2 to 7.3; p = 0.021), lateral orbital retrusion (OR, 4.9; 95 percent CI, 1.9 to 12.7; p = 0.001), and Whitaker class III or IV classification (OR, 4.0; 95 percent CI, 1.5 to 10.6; p = 0.006) compared with those with less than 5 years’ follow-up. Conclusion: This study reports low complication and reoperation rates in the treatment of isolated metopic craniosynostosis, but demonstrates a clear trend toward worsening aesthetic outcomes over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Complications in body contouring procedures: an analysis of 1797 patients from the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases.

Background: The purpose of this study was to examine the incidence and predictors of surgical and medical morbidity following body contouring procedures. Methods: The authors reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2010 for all identifiable body contouring cases including Current Procedural Terminology codes for brachioplasty, medial thigh lift, abdominoplasty, and suction-assisted lipectomy. Independent predictors of morbidity were determined. Results: A total of 1797 patients underwent body contouring during the study period, and most were female (n = 1600; 89.0 percent). The average body mass index was 31.6 kg/m2, and 239 were morbidly obese (body mass index ≥ 40 kg/m2). The most common area of intervention was the trunk region, with 1652 patients (91.9 percent) receiving abdominal contouring and/or contouring of the hips and buttocks. Minor wound complications occurred in 114 individuals (6.3 percent), 122 patients (6.8 percent) suffered a major surgical morbidity, and 40 (2.2 percent) experienced a medical complication. Multiple comorbidities (OR, 15.87; p = 0.014), presence of bleeding disorder (OR, 20.31; p = 0.026), preoperative albumin level (OR, 0.14; p = 0.003), and malnutrition (OR, 0.19; p = 0.065) were associated with an increased odds of minor wound complications. Inpatient procedures (OR, 4.64; p = 0.06) and functional status (OR, 9.71; p = 0.011) were associated with an increased odds of major surgical morbidity. Conclusions: This study characterizes the 30-day morbidity rates in patients undergoing body contouring procedures using a large, prospective, validated national data set, highlighting the critical importance of careful preoperative patient evaluation and underscoring the need for detailed preoperative counseling and risk stratification. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Factors associated with readmission following plastic surgery: a review of 10,669 procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program data set.

Background: This study explored factors associated with readmission following plastic surgery using a prospective, validated, national database. Methods: Patients who underwent primary plastic surgery procedures (n = 10,669) were identified from the 2011 American College of Surgeons National Surgical Quality Improvement Program databases. Those who were readmitted were compared with those who were not. Preoperative patient comorbidities, laboratory values, and intraoperative details derived from the data set were analyzed, and multivariate regression analysis was used to identify predictors of readmission. Results: A total of 10,669 patients were included, with a 4.5 percent readmission rate. Their average age was 49.5 years, 32.2 percent were obese, 15.2 percent were smokers, and 81.7 percent were women. The most commonly performed procedures included elective/cosmetic breast (23.4 percent), implant breast reconstruction (16.5 percent), revision breast procedures (14.9 percent), hand operations (9.7 percent), and body contouring (5.9 percent). The wound complication rate was 4.6 percent and the medical complication rate was 4.9 percent. The overall incidence of any postoperative complication was 10.9 percent, of which 4.8 percent were defined as major surgical complications. Independent risk factors associated with readmission included procedure type (p = 0.029); obesity (p = 0.011); anemia (p = 0.003); and medical (p < 0.001), major surgical (p < 0.001), and wound (p < 0.001) complications. Conclusions: The most significant predictor of readmission was postoperative complications. Patients experiencing postoperative surgical complications were six times more likely to be readmitted. These findings can assist surgeons and health systems to better tailor preoperative risk counseling, resource allocation, and postoperative discharge services. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The impact of surgical resident participation in breast reduction surgery – Outcome analysis from the 2005–2011 ACS-NSQIP datasets

Abstract Breast reduction surgery is a common and effective surgical technique for treating symptomatic macromastia. There is limited data on the impact of resident involvement on outcomes. This study uses the ACS-NSQIP datasets to assess the impact of surgical resident participation in breast reduction surgery. This study reviewed the 2005–2011 ACS-NSQIP databases identifying primary encounters for reduction mammaplasty with CPT code “19318”. It characterised surgical complications into three groups: any, major, and wound complications. Propensity scoring and matched analysis were used to account for non-randomised assignment. In total, 4328 patients underwent reduction mammoplasty during the study period. Resident participation was identified in 56.3% of cases. Logistic regression analysis determined the following factors independently associated with resident participation: class II obesity (OR = 0.73, p < 0.001), class III obesity (OR = 0.68, p < 0.001), dyspnea (OR = 1.59, p = 0.04), and ASA physical status of 3 (OR = 1.51, p < 0.001). A propensity score was assigned based on probability of resident involvement and matched cohorts were created and analyzed. A logistic regression analysis of the matched cohort data revealed that resident participation was independently associated with major surgical complications (OR = 2.18, p = 0.008). Prolonged operative (>2 SD) was associated with any (OR = 3.3, p = 0.039) and wound (OR = 10.2, p = 0.028) complications. A separate logistic regression analysis of the unmatched cohort using stratified PGY experience demonstrated that junior PGY was most highly associated with any (OR = 1.93, p = 0.013), major (OR = 2.4, p = 0.034), and wound (OR = 1.9, p = 0.04) complications. Resident participation was associated with added risk of surgical morbidity, and PGY experience was inversely related to risk of surgical complications in breast reduction surgery. Level of Evidence: Prognostic/risk category, level III.

A critical evaluation of long-term aesthetic outcomes of fronto-orbital advancement and cranial vault remodeling in nonsyndromic unicoronal craniosynostosis.

Background: This study reports long-term aesthetic outcomes with fronto-orbital advancement and cranial vault remodeling in treating unicoronal synostosis over a 35-year period. Methods: Retrospective review was performed on patients with isolated unicoronal synostosis from 1977 to 2012. Demographic, preoperative phenotypic, and long-term aesthetic outcomes data were analyzed with chi-squared and Fisher’s exact test for categorical data and Wilcoxon rank-sum and Kruskal-Wallis rank for continuous data. Results: A total of 238 patients were treated; 207 met inclusion criteria. None underwent secondary intervention for intracranial pressure. At definitive intervention, there 96 (55 percent) Whitaker class I patients, 11 (6 percent) class II, 62 (35 percent) class III, and six (3 percent) class IV. Nasal root deviation and occipital bossing each conferred an increased risk of Whitaker class III/IV [OR, 4.4 (1.4 to 13.9), p = 0.011; OR, 2.6 (1.0 to 6.8), p = 0.049]. Patients who underwent bilateral cranial vault remodeling with extended unilateral bandeau were less likely Whitaker class III/IV at latest follow-up compared with those undergoing strictly unilateral procedures [OR, 0.2 (0.1 to 0.7), p = 0.011]. Overcorrection resulted in decreased risk of temporal hollowing [OR, 0.3 (0.1 to 1.0), p = 0.05]. Patients with 5 years or more of follow-up were more likely to develop supraorbital retrusion [OR, 7.2 (2.2 to 23.4), p = 0.001] and temporal hollowing [OR, 3.7 (1.5 to 9.6), p = 0.006] and have Whitaker class III/IV outcomes [OR, 4.9 (1.8 to 12.8), p = 0.001]. Conclusion: Traditional fronto-orbital advancement and cranial vault remodeling appears to mitigate risk of intracranial pressure but may lead to aesthetic shortcomings as patients mature, namely fronto-orbital retrusion and temporal hollowing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Mastectomy with or without immediate implant reconstruction has similar 30-day perioperative outcomes

BACKGROUND Immediate breast reconstruction (IBR) using implants remains a favorable reconstructive option in breast cancer. Understanding the added risk associated with IBR continues to enhance the risk counseling process and management of these patients. METHODS Women undergoing mastectomy alone and mastectomy with tissue expander (TE) were identified in the ACS-NSQIP datasets. Specific complications examined included any, wound, medical complications, and deep infections. Bivariate and multivariate analyses were performed to identify predictors of outcomes, and propensity-matching was used to compare cohorts. RESULTS A total of 42,823 patients who underwent either mastectomy alone (N = 30,440) or mastectomy with immediate TE placement (N = 12,383) were identified. Notable independently associated perioperative differences between mastectomy and TE patients included: race (P < 0.001), comorbidity burden (P < 0.001), year of surgery (P < 0.001), ASA physical status (P < 0.001), functional status (P < 0.001), inpatient procedures (P < 0.001), bilateral procedures (P < 0.001), BMI (P < 0.001), age (P < 0.001), and lymphadenectomy (P < 0.001). IBR using TE was not found to be associated with greater risk of wound (3.3% vs. 3.2%, P = 0.855), medical (1.7% vs. 1.6%, P = 0.751), or overall (9.6% vs. 10.0%, P = 0.430) complications. TE placement was associated with higher rates of deep wound infections (2.0% vs. 1.0%, P < 0.001) and unplanned reoperations (6.9% vs. 6.1%, P = 0.025). Additionally, the rate of 30-day device loss was 0.8% in patients receiving reconstruction. Multivariate conditional (fixed-effects) logistic regression analysis failed to demonstrate significantly associated independent risk of wound, medical, or overall complications with the addition of TE. CONCLUSIONS Undergoing IBR with TE placement does not confer added risk of wound, medical, or overall morbidity relative to mastectomy alone based upon propensity-matched 30-day complication rates in 15,238 patients from the 2005-2011 ACS-NSQIP datasets. These findings further confirm the safety profile of prosthetic-based IBR. LEVEL OF EVIDENCE Prognostic/risk category, level II.

Concurrent panniculectomy with open ventral hernia repair has added risk versus ventral hernia repair: An analysis of the ACS-NSQIP database

BACKGROUND Recent studies have assessed the risks and benefits of performing concurrent panniculectomy (PAN) in the setting of hernia repair, gynecologic surgery, and oncologic resections with conflicting results. The aim of this study is to assess the added risk of ventral hernia repair and panniculectomy (VHR-PAN) using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data sets. METHODS The 2005-2011 ACS-NSQIP databases were queried to identify all patients undergoing VHR alone or VHR-PAN. Propensity scores were used to account for potential selection bias given the non-randomized assignment of concurrent panniculectomy and the retrospective nature of this study. Multivariate logistic regression analyses were used to assess the impact of concurrent PAN on complications. RESULTS A total of 55,537 patients were identified. Propensity matching yielded two groups of patients: VHR (n = 1250) and VHR-PAN (n = 1250). Few statistically significant differences existed between matched cohorts. Overall, wound complications (P < 0.001), venous thromboembolism (P = 0.044), incidence of reoperation (P < 0.001), and medical morbidity (P < 0.001) were significantly higher in the VHR-PAN group. In an adjusted, fixed-effects analysis, concurrent panniculectomy was associated with wound healing complications (OR = 1.69, P < 0.001), increased incidence of unplanned reoperations (OR = 2.08, P ≤ 0.001), venous thromboembolism (OR = 2.48, P = 0.043), and overall medical morbidity (OR = 2.08, P < 0.001). Sub-group analysis of wound complications demonstrated that superficial surgical site infections occurred significantly more often in concurrent cases (P = 0.018). CONCLUSIONS This analysis quantifies the added risk of performing a panniculectomy concurrent with ventral hernia repair, demonstrating higher incidence of wound complications (superficial infections), unplanned reoperations, and VTE. LEVEL OF EVIDENCE Prognostic/risk category, level II.

Venous thromboembolism risk in mastectomy and immediate breast reconstruction: analysis of the 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets.

Background: Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a morbid and costly complication following surgical procedures. The authors aim to assess the added risk of venous thromboembolism in patients undergoing immediate breast reconstruction. Methods: The 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets were used to identify patients undergoing mastectomy with or without immediate breast reconstruction. The dependent variable and our primary outcome was 30-day venous thromboembolism. Venous thromboembolism events were treated as a dichotomous variable. Subgroup analyses were performed with respect to procedure and body mass index stratifications. Results: A total of 48,634 patients were identified. Postoperative venous thromboembolism occurred in 184 patients (0.4 percent), including deep venous thrombosis (n = 118) and pulmonary embolism (n = 82). A multivariate regression analysis demonstrated that immediate breast reconstruction, either implant-based (OR, 1.65; p = 0.01) or autologous (OR, 2.14; p = 0.009), was associated with a greater odds of venous thromboembolism. Obesity was also identified as a risk factor for venous thromboembolism: class I (OR, 2.20; p < 0.001), class II (OR, 1.6; p < 0.092), and class III (OR, 2.88; p < 0.001). Impaired patient functional status (OR, 2.56; p = 0.035), recent irradiation (OR, 3.60; p = 0.03), and underlying renal comorbidities (OR, 5.60; p < 0.001) were associated with venous thromboembolism in adjusted analysis. Subgroup analysis of nonobese patients demonstrated that implant reconstruction (0.2 percent versus 0.3 percent; p = 0.383) did not confer an added risk of venous thromboembolism, whereas analysis of obese patients revealed a modality-specific increased risk of venous thromboembolism (0.4 percent versus 0.8 percent versus 1.8 percent; p < 0.001) between mastectomy compared to implant and autologous reconstruction, and for which all intergroup comparisons were significant (p < 0.05). Conclusions: Immediate breast reconstruction is associated with an added risk of venous thromboembolism relative to mastectomy, but this risk is procedure and body mass index dependent. Overall, autologous reconstruction and states of obesity placed patients at significant added risk for venous thromboembolism, particularly when both factors are present. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Perioperative complications associated with intracranial procedures in patients with nonsyndromic single-suture craniosynostosis.

AbstractWithin the diagnosis “craniosynostosis,” there is a subset of patients who present with isolated, nonsyndromic, single-suture involvement. This study evaluates perioperative complications in this specific subset of patients over 4 decades at a single institution. To do so, we performed a retrospective review on consecutive patients undergoing correction of single-suture synostosis from May 1977 to January 2013 at a tertiary pediatric craniofacial center. Demographic information, operative details, and perioperative course were collected. Complications were categorized as either major or minor. A &khgr;2 test and Fisher exact test were used to compare all categorical variables. Continuous variables were analyzed using Wilcoxon rank-sum and Kruskal-Wallis tests.Seven hundred forty-six patients underwent surgical correction of nonsyndromic craniosynostosis. Of these, there were 307 (41.2%) sagittal, 201 (26.9%) metopic, and 238 (31.9%) unicoronal. Thirty-four patients had complications (4.6%). Eight were considered major (1.1%), including one postoperative mortality in a patient with hypoplastic left-sided heart syndrome. Minor complications occurred in 26 patients (3.5%) and included subgaleal hematoma (n = 3), seroma (n = 4), and superficial wound infection (n = 5). Metopic and sagittal suture involvement was significantly associated with a higher complication rate (P = 0.04). A child with isolated single suture synostosis and any comorbidity had a significantly greater risk of any complication (P < 0.001; odds ratio, 3.8) and specifically an increased risk of major complication (P = 0.031; odds ratio, 6.0). Subclassification of patients by time period yielded no statistically significant changes in perioperative morbidity. To conclude, these data allow us to counsel families more accurately with regard to morbidity and mortality and may potentially serve as a benchmark for future quality improvement work.

Optimizing patient selection in ventral hernia repair with concurrent panniculectomy: An analysis of 1974 patients from the ACS-NSQIP datasets

BACKGROUND Panniculectomy (PAN) during ventral hernia repair (VHR) can be a challenging procedure associated with added risk. We utilized the ACS-NSQIP datasets to generate a risk model of morbidity following these combined interventions. METHODS The 2005-2012 ACS-NSQIP databases were queried to identify all patients undergoing VHR-PAN. Multivariate logistic regression analyses were used to assess perioperative factors associated with surgical and medical morbidity. Internal validation was performed using bootstrap analysis and risk stratification was performed using weighted β-coefficients. RESULTS 1974 patients underwent VHR-PAN with an average age of 53.6 ± 12.4 years and BMI of 36.4 ± 10.1 kg/m2. Surgical complications occurred in 23.8% of patients, whereas medical complications occurred in 11.5%. A multivariate logistic regression identified the presence of a renal comorbidity (OR = 1.62, P = 0.045), class II obesity (BMI = 34.9-40.0 kg/m2) (OR = 1.89, P < 0.001), class III obesity (BMI≥40 kg/m2) (OR = 2.66, P < 0.001), dirty/infected wound class (OR = 2.01, P = 0.003), smoking (OR = 1.41, P = 0.026), prolonged operative time (OR = 2.12, P = 0.001), and ASA physical status of ≥3 (OR = 1.69, P < 0.001) as independently associated with higher incidences of postoperative surgical complications. A multivariate regression analysis identified class II or III obesity (OR = 1.70, P = 0.003), contaminated or dirty/infected wounds (OR = 1.95, P < 0.001), diabetes (OR = 1.96, P = 0.001), pulmonary comorbidity (OR = 2.08, P = 0.005), and component separation (OR = 2.65, P < 0.001) as independently associated with higher incidences of postoperative medical complications. Simplified risk models of surgical and medical morbidity demonstrated good discrimination with C statistics of 0.69 and 0.70, respectively. CONCLUSIONS We report a simple preoperative, internally-validated risk model of surgical and medical morbidity following VHR-PAN to guide patient selection. LEVEL OF EVIDENCE Prognostic/risk category, level II.