Charles Rodriguez-Feo

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients

BACKGROUND Nearly 70% of US adults are overweight or obese (body mass index, BMI ≥ 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI ≥ 30) or morbidly obese (BMI ≥ 40) patients, with mixed results. OBJECTIVES This study evaluates BMI 25 to 29.9 and BMI ≥ 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database. METHODS A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility. RESULTS Of the 127,961 patients, 36.2% had BMI ≥ 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (≥40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI ≥ 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56). CONCLUSIONS Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk.

Aesthetic Breast Surgery and Concomitant Procedures: Incidence and Risk Factors for Major Complications in 73,608 Cases

Background: Major complications following aesthetic breast surgery are uncommon and thus assessment of risk factors is challenging. Objectives: To determine the incidence and risk factors of major complications following aesthetic breast surgery and concomitant procedures. Methods: A prospective cohort of patients who enrolled into the CosmetAssure (Birmingham, AL) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, readmission, or emergency room visit) within 30 days of surgery were recorded. Risk factors including age, smoking, body mass index (BMI), diabetes, type of surgical facility, and combined procedures were evaluated. Results: Among women, augmentation was the most common breast procedure (n = 41,651, 58.6%) followed by augmentation‐mastopexy, mastopexy, and reduction. Overall, major complications occurred in 1.46% with hematoma (0.99%) and infection (0.25%) being most common. Augmentation‐mastopexy had a higher risk of complications, particularly infection (relative risk [RR] 1.74, P < 0.01), than single breast procedures. Age was the only significant predictor for hematomas (RR 1.01, P < 0.01). Increasing age (RR 1.02, P = 0.03) and BMI (RR 1.09, P < 0.01) were risk factors for infection. Concomitant abdominoplasty was performed in 4162 (5.8%) female patients and was associated with increased risk of complications compared to breast procedures or abdominoplasty performed alone. Among men, correction of gynecomastia was the most common breast procedure (n = 1613, 64.6%) with a complication rate of 1.80% and smoking as a risk factor (RR 2.73, P = 0.03). Conclusions: Incidence of major complications after breast cosmetic surgical procedures is low. Risk factors for major complications include increasing age and BMI. Combining abdominoplasty with any breast procedure increases the risk of major complications. Level of Evidence: 2 Figure. No caption available.

Adjuvant neurotrophic factors in peripheral nerve repair with chondroitin sulfate proteoglycan-reduced acellular nerve allografts.

BACKGROUND Acellular nerve allografts are now standard tools in peripheral nerve repair because of decreased donor site morbidity and operative time savings. Preparation of nerve allografts involves several steps of decellularization and modification of extracellular matrix to remove chondroitin sulfate proteoglycans (CSPGs), which have been shown to inhibit neurite outgrowth through a poorly understood mechanism involving RhoA and extracellular matrix-integrin interactions. Chondroitinase ABC (ChABC) is an enzyme that degrades CSPG molecules and has been shown to promote neurite outgrowth after injury of the central and peripheral nervous systems. Variable results after ChABC treatment make it difficult to predict the effects of this drug in human nerve allografts, especially in the presence of native extracellular signaling molecules. Several studies have shown cross-talk between neurotrophic factor and CSPG signaling pathways, but their interaction remains poorly understood. In this study, we examined the adjuvant effects of nerve growth factor (NGF) and glial cell line-derived neurotrophic factor (GDNF) on neurite outgrowth postinjury in CSPG-reduced substrates and acellular nerve allografts. MATERIALS AND METHODS E12 chicken DRG explants were cultured in medium containing ChABC, ChABC + NGF, ChABC + GDNF, or control media. Explants were imaged at 3 d and neurite outgrowths measured. The rat sciatic nerve injury model involved a 1-cm sciatic nerve gap that was microsurgically repaired with ChABC-pretreated acellular nerve allografts. Before implantation, nerve allografts were incubated in NGF, GDNF, or sterile water. Nerve histology was evaluated at 5 d and 8 wk postinjury. RESULTS The addition of GDNF in vitro produced significant increase in sensory neurite length at 3 d compared with ChABC alone (P < 0.01), whereas NGF was not significantly different from control. In vivo adjuvant NGF produced increases in total myelinated axon count (P < 0.005) and motor axon count (P < 0.01), whereas significantly reducing IB4+ nociceptor axon count (P < 0.01). There were no significant differences produced by in vivo adjuvant GDNF. CONCLUSIONS This study provides initial evidence that CSPG-reduced nerve grafts may disinhibit the prosurvival effects of NGF in vivo, promoting motor axon outgrowth and reducing regeneration of specific nociceptive neurons. Our results support further investigation of adjuvant NGF therapy in CSPG-reduced acellular nerve grafts.

Complications of Aesthetic Breast Surgery - Analysis of 73,608 Cases.

MATERIALS AND METHODS: A cohort of patients who enrolled into the CosmetAssure (Birmingham, Alabama, USA) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, re-admission or emergency room visit) within 30 days of surgery were recorded. Univariate and multivariate analysis evaluated risk factors including age, smoking, BMI, gender, diabetes, type of surgical facility and combined procedures.

Twenty-Year Review of a Single Surgeonʼs Experience Using a Unique Surgical Technique to Correct Lambdoidal Synostosis

Background: Numerous techniques for the surgical management of lambdoidal synostosis have been previously described; however, no best practice technique currently exists. Surgical procedures range from complete posterior calvarial reconstruction to distraction osteogenesis techniques. Our primary purpose is to describe a novel approach to correct unilateral or bilateral lambdoidal synostosis. Methods: A retrospective review was performed on a single surgeons experience with craniosynostosis (1994–2014). Specifically, craniosynostosis cases involving the lambdoidal suture, which were repaired using a novel ‘tongue and groove’ technique, were identified. Results: A total of 664 craniosynostosis cases were retrieved, with 21 primarily involving the lambdoidal suture (3.2%). Of these, 18 were unilateral and 3 were bilateral lambdoidal synostosis. Male-to-female ratio was 3:1. Average age of first encounter with a craniofacial physician was 33 weeks (8 months). Average age at time of surgery was 43 weeks (10.75 months). Complications of this technique included 1 patient who experienced refusion of his lambdoidal suture and fusion of his sagittal suture, and 4 who returned for bone graft coverage of full-thickness calvarial defects owing to a lack of complete reossification. Conclusion: The “tongue and groove” technique represents a novel method for the management of lambdoidal synostosis with good esthetic outcomes, allowing immediate cranial stabilization with increased skull volume. This technique, used by the senior author for >20 years, provides a reproducible and reliable method of correcting lambdoidal synostosis.

Need Cost Effective Surgical Simulation, Send a Resident to the HardwareStore

Background: The purpose of this project was to design a novel, cost-effective simulator for a vascular surgery skills workshop. The simulator had to be realistic, durable, cost less than

Abstract 221: SELECTIVE ENHANCEMENT OF AXONAL INGROWTH IN PROCESSED NERVE ALLOGRAFTS LOADED WITH NEUROTROPHIC FACTORS IN THE RAT SCIATIC NERVE MODEL

10 per unit to produce, and allow for practicing multiple vascular techniques. Vascular Surgery has a unique challenge in that vascular anastomoses are constructed at various apertures in body cavities making the surgeon constantly adapt. Methods: After interviewing two vascular surgeons, the unifying themes identified were that the learner needed to practice multiple techniques (an end to side anastomosis, an end to end anastomosis, and the sewing of a patch) at various depths. Using these criteria, 18 simulators were created and 25 surgical interns attended a 2-hour workshop during which they were asked to perform the tasks mentioned above. Post-workshop, an online survey was administered. Results: The number of vascular anastomoses performed prior to the workshop was 0 for 86%of respondents. During the workshop participants performed an average of 3 anastomoses and participated in an average of 6 anastomoses. On a visual analog scale, residents rated their ability to complete a vascular anastomosis subjectively higher after the workshop (p= .009, Wilcoxon matched-pairs rank sum test). 100% of respondents would like to have the simulator for personal use and 71% were willing to pay for the simulator. 86% reported they would be comfortable demonstrating competency on the simulator prior to being able to perform the skill in the operating room. Conclusions: This study demonstrates viability of inexpensive, durable, open vascular simulation with varying degrees of difficulty and techniques. Subjectively, the simulator led to an increased ability of residents to perform an anastomosis. All residents wished for a personal simulator to use in their home for practice, indicating that there is a market for personal simulators to be used as the learner desires.

Blocking the P2X7 receptor improves outcomes after axonal fusion.

Background: Traumatic peripheral nerve injuries can result in lifelong disability. Primary nerve repair is used for short nerve defects. Autologous nerve can be used in longer defects but creates donor site morbidity. Nerve conduits lack an aligned internal scaffold to support and guide axonal regeneration. Peptide amphiphiles (PA) can self-assemble into aligned nano bers and promote peripheral nerve regeneration in vivo. Bioactive epitopes IKVAV (Ile-Lys-Val-Ala-Val) and RGDS (Arg-Gly-Asp-Ser) can be incorporated into PA nano bers and can promote cell adhesion, growth, and migration. There are no studies to date that examine the ability of PA nano bers to support the regeneration of injured nerves that supply the musculoskeletal system. In this preliminary study, we investigate the viability of rat Schwann cells after incorporation into PA gels.