Gregory A. Dumanian

Resident involvement and plastic surgery outcomes: an analysis of 10,356 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

Background: Intraoperative experience is an essential component of surgical training. The impact of resident involvement in plastic surgery has not previously been studied on a large scale. Methods: The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2010 for all reconstructive plastic surgery cases. Resident involvement was tracked as an individual variable to compare outcomes. Results: A total of 10,356 cases were identified, with 43 percent noted as having resident involvement. The average total relative value units, a proxy for surgical complexity, and operative time were higher for procedures with residents present. When balanced by baseline characteristics using propensity score stratification into quintiles, no differences in graft, prosthesis, or flap failure or mortality were observed. Furthermore, there were no differences in overall complications or wound infection with resident involvement for a majority of the quintiles. Multivariable logistic regression analysis revealed that resident involvement was a significant predictor of overall morbidity, but not associated with increased odds of wound infection, graft, prosthesis or flap failure, or overall mortality. Conclusions: Residency has the dual mission of training future physicians and also providing critical support for academic medical centers. Using a large-scale, multicenter database, the authors were able to confirm that well-matched cohorts with—and without—resident presence had similar complication profiles. Moreover, even when residents were involved in comparably more complex cases with longer operative times, infection, graft and flap failure, and mortality remained similar. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Targeted Muscle Reinnervation: A Novel Approach to Postamputation Neuroma Pain

BackgroundPostamputation neuroma pain can prevent comfortable prosthesis wear in patients with limb amputations, and currently available treatments are not consistently effective. Targeted muscle reinnervation (TMR) is a decade-old technique that employs a series of novel nerve transfers to permit intuitive control of upper-limb prostheses. Clinical experience suggests that it may also serve as an effective therapy for postamputation neuroma pain; however, this has not been explicitly studied.Questions/purposesWe evaluated the effect of TMR on residual limb neuroma pain in upper-extremity amputees.MethodsWe conducted a retrospective medical record review of all 28 patients treated with TMR from 2002 to 2012 at Northwestern Memorial Hospital/Rehabilitation Institute of Chicago (Chicago, IL, USA) and San Antonio Military Medical Center (San Antonio, TX, USA). Twenty-six of 28 patients had sufficient (>xa06xa0months) followup for study inclusion. The amputation levels were shoulder disarticulation (10 patients) and transhumeral (16 patients). All patients underwent TMR for the primary purpose of improved myoelectric control. Of the 26 patients included in the study, 15 patients had evidence of postamputation neuroma pain before undergoing TMR.ResultsOf the 15 patients presenting with neuroma pain before TMR, 14 experienced complete resolution of pain in the transferred nerves, and the remaining patient’s pain improved (though did not resolve). None of the patients who presented without evidence of postamputation neuroma pain developed neuroma pain after the TMR procedure. All 26 patients were fitted with a prosthesis, and 23 of the 26 patients were able to operate a TMR-controlled prosthesis.ConclusionsNone of the 26 patients who underwent TMR demonstrated evidence of new neuroma pain after the procedure, and all but one of the 15 patients who presented with preoperative neuroma pain experienced complete relief of pain in the distribution of the transferred nerves. TMR offers a novel and potentially more effective therapy for the management of neuroma pain after limb amputation.Level of Evidence Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Routine use of bioprosthetic mesh is not necessary: a retrospective review of 100 consecutive cases of intra-abdominal midweight polypropylene mesh for ventral hernia repair.

BACKGROUNDnThe Ventral Hernia Working Group (VHWG) recently proposed a grading system to assist surgeons in selecting the appropriate mesh based on an individual patients risk of developing a postoperative complication. The VHWG grading scale was used to evaluate the incidence of surgical-site complications in 100 consecutive midline ventral hernias repaired with uncoated mid-weight polypropylene mesh.nnnMETHODSnA retrospective review was conducted of 100 consecutive cases of midline ventral hernia repair using an intra-abdominal mesh underlay between July 2005 and May 2010. The median duration of follow-up was 23 months.nnnRESULTSnUsing the VHWG scale, 50 percent of cases were considered grade 2 (Co-morbid) and 28 percent considered Grade 3 (Potentially Contaminated). The remaining cases were Grade 1 (Low-risk). Overall, there was a 5.6 percent rate of hernia recurrence, with a mean time to recurrence of 17 months. There were no enterocutaneous fistulae or infections requiring mesh removal.nnnCONCLUSIONnThe use of uncoated mid-weight polypropylene mesh for reinforcement of midline ventral hernia repairs was not associated with increased rates of infection, fistula formation, or clinically significant adhesions. These findings challenge the recommendation by the VHWG to avoid synthetic repair material in patients with comorbidities or in potentially contaminated fields.

Burnout phenomenon in u.s. plastic surgeons: Risk factors and impact on quality of life

Background: Recent studies by the American College of Surgeons reveal that nearly 40 percent of U.S. surgeons exhibit signs of burnout. The authors endeavored to quantify the incidence of burnout among U.S. plastic surgeons, determine identifiable risk factors, and evaluate its impact on quality of life. Methods: All U.S. residing members of the American Society of Plastic Surgeons were invited to complete an anonymous survey between September of 2010 and August of 2011. The survey contained a validated measure of burnout (Maslach Burnout Inventory) and evaluated surgeon demographics, professional and personal risk factors, career satisfaction, self-perceived medical errors, professional impairment, and family-home conflicts. Results: Of the 5942 surgeons invited, 1691 actively practicing U.S. plastic surgeons (28.5 percent) completed the survey. The validated rate of burnout was 29.7 percent. Significant risk factors for burnout included subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Approximately one-fourth of plastic surgeons had significantly lower quality-of-life scores than the U.S. population norm, and this risk increases in burned out surgeons. In addition to having lower career satisfaction and more work-home conflicts, plastic surgeons with burnout also had a nearly two-fold increased risk of self-reported medical errors and self-reported impairment. Conclusions: Over one-fourth of plastic surgeons in the United States experience validated burnout, with concomitant attenuated career satisfaction and quality of life. Multivariate analysis identified predisposing factors that may aid in better understanding risk profiles that lead to burnout; therefore, efforts to understand and thereby avoid this burnout phenomenon are warranted.

Risk factors for 30-day readmission in patients undergoing ventral hernia repair

BACKGROUNDnVentral hernia repair (VHR), an increasingly common procedure, may have a greater impact on health care costs than is currently appreciated. Readmissions have the potential to further increase these costs and negatively impact patient outcomes. New national registry data allows for an in-depth look at the predictors and rates of readmission after VHR.nnnMETHODSnThe American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent only an incisional or VHR in 2011. Patients who had any concomitant procedure were excluded. Using readmission as the dependent variable, a multivariate logistic regression model was created to identify independent predictors of readmission.nnnRESULTSnVHR had a 4.9% 30-day readmission rate in 2011. Deep/incisional (12.6%) and superficial site infections (10.5%) were the most common wound complications seen in readmitted patients (both P < .001), whereas sepsis/septic shock (10.14%; P < .001) was the most common systemic complication. Higher class body mass index is not associated with readmission (P = .320). Smoking and chronic obstructive pulmonary disease function as predictors of readmission independently from their association with complications (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.6; and OR, 1.6, 95% CI, 1.1-2.3, respectively). Operative factors such as the use of mesh (OR, 1.3; 95% CI, 0.995-1.7) or laparoscopy (OR, 1.2; 95% CI, 0.96-1.6) do not increase likelihood of readmission.nnnCONCLUSIONnThere is room for improvement in VHR readmission rates. Although complications are the main driver of readmission, surgeons must be aware of comorbidities that independently increase the odds of readmission, even when a complication does not occur.

Targeted Muscle Reinnervation and Advanced Prosthetic Arms

Targeted muscle reinnervation (TMR) is a surgical procedure used to improve the control of upper limb prostheses. Residual nerves from the amputated limb are transferred to reinnervate new muscle targets that have otherwise lost their function. These reinnervated muscles then serve as biological amplifiers of the amputated nerve motor signals, allowing for more intuitive control of advanced prosthetic arms. Here the authors provide a review of surgical techniques for TMR in patients with either transhumeral or shoulder disarticulation amputations. They also discuss how TMR may act synergistically with recent advances in prosthetic arm technologies to improve prosthesis controllability. Discussion of TMR and prosthesis control is presented in the context of a 41-year-old man with a left-side shoulder disarticulation and a right-side transhumeral amputation. This patient underwent bilateral TMR surgery and was fit with advanced pattern-recognition myoelectric prostheses.

Analysis of risk factors for complications in expander/implant breast reconstruction by stage of reconstruction.

Background: Expander/implant breast reconstruction is a common approach to breast reconstruction. Although several studies evaluate risk factors for complications during the overall reconstructive process, no studies currently evaluate risk factors by stage of reconstruction. This information is important, as it can help guide physician and patient decision making. Methods: This is a retrospective review of the records of 876 patients who underwent expander/implant breast reconstruction. Average follow-up time was 42 months. Multivariate analysis and odds ratios were used to calculate the significance of the variables of interest and to compare the risk of complications attributable to each of the independent variables during each stage of the procedure. Results: During the expander stage, body mass index greater than 30 kg/m2 had the strongest effect on the development of complications leading to explantation/conversion to flap (OR, 3.07). During the permanent implant stage, history of prereconstruction irradiation had the strongest association with the development of complications leading to explantation/conversion to flap (OR, 3.45). The only risk factors that had a statistically significant effect on the development of complications during both stages were age older than 50 years, smoking within the past month, and a history of premastectomy or postmastectomy radiation therapy. Conclusions: The results of this study indicate that the risk factors for complications during expander/implant breast reconstruction differ during each stage of the procedure. The individual impact of risk factors must be considered within the context of each patient’s oncologic and surgical needs so that surgeons and patients may make more informed decisions toward their goal of a successful breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Predictors of readmission after outpatient plastic surgery

Background: Hospital readmissions have become a topic of focus for quality care measures and cost-reduction efforts. However, no comparative multi-institutional data on plastic surgery outpatient readmission rates currently exist. The authors endeavored to investigate hospital readmission rates and predictors of readmission following outpatient plastic surgery. Methods: The 2011 National Surgical Quality Improvement Program database was reviewed for all outpatient procedures. Unplanned readmission rates were calculated for all 10 tracked surgical specialties (i.e., general, thoracic, vascular, cardiac, orthopedics, otolaryngology, plastics, gynecology, urology, and neurosurgery). Multivariate logistic regression models were used to determine predictors of readmission for plastic surgery. Results: A total of 7005 outpatient plastic surgery procedures were isolated. Outpatient plastic surgery had a low associated readmission rate (1.94 percent) compared with other specialties. Seventy-five patients were readmitted with a complication. Multivariate regression analysis revealed obesity (body mass index ≥30), wound infection within 30 days of the index surgery, and American Society of Anesthesiologists class 3 or 4 physical status as significant predictors for unplanned readmission. Conclusions: Unplanned readmission after outpatient plastic surgery is infrequent and compares favorably to rates of readmission among other specialties. Obesity, wound infection within 30 days of the index operation, and American Society of Anesthesiologists class 3 or 4 physical status are independent predictors of readmission. As procedures continue to transition into outpatient settings and the drive to improve patient care persists, these findings will serve to optimize outpatient surgery use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Bone biology and physiology: Part I. the fundamentals

Summary: The principles of bone biology and physiology permeate all subspecialty practices in plastic and reconstructive surgery from hand surgery to aesthetic surgery. Despite its importance in our practices, the biology of bone healing and bone physiology rarely surfaces within textbooks, literature reviews, or residency curricula. In this article, the authors present the first of a two-part series reviewing the important concepts of bone biology and bone physiology relevant to plastic surgery in an effort to ameliorate this educational gap.

Simultaneous prosthetic mesh abdominal wall reconstruction with abdominoplasty for ventral hernia and severe rectus diastasis repairs

Background: Standard abdominoplasty rectus plication techniques may not suffice for severe cases of rectus diastasis. In the authors’ experience, prosthetic mesh facilitates the repair of severe rectus diastasis with or without concomitant ventral hernias. Methods: A retrospective review of all abdominal wall surgery patients treated in the past 8 years by the senior author (G.A.D.) was performed. Patients with abdominoplasty and either rectus diastasis repair with mesh or a combined ventral hernia repair were analyzed. Results: Thirty-two patients, 29 women and three men, underwent mesh-reinforced midline repair with horizontal or vertical abdominoplasty. Patient characteristics included the following: mean age, 53 years; mean body mass index, 26 kg/m2; average width of diastasis or hernia, 6.7 cm; and average surgery time, 151 minutes. There were no surgical-site infections and two surgical-site occurrences—two seromas treated with drainage in the office. After an average of 471 days’ follow-up, none of the patients had recurrence of a bulge or a hernia. Conclusions: For patients with significant rectus diastasis, with or without concomitant hernias, the described mesh repair is both safe and durable. Although this operation requires additional dissection and placement of prosthetic mesh in the retrorectus plane, it may be safely combined with standard horizontal or vertical abdominoplasty skin excision techniques to provide an aesthetically pleasing overall result. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.