Gregory D. Pearson

Surgery for cleft palate and velopharyngeal dysfunction.

Cleft palate is a common congenital anomaly that, if left untreated, results in subsequent velopharyngeal dysfunction. After surgical repair of the palatal cleft, patients must be monitored clinically for any postoperative velopharyngeal dysfunction. If this sequela develops, patients must be evaluated in a multidisciplinary manner with diagnostic procedures performed and individualized care plans made prior to embarking upon surgery for velopharyngeal dysfunction. This article discusses surgical management of patients with cleft palate as well as the proper workup and management of postoperative velopharyngeal dysfunction.

Patient Satisfaction After Rhinoplasty: A Social Media Analysis

BACKGROUNDnCompared to other cosmetic procedures, rhinoplasty has a relatively low patient satisfaction rate, due to the difficulty of the procedure, and potentially unrealistic patient expectations. Understanding the reasons behind patient dissatisfaction is key to improving outcomes. Previous authors have done surgeon-initiated surveys, expert ratings, and morphologic measurements, to measure rhinoplasty success. No study has analyzed online reviews by patients to identify reasons for dissatisfaction with rhinoplasty.nnnOBJECTIVESnThe goal of this study was to analyze satisfaction patterns in rhinoplasty using online reviews.nnnMETHODSnAll primary rhinoplasty reviews on RealSelf (Seattle, WA), a social media website for patients undergoing cosmetic surgery, were reviewed. The researchers recorded patient gender, whether they were satisfied, and the reasons for satisfaction or dissatisfaction. Male and female patients were compared, using chi-squared analysis.nnnRESULTSnThere were 2326 reviews for primary rhinoplasty (2032 females, 294 males). The overall satisfaction rate was 83.6%. Significantly more females than males were satisfied (87.6% vs 56.1%, P < .001). Among males, the most common reasons for dissatisfaction were residual dorsal hump, under-rotated tip, and a nose that was too small. Among females, the most common reasons for dissatisfaction were residual dorsal hump, under-rotated tip, and bulbous tip. Among dissatisfied patients, females were significantly more likely than males to precisely verbalize the morphologic or functional reason for their dissatisfaction.nnnCONCLUSIONSnWe found that males had lower satisfaction with rhinoplasty, and were more vague when expressing reasons for dissatisfaction, than females. Social media provides a novel way to understand reasons for patient dissatisfaction after cosmetic surgery.

Intra-flap thrombosis secondary to acute sickle crisis: A case report

We present the case of a 40‐year‐old patient with sickle cell trait who underwent bilateral breast reconstruction with microvascular TRAM flap transfer. Intraoperatively, the patient developed arterial anastomotic thrombosis of the right breast flap. The left breast flap had already been harvested and was placed on ice. Both anastomoses were then successfully completed. Postoperatively, the patient developed a pulmonary embolism and heparin‐induced thrombocytopenia. On postoperative day 12, the left cutaneous Doppler signals were lost, and exploration revealed a thrombosed pedicle and nonviable left breast flap. Pathologic specimen evaluation revealed sickled cells within the flap microvasculature. We believe that prolonged ischemia time and hypothermia precipitated erythrocyte sickling within the flap, causing intra‐flap thrombosis that propagated to the pedicle. While sickle cell diseases are not a contraindication to free tissue transfer, we believe that flap cooling should be utilized with caution in this circumstance.

Surgeon Reimbursements in Maxillofacial Trauma Surgery: Effect of the Affordable Care Act in Ohio.

Background: Surgical treatment of maxillofacial injuries has historically been associated with low reimbursements, mainly because of the high proportion of uninsured patients. The Affordable Care Act, implemented in January of 2014, aimed to reduce the number of uninsured. If the Affordable Care Act achieves this goal, surgeons may benefit from improved reimbursement rates. The authors’ purpose was to evaluate the effects of the Affordable Care Act on payor distribution and surgeon reimbursements for maxillofacial trauma surgery at their institution. Methods: A review of all patients undergoing surgery for maxillofacial trauma between January of 2012 and December of 2014 was conducted. Insurance status, and amounts billed and collected by the surgeon, were recorded. Patients treated before implementation of the Affordable Care Act were compared to those treated after. Results: Five hundred twenty-three patients were analyzed. Three hundred thirty-four underwent surgery before implementation of the Affordable Care Act, and 189 patients underwent surgery after. After implementation of the Affordable Care Act, the proportion of uninsured decreased (27.2 percent to 11.1 percent; p < 0.001) and the proportion of patients on Medicaid increased (7.8 percent to 25.4 percent; p < 0.001). Overall surgeon reimbursement rate increased from 14.3 percent to 19.8 percent (p < 0.001). Conclusions: After implementation of the Affordable Care Act, we observed a significant reduction in the proportion of maxillofacial trauma patients who were uninsured. Surgeons’ overall reimbursement rate increased. These trends should be followed over a longer term to determine the full effect of the Affordable Care Act.

Patient Attitudes Toward Resident Participation in Cosmetic vs Reconstructive Outpatient Consultations

OBJECTIVESnThe goal of residency programs is to provide trainees with exposure to all aspects of their chosen field so that they exit the program ready to be independent practitioners. However, it is common in some plastic surgery residency training programs to exclude residents from participation in consultations with patients who are seeking cosmetic surgery. The purpose of this study was to determine whether cosmetic surgery patients had a different view about resident involvement than reconstructive surgery patients and to evaluate what factors might be linked to patient attitudes on this topic.nnnMETHODSnnnnPARTICIPANTSnAll new patients older than 18 years presenting to either academic or nonacademic locations were asked to complete the voluntary survey at their initial consultation.nnnSETTINGnThe study was conducted at both the Ohio State University (academic) and Advanced Aesthetic and Laser Surgery (private practice) in Columbus, Ohio.nnnDESIGNnThe survey asked patients to identify their surgical concern as either cosmetic or reconstructive and to indicate the location on their body where they were having surgery. Additionally, a series of statements regarding resident involvement was presented with a 5-point Likert-type rating system to assess each patients attitudes about a range of factors, such as resident sex and seniority.nnnRESULTSnIn total, 119 patients participated in the study by completing the survey. Of this population, 59.7% (n = 71) were classified as reconstructive surgery patients and 40.3% (n = 48) were classified as cosmetic surgery patients. Based on responses, it was determined that reconstructive surgery patients were more approving of resident involvement in their care than cosmetic surgery patients were. When other factors were analyzed, the patients seeking breast surgery were found to be more apprehensive about resident participation than non-breast surgery patients were.nnnCONCLUSIONnAlthough there were some differences in the way resident participation was perceived by cosmetic and reconstructive surgery patient populations, neither group strongly believed that resident participation decreased the quality of patient care. Based on these findings, plastic surgery training programs should begin to allow residents to become more involved in the care of cosmetic surgery patients.

Identifying Psychosocial Risk Factors Among Families of Children With Craniofacial Conditions: Validation of the Psychosocial Assessment Tool–Craniofacial Version

Objective: To evaluate the psychometric properties of the Psychosocial Assessment Tool–Craniofacial Version (PAT-CV), a screening instrument for psychosocial risk in families of children with craniofacial conditions, and to examine risk classification of patients in a craniofacial population. Design: Prospective, cross-sectional, single-center study. Setting: Interdisciplinary cleft lip and palate/craniofacial center at a US children’s hospital. Participants: Parents/caregivers (n = 242) of 217 children ages 1 month to 17 years being treated for a congenital syndromic or nonsyndromic craniofacial condition completed the PAT-CV and validating measures from July 2015 to July 2016. The PAT-CV was completed by 121 caregivers a second time to assess test-retest reliability. Main Outcome Measures: PAT-CV, Child Behavior Checklist, Adult Self-Report, Pediatric Quality of Life Inventory, Craniofacial Experiences Questionnaire, and Family Environment Scale. Results: Construct validity of the PAT-CV was supported by significant correlations (P < .001) between PAT-CV total and subscale scores and the validated measures. PAT-CV total scores categorized 59.9% of families within the universal risk group, 32.3% within the targeted risk group, and 7.8% within the clinical range. Good criterion validity was indicated by significantly higher scores (P < .0001) obtained on the validated measures for those in the targeted and clinical risk groups. Internal consistency (Cronbach’s α = 0.86) and test-retest reliability for the PAT-CV total score (r = 0.77, P < .0001) were acceptable. Conclusions: The PAT-CV appears to be a reliable and valid screening instrument for psychosocial risk. Accurate identification of risk and implementation of appropriate interventions may contribute to improvements in medical and psychosocial outcomes.

Effects of the Affordable Care Act on Payer Mix and Physician Reimbursement in Hand Surgery

PURPOSEnTo evaluate the effect of the Affordable Care Act (ACA) on the payer distribution and reimbursement rate for hand surgery at our institution.nnnMETHODSnWe reviewed records of 4,257 patients who underwent hand surgery at our institution between January 2008 and June 2016; 2,601 patients underwent surgery before the implementation of the ACA, and 1,656 patients after. Type of procedure, insurance status, amount of money billed, and amount collected were recorded.nnnRESULTSnAfter the implementation of the ACA, we performed fewer metacarpal fracture repairs, distal radius fracture repairs, and abscess incision and drainage procedures. We performed more endoscopic carpal tunnel releases. The proportion of uninsured patients decreased significantly (15% to 6.4%), and the proportion of patients on Medicare (15.4% to 20.3%) and Medicaid (9.5% to 17.8%) increased significantly. The overall reimbursement rate did not change significantly (32.3% to 30.3%) between the 2 time periods.nnnCONCLUSIONSnAfter the implementation of the ACA, we observed a significant reduction in the number of uninsured patients and an increase in Medicaid and Medicare patients. However, this led to no significant change in reimbursement rates.nnnTYPE OF STUDY/LEVEL OF EVIDENCEnEconomic and design analysis II.

Assessment of Psychosocial Risk in Families of Children With Craniofacial Conditions Using the Psychosocial Assessment Tool—Craniofacial Version

Objectives: Using the Psychosocial Assessment Tool—Craniofacial Version (PAT-CV), this study measured variation in psychosocial risk in families of children with craniofacial conditions by demographic and clinical characteristics, frequency of condition-related problems, concordance between caregivers’ report of risk, and association between risk level and psychosocial service utilization. Design: Caregivers (n = 242) of 217 children with craniofacial conditions completed the PAT-CV, a psychosocial risk screener. Medical records were also abstracted. Results: The PAT-CV scores varied significantly by insurance type and syndromic versus nonsyndromic diagnosis type. Language problems were most commonly reported on the Craniofacial Problems subscale, though 13% to 56% of parents endorsed specific problems. Mothers and fathers reported similar risk levels. Families with past social work or behavioral health consults had higher PAT-CV scores than those without consultations. Conclusion: The PAT-CV efficiently screens for psychosocial risk and craniofacial-specific problems. This tool may help clinicians identify families in need of intervention.

A Quality Improvement Initiative to Improve Feeding and Growth of Infants With Cleft Lip and/or Palate:

Objective: The purpose of this quality improvement initiative was to improve feeding and growth outcomes in infants with cleft lip and/or palate (CL/P). Design: Institute for Healthcare Improvement quality improvement model. Setting: Large pediatric academic medical center in the Midwestern United States. Participants: One hundred forty-five infants with nonsyndromic CL/P ages 0 to 12 months. Interventions: Key drivers included (1) caregiver education and resources, (2) care coordination and flow, and (3) provider education and training. Interventions were designed around these themes and included targeting improved team communication, increased social work consultations, patient tracking, staff education, improved access to feeding equipment, and the launch of a new cleft palate feeding team. Main Outcome Measure(s): The primary outcome measure was the percentage of new patients with CL/P who met criteria for failure to thrive (FTT) per month. The secondary outcome measure was the frequency of hospitalization for infants with CL/P with a primary reason for admission of feeding difficulties or FTT. Results: The institutional FTT rate for infants with CL/P decreased from 17% to 7% (P < .003). The frequency of hospitalization for FTT improved from once every 30 days to once every 118 days. Conclusions: Targeted interventions aimed at improving feeding efficiency and effectiveness, as well as changes in care delivery models, can reliably promote improvements in feeding and growth outcomes for infants with CL/P, even with psychosocial risk factors present.

Pediatric Ganglion Cysts: A Retrospective Review:

Background: Ganglion cysts are the most common type of soft tissue tumors of the hand. In the pediatric population, monitoring may be appropriate unless cysts are painful, interfering with range of motion or parental concerns exist. Reported recurrence rates after surgical removal of pediatric ganglion cysts vary widely in the literature. Notably, recurrence rates are higher for children than adults, ranging from as low as 6% to as high as 35%. Methods: A retrospective review was performed of a single pediatric hand surgeon’s patients undergoing excision of primary and recurrent ganglion cysts from 2010 to 2015. Variables measured included patient age at diagnosis of ganglion cyst, time to presentation, location of cyst, hand dominance, previous therapy, previous surgery, length of surgery, tourniquet time, length of follow-up, any associated complications, and recurrence of cyst. Results: Ninety-six patients were identified with an average age of diagnosis 10.2 years. Indications for surgery: 95.8% for pain or decreased range of motion, 4.2% for cosmetic or parental concern. About 75% of the cysts were dorsally located, with the remaining 24.2% being volar. A total of 5 (5.3%) recurrences were recorded. Tourniquet time was on average 9.8 minutes longer for cases that resulted in recurrence. Multivariate analysis of the data demonstrated a 25% increased risk of recurrence with patients who had a previous aspiration. Conclusions: This is a retrospective review of a single pediatric hand surgeon’s outcomes of pediatric wrist ganglion cysts. Our recurrence rate of 5.3% is low for a pediatric population indicating potential merit in this surgeon’s operative and postoperative techniques. We demonstrate significantly increased rates of recurrence when a cyst had been previously aspirated, possibly indicating scarring and disruption of planes resulting in difficult dissection, increased tourniquet times, and incomplete excision.