Lauren M. Mioton

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.

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.

Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: A multivariate analysis of 13,082 patients?

BACKGROUND There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes. METHODS Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL). RESULTS A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes. CONCLUSIONS Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.

Immediate two-stage tissue expander breast reconstruction compared with one-stage permanent implant breast reconstruction: A multi-institutional comparison of short-term complications

Abstract Prosthesis-based techniques are the predominant form of breast reconstruction worldwide, with two-stage tissue expander procedures being the most popular. In the past decade, there has been increasing interest in performing single-stage implant reconstruction immediately following mastectomy as an attempt to simplify the reconstructive course and improve psychosocial morbidity. However, there is a paucity of large-scale, multi-institutional data comparing the outcomes of these two reconstructive strategies. Patients who underwent immediate tissue expander or implant reconstruction following mastectomy from 2006–2010 were identified using standardised operation codes. Demographic information for patients, 30-day outcomes, and adverse events for each type of reconstruction were analysed and compared between groups. A total of 10,561 patients underwent immediate breast reconstruction. There were 9033 patients who underwent tissue expander placement (2752 bilateral), and 1528 patients who underwent immediate implant placement (485 bilateral). Patients who had implant placement demonstrated increased rates of overall complications (6.8% compared with 5.4%, p = 0.02) and prosthesis failure (1.4% compared with 0.8%, p = 0.04). There was no difference in the rate of any surgical site infections (3.9% compared with 3.4%, p = 0.39), reoperation (7.5% compared with 6.9%, p = 0.40), or major medical complications (1.8% compared with 1.6%, p = 0.57). Both immediate one-stage, direct-to-implant, and two-stage tissue expander reconstructions result in low rates of morbidity. One-stage reconstruction suggests a slightly higher complication rate related to prosthesis failure.

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.

A multivariate regression analysis of panniculectomy outcomes: does plastic surgery training matter?

Background: Panniculectomy can improve quality of life in morbidly obese patients, but its functional benefits are counterbalanced by relatively high complication rates. The authors endeavored to determine the impact of plastic surgery training on panniculectomy outcomes. Methods: A retrospective review was performed of the prospectively maintained American College of Surgeons National Surgical Quality Improvement Program database for all patients undergoing panniculectomy from 2006 to 2010. Patient demographic details, surgeon specialty training, and 30-day outcomes were assessed. Results: A total of 954 panniculectomies meeting inclusion criteria were identified. Plastic surgeons performed 694 (72.7 percent) of the procedures, and 260 (27.3 percent) were performed by nonplastic surgeons. Nonplastic surgeons had significantly higher rates of overall complications (23.08 percent versus 8.65 percent; p < 0.001) and wound infections (12.69 percent versus 5.33 percent; p < 0.001) than plastic surgeons. Average operative time for plastic surgeons was significantly longer than that for nonplastic surgeons (3.00 ± 1.48 hours versus 1.88 ± 0.93 hours; p < 0.001). Risk-adjusted multivariate regression showed that undergoing a panniculectomy by a nonplastic surgeon was a significant predictor of overall postoperative complications (odds ratio, 2.09; 95 percent CI, 1.35 to 3.23) and wound infection (odds ratio, 1.73; 95 percent CI, 1.004 to 2.98). Subgroup analysis of propensity-matched samples supported this finding. Conclusion: Multivariate regression analysis of National Surgical Quality Improvement Program data showed that panniculectomy performed by plastic surgeons results in lower rates of overall postoperative complications compared with that performed by nonplastic surgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

A predictive model of risk and outcomes in tissue expander reconstruction: A multivariate analysis of 9786 patients

Abstract Outcomes of tissue expander breast reconstruction show variability based on presurgical risk factors. Few comprehensive, multi-institutional risk analyses exist. Patients who underwent tissue expander reconstruction were identified in a multi-institutional registry that spans over 240 institutions with over 200 variables per patient. Bivariate analysis of preoperative variables was performed across outcomes. Multivariate logistic regression was used to adjust for confounders and identify risk factors for complications. In 9786 total tissue expander patients, 526 (5.38%) patients experienced one or more complications. Wound infection and reoperations occurred in 3.45% and 6.76% of patients, respectively. Body mass index (BMI) was found to be a significant independent risk factor for overall morbidity, reoperation, prosthesis failure, and wound infection. Overweight, obese, and morbidly obese patients were at 1.7-, 2.6-, and 5.1-times greater risk of morbidity, respectively (p < 0.001 for all). Reconstructive timing, combined surgical procedures, and neoadjuvant chemotherapy were not found to be significant predictors of morbidity. The odds of developing complications were 1.5- and 1.3-times greater in smokers and patients over the age of 50, respectively (p = 0.001 and p = 0.015). For each additional hour of surgery, the odds of morbidity increased 1.26-times (p < 0.001). Precise risk profiles garnered from multi-institutional studies can help improve patient selection and education. Overall, tissue expander reconstruction was found to be safe, with relatively few complications. Operative time, BMI, and smoking were consistently found to be independent risk factors for postoperative morbidity.

The relationship between preoperative wound classification and postoperative infection: A multi-institutional analysis of 15,289 patients

Background Despite advances in surgical techniques, sterile protocols, and perioperative antibiotic regimens, surgical site infections (SSIs) remain a significant problem. We investigated the relationship between wound classification (i.e., clean, clean/contaminated, contaminated, dirty) and SSI rates in plastic surgery. Methods We performed a retrospective review of a multi-institutional, surgical outcomes database for all patients undergoing plastic surgery procedures from 2006-2010. Patient demographics, wound classification, and 30-day outcomes were recorded and analyzed by multivariate logistic regression. Results A total of 15,289 plastic surgery cases were analyzed. The overall SSI rate was 3.00%, with superficial SSIs occurring at comparable rates across wound classes. There were similar rates of deep SSIs in the clean and clean/contaminated groups (0.64%), while rates reached over 2% in contaminated and dirty cases. Organ/space SSIs occurred in less than 1% of each wound classification. Contaminated and dirty cases were at an increased risk for deep SSIs (odds ratios, 2.81 and 2.74, respectively); however, wound classification did not appear to be a significant predictor of superficial or organ/space SSIs. Clean/contaminated, contaminated, and dirty cases were at increased risk for a postoperative complication, and contaminated and dirty cases also had higher odds of reoperation and 30-day mortality. Conclusions Analyzing a multi-center database, we found that wound classification was a significant predictor of overall complications, reoperation, and mortality, but not an adequate predictor of surgical site infections. When comparing infections for a given wound classification, plastic surgery had lower overall rates than the surgical population at large.

Risk profiles and outcomes of total laparoscopic hysterectomy compared with laparoscopically assisted vaginal hysterectomy.

OBJECTIVE: With the increasing rates of minimally invasive hysterectomy procedures serving as impetus, the aim of this study was to analyze the 30-day risk profiles associated with total laparoscopic hysterectomy and laparoscopically assisted vaginal hysterectomy (LAVH). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients who underwent a total laparoscopic hysterectomy or LAVH operation between 2006 and 2010. Patient demographics and 30-day complication rates were calculated. Multivariable regression analyses were used to study the effect of hysterectomy approach on outcomes. RESULTS: A total of 6,190 patients underwent laparoscopic hysterectomy, with 66.3% receiving LAVH and 33.7% receiving a total laparoscopic hysterectomy. The patient cohorts were well-matched. Although total laparoscopic hysterectomy procedures were significantly longer than LAVH operations (2.66 hours compared with 2.20 hours; P<.001), there was no difference in overall morbidity or reoperation rates between the LAVH and total laparoscopic hysterectomy populations (7.05% compared with 6.3% for overall morbidity; 1.3% compared with 1.7% for reoperation). Regression analyses revealed that surgical approach was not a significant predictor of overall postoperative morbidity or reoperation in minimally invasive hysterectomy patients. Additionally, obesity did not demonstrate a significant association with morbidity or reoperation rates; however, operative time was found to be a significant predictor of reoperation (odds ratio 1.23, 95% confidence interval 1.07–1.42). CONCLUSION: Laparoscopic hysterectomy is well-tolerated with total laparoscopic hysterectomy and LAVH, yielding comparable rates of postoperative morbidity and reoperation. On average, LAVH procedures were 28 minutes faster than total laparoscopic hysterectomy. Additionally, increasing body mass index was not associated with higher rates of morbidity. LEVEL OF EVIDENCE: II

A comparative analysis of readmission rates after outpatient cosmetic surgery

BACKGROUND Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures. OBJECTIVES The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures. METHODS The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients. RESULTS The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08-1.81; P=.010). CONCLUSIONS Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.