Oluwaseun A. Adetayo

A Meta-Analysis of Outcomes Using Acellular Dermal Matrix in Breast and Abdominal Wall Reconstructions: Event Rates and Risk Factors Predictive of Complications.

BackgroundThe use of acellular dermal matrix (ADM) has gained acceptance in breast and abdominal wall reconstructions. Despite its extensive use, there is currently a wide variation of reported outcomes in the literature. This study definitively elucidates the outcome rates associated with ADM use in breast and abdominal wall surgeries and identifies risk factors predisposing to the development of complications. MethodsA literature search was conducted using the Medline database (PubMed, US National Library of Medicine) and the Cochrane Library. A total of 464 articles were identified, of which 53 were eligible for meta-analysis. The endpoints of interest were the incidences of seroma, cellulitis, infection, wound dehiscence, implant failure, and hernia. The effects of various risk factors such as smoking, radiation, chemotherapy, and diabetes on the development of complications were also evaluated. ResultsA majority of the studies were retrospective (68.6%) with a mean follow-up of 16.8 months (SD ± 10.1 months) in the breast group and 14.2 months (SD ± 7.8 months) in the abdominal wall reconstructive group. The overall risks and complications were as follows: cellulitis, 5.1%; implant failure, 5.9%; seroma formation, 8%; wound dehiscence, 8.1%; wound infection, 16.1%; hernia, 27.6%; and abdominal bulging, 28.1%. Complication rates were further stratified separately for the breast and abdominal cohorts, and the data were reported. This provides additional information on the associated abdominal wall morbidity in patients undergoing autologous breast reconstruction in which mesh reinforcement was considered as closure of the abdominal wall donor site. Radiation resulted in a significant increase in the rates of cellulitis (P = 0.021), and chemotherapy was associated with a higher incidence of seroma (P = 0.014). ConclusionThis study evaluates the overall complication rates associated with ADM use by conducting a meta-analysis of published data. This will offer physicians a single comprehensive source of information during informed consent discussions as well as an awareness of the risk factors predictive of complications.

The use of intra-abdominal tissue expansion for the management of giant omphaloceles: review of literature and a case report.

AbstractGiant omphaloceles present a reconstructive challenge in planning, management, and eventual closure of the abdominal wall defect. The goal of reconstruction is to recreate a functional abdominal wall domain and return the extra-anatomically placed viscera into the peritoneal cavity in a safe manner. Traditionally, placement of tissue expanders has been in the subcutaneous and intramuscular planes. Recently, however, there have been reports of intra-abdominal placement of expanders. We present a detailed review of the literature regarding the use of tissue expanders in the management of giant omphaloceles with specific emphasis on the intra-abdominal technique of placement. We also present a case report with the longest follow-up till date in which the patient underwent staged reduction using the intra-abdominal approach. Initial reports of this modality are promising both as a primary strategy and in patients in whom conventional techniques have failed. Results from our review of literature and case report suggest that this technique appears to be durable and effective with successful functional and cosmetic outcomes.

The battle of words and the reality of never events in breast reconstruction: incidence, risk factors predictive of occurrence, and economic cost analysis.

Background: The Centers for Medicare and Medicaid Services has a list of 10 hospital-acquired conditions for which hospitals and physicians will not be reimbursed because it deems such conditions are preventable and should be considered “never events.” To evaluate the validity of this premise, the authors conducted a real-life analysis of the incidence and categories of never events occurring in a breast reconstruction cohort of a multisurgeon plastic surgery practice. Cost analysis of estimated revenue loss and risk factors associated with the development of never events are enumerated. Methods: A retrospective chart review of postmastectomy patients undergoing breast reconstruction from 2008 to August of 2010 was conducted. A total of 297 patients were identified and International Classification of Diseases, Ninth Revision codes corresponding to the never events of interest were applied to the study population. Results: Of the 297 patients, 24 (8.08 percent) developed never events in two categories: surgical-site infections (7.74 percent) and catheter-related urinary tract infections (0.34 percent). There were no complications in the remaining eight categories. Overweight body mass index and diabetes were strong independent risk factors for the development of never events (p < 0.0001). Cost estimates of associated revenue loss and economic analysis reveal substantial financial burdens to physicians and hospitals as a result of nonreimbursement. Conclusions: The “one-size-fits-all” approach of the Centers for Medicare and Medicaid Services may be misplaced and misleading. Certain risk factors are independent predictors of developing a never event, making it impossible to classify certain outcomes as “never” occurrences. The never events pendulum may have swung immensely to the left, and it is time to attain a much-needed equilibrium. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Perioperative Safety in Plastic Surgery: Is the World Health Organization Checklist Useful in a Broad Practice?

Introduction In October 2007, the World Health Organization (WHO) introduced the Safe Surgery Saves Lives Program, the cornerstone of which was a 19-item safe-surgery checklist (SSC), in 8 selected hospitals around the world. After implementation, death rates decreased significantly from 1.5% to 0.8% (P = 0.003), inpatient complications reduced from 11% to 7% (P < 0.001), as did rates of surgical site infection (P < 0.001) and wrong-sided surgery (P < 0.47), across all sites. On the basis of these impressive reductions in complications and mortality, our institution adopted the WHO SSC in April 2009, with a few additional measures included, such as assuring presence of appropriate implants and administration of preoperative antibiotics and thromboembolic prophylaxis. Our purpose was to evaluate the efficacy and applicability of the surgical safety checklist in a multisurgeon plastic surgery hospital-based practice, by analyzing its effect on morbidity and outcomes. Methods A retrospective review of the morbidity and mortality data from the Department of Plastic Surgery at Loma Linda University Medical Center was conducted from January 2006 to July 2012. Data on morbidity and mortality before and after implementation of the surgical safety checklist were analyzed. Results The most common complications were wound related, including infection, seroma and/or hematoma, dehiscence, and flap-related complications. No significant decrease in the measured complications, neither total nor each specific complication, occurred after the implementation of the SSC. Although verifying appropriate administration of antibiotic, presence of appropriate equipment and materials, performing a preoperative formal pause, and verifying the execution of the other measures included in the SSC is critical, untoward outcomes after implementation of the checklist did not measurably decrease. In its current form as this time, the checklist does not seem to be efficacious in Plastic Surgery. Conclusions Although certain elements of the WHO SSC checklist are universal and should be adopted, certain specific aspects require modification to improve applicability in a plastic surgery–specific practice. This necessitates the creation of a surgical safety checklist specifically for plastic surgery as other surgical specialties have proposed.

Retrospective Analysis of Never Events in Panniculectomy and Abdominoplasty Patients and Their Financial Implications

AbstractIn 2008, the Centers for Medicare and Medicaid Service adapted a list from the National Quality Forum consisting of 10 hospital-acquired conditions, also known as never events. Deeming such events as preventable in a safe-hospital setting, reimbursement is no longer provided for treatments arising secondary to these events. A retrospective chart review identified 90 panniculectomy and abdominoplasty patients. The hospital-acquired conditions examined include surgical-site infections (SSI), vascular-catheter associated infections, deep venous thrombosis/pulmonary embolism, retained foreign body, catheter-related urinary tract infection, manifestations of poor glycemic control, falls and trauma, air embolism, pressure ulcers (stages III and IV), and blood incompatibility. Information regarding age, American Society of Anesthesiologists (ASA) classification, body mass index, smoking, and chemotherapy were collected. Patients were divided into 2 groups, namely, those who developed never events and those with no events. Of the 90 patients, 14 (15.5%) developed never events because of SSI. No events occurred in the remaining 9 categories. Statistically significant risk factors included American Society of Anesthesiologists classification, age, and diabetes mellitus. The most common never event was SSI. In light of the obvious prevalence of the risk factors in patients who develop these events, the question of whether never events are truly unavoidable arises. Despite this, awareness of the impact on patient care, health care and hospital reimbursement is vital to understanding the new paradigm of the “one size fits all.”

A Unique Case of Tessier 30 and Bilateral Cleft Lip and Palate: A New Clinical Syndrome?

Background Tessier 30 cleft is rare and sparsely reported in the literature. A unique case of an infant with a Tessier 30 cleft, bilateral cleft lip and palate, and other anomalies is presented. In addition to craniofacial anomalies, he had cardiac, gastrointestinal, and genitourinal defects. The constellation of these findings suggests the possibility of a new clinical syndrome. We present these findings and postoperative results following surgical treatment. Patient and Methods A 37-week gestational male infant with multiple congenital anomalies is presented. Findings on clinical exam were notable for Tessier 30 median mandibular cleft, bilateral cleft of the lip and palate, and bifid tongue. Further workup revealed levocardia, perimembranous moderate-to-large ventricular septal defect, patent foramen ovale, double outlet right ventricle, intestinal malrotation, and bilateral undescended testicles. There were no extremity anomalies, and cytogenetic studies for 22q deletion were negative. Results The preoperative, intraoperative, and postoperative findings and images are discussed. Conclusion We present a unique case of a child with a Tessier 30 cleft associated with bilateral cleft lip and palate in the absence of intraoral masses or limb anomalies. Previous reports of median facial clefts have occurred either in the presence of intraoral hamartomas, suggesting the palatal defects are a result of sequence abnormalities, or in association with extremity findings consistent with the spectrum of orofaciodigital syndrome. The case we present is distinct and may represent a new clinical syndrome.

Craniosynostosis reconstruction in patients with cyanotic heart defects—risk factors for venous air embolism and overview of preventative strategies

SIR—We commend the authors, Bergmans et al. (1), for a thoughtful case report of craniosynostosis surgery in an infant with complex congenital heart disease. The judicious replacement of intraoperative blood loss and use of a higher transfusion threshold owing to the patient’s chronic hypoxia and tendency toward polycythemia were indispensable to the success of the operation. While the report addresses crucial issues of perioperative monitoring and hemodynamic management, we would also like to bring attention to a unique perioperative risk in this patient population—the risk of venous air embolism (VAE). Reports of the incidence of VAE during craniosynostosis repair ranges from 8 to 82.6% (2,3). Recognition of VAE is of particular importance in patients with cardiac defects and right-to-left shunts due to the high risk of developing paradoxical arterial emboli. A small amount of air into the cerebral or coronary circulation can be fatal. The patient described had a double outlet right ventricle, multiple ventricular septal defects, atrial septal defect, and transposition of the great vessels. This anatomy placed the patient at risk for arterial emboli due to mixing within the dominant right ventricle and a smaller fraction of pulmonary arterial flow, thereby diminishing the capacity of pulmonary vessels to potentially filter air emboli. In addition, patient positioning during craniofacial and neurosurgical procedures increases the inherent risk of VAE by virtue of the surgical site being elevated above the level of the right atrium. Monitoring for VAE is important and signs of VAE include sudden drop in blood pressure, characteristic change in Doppler tones, decreased endtidal carbon dioxide (ETCO2), increased central venous pressure (CVP), decreased oxygen saturation, right ventricular strain pattern on the EKG, and increased pulmonary artery pressure. In the event that a VAE is suspected, the following measures should be taken (3–5): prompt flooding of the surgical field with saline, continuous monitoring of end-tidal carbon dioxide (ETCO2) and nitrogen (if possible), use of bone wax to prevent entry of atmospheric air, use of precordial Doppler ultrasonography for detection, search for open venous sinuses, and strict intra-arterial blood pressure monitoring. Additional therapeutic maneuvers include aspiration via right atrial catheter and left lateral decubitus or Trendelenburg positioning. Interestingly, this patient’s unique physiology may have potentially reduced the risk of VAE in one respect—the confluence of cardiac defects resulted in an elevated CVP (9–14 mmHg). As jugular venous pressure was already above atmospheric pressure, violation of a vein would favor bleeding instead of air entrainment. Management of patients with comorbid congenital anomalies necessitates the collaboration of multiple disciplines. This approach allows risk reduction with appreciation of each patient’s relevant anatomic and physiologic aberrancies. The occurrence of VAE is exceptionally ominous in patients with cardiac defects, thus intraoperative avoidance, detection, and response are paramount to maximizing patient safety. Communication among all treating specialists is critical both during the time-out process and during the surgical procedure to optimize patient outcomes.

Implementation of Google Glass technology in patient care: evaluating its potential benefits and pitfalls

1 Bergmans B, Kammeraad JAE, van Adrichem LNA et al. Craniosynostosis surgery in an infant with a complex cyanotic cardiac defect. Pediatr Anesth 2014; 24: 788–790. 2 Tobias J, Johnson J, Jimenez DF et al. Venous air embolism during endoscopic strip craniectomy for repair of craniosynostosis in infants. Anesthesiology 2011; 95: 340–342. 3 Faberowski LW, Black S, Mickle JP. Incidence of venous air embolism during craniectomy for craniosynostosis repair. Anesthesiology 2000; 92: 20–23. 4 Soriano SG, Rockoff MA. Neuroanesthesia in children. In: Winn HR, ed. Youmans Neurological Surgery, 6th edn. Philadelphia, PA: Saunders, 2011: 1861–1869. 5 Felema GG, Bryskin RB, Heger IM et al. Venous Air Embolism from Tisseel use during endoscopic cranial vault remodeling for craniosynostosis repair: a case report. Pediatr Anesth 2013; 23: 754–756.

Demographics of cleft care providers in Africa and reported experience in training and practice: direct analysis of continent-based practitioners.

Objective To elucidate the impact of several geographic, cultural, and socioeconomic variables on cleft care delivery in Africa, and to investigate the current status of cleft care delivery in Africa. Design Survey of practitioners attending the second Pan-African Congress on Cleft Lip and Palate (PACCLIP). Setting The annual PACCLIP conference in Ibadan, Nigeria, West Africa, February 2007. Main Outcome Measure To provide an analysis of the demographics and training experience of cleft care providers in Africa by collating information directly from the continent-based practitioners. Results Plastic surgeons and oral and maxillofacial surgeons provide the majority of cleft care. Most of the participants reported availability of formal training programs in their respective countries. The predominant practice settings were university and government-based. During training, half of the providers had encountered up to 30 cleft cases, and a quarter had managed more than 100 cases. Representation of visiting surgeons were equally distributed between African and non-African countries. Conclusions This study provides initial and detailed analysis crucial to understanding the underlying framework of cleft care composition teams, demographics of providers, and training and practice experience. This awareness will further enable North American and other non-African plastic surgeons to effectively partner with African cleft care providers to have a further reaching impact in the region.

Craniosynostosis and Guanine Nucleotide-binding Protein Alpha Stimulating Mutation: Risk of Bleeding Diathesis and Circulatory Collapse in Patients Undergoing Cranial Vault Reconstruction

Abstract Reconstruction of the craniosynostosis deformity is a relatively safe operation with low overall complication risks. Despite expected risk of significant blood loss, life-threatening bleeding is relatively rare, and there is a low incidence of reported deaths in the literature. Several modalities have been described for perioperative mitigation of blood loss and transfusion requirements. Due to the low overall risk of life-threatening bleeding and circulatory collapse, it is judicious that any potential causes of such unusual but potentially significant fatal bleeding complication be evaluated and reported to increase awareness for craniofacial surgeons treating these conditions. In this report and literature review, the authors present a highly unusual patient with significant bone bleeding and circulatory collapse in a metopic craniosynostosis patient with guanine nucleotide-binding protein alpha stimulating (GNAS) mutation; perform a literature review regarding bleeding diathesis in craniosynostosis patients with GNAS mutations; and suggest guidelines to potentially prevent mortality in such patients.