Paymon Sanati-Mehrizy

Risk Factors for Readmission and Adverse Outcomes in Abdominoplasty.

Background: In an era of outcomes-driven medicine, being able to benchmark complication rates of various procedures is of utmost importance. The rates of readmission, reoperation, and adverse outcomes in abdominoplasty have been previously reported, although risk factors for these adverse outcomes have not been thoroughly elucidated. This study aims to identify specific independent risk factors for readmission and other adverse outcomes of abdominoplasty. Methods: This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and identified all abdominoplasties performed in 2011 and 2012. Univariate logistic regression analysis was used to identify significant associations between preoperative risk factors and adverse outcomes. Multivariate logistic regression analysis was then used to identify independent risk factors and causes of readmission and other adverse outcomes. Results: Of the 2946 abdominoplasties identified, there were 251 readmissions (8.5 percent), 146 reoperations (5.0 percent), and 574 patients (19.5 percent) who experienced a general complication. The most common adverse outcomes were wound complications in 281 patients (9.5 percent), pulmonary complications in 67 patients (2.3 percent), and thromboembolic complications in 34 patients (1.2 percent). Multivariate regression analysis demonstrated that American Society of Anesthesiologists class above 3, preoperative cardiac comorbidities, pulmonary comorbidities, wounds or wound infections, postoperative thromboembolic complications, wound complications, and having returned to the operating room on the primary admission were independent risk factors for readmission. Conclusions: This study provides the first critical analysis of risk factors for 30-day readmission in abdominoplasty. These risk factors can aid in patient selection, surgical planning, and postoperative allocation of resources for patients undergoing abdominoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Resident Participation in Outpatient Plastic Surgical Procedures

IntroductionEnsuring patient safety along with a complete surgical experience for residents is of utmost importance in plastic surgical training. The effect of resident participation on the outcomes of outpatient plastic surgery procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a prospective, validated, national database.MethodsWe identified all outpatient procedures performed by plastic surgeons between 2007 and 2012 in the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate regression models assessed the impact of resident participation when compared to attendings alone on 30-day wound complications, overall complications, and return to the operating room (OR).ResultsA total of 18,641 patients were identified: 12,414 patients with an attending alone and 6227 with residents participating. The incidence of overall complications, wound complications, and return to OR was increased with resident participation. When confounding variables were controlled for in multivariate analysis, resident participation was no longer associated with increased risk of wound complications. When stratified by year, incidence of overall complications, wound complications, and return to OR in the resident participation group are trending down and fail to be significantly different in 2011 and 2012. Multivariate analysis shows a similar trend.ConclusionsResident participation is no longer independently associated with increased complications in outpatient plastic surgery in recent years, suggesting that plastic surgical training is successfully continuing to improve in both outcomes and safety. Additional prospective studies that characterize patient outcomes with resident seniority and the degree of resident participation are warranted.Level of Evidence IIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Review of Maxillofacial Hardware Complications and Indications for Salvage.

From 2002 to 2006, more than 117,000 facial fractures were recorded in the U.S. National Trauma Database. These fractures are commonly treated with open reduction and internal fixation. While in place, the hardware facilitates successful bony union. However, when postoperative complications occur, the plates may require removal before bony union. Indications for salvage versus removal of the maxillofacial hardware are not well defined. A literature review was performed to identify instances when hardware may be salvaged. Articles considered for inclusion were found in the PubMed and Web of Science databases in August 2014 with the keywords maxillofacial trauma AND hardware complications OR indications for hardware removal. Included studies looked at human patients with only facial trauma and miniplate fixation, and presented data on complications and/or hardware removal. Fifteen articles were included. None were clinical trials. Complication data were presented by patient, fractures, and/or plate without consistency. The data described 1,075 fractures, 2,961 patients, and 2,592 plates, nonexclusive. Complication rates varied from 6 to 8% by fracture and 6 to 13% by patient. When their data were combined, 50% of complications were treated with plate removal; this was consistent across the mandible, midface, and upper face. All complications caused by loosening, nonunion, broken hardware, and severe/prolonged pain were treated with removal. Some complications caused by exposures, deformities, and infections were treated with salvage. Exposed plates were treated with flaps, plates with deformities were treated with secondary procedures including hardware revision, and hardware infections were treated with antibiotics alone or in conjunction with soft-tissue debridement and/or tooth extraction. Well-designed clinical trials evaluating hardware removal versus salvage are lacking. Some postoperative complications caused by exposure, deformity, and/or infection may be successfully treated with plate salvage. We propose an algorithm using this review and clinical expertise. We also propose that a national databank be created where surgeons can uniformly compile their patient information and examine it in a standardized format to further our understanding of clinical management.

Resident Participation: Impact on Plastic Surgical Outcomes.

DISCUSSION: There was a tremendous rise in costs associated with skin adhesive usage in 2014, when compared to 2013. However, much of this increase occurred in the first half of the year, prior to implementation of the cost-reduction educational initiative. Data from the study period suggest that passive education at the point-of-care can shape plastic surgeon preferences. Despite increasing surgical case volume, the stability of Prineo use and relatively smaller growth of Dermabond use during the pilot period suggest that plastic surgeons may be willing to limit overall usage of surgical supplies or choose more cost-effective alternatives when aware of costs. These results also suggest that surgeons are well versed in the indications for surgical supplies, but may lack knowledge of their cost at the institutional and payer levels.

Surgical Treatment of Pediatric Craniofacial Fractures: A National Perspective.

Introduction:Head trauma is the most common cause of death because of injury in children, and trauma alone is the leading cause of morbidity and mortality in pediatrics. This study aimed to characterize the demographics and economic burden associated with the surgical and nonsurgical repair of craniofacial fractures in the pediatric inpatient population in the United States. Methods:A retrospective cohort study was performed using the 2012 Kids’ Inpatient Database which identified 20,070 patients who had a skull or facial fracture, of whom 6395 (31.9%) were treated surgically. Epidemiologic patient and hospital data were analyzed as potential determinants of surgical treatment, prolonged hospitalizations, and higher charges. Results:Pediatric craniofacial fractures are estimated to represent

Use of antibiotic beads to salvage infected breast implants

1.2 billion of national healthcare expenditures annually. The average patient charge for surgical treatment of a craniofacial fracture in the pediatric population is

Risk Factors Associated with Free Flap Failure - An Analysis of 2103 Patients.

84,849 compared with

Age as a Risk Factor for Flap Failure in Free Tissue Transfer.

52,490 for nonsurgical management (P < 0.001), and the average length of stay was longer for surgical repair when compared with nonsurgical management for craniofacial fractures (5.3 days versus 4.6 days, P < 0.001). Patients who were older, African American, had nonprivate insurance, whose fracture was caused by external trauma, and who were treated in an urban hospital had an independently increased likelihood of surgical repair of craniofacial fractures. Patients who were older, female, insured, of lower income brackets, whose fracture was caused by a motor vehicle accident, who had surgical treatment of their craniofacial fracture, and who were treated in hospitals in the South, Midwest, or West, teaching hospitals, and government-owned hospitals had an independent risk for a prolonged hospitalization. Patients who were older, Caucasian, insured, whose fracture was caused by a motor vehicle accident, and who were treated in hospitals in the South, teaching hospitals, pediatric hospitals, larger hospitals, and government-owned hospitals had an independent risk for increased patient charges. Conclusions:Craniofacial fractures in the pediatric population represent a large economic burden to the patient and family, as well as the healthcare system as a whole. The identified patient and hospital demographics that are associated with prolonged hospital stays and higher patient charges may represent potential barriers to care, and additional research to elucidate these factors is warranted.

Lingual Pressure During Dingman-Assisted Cleft Palate Repair: An Investigatory Case Series

PURPOSE When an implant becomes infected, implant salvage is often performed where the implant is removed, capsulectomy is performed, and a new implant is inserted. The patient is discharged with a PICC line and 6-8 weeks of intravenous (IV) antibiotics. This method has variable success and subjects the patient to long-term systemic antibiotics. In the 1960s, the use of antibiotic-impregnated beads for the treatment of chronic osteomyelitis was described. These beads deliver antibiotic directly to the site of the infection, thereby eliminating the complications of systemic IV antibiotics. This study aimed to present a case series illustrating the use of STIMULAN calcium sulfate beads loaded with vancomycin and tobramycin to increase the rate of salvage of the infected implant and forgo IV antibiotics. METHODS A retrospective analysis was performed of patients who were treated at Mount Sinai Hospital for implant infection with salvage and antibiotic beads. RESULTS Twelve patients were identified, 10 of whom had breast cancer. Comorbidities included hypertension, smoking, and immunocompromised status. Infections were noted anywhere from 5 days to 8 years postoperatively. Salvage was successful in 9 out of the 12 infected implants using antibiotic bead therapy without home IV antibiotics. CONCLUSIONS The use of antibiotic beads is promising for salvaging infected breast implants without IV antibiotics. Seventy-five percent of the implants were successfully salvaged. Of the three patients who had unsalvageable implants, one was infected with antibiotic-resistant Rhodococcus that was refractory to bead therapy and one was noncompliant with postoperative instructions.

Abstract: Fat Grafting to Improve Results of Facelift

INTRODUCTION: The use of microvascular free tissue transfer has steadily increased over the years, due to the ability to reconstruct complex defects.1-4 Fortunately, failure rates have decreased over the past few years, with improvements in surgical technique combined with better preand post-operative assessments, including patient selection.5-7 The viability of free flaps depends upon various patient-based factors. The objective of this study was to further identify risk factors that are associated with increased incidence of flap failure, especially with regards to specific types of free flaps based on anatomic location.