Ryan S. Constantine

The Impact of Operative Time on Complications After Plastic Surgery: A Multivariate Regression Analysis of 1753 Cases

BACKGROUND Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity. OBJECTIVE The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk. METHODS A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity. RESULTS A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity (P < .0001). Compared with the first quintile of operative time (<2.0 hours), there was no change in complications until after 3.1 hours of surgery (odds ratio, 1.6; P = .017), with progressively greater odds increases of 3.1 times after 4.5 hours (P < .0001) and 4.7 times after 6.8 hours (P < .0001). When stratified by type of surgery, longer operations continued to be associated with greater morbidity. CONCLUSIONS Surgery duration is an independent predictor of complications, with a significantly increased risk above 3 hours. Although procedural complexity undoubtedly affects morbidity, operative time should factor into surgical decision making.

The Effect of Massive Weight Loss Status, Amount of Weight Loss, and Method of Weight Loss on Body Contouring Outcomes

BACKGROUND The impact of massive weight loss (MWL) on body contouring procedures and outcomes has not been firmly established in the literature. OBJECTIVE The authors investigate the correlations between MWL status, the method of achieving MWL, and the amount of weight lost with wound-healing complications after body contouring procedures. METHODS The charts of 450 patients (124 of whom had undergone MWL) who underwent body contouring procedures including abdominoplasty, brachioplasty, thighplasty, breast mastopexy/reduction, lower bodylift, bodylift, buttock lift, and liposuction were reviewed. MWL patients were classified as having achieved weight loss through diet and exercise, gastric banding or sleeving, or gastric bypass. Postoperative complication data were collected, including cases of infection, delayed wound healing, seroma, hematoma, dehiscence, and overall wound problems. Odds ratios (OR) were estimated using 4 multivariate logistic regression models. RESULTS MWL status was a significant predictor of wound problems (OR, 2.69; P < .001). Patients with 50 to 100 lbs of weight loss did not have a significantly increased risk of wound problems (OR, 1.93; P = .085), while patients with over 100 lbs of weight loss did (OR, 3.98; P < .001). Gastric bypass (OR, 3.01; P = <.001) had a higher risk correlation than did diet and exercise (OR, 2.72, P = .023) or restrictive bariatric surgery (OR, 2.31; P = .038) as a weight loss method. Patients who lost over 100 lbs demonstrated increased risk of complications if they had gastric bypass or restrictive procedures. CONCLUSIONS MWL was a significant risk factor for wound complications in the body contouring population. Method and amount of weight loss were also significant factors in predicting complications.

Barbed Sutures and Wound Complications in Plastic Surgery: An Analysis of Outcomes

BACKGROUND Barbed sutures may expedite dermal approximation and improve tissue support while requiring less time and material than conventional sutures. Several types of barbed sutures are available, each with unique advantages. OBJECTIVES The authors sought to determine whether the incidence of complications differed after wound approximation in plastic surgery when various brands of barbed vs nonbarbed traditional sutures were employed. METHODS The authors conducted a retrospective review of outcomes in body contouring, free flap, and breast reconstruction. Suture type and closure method were noted for each case. The number of complications after traditional 2-layer closure with nonbarbed sutures was compared with the number of complications after closure via 1- and 2-layer techniques with several brands of barbed sutures, and the brands of barbed sutures were compared with each other. RESULTS A total of 1011 unique surgical procedures, including 298 procedures with barbed sutures and 713 procedures with nonbarbed sutures, were performed by 5 members of the plastic surgery faculty. The 2-layer technique with barbed sutures was associated with significantly higher rates of wound separation than traditional methods. Excessive erythema along the incision site was significantly more frequent with Quill barbed sutures than with V-Loc barbed sutures. CONCLUSIONS Barbed sutures were associated with significantly higher rates of minor wound complications, specifically when the 2-layer closure technique was performed. Significantly higher rates of erythema were associated with Quill barbed sutures than with V-Loc barbed sutures. LEVEL OF EVIDENCE 4: Risk.

The Impact of Perioperative Hypothermia on Plastic Surgery Outcomes: A Multivariate Logistic Regression of 1062 Cases

BACKGROUND Perioperative hypothermia has been associated with increased rates of infection, prolonged recovery time, and coagulopathy. OBJECTIVES The authors assessed the impact of hypothermia on patient outcomes after plastic surgery and analyzed the impact of prewarming on postoperative outcomes. METHODS The medical charts of 1062 patients who underwent complex plastic surgery typically lasting at least 1 hour were reviewed. Hypothermia was defined as a temperature at or below 36°C. Postoperative complication data were collected for outcomes including infection, delayed wound healing, seroma, hematoma, dehiscence, deep venous thrombosis, and overall wound problems. Odds ratios (ORs) were estimated from 3 multivariate logistic regression models of hypothermia and one model of body contouring procedures that included prewarming as a parameter. RESULTS Perioperative hypothermia was not a significant predictor of wound problems (OR = 0.83; P = .28). In the stratified regression model, hypothermia did not significantly impact wound problems. The regression model measuring the interaction between hypothermia and operating time did not show a significantly increased risk of wound problems. Prewarming did not significantly affect perioperative hypothermia (P = .510), and in the model of body contouring procedures with prewarming as a categorical variable, massive weight loss was the most significant predictor of wound complications (OR = 2.57; P = .003). Prewarming did not significantly affect outcomes (OR = 1.49; P = .212). CONCLUSIONS Based on univariate and multivariate models in our study, mild perioperative hypothermia appears to be independent of wound complications. LEVEL OF EVIDENCE 4: Risk.

An Alternative Outpatient Care Model: Postoperative Guest Suite–Based Care

BACKGROUND Patients recovering from outpatient surgery are responsible for managing their pain, managing ambulation, and even implementing thromboembolism prophylaxis after discharge. Because of the importance of postoperative care to prevent complications, a model of care that helps a patient transition to independent self-care could provide optimal results. OBJECTIVES The authors investigated the safety and morbidity rate for patients who underwent body contouring procedures and overnight care at an attached, nurse-staffed guest suite facility. METHODS A retrospective review was conducted of 246 patients who underwent major body contouring and who stayed at least 1 night in the guest suite facility. Major complications included a return to the operating room within 48 hours, major wound infection, and unplanned hospitalization within 48 hours. Minor complications included any postsurgical effect necessitating unplanned physician intervention within the first 30 days. Univariate analyses correlating patient characteristics and complication rates were conducted, as well as comparison of complication rates among same procedures reported in the literature. RESULTS The complication rate (major and minor complications) was 25.20%. Surgical site infection occurred in 8.13% of patients. The most common wound complication was erythema around the incision site (12.20%). Death, deep vein thrombosis, or pulmonary embolism did not occur. Comparison with relevant results reported in the literature indicated a significant reduction in the occurrence of postoperative venous thromboembolism. CONCLUSIONS Patient education after surgery is essential to healing and adequate care. The guest suite model provides improved care and education for the patient and family postsurgery by addressing some of the known risk factors of plastic surgery. LEVEL OF EVIDENCE 4.

Validation of a laser-assisted wound measurement device in a wound healing model.

In the treatment and monitoring of a diabetic or chronic wound, accurate and repeatable measurement of the wound provides indispensable data for the patients medical record. This study aims to measure the accuracy of the laser‐assisted wound measurement (LAWM) device against traditional methods in the measurement of area, depth and volume. We measured four ‘healing’ wounds in a Play‐Doh®‐based model over five subsequent states of wound healing progression in which the model was irregularly filled in to replicate the healing process. We evaluated the LAWM device against traditional methods including digital photograph assessment with National Institutes of Health ImageJ software, measurements of depth with a ruler and weight‐to‐volume assessment with dental paste. Statistical analyses included analysis of variance (ANOVA) and paired t‐tests. We demonstrate that there are significantly different and nearly statistically significant differences between traditional ruler depth measurement and LAWM device measurement, but there are no statistically significant differences in area measurement. Volume measurements were found to be significantly different in two of the wounds. Rate of percentage change was analysed for volume and depth in the wound healing model, and the LAWM device was not significantly different than the traditional measurement technique. While occasionally inaccurate in its absolute measurement, the LAWM device is a useful tool in the clinicians arsenal as it reliably measures rate of percentage change in depth and volume and offers a potentially aseptic alternative to traditional measurement techniques.

Lessons Learned After 15 Years of Circumferential Bodylift Surgery

Circumferential bodylift is a powerful procedure for achieving dramatic and natural body contouring changes in the massive weight loss patient. The care of these patients has raised our awareness of several important issues including safety, nutritional status, skin quality, recurrent laxity, surgical steps, and postoperative scars. Integration of this knowledge with various technical modifications over the last 15 years has improved our care for this cohort. We have not only seen a rise in the number of surgeries performed, but also the development of principles, techniques, and details that the authors feel necessary to share to achieve improved contour and more predictable outcomes. LEVEL OF EVIDENCE 4: Therapeutic.

Fat Graft Viability in the Subcutaneous Plane versus the Local Fat Pad

Background: Fat grafting has been increasingly utilized in both aesthetic and reconstructive surgical procedures, yet the basic scientific understanding of fat grafting has lagged behind the pace of clinical innovation and utilization. This lack of basic scientific understanding has perhaps manifested itself in the wide range of graft viability reported across the literature. This study attempts to further the underlying mechanisms of fat graft take and viability through the comparison of the subcutaneous plane and the local fat pad in athymic rats. Methods: Lipoaspirate from a consenting patient was grafted into 2 locations in the subcutaneous plane and into the 2 inguinal fat pads in each of 4 athymic rats. Specimens were then collected after 47 days, and immunohistochemistry was utilized to determine angiogenesis in the fat grafts as a measure of fat graft take. Data were analyzed using the Student’s t test and analysis of variance followed by multiple comparisons. Results: There was no statistically significant difference (P = 0.2913) between the inguinal fat pad and the subcutaneous plane when measuring neovascularization. Analysis of variance comparing the graft locations also indicated no statistically significant difference when comparing each of the rats. Conclusions: Investigation into fat graft injection location indicates that there is no statistically significant difference in angiogenesis signals between the subcutaneous plane and the local fat pad in the athymic rat model. Further research should aim to continue to close the gap between clinical practice and basic scientific understanding of fat grafting.

Effectiveness of Prophylactic Antibiotics in Outpatient Plastic Surgery

BACKGROUND The effectiveness of prophylactic antibiotics has not been established for patients who undergo plastic surgery as outpatients, and consensus guidelines for antibiotic administration in clean-contaminated plastic surgery are not available. OBJECTIVES In a retrospective study of outpatients, the authors examined preoperative timing of prophylactic antibiotics, whether postoperative antibiotics were administered, and whether any correlations existed between these practices and surgical complications. METHODS The medical records of 468 plastic surgery outpatients were reviewed. Collected data included preoperative antibiotic timing, postoperative antibiotic use, comorbidities, and complications. Rates of complications were calculated and compared with other data. RESULTS All 468 patients received antibiotics preoperatively, but only 93 (19.9%) received them ≥1 hour before the initial incision. Antibiotics were administered 15 to 44 minutes before surgery in 217 patients (46.4%). There was no significant difference in complication rates between the 315 patients who received postoperative prophylactic antibiotics (16.2%) and the 153 who did not (20.9%). Comorbidities had no bearing on postoperative complications. CONCLUSIONS Postoperative antibiotic prophylaxis may be unnecessary for outpatient plastic surgery patients. LEVEL OF EVIDENCE 3.

Response to: “Is There a Link Between Longer Operating Times and Increased Risk?” and “Papers Regarding Operative Times and Complications Can Be Misleading”

Sirs: Thank you very much for your letters to the editor.1,2 We hope we can help clarify and address some of the concerns raised. Our study actually did address many of these concerns using multivariate logistic regression and risk adjustment. This method simultaneously analyzes the effect of multiple independent variables on a dependent variable in relation to one another. Logistic regression aims to find which of the independent variables (ie, operative time, age, BMI, sex, smoking status) has a true relationship to the observed outcome (postoperative complication) and to adjust the reported effect of the variable of interest by weighing the influence of the other variables. Essentially, by using this model, we were able to adjust for confounders of operative time. Thus, we did in fact control for the confounders and addressed the patient characteristics and various procedures statistically. There are some flaws in our data, including some aberrant operative times, which were subject to errors based on what was reported by nurses, time outs, and surgical reports. …