Common Plastic Surgery Research Articles

Challenges of dealing diabetic foot and step wise surgical management

Soft tissue reconstruction of the diabetic foot is a challenge for the perioperative team. This study aims to describe a group of methods for the management of diabetic foot ulcers in order to reduce deformity and salvage the lower limb. This study emphasizes the appropriate timing and staging of surgery, discusses the most common plastic surgery techniques, and underscores the importance of a team approach in the management of diabetic foot wounds. A group of different advanced methods for the management of Diabetic foot such as sharp debridement of ulcers, application of vacuum therapy, and other forms of reconstructive plastic surgical procedures were used. Data collection was done in Z. H. Sikder Womens Medical College Hospital where the treatments were given. The study period was Jan 2018 to July 2019. Thirty-four patients with type 2 and type 1 diabetes mellitus were enrolled in the current study. Females (61.05%) and males (38.95%) with different stages of diabetic ulcer and related problem underwent treatment within this time frame. They underwent different methods of surgical management: debridement (12%), vacuum therapy (24.06%), amputation (4.04%), skin grafting (38.00%) and flap reconstruction (21%). The outcome is satisfactory and offer less hospital stay. Using advanced surgical wound management including reconstructive plastic surgical procedures; it was possible to reduce the hospital stay, the rate of high amputations of the lower limb and the deformity.

The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures.

Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

A Comparison of Common Plastic Surgery Operations Using the NSQIP and TOPS Databases.

Using the 2008-2016 TOPS and NSQIP databases, we compared patient characteristics and postoperative outcomes for 5 common plastic surgery procedures. A weighted TOPS population was used to mirror the NSQIP population in clinical and demographic characteristics to compare postoperative outcomes. We identified 154,181 cases. Compared with NSQIP patients, TOPS patients were more likely to be younger (47.9 versus 50.0 years), have American Society of Anesthesiologists class I-II (92.1% versus 74.6%), be outpatient (66.0% versus 49.3%), and be smokers (18.7% versus 11.7%). TOPS had extensive missing data: body mass index (40.6%), American Society of Anesthesiologists class (34.9%), diabetes (39.3%), and smoking status (37.2%). NSQIP was missing <1% of all shared categories except race (15.6%). The entire TOPS cohort versus only TOPS patients without missing data had higher rates of dehiscence (5.1% versus 3.5%) and infection (2.1% versus 1.7%). TOPS versus NSQIP patients had higher dehiscence rates (5.1% versus 1.0%) but lower rates of return to the operating room (3.1% versus 6.6%), infection (2.1% versus 3.0%), and medical complications (0.3% versus 2.2%). Nonweighted and weighted TOPS cohorts had similar 30-day outcomes. NSQIP and TOPS populations are different in characteristics and outcomes, likely due to differences in collection methodology and the types physicians using the databases. The strengths of each dataset can be used together for research and quality improvement.

The rate of incidental atypical and malignant breast lesions in reduction mammoplasty specimens.

Reduction mammoplasty (RM) is one of the most common plastic surgeries in the United States. We aimed to demonstrate the rate of incidental atypical and malignant breast lesions (AMBL) found in RM specimens and the impact of the number of submitted tissue sections on the rate of AMBL. We analysed our database for patients who had undergone reduction mammoplasty between 2000 and 2018. Patients with a history of breast cancer were excluded from the study. All pathology reports were analysed for AMBL (ALH, LCIS, FEA, ADH, DCIS, invasive carcinoma). The grossing protocol was to submit 10sections from each breast between 2000 and 2013 and six sections between 2014 and 2018. One hundred and sixty-nine of 5208 patients (3.3%) and 216 of 10340 RM specimens (2.1%) showed at least one AMBL. Nineteen (0.36%) patients had incidental cancer. The median age of patients with AMBL was significantly higher than patients without ABL (aged 59years versus 45years). There was no cancer in patients aged <30years. The age-controlled rate of overall AMBL as well as atypia and cancer only did not decrease by submitting fewer sections during the 2014-18 period compared to the 2010-13 period. Decreasing the number of tissue sections from 10 to six did not lead to a significant decrease in the rate of overall AMBL or cancer. Our data suggest that submitting six tissue sections from each breast for patients aged >30years and two sections from each breast for patients aged <30years would be sufficient.

Interest in Plastic Surgery during COVID-19 Pandemic: A Google Trends Analysis.

The coronavirus pandemic emerged in the United States in Spring 2020. The resulting economic upheaval was substantial, demonstrated by a 1072% increase in unemployment claims over a single week.1 In efforts to maximize hospital bed capacity, elective surgical procedures were either formally suspended or discouraged in many jurisdictions.2 Stay-at-home orders and social distancing efforts have spurred the rapid adoption of telemedicine alternatives for patient care.3 This combination has laid a foundation which many plastic surgeons worry may decrease patient interest in surgical and nonsurgical procedures. However, limited information is available to quantify these concerns. Here, we present for the first time an analysis of Google Trends data focused on popular plastic-surgery–related search terms following the emergence of COVID-19 in the United States. Google Trends search filters were designed to collect data related to common plastic surgery procedures in the United States, from June 2018 through July 2020. Search terms were based on the most common surgical and nonsurgical procedures reported in the American Society of Plastic Surgeons 2019 survey.4 When available, Google Trends topic data were used in lieu of specific terminology to better capture procedure-specific terminology and colloquialisms (ie, “tummy-tuck” has been captured as the most searched term related to abdominoplasty). Our findings demonstrate the destabilizing effect of the coronavirus pandemic on search terminology related to plastic surgery. Coinciding with the first COVID-19-related death in the United States on February 29, 2020, and the national declaration of emergency on March 13, 2020, there was a precipitous drop in search engine traffic in early 2020, and the interest in nonsurgical procedures approached an all-time low (Fig. 1). However, the public’s interest rapidly recovered, with 2-year peaks reached for some terms beginning in April 2020 and into the current summer season. A similar trend is observed in surgical procedure keywords. Two-year troughs were reached for all terms, with rapid return to baseline or, in some cases, new peaks (Fig. 2). Google-Trends–based analyses have previously been shown to correlate with the actual number of procedures performed, although there are inherent limitations worth noting.5 Data represent a deidentified amalgam of searches from potential and prior patients, physicians, and third parties. Still, search-engine–based analysis is a facile, readily available means to gauge interest for surgical procedures on a nationwide level. While the United States was impacted uniformly during the initial adjustment to COVID-19, a heterogeneous pattern of poorly controlled hotspots has emerged. If this pattern continues, it is reassuring for plastic surgeons that patient interest appears to rebound over a short period of time. It would be beneficial to further investigate the locoregional impact of COVID-19 on interest in plastic surgery procedures. In conclusion, while interest in plastic surgery was acutely impacted by COVID-19, search interest was able to rapidly recover to baseline and reached new peaks. With more consumers working remotely from home, patients may be able to take advantage of unique opportunities to recuperate from procedures, with less downtime from work compared with that during pre-pandemic times.Fig. 1.: Public interest in common non-surgical procedures (Botox, hyaluronic acid fillers, and laser hair removal) pre- and post-COVID-19 pandemic.Fig. 2.: Public interest in most common plastic surgery procedures (breast augmentation, liposuction, mastopexy, abdominoplasty, and blepharoplasty) pre- and post-COVID-19 pandemic.

Geriatric Patients Carry Increased Risk for Deep Venous Thrombosis and Pulmonary Embolism in Reduction Mammaplasty: An Analysis of 1897 Geriatric Patients Among 25,909 Cases From 2005 to 2017 National Surgical Quality Improvement Project Databases.

Reduction mammaplasty is one of the most common plastic surgery procedures performed. No study has evaluated whether geriatric patients are at greater risk for developing postoperative complications relative to nongeriatric patients. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was reviewed for reduction mammaplasty procedures from 2005 to 2017. Hypothesis testing for demographics, comorbidities, and postoperative complications between geriatric and nongeriatric patients was performed. Statistically significant differences were then evaluated with multivariate logistic regression analysis. A total of 25,909 reduction mammaplasties were collected by NSQIP from 2005 to 2017, with 1897 patients older than 64 years (8% of all cases). The average age for geriatric breast reduction patients was 69 years versus 41.5 years for nongeriatric patients. Rates of comorbidities including diabetes, smoking status, dyspnea status, and hypertension medication were statistically different between the groups. Rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) were significantly higher in geriatric versus nongeriatric patients, respectively (0.32 vs 0.06, P < 0.001 and 0.37 vs 0.09, P < 0.001). Multivariate analysis demonstrated geriatric patients had a 4.2 and 3.9 times higher risk of developing a DVT and PE than nongeriatric patients (C.I. 1.5-11.6, P = 0.006 and C.I. 1.6-9.8, P = 0.004). This study represents the largest evaluation of geriatric reduction mammaplasties in the United States. Although rare, geriatric age confers a 4 times increased risk for developing DVT and PE relative to nongeriatric patients all while adjusting for preoperative risk factors in reduction mammaplasty. Plastic surgeons should consider counseling their geriatric patients regarding these increased risks.

Abstract 7: Operative Skills Progression in Plastic Surgery Residents

Background: Forming a better understanding of how quickly resident physicians demonstrate skill advancement in the operating room is vital to providing more efficient and effective training. We performed the current study to determine how long it takes residents to progress in skill level for two common plastic surgery cases, Breast Reconstruction (CPT 19357) and Endoscopic Carpal Tunnel Release (CPT 29848). Methods: Operative Entrustability Assessment (OEA) data were abstracted from MileMarkerTM, a web-based program capable of storing trainee self-assessments and their associated attending assessments of any CPT-coded procedure. Ratings are based on a 5-point scale (1=“observed case,” 5=“can take junior resident through case”); a score of 4 (“resident can perform entire surgery”) demonstrates operative competence. We used data from two plastic surgery training programs to identify cases for which OEAs are most often completed. We stratified OEAs by CPT code, resident, and score level to assess the number of cases for which OEAs are completed before OEA score increase. We used descriptive statistics (e.g., average, range) to assess outcomes. Results: We identified 682 OEAs completed by 54 unique residents for CPT 19357 (n=400) and 29848 (n=282). For CPT 19357, residents logged the greatest number of OEAs to progress between levels 3 and 4 (mean=5.2). For CPT 29848, residents logged the greatest number of OEAs to progress from level 4 to level 5 (mean=3.4). For CPT 19357, the next greatest number of cases were logged between levels 2 and 3 (mean=3.5) while in CPT 29848 the next greatest number were logged between levels 3 and 4 (mean=3.2). Conclusion: Our dataset including 5.5 years of data from 2 plastic surgery training programs showed that residents logged the most cases to progress between OEA skill level 3 (“needs verbal guidance”) and 4 (“operates independently”) for CPT 19357 and from level 4 to 5 (“can take junior resident through case”) for CPT 29848. By aligning instructional approaches with the Conscious Competence Matrix wherein OEA level 3 correlates with conscious incompetence, level 4 with conscious competence, and level 5 with unconscious competence, attending surgeons may more efficiently assist learners with operative skills acquisition.

Lessons from American Board of Plastic Surgery Maintenance of Certification Tracer Data: A 16-Year Review of Clinical Practice Patterns and Evidence-Based Medicine in Cleft Palate Repair.

As a component of the Maintenance of Certification process from 2003 to 2019, the American Board of Plastic Surgery tracked 20 common plastic surgery operations. By evaluating the data collected over 16 years, the authors are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States. Cumulative tracer data for cleft palate repair was reviewed as of April of 2014 and September of 2019. Evidence-based medicine articles were reviewed. Results were tabulated in three categories: pearls, or topics that were covered in both the tracer data and evidence-based medicine articles; topics that were covered by evidence-based medicine articles but not collected in the tracer data; and topics that were covered in tracer data but not addressed in evidence-based medicine articles. Two thousand eight hundred fifty cases had been entered as of September of 2019. With respect to pearls, pushback, von Langenbeck, and Furlow repairs all declined in use, whereas intravelar veloplasty increased. For items not in the tracer, the quality of studies relating to analgesia is among the highest of all areas of study regarding cleft palate repair. In terms of variables collected by the tracer but not studied, in 2019, 41 percent of patients received more than 1 day of antibiotics. This article provides a review of cleft palate tracer data and summarizes the research in the field. Review of the tracer data enables cleft surgeons to compare their outcomes to national norms and provides an opportunity for them to consider modifications that may enhance their practice.

Abstract 58: Clinical Practice Patterns And Evidence-based Medicine In Cleft Palate Repair: A Sixteen-year Review Of Maintenance Of Certification Tracer Data From The American Board Of Plastic Surgery

Purpose: As a component of the Maintenance of Certification (MOC) process from 2003 to 2019, the American Board of Plastic Surgery (ABPS) tracked 20 common plastic surgery operations, or tracer procedures. By evaluating the data collected over 16 years, we are able to examine the practice patterns of pediatric/craniofacial surgeons in the United States. Methods: Cumulative data for the tracer procedure on primary cleft palate repair that had been accumulated since 2003 were reviewed as of April, 2014 and September, 2019. To assess points covered by evidence-based medicine articles, cleft palate Evidence-Based Medicine (EBM) articles published in Plastic and Reconstructive Surgery were reviewed. Changes in tracer data from 2014 to 2019 were compared using a Chi square test, Fisher’s exact test, or Student’s t-test as appropriate. Results: 2,850 cases (1,507 male, 1,343 female) had been entered into the tracer as of September, 2019. The median age of patients operated on was 12 months. 15% of patients had a “previous airway problem”. 3% of patients receiving a two-stage repair. Several significant changes in operative techniques were noted including a decrease in pushback, Von Langenbeck and Furlow palatoplasty. Several additional questions in the ABPS tracer are not addressed in the EBM literature, a few of which provide potential topics for further study. These include use of greater than 24 hours of postoperative antibiotics, and injection of epinephrine, which changed significantly from 2014 to 2019. 94.2% of the 2850 patients reported in the ABPS tracer data experienced no postoperative adverse events. 58 complications, or 34.9% of all complications, did not fit into any of the categories specified in the tracer data. Conclusion: ABPS MOC tracer data enables surgeons to evaluate their outcomes in light of national statistics. We have used these tracer data combined with published evidence-based medicine articles relevant to cleft palate repair to identify trends in cleft palate repair from 2014 to 2019. By providing an overview of areas of focus in the MOC tracer data as well as EBM articles, we hope to provide a venue for surgeons to further evaluate their own practice through review of the literature. We have additionally identified areas of cleft palate research that have not been addressed by the tracer and may be valuable to include in the MOC tracer module in the future. Finally, areas collected in the tracer but not addressed in the literature provide opportunities for further research into aspects of cleft palate repair.

Comparison of Bilateral Mandibular Angle Ostectomy Between East Asian Males and Females: A Study Based on Three-Dimensional Computed Tomography Reconstruction.

Mandibular angle ostectomy is a common plastic surgery for facial contouring in East Asians. However, rarely we could find reports on differences between East Asian males and females undergoing this surgery. To describe the differences between East Asian males and females before and after mandibular angle ostectomy. A total of 22 Asian males and 52 Asian females who underwent mandibular angle ostectomy from April 2015 to November 2018 were enrolled. Three-dimensional computed tomography was used to evaluate the preoperative and postoperative data of the mandible. Thirteen clinical data were measured on reconstructed mandibular models. The differences in data between males and females were analyzed to identify the causes of the differences before and after surgery. The follow-up was 6-12months, and patient satisfaction was also evaluated. The ostectomy volumewas positively correlated with the distance from the intersection of the occlusal plane and the anterior margin of the mandibular ramus to gonion (MR-Go; female, p < 0.01; male, p = 0.02). There was a positive correlation between the ostectomyvolume and the postoperative drainage fluid (The drainage fluid is mainly blood)volumeafter surgery in females (p < 0.05), while there is no significant correlation between these two data in males (p = 0.19). Patients with a long distance from the second molar to the lower edge of the mandibular body (SM-MB) tended to have a higher risk of postoperative bleeding (female, r = 0.56, p < 0.01; male, r = 0.73, p = 0.01). Because of the difference in the anatomical size of the mandible and different aesthetic requirements for facial contouring between males and females, surgeons encounter different intraoperative conditions resulting in difficulties during surgery. Understanding differences in mandibular angles predicts differences in ostectomyvolume and postoperative bleeding risk, thus aiding surgeons and leading to better operative outcomes. This 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.

Expanding the Use of Orthodontic Appliance in the Management of Maxillo-Mandibular Fractures

Background: Maxillofacial fractures are common presentationin Plastic Surgery Emergency Department. Many techniquesof maxillary mandibular fixation have evolved overthe years. Orthodontic appliance technique as a reliable methodfor Maxillary-mandibular fixation has been introduced.Methods: Prospective clinical study was conducted on20 patients complaining of different types of maxillo-facialfractures who were candidates for maxillary-mandibularfixation with or without open reduction and internal fixation.The objective of the study is to demonstrate technical feasibility,overall outcomes and complications of the technique,in the period from October 2017 till March 2018 at in theEmergency Plastic Surgery Department in Cairo UniversityHospital.Results: In suitable cases orthodontic brackets and elasticscan be used as an effective method of Maxillary-mandibularfixation with good patients' satisfaction. It can reduce thehospital admission rate and need for general anesthesia; itwill not only reduce costs for the hospital but also costs forthe patient.Conclusion: Orthodontic brackets technique's stabilityallowed using it as a maxillary mandibular fixation even aloneor with open reduction and internal fixation, thus it used asan effective method for maxillary-mandibular fixation, andhas proven to cause a significant impact on returning thepatients to their pre-traumatic bite. This makes it able toreplace the Erich arch bar in maxillofacial fracture as a methodof maxillary-mandibular fixation. Orthodontic brackets techniquehas shown to offer patients better oral hygiene, convenienceand no mucosal injuries.

YouTube for Cosmetic Plastic Surgery: An Effective Patient Resource?

YouTube is increasingly being utilized as a major educational resource by patients. It is important for plastic surgeons to understand the quality and characteristics of videos that patients are likely to view about procedures of interest. The aim of this study was to evaluate the quality of the videos that patients are most likely to encounter when searching YouTube for the most common cosmetic plastic surgery procedures. Based on Google Trends data, the most searched medical and colloquial terms were identified for common cosmetic surgery procedures: "abdominoplasty," "tummy tuck," "breast augmentation," "boob job," "liposuction," "lipo," "mastopexy," "breast lift," "reduction mammoplasty," and "breast reduction." On YouTube, videos were searched by relevance (default) and view count; the top 10 results were collected in each group and rated according to the DISCERN criteria. Each video was assigned an overall and bias DISCERN score (DS). A score of 1 indicates high bias and low overall quality and a score of 5 indicates the opposite. In total, 143 unique videos were identified, which resulted in a mean bias DS of 2.29 and mean overall DS of 2.44. Seventy-two videos included US board-certified plastic surgeons and 58 were classified as patient experience. Videos had 667,373,209 total views and were an average of 4.27 years old. Videos including US board-certified plastic surgeons were of significantly higher quality and showed lower bias than videos without these practitioners (P < 0.05). Overall, YouTube videos showed high bias and low quality. Plastic surgeons should be aware of this popular resource and counsel patients about the bias that is often present. Plastic surgeons and academic plastic surgery organizations should strive to upload high-quality, unbiased videos to provide patients with a more appropriate resource.

Female Genital and Vaginal Plastic Surgery: An Overview.

After studying this article and viewing the video, the participant should be able to: 1. Accurately describe the relevant aesthetic anatomy and terminology for common female genital plastic surgery procedures. 2. Have knowledge of the different surgical options to address common aesthetic concerns and their risks, alternatives, and benefits. 3. List the potential risks, alternatives, and benefits of commonly performed female genital aesthetic interventions. 4. Be aware of the entity of female genital mutilation and differentiation from female genital cosmetic surgery. This CME activity is intended to provide a brief 3500-word overview of female genital cosmetic surgery. The focus is primarily on elective vulvovaginal procedures, avoiding posttrauma reconstruction or gender-confirmation surgery. The goal is to present content with the best available and independent unbiased scientific research. Given this relatively new field, data with a high level of evidence are limited. Entities that may be commonly encountered in a plastic surgery practice are reviewed. The physician must be comfortable with the anatomy, terminology, diagnosis, and treatment options. Familiarity with requested interventions and aesthetic goals is encouraged.

Economic Burden of Out-of-Pocket Spending for Plastic Surgery Procedures: Value From the Patient’s Perspective

PURPOSE: Health insurance reimbursement structure has evolved with patients becoming increasingly responsible for their healthcare costs through rising out-of-pocket (OOP) expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients.1,2 Given the possible negative effects of OOP expenses on the patient, we aim to investigate temporal trends in OOP expenses for plastic and reconstructive surgical procedures and determine drivers for increased cost sharing. METHODS: The study cohort comprised of patients undergoing the most common outpatient reconstructive plastic surgeries (skin cancer excision with closure, breast reconstruction, breast reduction, hand surgery, facial fracture repair, and scar revision/complex closure),3 using Truven MarketScan databases from 2009 to 2017. Sociodemographic characteristics, insurance type, and outpatient surgery location data were collected. Total cost of the surgery paid to the insurer and OOP expenses, including deductible, copayment, and coinsurance, were examined over time. OOP expenses were investigated using multivariable generalized linear modeling with log link and gamma distribution. All costs were inflation adjusted to 2017 dollars. RESULTS: We evaluated 3,181,125 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. The adjusted mean total cost in 2009 was $1,055 and in 2017 was $1,338 (increase in 27%), and the adjusted mean OOP expenses in 2009 were $121 and in 2017 were $184 (increase in 52%). Patients undergoing hand surgical procedures had the largest increase in total cost ($1,776 in 2009 to $2,545 in 2017, increase of 43%, P < 0.001) and OOP expenses ($197 in 2009 to $331 in 2017, increase of 68%, P < 0.001). Procedures performed in ambulatory surgical centers accounted for the largest increase in cost sharing between 2009 and 2017 (increase of 74%), but total costs only increased 24%. Facility fees were $385 on average in 2009 compared to $704 in 2017 (P < 0.001), and mean professional fees were $538 in 2009 compared to $635 in 2017 (P < 0.001). In the adjusted regression, managed care, Medicare-managed care, and Medicare-fee-for-service had approximately 42%–64% of the OOP expenses compared to fee-for-service insurance (P < 0.001). CONCLUSION: For outpatient plastic surgery procedures, OOP expenses are increasing at a faster rate than total costs. Wide variability in cost sharing was seen across the different plastic surgery procedures, surgical location, and insurance type. For outpatient plastic surgical care that is largely elective, these temporal trends in OOP expenses must be explored and should be incorporated in the decision-making process for surgery. Given the increased scrutiny placed on rising healthcare costs, policy makers should consider the impact of cost sharing and the financial burden placed on the patient when discussing value-based reimbursement reform. REFERENCES: 1. Adrion ER, Ryan AM, Seltzer AC, et al. Out-of-pocket spending for hospitalizations among nonelderly adults. JAMA Intern Med. 2016;176:1325–1332. 2. Ubel PA, Abernethy AP, Zafar SY. Full disclosure--out-of-pocket costs as side effects. N Engl J Med. 2013;369:1484–1486. 3. American Society of Plastic Surgeons. Plastic Surgery Statistics Report. 2017. Available at https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf. Accessed February 21, 2019.

Multilevel Breast Reduction: A Retrospective Study of 338 Breast Reduction Surgeries.

Background:Aesthetic breast reduction is a common plastic surgery procedure with the potential for considerable improvement of the patient’s quality of life in addition to its aesthetic value. Many different approaches have been described for breast reduction to improve upon previous techniques in terms of scarring, nipple position, amount of breast tissue excised, shape, and longevity of the results. However, medium size resections in ptotic and wide breasts are difficult to treat using both the most common inferior pedicle wise procedure and the various vertical scar techniques.Methods:A retrospective study of 338 consecutive bilateral breast reduction patients between January of 2010 and January of 2018 at a single center by a single surgeon using a vertical scar technique. Demographic and postoperative outcome data were collected and evaluated.Results:Patient satisfaction with the results was high. Complication rates were comparable or lower than previously published series. Major complications requiring revision surgery: 3 (0.8%) hematomas; minor complications: 68 (20%) cases of superficial dehiscence; 12 (3.5%) superficial surgical site infections; 11 (3.2%) seromas; 4 (1.2%) fat necrosis; and 1 (0.2%) partial areola necrosis.Conclusion:The Borenstein Breast Reduction technique aims to recreate the breast mound support from the “bottom up” facilitating long-lasting results and high patient satisfaction rates. This approach can be helpful in all breast reductions and is most effective in wide ptotic breasts.

Incidental breast carcinoma: incidence, management, and outcomes in 4804 bilateral reduction mammoplasties.

Bilateral reduction mammoplasty is one of the most common plastic surgery procedures performed in the U.S. This study examines the incidence, management, and prognosis of incidental breast cancer identified in reduction specimens from a large cohort of reduction mammoplasty patients. Breast pathology reports were retrospectively reviewed for evidence of incidental cancers in bilateral reduction mammoplasty specimens from five institutions between 1990 and 2017. A total of 4804 women met the inclusion criteria of this study; incidental cancer was identified in 45 breasts of 39 (0.8%) patients. Six patients (15%) had bilateral cancer. Overall, the maximum diagnosis by breast was 16 invasive cancers and 29 ductal carcinomas in situs. Thirty-three patients had unilateral cancer, 15 (45.5%)of whichhad high-risk lesions in the contralateral breast. Twenty-one patients underwent mastectomy (12 bilateral and nine unilateral), residual cancer was found in 10 in 25 (40%) therapeutic mastectomies. Seven patients did not undergo mastectomyreceived breast radiation. The median follow-up was 92months. No local recurrences were observed in the patients undergoing mastectomy or radiation. Three of 11 (27%) patients who did not undergo mastectomy or radiation developed a local recurrence. The overall survival rate was 87.2% and disease-free survival was 82.1%. Patients undergoing reduction mammoplasty for macromastia have a small but definite risk of incidental breast cancer. The high rate of bilateral cancer, contralateral high-risk lesions, and residual disease at mastectomy mandates thorough pathologic evaluation and careful follow-up of these patients. Mastectomy or breast radiation is recommended for local control given the high likelihood of local recurrence without either.

A Novel Method to Enhance Dynamic Rhinoplasty Outcomes: Double "V" Carving for Alloplastic Grafts.

Augmentation rhinoplasty is one of the most common plastic surgery procedures performed in Asia. Most Asian patients desire not only a natural-looking nose but also a nose with natural feel. Achieving such rhinoplasty outcomes with grafts has been a challenge for surgeons due to rigidity of grafting material. We propose a novel technique to address this limitation. A total of 200 healthy adult patients aged from 18 to 25 years were randomly chosen and classified into 5 groups: A, B, C, D, and control. Each group included 40 patients. The patients assigned to conventional grafting underwent rhinoplasty with L-shaped silicone prosthesis (group A) or expanded polytetrafluoroethylene (e-PTFE; group B), using traditional carving methods. The patients assigned to dynamic rhinoplasty underwent silicone (group C) or e-PTFE grafts (group D) using the modified double "V" method, which involves removing bilateral wedges from the graft to decrease rigidity. Patients in control group do not undergo the surgery. A 3-dimensional raster surface scanner was used to capture the images of the patients accurately and nasal mobility was measured. Subjective evaluations were carried out by a series of questionnaires asked to the patients. The angle α of nasal mobility was significantly lower in conventional grafting (23.09 [5.34] mm for silicone and 17.88 [4.96] mm for e-PTFE) versus the "V" carving (30.53 [3.76] mm for silicone and 23.77 [4.53] mm for e-PTFE; P < .05). The double "V" carving method is a simple, effective, and practical method for improving dynamic nasal outcomes in patient undergoing augmentation rhinoplasty.

An Assessment of Bleeding Complications Necessitating Blood Transfusion across Inpatient Plastic Surgery Procedures: A Nationwide Analysis Using the National Surgical Quality Improvement Program Database.

This study described the prevalence of bleeding complications necessitating blood transfusion across plastic surgery procedures and identified those procedures that may be associated with higher rates of bleeding. The authors retrospectively identified patients who suffered from postoperative bleeding complications from 2010 to 2015 using the National Surgical Quality Improvement Program database. This is defined by the National Surgical Quality Improvement Program as the need for transfusion of at least one unit of packed or whole red blood cells. Patient characteristics were described using summary statistics, and National Surgical Quality Improvement Program and univariate analysis of patient characteristics and bleeding complications was performed. Overall, 1955 of 95,687 patients experienced bleeding complications. Patients with bleeding complications were more likely to be diagnosed with hypertension, have a longer total operative time, and have a previously diagnosed bleeding disorder. The most common primary plastic surgery procedure associated with bleeding complications was breast reconstruction with a free flap, and breast reconstruction with a pedicled transverse rectus abdominis musculocutaneous flap had the highest rate of bleeding. A return to the operating room was required in 539 patients (27.6 percent) who suffered a postoperative bleeding complication. Patients with a preexisting bleeding disorder [n = 1407 (1.5 percent)] were more likely to be diabetic, have a lower preoperative hematocrit, and have a longer operative time. In addition, these patients were more likely to suffer from other nonbleeding complications (1.29 percent versus 0.35 percent; p < 0.01). Complex procedures (i.e., free flap breast reconstruction) have a higher prevalence of bleeding requiring a transfusion. Furthermore, patients undergoing combined procedures-specifically, breast oncologic and reconstructive cases-may be at a higher risk for experiencing bleeding-related complications. Therapeutic, III.

Analgesic efficacy of modified pectoral block plus serratus plane block in breast augmentation surgery: A randomised, controlled, triple-blind clinical trial

Abstract Introduction Prosthetic breast surgery is a very common plastic surgery procedure, but its postoperative analgesic management is a challenge for the surgical team. The purpose of the present study is to validate the analgesic efficacy of pectoral block and serratus plane block in retropectoral mammoplasty. Patients and methods A randomised, controlled, triple-blind, clinical trial was designed, and included 30 patients undergoing retropectoral augmentation mammoplasty. All of them had a modified PEC II block and a serratus plane block with a total volume of 40 ml per breast. In 15 of them bupivacaine 0.25% (GPEC) was injected and in the other 15 patients saline was used (GC). Standardised management of anaesthesia and postoperative analgesia was performed. Intra-operative haemodynamic parameters required for postoperative analgesia, and a numeric verbal scale on arrival in the recovery unit were measured and at 3, 6, and 24 h. The quality perceived by patients and surgeons was also measured. Results Post-operative pain was significantly better in GPEC (5.3 ± 2.3 vs. 2.9 ± 2.7; p = 0.018). No significant differences were observed at 3, 6, and 24 h. The surgeons rated the anaesthetic–analgesic quality as very good in 80% of the cases in GPEC versus 33% in CG (p = 0.01). Conclusions The use of these blocks is a good perioperative analgesic strategy in the multimodal management of retropectoral augmentation mammoplasty.

State Variations in Public Payer Reimbursement for Common Plastic Surgery Procedures.

Existing data suggest decreased willingness of plastic surgeons to participate in Medicare and Medicaid. Significant disparities exist in Medicare and Medicaid reimbursement for various general surgical procedures. The aims of this study were to investigate variations in Medicare and Medicaid reimbursement across the nation for common plastic surgery procedures. Medicare and Medicaid reimbursement data for 2017 were obtained by means of the Centers for Medicare & Medicaid Services and publicly available fee schedules from each state, respectively, for eight common plastic surgery procedures. The difference in Medicare and Medicaid reimbursement was calculated across all states. The difference in value ascribed to each procedure was determined by comparing the payment from each payer to the work relative value units. Medicaid reimbursement rates were significantly lower for the selected procedures, with a median national discount of -25 percent ($16.09 per work relative value unit) compared to Medicare. There were higher median rates of reimbursement per work relative value unit by Medicaid in only five states when compared to Medicare. Significant variations of more than 15 percent in the Medicaid-to-Medicare reimbursement ratios between our selected procedures were identified in 28 states. Variations exist between Medicare and Medicaid reimbursement for common plastic surgery procedures. The within-state variations in Medicaid reimbursement are likely reflective of important yet nontransparent differences in determining Medicaid reimbursement. These variations likely affect access to care for underserved populations. Professional societies should continue to convey the value of these important procedures and raise awareness regarding disparities in access to care.