Inpatient versus Outpatient Immediate Alloplastic Breast Reconstruction: Recent Trends, Outcomes, and Safety.

Background: Immediate alloplastic breast reconstruction was traditionally performed as an inpatient procedure. Despite several reports in the literature demonstrating comparable safety outcomes, there remains hesitancy to accept breast reconstruction performed as an outpatient procedure. Methods: A retrospective review of National Surgical Quality Improvement Program data from 2014 to 2018 was utilized to evaluate recent trends and 30-day postoperative complication rates for inpatient versus outpatient immediate prosthetic-based breast reconstruction. Propensity score matching was used to obtain comparable groups. Results: During the study period, 33,587 patients underwent immediate alloplastic breast reconstruction. Of those, 67.5% of patients were discharged within 24 hours, and 32.4% of patients had a hospital stay of more than 24 hours. Immediate alloplastic reconstruction had an overall growth rate of 16.9% from 2014 to 2018. After propensity score matching, intraoperative variables that correlated with significantly increased inpatient status included increased work relative value units (16.3 ± 2.3 versus 16.2 ± 2.6; P < 0.001), longer operative times (228 ± 86 versus 206 ± 77; P < 0.001), and bilateral procedure (44.0% versus 43.5%; P < 0.001). There were higher rates of pulmonary embolism, wound dehiscence, urinary tract infection, transfusions, sepsis, readmissions, and reoperations in the group with the longer hospital stay. Conclusion: Based on increased complication rates and costs in the inpatient setting, we propose outpatient reconstructive surgery as a safe and cost-effective alternative for immediate alloplastic breast reconstruction.

Cost effectiveness of interventions to improve adherence to statin therapy in ASCVD patients in the United States.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death in the United States, and high cholesterol is a leading risk factor for CVD. While statins are effective at reducing cholesterol, they are frequently underused in patients at highest risk of CVD. The objective of this study was to identify interventions which may improve adherence to statins and to assess their cost effectiveness within the US Medicare population. METHODS: A literature review was undertaken to identify interventions to improve adherence in patients with CVD at highest risk of a recurrent event and to quantify non-adherence and the consequences of non-adherence to statins in this population. A Markov cost-utility model was developed to assess the cost effectiveness of these interventions. RESULTS: Ten adherence interventions were identified in the literature, with 6 demonstrating statistically significant improvement in adherence. The six interventions were disease management, interactive voice response, nurse counselling, discharge letter, nurse/dietician counselling and electronic pill bottle with feedback. The model found the cost effectiveness of an intervention was highly dependent on its effectiveness and costs. Incremental cost effectiveness ratios ranged from $27,545/QALY for discharge letter with large adherence gain to $130,399/QALY for disease management program with small adherence gain. CONCLUSION: Some interventions to improve adherence have been shown to be effective, but little attention has been paid to the costs. Further studies on adherence interventions should include economic evaluations.

Temporal changes in statin prescription and intensity at discharge and impact on outcomes in patients with newly diagnosed atherosclerotic cardiovascular disease-Real-world experience within a large integrated health care system: The IMPRES study.

BACKGROUND: Statins are indicated for secondary atherosclerotic cardiovascular disease (ASCVD) prevention; however, multiple surveys have found treatment gaps in clinical application. OBJECTIVE: To determine trends over 15 years in the prevalence and impact of a statin prescription and dose intensity at discharge after a first ASCVD event. METHODS: The Intermountain Enterprise Data Warehouse was searched to identify all adults with a first encounter for ASCVD between January 1, 1999 and December 31, 2013, including coronary artery disease, cerebrovascular disease, and peripheral arterial disease, who survived the index event and were followed for ≥3 years or until death. Major adverse cardiovascular events (MACE) were assessed overall and in 5-year increments. RESULTS: A total of 62,070 patients met inclusion criteria. Mean age was 65.9 ± 13.7 years, and most of them were male (64.7%). Increases in any statin (59.3% to 72.6% to 80.8%) and high-intensity prescription (3.1% to 14.2% to 28.1%) occurred over consecutive 5-year intervals and were greatest in coronary artery disease patients. Statin therapy was associated with a reduced risk of 3-year MACE (multivariable hazard ratio = 0.75 [0.72, 0.78], P < .0001), with a significant linear trend across dose intensities. CONCLUSION: In a real-world experience within a large, integrated health care system, significant reductions in MACE were found in association with both any and high-intensity statin prescriptions following an ASCVD event. Temporal trends indicated progressive improvement in guideline-recommended prescriptions. However, treatment gaps remain in receipt of both any statin and, especially, a high-intensity statin prescription, and these represent prime opportunities for further improvement in secondary ASCVD prevention.

Efficacy and Safety of Oritavancin Relative to Vancomycin for Patients with Acute Bacterial Skin and Skin Structure Infections (ABSSSI) in the Outpatient Setting: Results From the SOLO Clinical Trials.

BACKGROUND: The objective of this analysis was to evaluate the efficacy and safety of oritavancin compared with vancomycin for patients with acute bacterial skin and skin structure infections (ABSSSIs) who received treatment in the outpatient setting in the Phase 3 SOLO clinical trials. METHODS: SOLO I and SOLO II were 2 identically designed comparative, multicenter, double-blind, randomized studies to evaluate the efficacy and safety of a single 1200-mg dose of intravenous (IV) oritavancin versus 7-10 days of twice-daily IV vancomycin for the treatment of ABSSSI. Protocols were amended to allow enrolled patients to complete their entire course of antimicrobial therapy in an outpatient setting. The primary efficacy outcome was a composite endpoint (cessation of spread or reduction in size of the baseline lesion, absence of fever, and no rescue antibiotic at early clinical evaluation [ECE]) (48 to 72 hours). Key secondary endpoints included investigator-assessed clinical cure 7 to 14 days after end of treatment (posttherapy evaluation [PTE]) and 20% or greater reduction in lesion area at ECE. Safety was assessed until day 60. RESULTS: Seven hundred ninety-two patients (oritavancin, 392; vancomycin, 400) received entire course of treatment in the outpatient setting. Efficacy response rates at ECE and PTE were similar (primary composite endpoint at ECE: 80.4% vs 77.5% for oritavancin and vancomycin, respectively) as was incidence of adverse events. Five patients (1.3%) who received oritavancin and 9 (2.3%) vancomycin patients were subsequently admitted to a hospital. CONCLUSIONS: Oritavancin provides a single-dose alternative to multidose vancomycin for treatment of ABSSSI in the outpatient setting.

Outcomes and costs of left atrial appendage closure from randomized controlled trial and real-world experience relative to oral anticoagulation.

AIMS: The aim of this study was to analyse randomized controlled study and real-world outcomes of patients with non-valvular atrial fibrillation (NVAF) undergoing left atrial appendage closure (LAAC) with the Watchman device and to compare costs with available antithrombotic therapies. METHODS AND RESULTS: Registry data of LAAC from two centres were prospectively collected from 110 patients with NVAF at risk of stroke, suitable and unsuitable for long-term anticoagulation (age 71.3 ± 9.2 years, CHADS2 2.8 ± 1.2, CHA2DS2-VASc 4.5 ± 1.6, and HAS-BLED 3.8 ± 1.1). Outcomes from PROTECT AF and registry study LAAC were compared with warfarin, dabigatran, rivaroxaban, apixaban, aspirin, and no treatment using a network meta-analysis. Costs were estimated over a 10-year horizon. Uncertainty was assessed using sensitivity analyses. The procedural success rate was 92% (103/112). Follow-up was 24.1 ± 4.6 months, during which annual rates of stroke, major bleeding, and all-cause mortality were 0.9% (2/223 patient-years), 0.9% (2/223 patient-years), and 1.8% (4/223 patient-years), respectively. Anticoagulant therapy was successfully stopped in 91.2% (93/102) of implanted patients by 12 months. Registry study LAAC stroke and major bleeding rates were significantly lower than PROTECT AF results: mean absolute difference of stroke, 0.89% (P = 0.02) and major bleeding, 5.48% (P < 0.001). Left atrial appendage closure achieved cost parity between 4.9 years vs. dabigatran 110 mg and 8.4 years vs. warfarin. At 10 years, LAAC was cost-saving against all therapies (range £1162-£7194). CONCLUSION: Left atrial appendage closure in NVAF in a real-world setting may result in lower stroke and major bleeding rates than reported in LAAC clinical trials. Left atrial appendage closure in both settings achieves cost parity in a relatively short period of time and may offer substantial savings compared with current therapies. Savings are most pronounced among higher risk patients and those unsuitable for anticoagulation.

Cost effectiveness of left atrial appendage closure with the Watchman device for atrial fibrillation patients with absolute contraindications to warfarin.

AIMS: Atrial fibrillation (AF) patients with contraindications to oral anticoagulation have had few options for stroke prevention. Recently, a novel oral anticoagulant, apixaban, and percutaneous left atrial appendage closure (LAAC) have emerged as safe and effective therapies for stroke risk reduction in these patients. This analysis assessed the cost effectiveness of LAAC with the Watchman device relative to apixaban and aspirin therapy in patients with non-valvular AF and contraindications to warfarin therapy. METHODS AND RESULTS: A cost-effectiveness model was constructed using data from three studies on stroke prevention in patients with contraindications: the ASAP study evaluating the Watchman device, the ACTIVE A trial of aspirin and clopidogrel, and the AVERROES trial evaluating apixaban. The cost-effectiveness analysis was conducted from a German healthcare payer perspective over a 20-year time horizon. Left atrial appendage closure yielded more quality-adjusted life years (QALYs) than aspirin and apixaban by 2 and 4 years, respectively. At 5 years, LAAC was cost effective compared with aspirin with an incremental cost-effectiveness ratio (ICER) of €16 971. Left atrial appendage closure was cost effective compared with apixaban at 7 years with an ICER of €9040. Left atrial appendage closure was cost saving and more effective than aspirin and apixaban at 8 years and remained so throughout the 20-year time horizon. CONCLUSIONS: This analysis demonstrates that LAAC with the Watchman device is a cost-effective and cost-saving solution for stroke risk reduction in patients with non-valvular AF who are at risk for stroke but have contraindications to warfarin.

Budget impact of incorporating one instillation of hexaminolevulinate hydrochloride blue-light cytoscopy in transurethral bladder tumour resection for patients with non-muscle-invasive bladder cancer in Sweden.

OBJECTIVES: To explore the cost impact on Swedish healthcare of incorporating one instillation of hexaminolevulinate hydrochloride (HAL) blue-light cystoscopy into transurethral resection of bladder tumour (TURBT) in patients with suspected new or recurrent non-muscle-invasive bladder cancer (NMIBC). MATERIALS AND METHODS: A decision tree model was built based on European Association of Urology guidelines for the treatment and management of NMIBC. Input data were compiled from two recent studies comparing recurrence rates of bladder cancer in patients undergoing TURBT with either the current standard of care (SOC) of white-light cystoscopy, or with the SOC and HAL blue-light cystoscopy. Using these published data with clinical cost data for surgical and outpatient procedures and pharmaceutical costs, the model reported on the clinical and economic differences associated with the two treatment options. RESULTS: This model demonstrates the significant clinical benefits likely to be observed through the incorporation of HAL blue-light cystoscopy for TURBT in terms of reductions in recurrences of bladder cancer. Analysis of economic outputs of the model found that the use of one instillation of HAL for TURBT in all Swedish patients with NMIBC is likely to be cost-neutral or cost-saving over 5 years relative to the current SOC of white-light cystoscopy. CONCLUSIONS: The results of this analysis provide additional health economic rationale for the incorporation of a single instillation of HAL blue-light cystoscopy for TURBT in the treatment of patients with NMIBC in Sweden.

Time to Cost-Effectiveness Following Stroke Reduction Strategies in AF: Warfarin Versus NOACs Versus LAA Closure.

BACKGROUND: Left atrial appendage closure (LAAC) and nonwarfarin oral anticoagulants (NOACs) have emerged as safe and effective alternatives to warfarin for stroke prophylaxis in patients with nonvalvular atrial fibrillation (AF). OBJECTIVES: This analysis assessed the cost-effectiveness of warfarin, NOACs, and LAAC with the Watchman device (Boston Scientific, Marlborough, Massachusetts) for stroke risk reduction in patients with nonvalvular AF at multiple time points over a lifetime horizon. METHODS: A Markov model was developed to assess the cost-effectiveness of LAAC, NOACs, and warfarin from the perspective of the Centers for Medicare & Medicaid Services over a lifetime (20-year) horizon. Patients were 70 years of age and at moderate risk for stroke and bleeding. Clinical event rates, stroke outcomes, and quality of life information were drawn predominantly from PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) 4-year data and meta-analyses of warfarin and NOACs. Costs for stroke risk reduction therapies, treatment of associated acute events, and long-term care following disabling stroke were presented in 2015 U.S. dollars. RESULTS: Relative to warfarin, LAAC was cost-effective at 7 years ($42,994/quality-adjusted life-years [QALY]), and NOACs were cost-effective at 16 years ($48,446/QALY). LAAC was dominant over NOACs by year 5 and warfarin by year 10. At 10 years, LAAC provided more QALYs than warfarin and NOACs (5.855 vs. 5.601 vs. 5.751, respectively). In sensitivity analyses, LAAC remained cost-effective relative to warfarin ($41,470/QALY at 11 years) and NOACs ($21,964/QALY at 10 years), even if procedure costs were doubled. CONCLUSIONS: Both NOACs and LAAC with the Watchman device were cost-effective relative to warfarin, but LAAC was also found to be cost-effective and to offer better value relative to NOACs. The results of this analysis should be considered when formulating policy and practice guidelines for stroke prevention in AF.

Acceptability of wristband activity trackers among community dwelling older adults.

Wristband activity trackers have become widely used among young adults. However, few studies have explored their use for monitoring and improving health outcomes among older adults. The purpose of this study was to evaluate the feasibility and utility of activity tracker use among older adults for monitoring activity, improving self-efficacy, and health outcomes. A 12-week pilot study was conducted to evaluate the feasibility and utility of mobile wristband activity trackers. The sample (N = 34) was 65% women 73.5 ± 9.4 years of age who had a high school diploma or GED (38%) and reported an income ≤$35,000 (58%). Participants completing the study (95%) experienced a decrease in waist circumference (p > 0.009), however no change in self-efficacy. Participants found activity trackers easy to use which contributed to minimal study withdrawals. It was concluded that activity trackers could be useful for monitoring and promoting physical activity and improving older adults' health.

Microbial growth within saline-filled tissue expanders.

BACKGROUND: Tissue expander based reconstruction is the most common restorative procedure used following mastectomy. Infection is a common complication in the post-operative period and may lead to failure of the reconstruction. Various previous studies have investigated the potential sources of infection during these procedures. The purpose of this study was to examine the fluid within the saline-filled tissue expander at time of implant exchange for the presence of microbial growth. METHODS: Twenty-five patients (39 breasts) were enrolled in the study. Fluid samples were sent for Gram stain, aerobic, anaerobic, fungal, and acid-fast bacilli (AFB) cultures. Average age was 53.1. Mean time to exchange was 7.7 months. Average follow-up was 25 months. RESULTS: None of the samples were positive for microbial growth at final culture (0/39). DISCUSSION: These results show the tissue expander fluid maintains a microbial-free environment during the expansion process, and is unlikely a significant source of contamination in cases of infection. LEVEL OF EVIDENCE: Level II, prospective cohort, therapeutic study.

The budget impact of left atrial appendage closure compared with adjusted-dose warfarin and dabigatran etexilate for stroke prevention in atrial fibrillation.

AIMS: Major practice changes require both clinical and economic rationale, especially where a novel device replaces an established pharmaceutical therapy. Recent studies have reported the clinical benefits of percutaneous left atrial appendage closure (LAAC) for stroke prevention in atrial fibrillation (AF) relative to standard warfarin anticoagulation, but little is published on the cost implications of LAAC. This analysis sought to quantify the budget impact of LAAC compared with warfarin and dabigatran etexilate for stroke prevention in AF. METHODS AND RESULTS: A budget impact model was constructed from a German payer perspective across a 10-year time horizon. Clinical event probabilities were taken from the PROTECT AF and RE-LY clinical studies. Clinical events included stroke, major extracranial bleeding, systemic embolism, procedure-related complications, and death. Costs for stroke included acute, direct costs, as well as long-term disability costs. Cost inputs were taken from German inpatient diagnosis related groups (DRGs), German pharmaceutical pricing databases, and the literature. The findings from this model suggest that LAAC provides long-term clinical and economic benefit while also reducing overall mortality. At 8 years, LAAC was less expensive than dabigatran (€15 061 vs. €16 184), and at 10 years, it was only 10% more expensive than warfarin (€16 736 vs. €15 168). CONCLUSION: The majority of LAAC costs are borne in the first year, while costs for pharmaceutical strategies continue to accrue year on year. Thus, LAAC represents an opportunity for savings to healthcare systems in the long term. This is an important consideration for payers in evaluating lifetime treatment strategies in AF.

Porous polyurethaneurea (Artelon) joint spacer compared to trapezium resection and ligament reconstruction.

PURPOSE: To examine outcomes and complications of the porous polyurethaneurea (Artelon; Small Bone Innovations, Morrisville, PA) spacer compared to traditional surgical treatment of trapeziectomy with ligament reconstruction and tendon interposition (LRTI). METHODS: A retrospective chart review was undertaken of patients with carpometacarpal (CMC) arthritis who had either placement of an Artelon spacer or LRTI. Patients were brought back to clinic for interview and functional testing. Pain was graded using a visual analog scale. Grip and pinch strength, as well as range of motion at the first CMC joint, were measured. Nine-hole peg, Moberg pickup, and Jebson-Taylor tests were performed. Research and Development 36, Michigan Hand Outcomes, and Quick Disabilities of the Arm, Shoulder, and Hand questionnaires were administered. RESULTS: Thirty-eight patients received Artelon implants into the CMC joint, and 6 were lost to follow-up. Twelve of 32 patients (37%) required revision surgery with removal of implant and salvage arthroplasty. Twenty patients with nonrevised Artelon implants were compared with 10 patients who received 13 LRTI procedures. Patients with Artelon had significantly less pain improvement compared to those receiving the LRTI procedure. In addition, satisfaction was significantly decreased. There was no significant difference in any other functional or quality of life measures. CONCLUSIONS: In our practice, use of the Artelon joint spacer resulted in an explantation rate of 37%. Due to these findings, we have abandoned its use for treatment of basilar thumb osteoarthritis. In contrast to previous studies, pain and satisfaction are worse in patients with intact Artelon spacers than those who had received LRTI.

The cost-effectiveness of blue light cystoscopy in bladder cancer detection: United States projections based on clinical data showing 4.5 years of follow up after a single hexaminolevulinate hydrochloride instillation.

INTRODUCTION: Several studies, including the recently published phase III study by Stenzl and colleagues have demonstrated that hexaminolevulinate hydrochloride, when used with blue light fluorescence cystoscopy, improves detection of non-muscle invasive bladder tumors compared to white light cystoscopy and transurethral resection of bladder tumors (TURB) alone. MATERIALS AND METHODS: The objective of this study was to conduct a detailed assessment of the cost-effectiveness of using hexaminolevulinate hydrochloride with blue light cystoscopy as an adjunct to white light versus white light cystoscopy alone at time of initial TURB in the United States. A probabilistic decision tree model, using TreeAge Pro 2011 software, was developed using base case scenario cost and utility estimates. RESULTS: Incorporation of hexaminolevulinate hydrochloride into diagnostic cystoscopy results in lower costs over 5 years ($25,921) as compared to those patients who initially receive white light cystoscopy ($30,581). Those patients who initially receive hexaminolevulinate hydrochloride blue light TURB also experience a lower overall cancer burden. CONCLUSIONS: Hexaminolevulinate hydrochloride may be cost effective when used at first TURB for patients with suspected new or recurrent non-muscle invasive bladder cancer.

Brachioplasty outcomes: a review of a multipractice cohort.

BACKGROUND: Upper arm deformities secondary to massive weight loss or senile elastosis have led to an increased demand for aesthetic contouring procedures such as brachioplasty. METHODS: The records of all patients who underwent a brachioplasty procedure from a multipractice medical center were reviewed. Outcomes measured included patient demographics, operative interventions, and postoperative course. RESULTS: Ninety-six patients were analyzed. Fifty-three patients (55.2 percent) underwent a concomitant procedure, with 53.1 percent undergoing arm liposuction at the time of brachioplasty. Major and minor complications rates were 17.7 percent and 44.8 percent, respectively. Common complications included hypertrophic scarring (24.0 percent) and infection (14.6 percent). The total revision rate was 22.9 percent, with residual contour deformity (40.9 percent of revisions) and hypertrophic scarring (36.4 percent of revisions) representing the most common causes for revision. Patients who underwent a previous bariatric procedure were at an increased risk of developing a major complication (p = 0.02). Concomitant upper arm liposuction and concomitant procedures were not associated with a significantly increased complication rate. CONCLUSIONS: Brachioplasty, despite being an effective treatment for contour irregularities of the upper arm, is associated with significant revision and complication rates. Post-bariatric surgery patients should be informed of the potential for increased complications. Additional procedures performed at the time of brachioplasty do not significantly increase complications. Liposuction of the upper arm can be performed safely in conjunction with brachioplasty.

Outcomes of traditional cosmetic abdominoplasty in a community setting: a retrospective analysis of 1008 patients.

BACKGROUND: Abdominoplasty is one of the most commonly performed cosmetic operative procedures. Few large studies have examined outcomes of cosmetic abdominoplasty in a community setting. The authors explored postoperative outcome and the preoperative and intraoperative factors that may contribute to these complications. METHODS: A retrospective review of consecutive patients undergoing abdominoplasty over an 11-year period was performed. Baseline patient demographics, intraoperative technique, and postoperative outcomes were recorded. Preoperative and intraoperative characteristics were analyzed to determine characteristics that predispose patients to complications and undesirable outcomes. RESULTS: The 1008 study patients underwent either a full or modified abdominoplasty with a total complication rate of 32.6 percent. The most common complication was seroma (15.4 percent). Liposuction of the abdominal flap was performed in 469 patients (46.5 percent) and liposuction of the flanks was performed in 555 patients (55.1 percent). Chi-square analysis followed by logistic regression revealed that liposuction of the flanks and abdomen was independently associated with seroma formation in addition to major and minor complications (p < 0.05). CONCLUSIONS: Seroma formation following abdominoplasty is the most common complication. Concomitant liposuction of the flanks and abdomen with the addition of aggressive undermining leads to higher seroma rates. This association is likely multifactorial and may be secondary to increased resorptive demands placed on the abdominal lymphatics in the setting of greater dead space and larger fluid shifts as a result of liposuction. To reduce seroma rates, surgeons should avoid aggressive liposuction and undermining, particularly in high-risk patients.

The impact of antibiotic impregnated PICC lines on the incidence of bacteremia in a regional burn center.

INTRODUCTION: Peripherally inserted central catheters (PICCs) have been used increasingly in burn patients who often have decreased intravascular volumes and obtaining intravascular access for resuscitative efforts can be difficult. A potentially serious complication is bloodstream infection. The purpose of our study is to examine the impact of antibiotic impregnated PICC lines on the bacteremia rate in a regional burn center. METHODS: Consecutive patients admitted to the burn unit and receiving an antibiotic impregnated PICC line were included in the study. Baseline demographics and bacteremia rate was recorded. A retrospective chart review was then undertaken of the 30 consecutive patients admitted to the burn unit and receiving a PICC line prior to the study period. RESULTS: Nineteen patients were enrolled over the two-year period. The bacteremia rate for the study group was 0% compared to the 50% bacteremia rate of the retrospective control group (p=<0.001). CONCLUSION: Antibiotic impregnated PICC lines decrease the bacteremia rate in our burn population. This has potential benefits for both patient morbidity and mortality as well as potential cost savings for the healthcare system.

Vertical reduction mammaplasty utilizing the superomedial pedicle: is it really for everyone?

BACKGROUND: Classically, the vertical-style reduction mammaplasty utilizing a superomedial pedicle has been limited to smaller reductions secondary to concerns for poor wound healing and nipple necrosis. OBJECTIVES: The authors reviewed a large cohort of patients who underwent a vertical-style superomedial pedicle reduction mammaplasty in an attempt to demonstrate its safety and efficacy in treating symptomatic macromastia. METHODS: A retrospective review was performed of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty. All procedures were conducted by one of 4 plastic surgeons over 6 years (JDR, MAA, DLV, DRA). RESULTS: The average resection weight was 551.7 g (range, 176-1827 g), with 4.6% of resections greater than 1000 g. A majority of patients (55.2%) concomitantly underwent liposuction of the breast. The total complication rate was 22.7%, with superficial dehiscence (8.8%) and hypertrophic scarring (8.8%) comprising the majority. Nipple sensory changes occurred in 1.6% of breasts, with no episodes of nipple necrosis. The revision rate was 2.2%. Patients with complications had significantly higher resection volumes and nipple-to-fold distances (P = .014 and .010, respectively). CONCLUSIONS: The vertical-style superomedial pedicle reduction mammaplasty is safe and effective for a wide range of symptomatic macromastia. The nipple-areola complex can be safely transposed, even in patients with larger degrees of macromastia, with no episodes of nipple necrosis. The adjunctive use of liposuction should be considered safe. Last, revision rates were low, correlating with a high level of patient satisfaction.

The double-opposing buccal flap procedure for palatal lengthening.

BACKGROUND: Velopharyngeal dysfunction has been treated with either a pharyngeal flap or sphincteroplasty with varying degrees of success. Both of these entities have their own series of problems, with sleep apnea and nasal mucous flow disruptions at the forefront. The purpose of this study was to review the senior author's (R.J.M.) experience performing the double-opposing buccal flap for palatal lengthening. METHODS: All patients who were treated with double-opposing buccal flaps between October of 1994 and July of 2007 were reviewed. These patients presented with varying degrees of velopharyngeal dysfunction showing some degree of velar movement at the time of surgery. Preoperative and postoperative speech results were reviewed for comparison. RESULTS: Twenty-seven patients underwent palatal lengthening, with an average length of follow-up of 58 months. Distal flap necrosis occurred in two patients. The level of intelligibility (65.4 percent versus 95.5 percent) and resonance (moderately hypernasal versus normal resonance) improved significantly postoperatively (p < 0.0001). Only one patient required the addition of a pharyngeal flap for persistent velopharyngeal dysfunction, and there were no postoperative issues with sleep apnea. CONCLUSIONS: The double-opposing buccal flap is an effective technique for lengthening the palate, improving speech, and decreasing the risks of postoperative sleep apnea. All patients experienced a dramatic improvement in their resonance and intelligibility. This technique appears most effective in patients with intact velar movement who demonstrate a small to moderate posterior velar gap. The double-opposing buccal flap is a useful means of treating velopharyngeal dysfunction, thus serving as an adjunct when improving pharyngeal closure.