Abdominoplasty in the Overweight and Obese Population: Outcomes and Patient Satisfaction.

BACKGROUND: Abdominoplasty is a safe, efficacious body contouring procedure commonly performed on patients after massive weight loss or pregnancy, or because of general aging. However, complication rates and patient satisfaction levels remain largely unexplored for the overweight and obese patient population. The purpose of this study was twofold: to determine the complication rate and to gauge the psychological impact of abdominoplasty in the overweight or obese patient. METHODS: A retrospective review was conducted of consecutive overweight and obese patients undergoing abdominoplasty or panniculectomy over a 12-year period from January of 2004 to December of 2016. Patient medical records were reviewed to identify patient demographics and comorbidities, operative details, and postoperative course. A patient survey was used to assess satisfaction, personal experience with complications, and the recovery process. RESULTS: Forty-six total patients underwent abdominoplasty or panniculectomy during the 12-year period and met the criterion of body mass index greater than or equal to 25 kg/m. The average patient body mass index was 32.0 kg/m, with the majority of the patients categorized as overweight. The average abdominal resection weight was 4834.9 g. Major complications, defined as complications requiring return to the operating room, occurred in four patients (8.7 percent). Minor complications, defined as complications that could be handled in an office setting, occurred in 18 patients (39.1 percent). Thirty-six patients (78.3 percent) responded to the survey. The overwhelming majority of patients who responded to the survey [n = 35 (97.2 percent)] stated that they were satisfied with the final outcome and would choose to have the procedure again. CONCLUSION: Abdominoplasty and panniculectomy in overweight and obese patients are associated with an elevated complication rate, yet patient satisfaction is overwhelmingly high, suggesting the viability of body contouring procedures in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Prospective Analysis of Payment per Hour in Head and Neck Reconstruction: Fiscally Feasible or Futile?

BACKGROUND: The authors assess the fiscal viability of complex head and neck reconstructive surgery by evaluating its financial reimbursement in the setting of resources used. METHODS: The authors prospectively assessed provider reimbursement for consecutive patients undergoing head and neck reconstruction. Total care time was determined by adding 15 minutes to the operative time for each postoperative hospital day and each postoperative follow-up appointment within the 90-day global period. Physician reimbursement was divided by total care time hours to determine an hourly rate of reimbursement. A control group of patients undergoing carpal tunnel release was evaluated using the same methods described. RESULTS: A total of 50 patients met the inclusion criteria for study. The payer was Medicaid for nine patients (18 percent), Medicare for 19 patients (38 percent), and commercial for 22 patients (44 percent). The average provider revenue per case was $3241.01 ± $2500.65. For all patients, the mean operative time was 10.6 ± 3.87 hours and the mean number of postoperative hospital days was 15.1 ± 8.06. The mean reimbursement per total care time hour was $254 ± $199.87. Statistical analysis demonstrated difference in reimbursement per total care time hour when grouped by insurance type (p = 0.002) or flap type (p = 0.033). Of the 50 most recent patients to undergo carpal tunnel release, the average revenue per case was $785.27. CONCLUSION: Total care time analysis demonstrates that physician reimbursement is not commensurate with resources used for complex head and neck reconstructive surgery.

Predictive Factors for Preoperative Percutaneous Endoscopic Gastrostomy Placement: Novel Screening Tools for Head and Neck Reconstruction.

OBJECTIVE: The treatment of head and neck cancer has varying impact on postoperative recovery and return of swallowing function. The authors aim to establish screening tools to assist in preoperatively determining the need for gastrostomy tube placement. METHODS: The authors prospectively assessed all patients undergoing complex head and neck reconstructive surgery during a 1-year study period. Only patients tolerating an oral diet, without preoperative gastrostomies, were enrolled for study. Eight parameters were assessed including: body mass index (BMI), prealbumin, albumin, smoking history, comorbidities [including coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM)], age, use of microvascular reconstruction, and type of defect. Two specific screening tools were assessed. In the first, a multivariate logistic regression model was employed to determine factor(s) that predict postoperative gastrostomy tube. In a second screening tool, the 8 parameters were scored between 0 to 1 points. The total score obtained for each patient was correlated with postoperative gastrostomy placement. RESULTS: Out of the 60 study patients enrolled in the study, 24 patients (40%) received a postoperative gastrostomy. In the logistic regression model, albumin level was the only factor that was significantly associated with need for postoperative gastrostomy (P < 0.0023). A score of 4 or greater was determined to have a sensitivity of 83% and specificity of 61% for postoperative gastrostomy. CONCLUSIONS: Patients with a score of 4 or more with this screening scoring system or those patients with an albumin level <3.5 g/dL were at high risk for postoperative feeding tube placement.

Introducing the tibial-dorsalis pedis osteocutaneous shin flap: a new option for oromandibular reconstruction.

BACKGROUND: The authors investigated the possibility of incorporating a well-vascularized, partial corticotomy of the anterolateral aspect of the tibia "in-series" with a dorsalis pedis fasciocutaneous free flap for oromandibular reconstruction. METHODS: A cadaveric injection study was performed to characterize the vascular territory of the anterior tibial artery with regard to the surrounding osseous and soft tissue. The two-point breaking strength of the tibia (twist) was examined with fracture strain gauge analysis to determine the threshold of tibia corticotomy that would lead to a pathologic fracture. Finally, the authors performed an in vivo prospective clinical examination of the tibial-dorsalis pedis osteocutaneous shin flap. RESULTS: The perfusion study revealed that the anterior tibial artery provided a rich matrix of musculofascial periosteal blood supply to the anterolateral cortex of the tibia that could potentially support free osseous tibial transfer. Two-point osteotomy fracture strain gauge analysis demonstrated that the threshold of tibia corticotomy that would lead to pathologic fracture of the remaining tibia was greater than 30 percent. The osteocutaneous shin flap was performed in eight patients. The mean follow-up was 61 months. There were no cases of flap loss, salivary fistula, nonunion, or tibia pathologic fracture. All patients achieved ambulation. CONCLUSIONS: The authors introduce the osteocutaneous tibial-dorsalis pedis free vascularized flap as a viable option for oromandibular reconstruction. Its most notable advantage is the independent mobility of the skin paddle, in combination with bone stock that replicates mandibular bone dimensions, facilitating primary osseointegration or denture rehabilitation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Female mice and rats exhibit species-specific metabolic and behavioral responses to ovariectomy.

Ovariectomy (OVX) leads to hyperphagia and weight gain in rats, which can be prevented by estradiol (E2) replacement; however, the role of endogenous E2 on feeding and energy homeostasis in female mice has not been well characterized. The primary goal of this study was to assess the relative contribution of increased energy intake and decreased energy expenditure to OVX-induced weight gain in female rats and mice. OVX led to hyperphagia in rats, but did not produce daily, nor cumulative, hyperphagia in mice. OVX decreased mass-specific metabolic rate in mice, but not in rats. OVX decreased home cage locomotor activity in both species. Pair-feeding attenuated OVX-induced weight gain in rats and produced both short- and long-term changes in expression of key hypothalamic genes involved in food intake and energy homeostasis, i.e., the anorexigenic neuropeptide pro-opiomelanocortin (POMC) and the orexigenic neuropeptides: melanin-concentrating hormone (MCH) and agouti-related peptide (AgRP). No differences in hypothalamic gene expression were observed between OVX'd and sham mice. The results suggest that OVX-induced weight gain is mediated by hyperphagia and reduced locomotor activity in rats, but that in mice, it is primarily mediated by reduced locomotor activity and metabolic rate.