Challenging Traditional Thinking: Early Free Tissue Transfer for Active Hemifacial Atrophy in Children.

BACKGROUND: Hemifacial atrophy (Parry-Romberg syndrome) is an enigmatic craniofacial disorder characterized by progressive facial atrophy. Early age at onset is associated with significant skeletal involvement and jaw abnormalities. Standard reconstructive dogma dictates that the disease should "burn out," with at least 2 years of no disease progression, before pursuing reconstructive intervention. The purpose of this article is to present the senior author's (J.W.S.) experience treating preadolescent children with free soft-tissue transfer for reconstruction of progressing hemifacial atrophy, and to review surgical techniques in this patient population. METHODS: Pediatric free tissue transfer cases performed by the senior author were reviewed. Free tissue transfer using a circumflex scapular adipofasciocutaneous flap was performed to treat deformities arising from hemifacial atrophy. RESULTS: Thirty-six patients aged 3 to 6 years underwent free tissue transfer in the presence of progressing, active disease. Follow-up ranged from 7 months to 25 years. There were no cases of flap loss. In all patients, the disease process seemed to be altered, with no symptoms recurring to date. CONCLUSIONS: The authors believe that early microsurgical correction of hemifacial atrophy in children as young as 3 years is reliable and effective. The authors theorize that the interposition of vascularized, healthy tissue may alter or even halt the progression of disease, and may also prevent the skeletal hypoplasia classically seen in older patients. Further study incorporating autologous fat grafting as a control procedure may provide additional insight into this challenging disease process. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Implementation of a Modified Enhanced Recovery Protocol in Cleft Palate Repairs.

AIMS: Enhanced Recovery after Surgery (ERAS) protocols have been shown to improve patient outcomes in numerous adult surgical populations, but there are few known standards for their use in pediatric patients. To assess the effectiveness in pediatric craniofacial surgery, we present our results following the application of a modified ERAS protocol for patients undergoing primary palatoplasty. METHODS: A modified ERAS program was developed and implemented in a multidisciplinary manner. The primary components of the protocol included: (1) administration of gabapentinoids, (2) minimal perioperative narcotic use, and (3) post-operative pain control using nonnarcotic first-line agents. Fifty patients were collected prospectively, assigned to the modified ERAS protocol and compared to historic controls. We reviewed patient demographics, narcotic use, length of stay (LOS), oral intake, and complication rates. RESULTS: Between April 2017 and June 2018, 50 patients underwent palatoplasty under the modified ERAS protocol. The mean age (control: 9.7 ±â€Š2.3 months; ERAS: 9.9 ±â€Š1.6 months), weight (8.8 ±â€Š1.3 kg; 8.6 ±â€Š1.3 kg), and comorbidities did not vary between the groups. ERAS patients evidenced an increase in oral intake normalized per LOS (22.3 mL/h vs 15.4 mL/h). Total narcotic usage (morphine equivalents) during each phase of care was greater in the controls compared with ERAS (Intraop: 3.71 mg vs 0.12 mg; PACU: 0.51 mg vs 0.05 mg; Postop: 2.6 mg vs 0.07 mg). The implementation of this protocol led to a 36.6% decrease in LOS (1.83 days vs 1.16 days) without an increase in perioperative complications. CONCLUSIONS: Implementation of a modified ERAS protocol provided effective perioperative pain control allowing narcotic minimization, increased post-operative oral intake, and a shorter LOS without an increased complication rate.

Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review.

BACKGROUND: Free tissue transfer for lower extremity reconstruction is a safe and reliable option for a wide range of challenging wounds; however, no consensus exists regarding postoperative management. METHODS: A systematic review of postoperative management of lower extremity free tissue transfer was conducted using Medline, Cochrane Database, and Web of Science. Multicenter surveys, randomized controlled trials, cohort studies, and case series were reviewed. RESULTS: Fifteen articles investigating current protocols, flap physiology, and aggressive dangle protocols were reviewed. The following evidence-based conclusions were made: (1) Free tissue transfer to the lower extremity is unique due to altered hemodynamics and dependency during orthostasis. Free flap circulation is dependent on locally mediated responses and deprived of compensatory muscular and neurovascular mechanisms that prevent venous congestion in the normal extremity. (2) Compressive wrapping reduces venous congestion and edema and may induce ischemic conditioning, which can increase blood flow. (3) Dangle protocols vary widely in timing of initiation, frequency, and monitoring. Small volume studies examining aggressive mobilization protocols initiating early dependency have led to earlier ambulation and discharge, with no change in flap survival as compared with conservative protocols. (4) Weight bearing may begin after the completion of dangle protocol if no orthopedic injury is present. CONCLUSIONS: Early initiation of a dangle protocol does not appear to negatively impact flap survival based on this systematic review. Compressive wrapping may be a useful adjunct. Many surgeons agree that clinical monitoring is sufficient; there is no consensus on the utility of adjunct monitoring techniques. Weight bearing may begin after completion of dangle protocol with close flap monitoring, if not prevented by orthopedic restrictions. By providing additional outflow vasculature to reduce venous congestion, flow-through anastomoses may eliminate the need for a dangle protocol. Further research, including large randomized controlled trials is still needed to establish high-level evidence-based conclusions.

A 26-Year Experience with Microsurgical Reconstruction of Hemifacial Atrophy and Linear Scleroderma.

BACKGROUND: Parry Romberg disease (hemifacial atrophy) and linear scleroderma (coup de sabre) are progressive, usually unilateral facial atrophies of unknown cause. The gold standard treatment for these patients has been microsurgical reconstruction following the "burning out" of the facial atrophy and stable contour for 2 years. METHODS: The authors report their experience treating patients with hemifacial atrophy and linear scleroderma with free tissue transfers between 1989 and 2016. A modified parascapular flap based on the circumflex scapular artery was most commonly used. RESULTS: A total of 177 patients were included. The most common complication was hematoma, occurring in 12 patients (7 percent). Follow-up ranged from 1 to 26 years. All patients subjectively experienced improved facial symmetry and aesthetics. No disease process has recurred to date, even in cases of severe, progressive disease. CONCLUSIONS: In the authors' experience, patients treated early in their disease course have immediate and sustained correction of their deformity, with slowing or in most cases cessation of the disease process following free tissue transfer. The authors now advocate for immediate reconstruction for active disease, especially in young children. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Therapeutic, IV.

Medicare for the Plastic and Reconstructive Surgeon.

Medicare, a federally funded insurance program in the United States, is a complex program about which many physicians may not receive formal training or education. Plastic surgeons, residents, and advanced practitioners may benefit from at least a basic understanding of Medicare, its components, reimbursement methods, and upcoming health care trends. Medicare consists of Parts A through D, each responsible for a different form of insurance coverage. Medicare pays hospitals, physicians, and graduate medical education. Since the introduction of Medicare, several reforms and programs have been introduced, particularly in recent years with the implementation of the Affordable Care Act. Many of these changes are moving reimbursement systems away from the traditional fee-for-service model toward quality-of-care programs. The aim of this review is to provide a brief history of Medicare, explain the basics of coverage and relevant reforms, and describe how federal insurance programs relate to plastic surgery both at academic institutions and in a community practice environment.

10 Years Later: Lessons Learned from an Academic Multidisciplinary Cosmetic Center.

BACKGROUND: In 2006, a Centers for Medicare and Medicaid Services-accredited multidisciplinary academic ambulatory surgery center was established with the goal of delivering high-quality, efficient reconstructive, and cosmetic services in an academic setting. We review our decade-long experience since its establishment. METHODS: Clinical and financial data from 2006 to 2016 are reviewed. All cosmetic procedures, including both minimally invasive and operative cases, are included. Data are compared to nationally published reports. RESULTS: Nearly 3,500 cosmetic surgeries and 10,000 minimally invasive procedures were performed. Compared with national averages, surgical volume in abdominoplasty is high, whereas rhinoplasty and breast augmentation is low. Regarding trend data, breast augmentation volume has decreased by 25%, whereas minimally invasive procedural volume continues to grow and is comparable with national reports. Similarly, where surgical revenue remains steady, minimally invasive revenue has increased significantly. The majority of surgical cases (70%) are reconstructive in nature and insurance-based. Payer mix is 71% private insurance, 18% Medicare and Medicaid, and 11% self-pay. Despite year-over-year revenue increases, net profit in 2015 was $6,120. Rent and anesthesia costs exceed national averages, and employee salary and wages are the highest expenditure. CONCLUSION: Although the creation of our academic cosmetic ambulatory surgery center has greatly increased the overall volume of cosmetic surgery performed at the University of Wisconsin, the majority of surgical volume and revenue is reconstructive. As is seen nationwide, minimally invasive cosmetic procedures represent our most rapidly expanding revenue stream.

The Economics of Skin Cancer: An Analysis of Medicare Payment Data.

The incidence and cost of nonmelanoma skin cancers are skyrocketing. Five million cases cost $8.1 billion in 2011. The average cost of treatment per patient increased from $1000 in 2006 to $1600 in 2011. We present a study of the economics and costs of skin cancer management in Medicare patients. METHODS: We studied data released by the Centers for Medicare and Medicaid Services in 2014. Treatment modalities for the management of skin cancer were reviewed, and costs of treatment were quantified for a sample of 880,000 providers. RESULTS: Review of Medicare payment records related to the management of skin cancer yielded data from over 880,000 health care providers who received $77 billion in Medicare payments in 2012. From 1992 to 2009, the rate of Mohs micrographic surgery (MMS) has increased by 700%, and these procedures typically have Medicare payments 120% to 370% more than surgical excision, even when including pathology fees. From 1992 to 2009, MMS increased by 700%, whereas surgical excisions increased by only 20%. In 2009, 1800 providers billed Medicare for MMS; in 2012, that number increased to 3209. On average, 1 in 4 cases of skin cancer is treated with MMS. CONCLUSION: Mohs excision is more expensive than surgical excision in an office setting. Procedures requiring the operating room are much more expensive than office procedures. In an era of high deductible health plans, patients' financial burden is much less with simple excisions of skin cancers done in a clinic when compared with Mohs surgery or operative interventions.

A Twelve-Year Consecutive Case Experience in Thoracic Reconstruction.

BACKGROUND: We describe the second largest contemporary series of flaps used in thoracic reconstruction. METHODS: A retrospective review of patients undergoing thoracomyoplasty from 2001 to 2013 was conducted. Ninety-one consecutive patients were identified. RESULTS: Thoracomyoplasty was performed for 67 patients with intrathoracic indications and 24 patients with chest wall defects. Malignancy and infection were the most common indications for reconstruction (P < 0.01). The latissimus dorsi (LD), pectoralis major, and serratus anterior muscle flaps remained the workhorses of reconstruction (LD and pectoralis major: 64% flaps in chest wall reconstruction; LD and serratus anterior: 85% of flaps in intrathoracic indication). Only 12% of patients required mesh. Only 6% of patients with <2 ribs resected required mesh when compared with 24% with 3-4 ribs, and 100% with 5 or more ribs resected (P < 0.01). Increased rib resections required in chest wall reconstruction resulted in a longer hospital stay (P < 0.01). Total comorbidities and complications were related to length of stay only in intrathoracic indication (P < 0.01). Average intubation time was significantly higher in patients undergoing intrathoracic indication (5.51 days) than chest wall reconstruction (0.04 days), P < 0.05. Average hospital stay was significantly higher in patients undergoing intrathoracic indication (23 days) than chest wall reconstruction (12 days), P < 0.05. One-year survival was most poor for intrathoracic indication (59%) versus chest wall reconstruction (83%), P = 0.0048. CONCLUSION: Thoracic reconstruction remains a safe and successful intervention that reliably treats complex and challenging problems, allowing more complex thoracic surgery problems to be salvaged.

Plastic surgeons' perceptions of the affordable care act: results of a national survey.

BACKGROUND: The Affordable Care Act (ACA) aims to expand coverage to the uninsured, improve quality, and contain costs. The goal of this study was to ascertain how plastic surgeons perceive the ACA. METHODS: An electronic questionnaire was e-mailed to members of the American Society of Plastic Surgeons between May and June 2014. The survey was anonymous and voluntary and included questions to assess understanding and opinions of the ACA. RESULTS: The survey was sent to 3070 members of the American Society of Plastic Surgeons, and the response rate was 17%. Sixty-eight percent agree or strongly agree that they understand the basic concepts of the ACA. The majority of respondents disagree (38% strongly disagree, 31% disagree) with the notion that the ACA will positively affect their practice, and 51% agree with the statement, "I do not support the ACA, and I believe it did too much." Two thirds (66%) believe that the ACA deserves a grade of D or F. When answers were analyzed across demographics, 42% of respondents with "Academic" practice background identify with the statement, "I support the ACA but I think it needs more work," compared to 15% of those who selected "Solo Practice" (p <0.001). CONCLUSIONS: The ACA will affect all specialties, including plastic surgery. The results of this survey suggest that many plastic surgeons believe that they have a baseline understanding of current health-care reform. The majority of surveyed surgeons do not support the Act. It is imperative that plastic surgeons possess the knowledge of the ACA; its changes, both current and impending, will likely affect patient mix, coverage of procedures, and reimbursement.

Free flap monitoring using an implantable anastomotic venous flow coupler: Analysis of 119 consecutive abdominal-based free flaps for breast reconstruction.

PURPOSE: The purpose of this study is to evaluate the use of the venous anastomotic Flow Coupler in monitoring free flaps used for breast reconstruction in a consecutive series of patients. METHODS: Retrospective data were collected on patients undergoing free flap breast reconstruction from May 2012 to March 2014. The venous anastomotic Flow Coupler was used in the first 85 flaps and a non-flow Coupler with clinical and external Doppler monitoring alone in the subsequent 34 flaps. Data collected included patient age, BMI, prior radiation, flap type, intra- and postoperative Flow Coupler events, along with rates of flap take back, salvage, and failure. Proportion data were compiled and statistically analyzed. RESULTS: One hundred nineteen consecutive abdominal based breast reconstruction free flaps were performed. The overall flap failure rate was 4.2% (4.7% Flow Coupler; 2.9% in non-flow Coupler; P = 1.0). The Flow Coupler demonstrated 100% sensitivity in the intra- and postoperative settings. A positive predictive value of 36% was noted intraoperatively which was significantly higher compared to the non-flow Coupler group (P = 0.015). Vessel thrombosis occurred in 17.6% of Flow Coupler flaps, which was significantly higher when compared to the non-flow Coupler (2.9%; P = 0.038). CONCLUSIONS: The Flow Coupler is a sensitive method to confirm patency of a microsurgical anastomosis. However, there is a high false positive rate in both the intraoperative and postoperative settings resulting in frequent intraoperative maneuvers to amend the cause of signal loss. Additionally, the Flow Coupler resulted in significantly more vascular thrombotic events when compared to the non-flow Coupler.

The Affordable Care Act: a primer for plastic surgeons.

The Patient Protection and Affordable Care Act, sometimes referred to as Obamacare, was signed into law on March 23, 2010. It represents the most extensive overhaul of the country's health care system since the passage of Medicare and Medicaid in 1965. The Affordable Care Act has two goals. The first goal is to reduce the uninsured population in the United States. Key elements to covering the uninsured include the following: (1) expanding Medicaid coverage for low-income individuals and (2) establishing health insurance marketplaces for moderate-income individuals with subsidies and tax cuts in an effort to make health insurance more affordable. The second goal of the Affordable Care Act is to address concerns about quality and the overall cost of U.S. health care. It is imperative that plastic surgeons thoroughly understand the impact that the Affordable Care Act will undoubtedly have on the country, on our patients, and on our clinical practices. Plastic surgery will see many changes in the future. This will include an overall increase in the number of insured patients, a push toward joining accountable care organizations, and a shift in payment systems to bundled reimbursement for episodes of care. In this article, the authors describe how these changes are likely to occur and what plastic surgeons must do to be part of the change.

Academic plastic surgery: faculty recruitment and retention.

BACKGROUND: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. METHODS: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. RESULTS: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. CONCLUSIONS: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.