Ambulatory facial feminization surgery: a comparative analysis of outcomes and complications.

BACKGROUND: To date, there are no studies investigating the safety and outcomes of facial feminization surgery (FFS) as an outpatient procedure. This is the first study of its kind analyzing the outcomes of ambulatory FFS based on a comparison of complications, post-operative emergency department or urgent care (ED/UC) visits, and readmissions between patients who underwent FFS with admission versus same-day surgery. METHODS: A retrospective analysis was conducted on all patients who underwent FFS in a single integrated healthcare system. Patient charts were reviewed for operative details, complications, post-operative ED/UC visits, readmission, and demographic factors. Major outcomes including complications, readmissions, and ED/UC visits were compared between groups with same-day discharge and post-operative hospital admission. RESULTS: Of 242 patients included in the study, ED/UC visits were comparable between patients discharged same-day (18.2%) and patients admitted post-operatively (21.6%, p = 0.52). Logistic regression showed no significant difference in the composite outcomes of minor complications, major complications, and readmissions (15.6% for ambulatory versus 19.3% for admission, p = 0.46). Temporary nerve palsy, infection, and hematoma were the most common post-operative complications. However, covariates of a lower face procedure and operative time were shown to have significant differences in the composite complication outcome (p = 0.04 and p = 0.045, respectively). CONCLUSION: Ambulatory FFS is a safe practice with no associated increase in adverse outcomes including complications, ED/UC visits, and readmission when compared to post-operative admission. Adoption of same-day FFS should be considered by high-volume gender health centers to potentially benefit from increased scheduling flexibility and efficiency, increased access to care, and lower healthcare costs.

Risk Factors for Delayed Diagnosis of Positional Plagiocephaly: A Review of 25,322 Patients.

OBJECTIVE: This study identifies risk factors for late positional plagiocephaly (PP) diagnosis and impact on helmet therapy. DESIGN: We conducted a retrospective review of all patients diagnosed with PP over 10 years at five Southern California hospitals. SETTING: Patients diagnosed with PP at an included hospital. PATIENTS: 25,332 patients were diagnosed with PP over 10 years. INTERVENTIONS: Patients diagnosed with PP early (< = 6 months) and late (>6 months) were compared. MAIN OUTCOME MEASURES: Cohorts were evaluated for demographics, gestational history, associated conditions, and hospitalizations through direct comparison, logistic regression, and correlation analyses. Rates of referrals and helmet orders were compared. RESULTS: Of patients reviewed, 4.8% (n = 1216) were diagnosed late. On multivariate analysis, late diagnoses were more likely Hispanic or Black/African-American. Early gestational age, hydrocephalus, and VP shunt were more frequent in late diagnoses. Patients diagnosed late had longer NICU and overall hospital stays. Earlier gestational age, longer NICU or overall hospital stay correlated with later age at PP diagnosis. 8.9% of patients were referred for helmet therapy evaluation. Patients diagnosed late were 2.63 and 1.64 times as likely to be referred and require helmet therapy, respectively. CONCLUSIONS: Patients who are Hispanic or Black/African-American, premature, have hydrocephalus, or VP shunt have higher rates of delayed PP diagnosis. Shorter gestational age or longer NICU or hospital stay correlates with later diagnosis, which increases helmet therapy requirements. Additional interventions are needed for at risk patients to routinely evaluate for and minimize the risk of developing PP.

Complexity of Online Facial Feminization Surgery Material Exceeds Patient Health Literacy.

The increase in healthcare coverage for transgender populations has made facial feminization surgeries (FFS) more accessible. Majority of patients interested in surgery regularly check online medical information to help understand surgical procedures, risks, and recovery. National health organizations recommend that patient information material should be written at a sixth-grade-reading level, but online material often surpasses patient health literacy. This study evaluates the readability of online FFS resources. An Internet search of the top 100 Web sites was conducted using the keywords "facial feminization surgery." Web sites were analyzed for relevant patient information articles on FFS and categorized into health care and nonhealth care groups. Readability examinations were performed for written text using the Automated Readability Index, Coleman-Liau Index, Flesch-Kincaid Grade Level, Gunning Fog Index, and Simple Measure of Gobbledygook Index. Statistical analysis was performed using 2-tailed z tests, with statistical significance set at P≤0.05. A total of 100 articles from 100 Web sites were examined. The average readability for all online FFS resources was at a 12th-grade-writing level. Articles from health care organizations were at a 13th-grade-reading level and nonhealth care organization articles were at a 12th-grade-reading level (P<0.01). Online patient information for FFS is more complex than nationally recommended writing levels, which may interfere with patient decision making and outcomes. Patient resources for FFS should be written at a lower reading level to promote patient education, satisfaction, and compliance.

Challenging the Norm: Is Routine Use of Cranial CT in Evaluation of Craniosynostosis Necessary?

BACKGROUND: Cranial CT is routinely taught to be the gold standard for diagnosis of craniosynostosis and used by craniofacial teams for suspected nonsyndromic single suture craniosynostosis. Given the risks associated with infant CTs, do these scans provide significantly enhanced diagnostic accuracy compared to the physical exam when performed by an experienced clinical provider? METHOD: A retrospective chart review was performed for children who underwent corrective surgery for nonsyndromic, single-suture craniosynostosis over an 11 year period by a single craniofacial team. Ages at presentation and surgery, preoperative clinical diagnosis and imaging, co-existing radiographic findings, and correlation with the intraoperative diagnosis were analyzed. RESULTS: A total of 138 patients were included in this study. The mean age was 4.2 months at initial craniofacial evaluation, and 8.0 months at time of surgery. Twenty-seven patients received imaging prior to our clinic. Of those, 21 had plain radiography and 6 had CT scans. Of the remaining 111 patients referred without imaging, craniosynostosis was clinically diagnosed in 102 (92%), whereas 9 (8%) had an unclear clinical diagnosis. Of these 9, 1 (1%) was diagnosed clinically at follow-up exam, and the remaining 8 (7%) were diagnosed using radiography (3 CT scans, 5 plain radiographs). In all patients, the preoperative diagnosis was confirmed during intraoperative assessment. CONCLUSIONS: Cranial CT was not needed by experienced craniofacial providers in 93% of nonsyndromic, single-suture craniosynostosis. Imaging obtained before craniofacial clinic referral may have been unnecessary. These findings question the classic teaching that preoperative cranial CT is the gold standard for diagnosis in infants with nonsyndromic, single-suture craniosynostosis.

A Single Lab Test to Aid Pierre Robin Sequence Severity Diagnosis.

OBJECTIVE: The workup of patients with Pierre Robin sequence (PRS) consists of a physical examination, O2 saturation, and polysomnography to determine the severity of respiratory obstruction and need for surgery. We suggest that capillary blood gas (CBG) may be a better physiologic representation of airway obstruction and should be routinely used in the management of patients with PRS. DESIGN: This is a multicenter study based on a retrospective review of medical records. SETTING: The study was performed at tertiary care centers. INTERVENTIONS: Patients with PRS <1 year old underwent mandibular distraction osteogenesis. MAIN OUTCOME MEASURE: Using successful treatment outcome as a reference standard, receiver operating characteristic (ROC) curve was used to determine the accuracy of the diagnostic test and values for the best sensitivity and specificity to determine the need for surgical intervention. RESULTS: Of 73 patients, 48 had sporadic PRS, 23 had syndromes, 2 had micrognathia, not otherwise specified. Mandibular distraction osteogenesis was performed in 62 patients at a mean age of 39 days. The mean initial Apnea-Hypopnea Index (AHI) in nonsurgical versus surgical groups was 10 versus 31 ( P = .063), pH 7.41 versus 7.34 ( P = .003), pCO2 43 versus 56 ( P < .001), and HCO3 27 versus 30 ( P = .022). The ROC curve showed that pCO2 of 49.5 has the best specificity (100%) and sensitivity (72.6%) profile in terms of need for definitive airway. CONCLUSION: A simple CBG heel stick may better predict the physiologic effects of obstructive apnea; therefore, it should be added to the algorithm of PRS workup.

To Admit or Not to Admit: That is the Cleft Lip Question. Confirming the Safety of Outpatient Cleft Lip Repair.

BACKGROUND: There is no accepted protocol for inpatient versus ambulatory cleft lip surgery. The aim of this study was to review the safety of outpatient repair and develop guidelines. METHODS: A retrospective review of patients younger than 2 years undergoing primary cleft lip repair from 2008 to 2015 at six centers was performed. Patients were divided into two groups: predominantly ambulatory (discharged or admitted for specific concerns) and inpatient (admitted due to surgeon's preference). The impact of independent variables on admission, emergency department visits, and readmission within 1 month of discharge was analyzed. RESULTS: Of 546 patients, 68.1 percent were boys, 4.4 percent had syndromes, and 23.6 percent had comorbidities. One hundred forty-two patients were admitted postoperatively. Forty-nine admissions were attributable to the surgeon's preference. After excluding this subset, our ambulatory surgery rate was 81 percent. There was no difference in emergency department visits (3 percent versus 2.2 percent; p = 0.6) or readmissions (0 percent versus 1.45 percent; p = 0.5) between groups. None of the ambulatory surgery patients were readmitted within 36 hours, for a successful ambulatory surgery rate of 100 percent. Female sex; surgical time; prematurity and/or postconceptional age younger than 52 weeks; and cardiac, respiratory, central nervous system, gastrointestinal, genitourinary, and other congenital comorbidities had significant impact on admission rates in the predominantly ambulatory group (p < 0.05). Respiratory comorbidities and syndromes were risk factors for readmission if patients presented to the emergency department (p < 0.05). CONCLUSIONS: Ambulatory cleft lip repair can be performed safely in most patients with no difference in emergency department visits or readmission. Patients with comorbidities should be admitted for observation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Heart Failure in an Infant With Pierre Robin Sequence: Is There a Diagnostic Test to Aid in Treatment Planning and Monitoring?

This case report describes an infant with Pierre Robin sequence who was managed conservatively until he presented at 4 months of age with right-sided heart failure. This rare clinical presentation displays the physiologic response to chronic respiratory obstruction and the acid-base disturbances, which become evident on metabolic panel and blood gas. We suggest that these tests can be added to the workup, especially in conservatively managed infants, to help predict which infants may fail conservative treatment and to avoid the rare complication of heart failure in infants with Pierre Robin sequence.

Reconstruction of an external hemipelvectomy defect with a two-stage fillet of leg-free flap.

The defect created by external hemipelvectomy for bone and soft tissue tumor resection is a challenge to reconstruct because of the exposure of bone, neurovascular structures, and peritoneal contents, particularly in the setting of previous radiotherapy. In a nonsalvageable limb with extensive tumor involvement and radiation damage, a free fillet of leg flap can be used to provide the necessary large volume of tissue for reconstruction without donor site morbidity. Because of the lengthy operative time for the hemipelvectomy procedure, the fillet of leg flap may be subject to long ischemia time and a subsequently compromised outcome. A two-stage fillet of leg flap for a hemipelvectomy defect was performed with two goals: to decrease ischemia time and to allow the necessary resuscitation of the patient between operative stages. Stage one was dissection of a lower fillet of leg flap, transfer and anastomosis to the contralateral femoral vessels, and temporary inset in the groin. The patient and flap were observed in the intensive care unit for several days. The patient returned to the operating room 3 days later for staged external hemipelvectomy and inset of the viable fillet of leg flap. Throughout follow-up, the reconstructive results and functional outcome were excellent.

Independent risk factors for infection in tissue expander breast reconstruction.

BACKGROUND: Postoperative infection in tissue expander breast reconstruction causes increased morbidity, cost, and suboptimal patient outcomes. To improve outcomes, it is important to preoperatively identify factors that might predispose to infection and minimize them when possible. It is hypothesized that certain patient characteristics are associated with an increased infection rate. METHODS: A retrospective, 6-year, single-institution review of patient records was performed from 413 tissue expanders placed in 300 women for postmastectomy breast reconstruction. Infection was defined as any case where antibiotics were given in response to clinical signs of infection. Fourteen potential risk factors were analyzed. A generalized estimation equations approach was used to perform univariable and multivariable analyses. RESULTS: Antibiotics were given to treat clinical infection in 68 of 413 expanders (16.5 percent), with a median time to diagnosis of 6.5 weeks (range, 1 to 52 weeks). Univariable analysis showed significant association with breast size larger than C cup (p < 0.001), previous irradiation (p = 0.007), repeated implant (p = 0.008), and delayed reconstruction (p = 0.04). All variables except delayed reconstruction remained significant (p < 0.002 for all) in a multivariable model. Additional significant covariates in this model included one surgical oncologist (p = 0.003) and contralateral surgery (p = 0.046). Given infection, one surgical oncologist was associated with an increased rate of mastectomy flap necrosis (p = 0.01). CONCLUSIONS: Certain patient characteristics are associated with increased infection in tissue expansion breast reconstruction. Understanding how these predispose to infection requires additional study. Patients identified with these characteristics should be educated about these risks and other reconstructive options to optimize the success of their breast reconstruction.