Plastic and Reconstructive Surgery Resident Indigent Care Clinic Optimization by Improving "No-Show" Rates.

ABSTRACT: Absenteeism among clinical patients is a significant source of inefficiency in the modern American health care system. Routine absenteeism limits access to care for indigent patients, thus providing additional strain on the health care system and timely administration of care.This quality improvement project set out to quantify, understand, and potentially reduce patient absenteeism in our weekly plastic and reconstructive surgery resident indigent care clinic. One year prior to our study was retrospectively reviewed to determine a baseline rate of absenteeism (no shows). The daily and monthly no-show percentages were calculated. Then, three consecutive 2-month Plan, Do, Study, Act (PDSA) cycles were performed and data were recorded.The initial year analysis demonstrated an average no-show rate of 25%. The first PDSA cycle attempted to ascertain factors contributing to absenteeism and to get patients rescheduled. The rate of clinical absenteeism was 27% over this period compared with a rate of 18% in the control period. During this period, we discovered a limitation of our institution's electronic medical record (EMR). Rescheduled patients were removed from the original schedule and were not counted as a missed appointment even though the opportunity for care was missed. The second PDSA cycle attempted to collect raw data while trying to understand the EMR error and rescheduling process. During this period, there was a 33% no-show rate compared with 27% in the control period. The third PDSA cycle attempted again to establish factors contributing to clinical absenteeism with a better understanding of the limitations of our EMR. A 33% no-show rate during this cycle was recorded compared with 22% in the control period. After three PDSA cycles were completed, our clinic had an average no-show rate of 31% compared with 25% during the same months in the previous year.This project brought to realization that our data were initially skewed by our ignorance of an EMR flaw that did not track patients who either canceled or rescheduled their appointments. We also learned that there is a certain subset of patients who are not able to be contacted and who do not follow up.

Antimicrobial Irrigation and Technique during Breast Augmentation: Survey of Current Practice.

Breast augmentation is among the most common procedures performed in the United States. Though bacterial contamination of breast prostheses is associated with adverse sequelae, there are no universally accepted guidelines and limited best practice recommendations for antimicrobial breast pocket irrigation. We designed a survey to identify pocket irrigation preferences and antimicrobial techniques during implant-based breast augmentation among American Society of Plastic Surgeons (ASPS) members. METHODS: In January 2018, a random cohort of 2,488 ASPS members was surveyed. Questions queried breast pocket irrigation methods and surgical techniques including implant placement, incision location, and implant soaking agents. An extensive literature review of breast pocket irrigation practices was completed and used as a basis for the survey. RESULTS: The survey response rate was above the ASPS average at 16% (n = 407). Respondents preferred an inframammary incision (90%) and submuscular implant placement (92%). Triple antibiotic solution (TAS) and TAS + Betadine ± Bacitracin were preferred by 61% and Betadine variants by 11%. Preferred dwell times stratified to 30 seconds (39%), 1 minute (18%), 2-5 minutes (21%), and >5 minutes (22%). Among those employing a TAS variant, 53% preferred a suboptimal dwell time of ≤1 minute. Prostheses were soaked in TAS (42%), TAS + Betadine ± Bacitracin (15%), a Betadine variant (12%), or other (31%). CONCLUSIONS: Periprosthetic bacterial contamination leads to comorbidity following breast augmentation. Our results reveal significant variability regarding breast pocket irrigation techniques among ASPS members during cosmetic breast augmentation. These data suggest the need for best practice guidelines regarding breast pocket irrigation and implant soaking agents.

Pocket Irrigation and Technique During Reconstructive Surgery: An American Society of Plastic Surgery Survey of Current Practice.

BACKGROUND: Expander-to-implant is the most common breast reconstruction procedure in the United States. Irrigation with triple antibiotic solution (TAS), as described by Adams et al in 2006, has become standard of care to lower bacterial bioburden. However, several alternative solutions have been implemented with the literature lacking a consensus regarding use (Plast Reconstr Surg. 2006;117:30-36). OBJECTIVE: We distributed a peer-reviewed survey among a cohort of American Society of Plastic Surgery (ASPS) members to assess pocket irrigation technique during implant-based reconstructive surgery. We then conducted a pilot in vitro study to determine antibacterial efficacy of the most preferred irrigation at preferred dwell times against select bacterial species linked to breast pocket contamination during reconstructive implant-based surgery. METHODS: The survey was distributed a total of 3 times to a random cohort of 2488 ASPS members in January 2018. During in vitro studies, pure cultures of common breast flora were exposed to TAS versus saline control at 1, 2, and 5 minutes in a simulated in vivo cavity. Viable plate counts were used to assess cell viability. RESULTS: The response rate was above the ASPS survey average at 16% (n = 407). The population reflected a cross-section of practice types and experience levels. Triple antibiotic solution without Betadine was the favored irrigation at 41%, with 73% of its users preferring dwell times of 2 minutes or less. Over 30 distinct breast pocket irrigation solutions were identified. Bacteria added to the in vivo cavity survived a 2-minute dwell time with TAS as follows: 51% Staphylococcus epidermidis, 69% Escherichia coli, 88% Enterococcus faecalis, 88% Pseudomonas aeruginosa, and 98% Acinetobacter baumannii. CONCLUSION: Our survey data demonstrate significant variability in practice and lack of consensus among ASPS members regarding antimicrobial irrigation during reconstructive breast surgery. Our in vitro data underscores the importance of relating clinical practices with laboratory studies of microorganisms potentially linked to breast pocket contamination and suggests that TAS requires either dwell times greater than 5 minutes and/or the inclusion of efficacious antimicrobial agents (eg, Betadine). This finding has the potential to impact antimicrobial pocket irrigation and technique during breast reconstruction.

Risk Assessment of Isolated Single-Wall Orbit Fractures and Eye Injury.

INTRODUCTION: Ideally, all patients with isolated orbit fracture would undergo ophthalmologic evaluation before surgical intervention to rule out concomitant globe injury and possible vision loss. Unfortunately, not all institutions are capable of providing the evaluation before surgery. The authors hypothesize that the anatomic location of a single-wall orbit isolated orbit fracture can help predict the likelihood of ocular injury and thus identify high-risk patients who mandate ophthalmologic evaluation before surgical repair. METHODS: A retrospective chart review was performed at a tertiary academic medical center using the institutional trauma registry for maxillofacial trauma. All subjects with an isolated single-wall orbit fracture were included in this study. Statistical analysis was performed using a Fisher exact test. RESULTS: Two hundred seventy-nine subjects with orbit fractures were identified for inclusion in this study. Forty-one of the 279 (14.7%) subjects had isolated single-wall orbit fractures. Isolated single-wall fractures included orbit floor = 19 of 41 (46.3%), medial wall = 15 of 41 (36.6%), lateral wall = 4 of 41 (9.8%), and orbit roof = 3 of 41 (7.3%). Concomitant ocular injury (13 of 41, 31.8%) was associated with isolated orbit wall fractures as follows: orbit floor = 4 of 19 (21.1%), medial wall = 6 of 15 (40%), lateral wall = 2 of 4 (50%), and orbit roof = 1 of 3 (33.3%). A Fisher exact test demonstrated that there was no statistically significant association between individual isolated wall fractures and ocular injury (P = 0.5000). CONCLUSIONS: Isolated orbit wall fractures are common in maxillofacial trauma and often require surgical repair. Concomitant ocular injury is common (31.8%) with this highest incidence occurring with lateral wall fractures (50%); however, statistical analysis did not demonstrate a significant relationship between the anatomic location of an isolated single-wall fracture and eye injuries.

Harvesting the Buccal Fat Pad Does Not Result in Aesthetic Deformity in Cleft Patients: A Retrospective Analysis.

BACKGROUND: Buccal fat is often used as a pedicled flap in cleft palate repairs to minimize scarring and fortify tenuous closures. Although many surgeons have adopted this technique, others have remained circumspect because of the concern for subsequent facial asymmetry. METHODS: Patients who underwent cleft palate repair using buccal fat pad flaps for closure between 2007 and 2015 were reviewed. Only patients with unilateral buccal fat pad flaps and three-dimensional photography were included. Volumetric analysis was performed on each patient to measure cheek volumes of both the flap and nonflap sides. A subgroup analysis on cleft palate and bilateral cleft lip and palate patients was performed to eliminate the confounding asymmetries of unilateral cleft lip and palate patients. Paired t tests were used to determine differences in cheek volumes. In addition, three reviewers examined photographs of patients and were asked to determine the side of fat pad harvest. RESULTS: Twenty-four patients met inclusion criteria. Mean follow-up was 55 months. The volume difference between the flap and nonflap sides was not significant (p = 0.81). Subgroup analysis on cleft palate and bilateral cleft lip and palate patients did not reveal a volume difference between the flap and nonflap sides (p = 0.98). When asked to determine which side buccal fat pads were harvested from based on patient photographs, the average percentage correct for three independent reviewers was 57 percent and the Cohen's kappa was -0.084, indicating poor agreement. CONCLUSION: Although the buccal fat pad is thought to play a role in facial aesthetics, the authors found no difference in volume between harvest and nonharvest sides, nor was there a clinically detectable difference. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Protruding Premaxilla: Is Our Current Approach the Right Answer?

BACKGROUND: In bilateral cleft patients, surgeons usually attempt to move the premaxillary segment posteriorly. These patients almost always develop maxillary hypoplasia, rendering our current algorithms questionable. The authors sought to determine if the lateral segments are in an appropriate position to serve as a target for movement of the premaxilla. METHODS: Bilateral cleft lip and palate patients treated at the University of Michigan from 1997 to 2015 were reviewed. Patients with skull radiographs or computed tomography (CT) imaging performed at age 3 or younger were included. Noncleft patients <3 years old seen in the craniofacial clinic during 2015 with negative imaging were included as comparative norms. Sella-nasion-A (SNA), sella-nasion-piriform (SNP), and sella-nasion-posterior nasal spine (SN-PNS) angles were determined in both the cleft patients and the comparative norms. Paired t tests assuming unequal variance were used to compare angles between normal and cleft patients. RESULTS: Eighty-six bilateral cleft patients were identified, and 16 had imaging. Only 7 patients had a CT or skull radiograph. Thirteen noncleft patients with negative imaging were included. The mean SNA angle was 100.8 in cleft patients and 86.1 in noncleft patients (P = 0.002). The mean SNP angle was 62.9 in cleft patients and 71.3 in noncleft patients (P = 0.02). The mean SN-PNS angle was 23.2 in cleft patients and 33.8 in noncleft patients (P = 0.005). CONCLUSIONS: Our results indicate that the maxilla is deficient early in life with posterior positioning of the lateral segments. Therefore, the lateral segments should not serve as a reference point when treating the premaxilla.

Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury.

OBJECTIVES/HYPOTHESIS: Maxillofacial trauma frequently involves the bony orbit that surrounds the ocular globe. Concomitant globe injury is a concern whenever orbit trauma occurs and in severe cases can occasionally result in vision loss. The mechanism of injury, physical exam findings, and radiographic imaging can provide useful information concerning the severity of the injury and concerns for vision loss. Using these three tools, it is hypothesized that the patient's history, physical exam, and radiographic findings can identify high-risk maxillofacial trauma patients with concomitant ocular injury. Identification of high risk patients who require comprehensive ophthalmologic evaluation may alter management and possibly preserve or restore vision. STUDY DESIGN: A retrospective clinical chart review was performed at a tertiary academic medical center. METHODS: Subjects were identified using the institutional trauma registry. Data collected included subject demographics, patient medical records and notes, ophthalmologic testing, and radiographic imaging. The incidence of orbit fracture and concomitant ocular injury associated with the mechanism of injury, physical exam findings, and radiographic imaging was determined. Statistical analysis was performed using a chi-square and Fisher exact test. RESULTS: In this study, 279 subjects with orbit fractures were identified and the incidence of concomitant ocular injury was 27.6% (77 of 279). Mechanism of injury was statistically associated with an increased risk of ocular injury (P = 0.0340), with penetrating trauma being the most likely etiology. The physical exam findings of visual acuity and an afferent pupillary defect were statistically associated with ocular injury (P = 0.0029 and 0.0001, respectively). Depth of orbit fracture on radiographic imaging was statistically associated with ocular injury (P = 0.0024), with fractures extending to the posterior third of the orbit being most likely to have associated ocular injury. CONCLUSION: Maxillofacial trauma patients with orbit fractures and concomitant ocular injury occur in more than one in four patients. Comprehensive ophthalmologic evaluation is recommended for all patients who sustain an orbit fracture. Subjects with a penetrating trauma mechanism of injury, physical exam findings of visual acuity deficits and an afferent pupillary defect, and radiographic imaging demonstrating fracture depth involvement of the posterior orbit are at highest risk for vision loss and warrant specific concern for ocular injury assessment. LEVEL OF EVIDENCE: IV.

A Multicenter Experience With Image-Guided Surgical Navigation: Broadening Clinical Indications in Complex Craniomaxillofacial Surgery.

PURPOSE: Image-guided surgical navigation, or computed tomography (CT)-guided surgery, is a technology used by many specialties to reduce complications and improve surgical outcomes. Its use has become widespread in neurosurgical intracranial and otolaryngological skull base procedures. The authors hypothesize that CT image-guided surgical navigation has a wide scope of utility in complex craniomaxillofacial procedures. With time and experience, its use will further advance the safety and efficacy of craniomaxillofacial surgery. METHODS: A multicenter retrospective study at the University of California-Los Angeles, New York University, University of Pittsburgh, and the University of Kansas Medical Center was conducted. All craniomaxillofacial procedures using CT image-guided surgical navigation were reviewed. RESULTS: Twenty subjects were identified who underwent a total of 26 CT-guided navigation procedures (6 cases were bilateral). Subunits reconstructed included: the upper face (n = 5), middle face (n = 7), and lower face (n = 6). Two additional patients used CT navigation to reconstruct multiple facial subunits. In all 20 subjects, the image-guided system correctly identified the surgical anatomy to less than 2 mm. There were no perioperative complications. Long-term follow-up demonstrated no revisionary procedures were required to date. CONCLUSIONS: Computed tomography-guided navigation is a safe and effective tool with multiple applications in craniomaxillofacial surgery. Indications for its use in complex craniomaxillofacial procedures continue to broaden. Further experience with this technology will continue to expand its clinical utility in craniomaxillofacial surgery.

Safety profile of wire osteosynthesis in craniosynostosis surgery.

With the advent of resorbable systems, most surgeons have stopped using wires for craniofacial fixation. Although numerous large retrospective reports regarding craniofacial surgery have been published, no documentation exists regarding the disadvantages or complications associated with wires. We review our experience with 47 consecutive patients with bicoronal and unicoronal craniosynostosis where wire osteosynthesis alone was used. Nine patients (19.1%) developed wire-related complications, but only 5 patients (10.6%) required reoperations. No other complications were observed including growth restrictions, implant migration, or interference with radiographic imaging. These results are comparable to those reported in the literature for other fixation systems and demonstrate that wires are a safe means of fixation of the cranial vault in infancy.

The importance of radical intravelar veloplasty during two-flap palatoplasty.

BACKGROUND: The purpose of this study was to compare the two-flap palatoplasty technique for cleft palate repair, with and without radical intravelar veloplasty, with special emphasis on the fistula rate and speech outcome. METHODS: A retrospective, time-series cohort of 213 consecutive patients with primary two-flap palatoplasty before and after the introduction of a radical intravelar veloplasty was studied. The main outcome measures were immediate postoperative complications, oronasal fistula rate, and speech. A perceptual speech evaluation was performed by two speech pathologists and included hypernasality, nasal emission, articulation, intelligibility, and overall velopharyngeal competence. The need for secondary palate surgery for velopharyngeal insufficiency was also analyzed. RESULTS: There were no differences in postoperative complications between the two study groups. Postoperative morbidity occurred in six patients (2.8 percent) and consisted of two patients with respiratory compromise, two patients who required reoperation for bleeding, and two patients with oronasal fistula. Perceptual speech evaluation demonstrated significantly better speech outcomes (81.9 percent versus 49.5 percent, p < 0.001) and a significantly lower rate of secondary palate surgery for velopharyngeal insufficiency (29 percent versus 6.7 percent, p = 0.008) in the radical intravelar veloplasty group. The most important predictive factor of speech outcome was the addition of a radical intravelar veloplasty (odds ratio, 0.175; 95 percent confidence interval, 0.039 to 0.785). CONCLUSIONS: Despite study design limitations, such as experience bias and follow-up differences, this study demonstrates that radical intravelar veloplasty may enhance the functional results of the two-flap palatoplasty without increasing postoperative morbidity. A novel classification of the muscle repair is proposed based on the amount of muscle dissection and retropositioning.

Anatomy and biomechanics of the vertebral aponeurosis part of the posterior layer of the thoracolumbar fascia.

There is significant paucity in the literature regarding vertebral aponeurosis. We were able to find only a few descriptions of this specific fascia in the extant medical literature. To elucidate further the anatomy of this structure, forty adult human cadavers were dissected. Both quantitation and anatomical observations were made of the vertebral aponeurosis. The vertebral aponeurosis was identified in 100% of specimens. This fascia was identified as a thin fibrous layer consisting of longitudinal and transverse connective tissue fibers blended together deep to the latissimus dorsi muscle. It attached medially to the spinous processes of the of the thoracic vertebrae; laterally to the angles of ribs; inferiorly to the fascia covering the serratus posterior inferior muscle (superficial lamina of the posterior layer of thoracolumbar fascia); superiorly it ran deep to the serratus posterior superior and splenius capitis muscles to blend with the deep fascia of the neck. At the level of the serratus posterior inferior muscle, the vertebral aponeurosis fused to form a continuous layer descending toward the sacrotuberous ligament covering the erector spinae muscle. Morphometrically, the mean length of the vertebral aponeurosis was 38 cm and the mean width was 24 cm. The mean thickness was three mm. There was no significant difference between left and right sides, gender or age with regard to vertebral aponeurosis length, width, or thickness (P > 0.05). During manual tension of the vertebral aponeurosis, the tensile force necessary for failure had a mean of 38.7 N. In all specimens, the vertebral aponeurosis was capable of holding sutures placed through its substance. We hope that these data will be of use for descriptive purposes and may potentially add to our understanding of the biomechanics involved in movements of the back. As back pain is perhaps the most common reason patients visit their physicians, additional knowledge of this anatomical region is important.