Transpalpebral Eyelid Approach for Supraorbital Frontal Craniotomy and Access to the Anterior Cranial Fossa.

SUMMARY: The transpalpebral eyelid approach is an innovative alternative to traditional incisions for exposure of the anterior cranial fossa for neurosurgery. However, there is a paucity of data on this surgical technique in the plastic surgery literature for accessing the anterior cranial fossa. A retrospective review was performed of patients who underwent supraorbital frontal craniotomy using an anterior skull base approach with transpalpebral exposure over 8 years by a single plastic surgeon. Surgical techniques, medical comorbidities, intraoperative complications, and long-term complications were assessed. Twenty patients (mean age 52 ± 12 years, 55% male, 45% female) underwent supraorbital frontal craniotomy using an anterior skull base approach with upper transpalpebral exposure. Operative indications included the following: 75% had anterior communicating aneurysms, with a mean aneurysm size of 5.36 ± 1.91 mm; 10% had meningiomas; 10% had dural fistulas; and 5% had an orbital hemangioma. A total of 60% of patients had a smoking history. No intraoperative complications were encountered, and no cases required conversion to a traditional open approach. Mean length of hospital stay was 3.2 ± 1.5 days. Postoperative imaging revealed no residual or recurrent pathology. Mean follow-up time was 62.2 ± 30.6 months. No long-term neurologic or ophthalmologic complications or infections occurred. No forehead paresthesias, brow ptosis, or brow paralysis were noted. The transpalpebral technique is a safe, minimally invasive method to approach lesions of the anterior cranial fossa. Successful application may require appropriate management of the frontal sinus and supraorbital nerve. This approach does not limit neurosurgical access or results and led to no neurosurgical complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facial Surgery in the Era of SARS-CoV-2 and Beyond: Challenges, Considerations, and Initiatives.

The SARS-CoV-2 pandemic resulted in the implementation of healthcare practice regulations and restrictions across the United States. To facilitate safe patient management practices for facial plastic and reconstructive surgeons, appropriate guidelines and recommendations should be followed. Guidelines and recommendations should include a synthesis of the best evidence available from public health authorities and respected members in the surgery community. This review contains evidence-based suggestions that prioritize the safety of healthcare professionals and patients to help guide facial and reconstructive surgeons toward safe patient management.

Reconstructing the Face of War.

INTRODUCTION: Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites. METHODS: A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images. RESULTS: Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed. CONCLUSION: While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

Autologous Reconstruction of a Face Transplant Candidate.

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.

Effect on Facial Growth of the Management of Cleft Lip and Palate.

Treatment of cleft lip and palate ordinarily requires multiple interventions spanning the time of birth to adulthood. Restriction of facial growth, a common occurrence in affected children, is due to multiple factors. There are multiple surgical and therapeutic options, which may have influence on facial growth in these patients. As restriction to facial development can have significant implications to form, function, and psychological well-being, practitioners should have an appreciation for the effects of the different cleft therapies to facial growth. We have outlined and thoroughly reviewed in chronological order all of the interventions from birth to adulthood necessary in the comprehensive care of the patient with cleft lip and palate, along with the effects they may or may not have on facial growth.

Combined Primary Cleft Lip and Palate Repair: Is It Safe?

BACKGROUND: Single-stage primary cleft lip and palate (PCLP) repair is controversial in the United States, and most patients are treated with a staged approach. In this study, early postoperative complications of the single-stage approach as compared to primary cleft lip (PCL) or primary cleft palate (PCP) alone were evaluated. This study represents the largest cohort of patients undergoing combined cleft lip and palate repair. METHODS: The American College of Surgeons National Surgical Quality Improvement Program-Pediatric database was used to identify patients undergoing single-stage PCLP, PCL, or PCP repairs. Preoperative factors and postoperative outcomes were compared between the 3 groups, as well as within the PCLP group between patients with and without complications. Univariate and multivariate analyses were performed. RESULTS: A TOTAL OF:: 181 patients were included in the single-stage PCLP group, 1007 in the PCP group and 783 in the PCL group. There was no difference in the rates of early complications between the 3 groups. Within the PCLP group, cardiac risk factors (ß = 35.19; 95% confidence interval [CI] 7.88-75.21; P = 0.04) and complications (ß = 77.31; 95% CI 35.82-118.79; P < 0.001) were significant risk factors for longer operative time. CONCLUSION: Analysis of a national database showed that single-stage PCLP repair is not associated with increased risk of early postoperative complications as compared to primary lip or palate repair alone. In-depth long-term analyses of craniofacial morphology, fistulae rate, speech, and dental outcomes are essential for a comprehensive assessment of the effects of combined cleft lip and palate repair.

A Prospective, Randomized, Blinded Trial Comparing Digital Simulation to Textbook for Cleft Surgery Education.

BACKGROUND: Simulation is progressively being integrated into surgical training; however, its utility in plastic surgery has not been well described. The authors present a prospective, randomized, blinded trial comparing digital simulation to a surgical textbook for conceptualization of cleft lip repair. METHODS: Thirty-five medical students were randomized to learning cleft repair using a simulator or a textbook. Participants outlined markings for a standard cleft lip repair before (preintervention) and after (postintervention) 20 minutes of studying their respective resource. Two expert reviewers blindly graded markings according to a 10-point scale, on two separate occasions. Intrarater and interrater reliability were calculated using intraclass correlation coefficients. Paired and independent t tests were performed to compare scoring between study groups. A validated student satisfaction survey was administered to assess the two resources separately. RESULTS: Intrarater grading reliability was excellent for both raters for preintervention and postintervention grading (rater 1, intraclass correlation coefficient = 0.94 and 0.95, respectively; rater 2, intraclass correlation coefficient = 0.60 and 0.92, respectively; p < 0.001). Mean preintervention performances for both groups were comparable (0.82 ± 1.17 versus 0.64 ± 0.95; p = 0.31). Significant improvement from preintervention to postintervention performance was observed in the textbook (0.82 ± 1.17 versus 3.50 ± 1.62; p < 0.001) and simulator (0.64 ± 0.95 versus 6.44 ± 2.03; p < 0.001) groups. However, the simulator group demonstrated a significantly greater improvement (5.81 ± 2.01 versus 2.68 ± 1.49; p < 0.001). Participants reported the simulator to be more effective (p < 0.001) and a clearer tool (p < 0.001), that allowed better learning (p < 0.001) than textbooks. All participants would recommend the simulator to others. CONCLUSION: The authors present evidence from a prospective, randomized, blinded trial supporting online digital simulation as a superior educational resource for novice learners, compared with traditional textbooks.

Free Ulnar Forearm Flap: Design, Elevation, and Utility in Microvascular Nasal Lining Reconstruction.

Reconstruction of the nasal lining has traditionally been performed using the folded radial forearm free flap, given its reliable blood supply, pliability, and familiarity to surgeons with respect to its harvest. More recently, the free ulnar forearm flap has been proposed as an alternative reconstructive option for the nasal lining, with safe and reliable outcomes, and improved donor-site morbidity compared with its radial counterpart. In this article, the authors provide educational video footage with accompanying text description of the senior author's (E.D.R) approach to design and elevation of the free ulnar forearm flap for the purpose of reconstructing a composite nasal defect. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Appraisal of the Free Ulnar Flap Versatility in Craniofacial Soft-tissue Reconstruction.

The unique anatomical characteristics of the forearm region make it especially popular as a free flap donor site for craniofacial soft-tissue reconstruction. The free ulnar forearm flap is less hirsute and allows for better concealment of donor site scar as compared with its radial counterpart. Despite these factors, the free radial forearm flap remains more popular among reconstructive surgeons. Through the presented case series, we hope to emphasize the versatile nature of the free ulnar forearm flap in addressing various craniofacial soft-tissue defects. Following institutional review board approval, a retrospective review of the senior authors' clinical experience performing microvascular free ulnar forearm flap reconstruction of craniofacial soft-tissue defects was performed. A total of 10 patients were identified through our review. Soft-tissue defect locations included lower eyelid (n = 2), tongue and floor of mouth (n = 2), lower lip (n = 2), palatopharyngeal area (n = 1), nose (n = 1), and palate (n = 1). Trauma was the most common defect etiology (n = 5), followed by malignancy (n = 4), and iatrogenic injury in 1 case. All patients demonstrated good aesthetic and functional outcomes related to vision, speech, and oral intake at follow-up when applicable. The free ulnar forearm flap is a versatile reconstructive option that can be used to address a wide spectrum of craniofacial soft-tissue defects and offers numerous advantages over its radial counterpart.

Facial Trauma Care in the Austere Environment.

As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.

Single-Stage Primary Cleft Lip and Palate Repair: A Review of the Literature.

BACKGROUND: Single-stage cleft lip and palate repair is a debated surgical approach. While some studies have described favorable outcomes, concerns include the effect on craniomaxillofacial growth and increased risk of complications. To this date, there has not been a comprehensive appraisal of available data following combined cleft lip and palate repair. METHODS: An extensive literature review was performed to identify all relevant articles. The level of evidence of these articles was graded according to the Oxford Centre for Evidence-Based Medicine Levels of Evidence Scale. RESULTS: A total of 22 relevant articles were identified, all of which were retrospective in nature. Patient age at the time of surgery ranged from 1 month to 10 years, the longest duration of follow-up was 18 years, and the largest study included 106 patients. Review of the literature shows that overall surgical outcomes following combined cleft lip and palate repair are encouraging. An increased rate of postoperative fistulas with associated speech abnormalities in some studies is noteworthy. Importantly, there is no evidence to suggest an impact on craniomaxillofacial growth, and psychosocial outcomes and parental satisfaction seem to be improved with single-stage surgery as compared with the staged approach. CONCLUSIONS: Our review shows overall favorable outcomes associated with combined cleft lip and palate repair. The limited follow-up time or nature of evaluated outcomes in some studies may underrepresent the true rate of adverse events, and highlights the need for additional long-term studies with standardized follow-up. To our knowledge, our review is the first to evaluate existing data regarding outcomes following combined cleft lip and palate repair.

Face Transplantation: An Update for the United States Trauma System.

Face transplantation has evolved over the last 12 years into a safe and feasible reconstructive solution, with good aesthetic and functional outcomes for patients with severe facial defects who are not amenable to reconstruction through conventional and autologous approaches. Among patients who underwent face transplantation to date, a significant proportion did so following trauma, mostly ballistic and thermal injuries. It is therefore important for trauma surgeons who deal with these injuries regularly to be familiar with the literature on face transplantation following traumatic injuries. In this study, we provide a focused review on this topic, with an emphasis on highlighting the limitations of conventional craniomaxillofacial reconstruction, while emphasizing data available on the risks, benefits, surgical indications, contraindications, as well as aesthetic and functional outcomes of face transplantation. The authors also provide an update on all face transplants performed to date including traumatic mechanisms of injury, and extent of defects. They finally describe 2 cases performed by the senior author for patients presenting with devastating facial ballistic and thermal injuries. The authors hope that this work serves as an update for the trauma surgery community regarding the current role and limitations of face transplantation as a craniomaxillofacial reconstructive option for their patient population. This can potentially expedite the reconstructive process for patients who may benefit from face transplantation.

One hundred consecutive endoscopic repairs of sagittal craniosynostosis: an evolution in care.

OBJECTIVE Endoscope-assisted repair of sagittal craniosynostosis was adopted at St. Louis Children's Hospital in 2006. This study examines the first 100 cases and reviews the outcomes and evolution of patient care protocols at our institution. METHODS The authors performed a retrospective chart review of the first 100 consecutive endoscopic repairs of sagittal craniosynostosis between 2006 and 2014. The data associated with length of hospital stay, blood loss, transfusion rates, operative times, cephalic indices (CIs), complications, and cranial remolding orthosis were reviewed. Measurements were taken from available preoperative and 1-year postoperative 3D reconstructed CT scans. RESULTS The patients' mean age at surgery was 3.3 ± 1.1 months. Of the 100 patients, 30 were female and 70 were male. The following perioperative data were noted. The mean operative time (± SD) was 77.1 ± 22.2 minutes, the mean estimated blood loss was 34.0 ± 34.8 ml, and the mean length of stay was 1.1 ± 0.4 days; 9% of patients required transfusions; and the mean pre- and postoperative CI values were 69.1 ± 3.8 and 77.7 ± 4.2, respectively. Conversion to open technique was required in 1 case due to presence of a large emissary vein that was difficult to control endoscopically. The mean duration of helmet therapy was 8.0 ± 2.9 months. Parietal osteotomies were eventually excluded from the procedure. CONCLUSIONS The clinical outcomes and improvements in CI seen in our population are similar to those seen at other high-volume centers. Since the inception of endoscope-assisted repair at our institution, the patient care protocol has undergone several significant changes. We have been able to remove less cranium using our "narrow-vertex" suturectomy technique without affecting patient safety or outcome. Patient compliance with helmet therapy and collaborative care with the orthotists remain the most essential aspects of a successful outcome.

Anthropometric Outcome Measures in Patients With Metopic Craniosynostosis.

PURPOSE: Treatment of metopic craniosynostosis is performed by either fronto-orbital advancement (FOA) or endoscopic-assisted techniques. Interfrontal angle (IFA) is a validated measure of trigonocephaly, but requires a computed tomography scan. The most common direct measure to assess surgical outcome in patients with trigonocephaly is frontal width (ft-ft). The aim of this study is to determine if frontal width correlates with IFA and successful surgical correction 1 year after treatment. A review of current morphologic assessment techniques is also provided. METHODS: Three-dimensional computed tomography scans (preoperative and 1 year postoperative) of patients who underwent FOA (n = 13) or endoscopic (n = 13) treatment of metopic craniosynostosis were reviewed. Age-matched scans of unaffected patients served as controls. Frontal width was measured by a straight line between the bilateral frontotemporal points. Measurements were performed by 2 experienced observers and compared to IFA. RESULTS: Mean frontal width at preoperative scan for endoscopic and open patients was 55 ±â€Š0.6 and 64 ±â€Š0.7 mm, respectively (Z-score 1.6 and -3.7). Mean frontal width at postoperative scan for endoscopic and open patients was 80 ±â€Š0.4 and 81 ±â€Š0.7 mm (Z-score 0.0 for both groups). Frontal width for endoscopic correction significantly correlated with IFA (r = 0.536, P = 0.005), as well as for the open patients (r = 0.704, P < 0.001). CONCLUSION: Frontal width normalizes 1 year after operation, regardless of technique. Advantage of frontal width is that it can be measured in the clinic using a spreading vernier caliper. It correlates well with IFA and can be used as a metric for morphologic outcome.

Improving Results in Closed Nasal Reduction: A Protocol for Reducing Secondary Deformity.

BACKGROUND: Nasal fractures are the most common facial fracture. Improper reduction is a common occurrence, resulting in a residual deformity that requires secondary surgery. A treatment protocol for nasal fracture management is presented with the aim of reducing secondary deformities requiring corrective surgery. METHODS: After institutional review board approval, a retrospective review of all closed nasal reductions performed by a single surgeon between 2006 and 2015 was conducted. Patient age, sex, presence of secondary deformity, and need for a correctional operation were recorded. Clinical records were analyzed for evidence of postoperative deformity and need for subsequent manipulation or surgery. RESULTS: A total of 90 patients with nasal bone fractures who underwent closed nasal reduction were identified. The mean age of patients was 24.9 years. The male-to-female ratio was 2.2:1. Postoperative deformity was reported in 14 patients (15.6 percent). Four of the 90 patients (4.4 percent) were found to have avulsion of their upper lateral cartilage from the nasal bone. Nine of the 14 subjects (64.3 percent) presenting with secondary deformity were managed with external manipulation, avoiding a secondary operation. Five patients (5.5 percent) from the original cohort of 90 underwent revision surgery. CONCLUSIONS: By using the described protocol to treat nasal fractures, we have seen a low rate of postreduction deformity and a small percentage of need for secondary operation. The overall success rate of closed nasal reduction with postoperative manipulation (when necessary) was identified to be 94.5 percent. Using this protocol, surgeons may see a decrease in secondary deformities following closed nasal reduction procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparison of Resorbable Plating Systems: Complications During Degradation.

INTRODUCTION: Several bioresorbable plating systems have become standard in pediatric craniosynostosis reconstruction. A comparison of these systems is needed to aid surgeons in the preoperative planning process. The authors aim to evaluate 1 institution's experience using Resorb-X by KLS Martin and Delta Resorbable Fixation System by Stryker (Stryker Craniomaxillofacial, Kalamazoo, MI). METHODS: A sample of patients with single-suture nonsyndromic craniosynostosis treated at St Louis Children's Hospital between 2007 and 2014 using either Resorb-X or Delta bioresorbable plating systems were reviewed. Only patients with preoperative, immediate, and long-term 3-dimensional photographic images or computed tomography scans were included. A comparison of plating system outcomes was performed to determine the need for clinic and emergency room visits, imaging obtained, and incidence of subsequent surgical procedures due to complications. RESULTS: Forty-six patients (24 Resorb-X and 22 Delta) underwent open repair with bioabsorbable plating for single suture craniosynostosis. The mean age at each imaging time point was similar between the 2 plating systems (P > 0.717). Deformity-specific measures for sagittal (cranial index), metopic (interfrontotemporale), and unicoronal (frontal asymmetry) synostosis were equivalent between the systems at all time points (0.05 < P < 0.904). A single Delta patient developed bilateral scalp cellulitis and abscesses and subsequently required operative intervention and antibiotics. CONCLUSION: Bioabsorbable plating for craniosynostosis in children is effective and has low morbidity. In our experience, the authors did not find a difference between the outcomes and safety profiles between Resorb-X and Delta.

Fenestration of Solid Orbital Implants: Reducing Retrobulbar Hematoma Rate.

PURPOSE: Retrobulbar hematoma is an uncommon but potentially devastating complication following repair of orbital fractures. Since 2007, the senior author routinely fenestrates the solid porous polyethylene implants commonly used for orbital reconstruction. The perforated implant may facilitate drainage of postoperative bleeding and may potentially reduce the risk of retrobulbar hematoma. This study examines the rates of retrobulbar hematoma in patients who underwent orbital fracture reconstruction with placement of fenestrated or nonfenestrated implants. METHODS: A retrospective chart review of patients with orbital fracture reconstruction using an implant performed by the senior author between 2006 and 2016 was conducted. Data collected included age, sex, implant type, and presence of retrobulbar hematoma. RESULTS: One hundred four patients were included in the study. One patient who was treated with a nonperforated implant was found to have a postoperative retrobulbar hematoma. The retrobulbar hematoma did not cause visual changes or increased intraocular pressure, so the patient was observed and did not undergo any surgical intervention. The hematoma resolved spontaneously without further sequela. No patients with fenestrated implants had a retrobulbar hematoma. CONCLUSIONS: Fenestration of solid implants used in orbital floor reconstruction is simple and easy to perform, and may reduce the incidence of postoperative retrobulbar hematoma.

Current Management of Zygomaticomaxillary Complex Fractures: A Multidisciplinary Survey and Literature Review.

Despite the prevalence of zygomaticomaxillary complex (ZMC) fractures, there is no consensus regarding the best approach to management. The aim of this study is to determine differences in ZMC fracture treatment among various surgical specialties. A survey was conducted regarding treatment of patients with different ZMC fractures that included a minimally displaced fracture (Case 1), a displaced fracture without diplopia (Case 2), a displaced fracture with diplopia (Case 3), and a complex comminuted fracture (Case 4). The survey was distributed to members of plastic surgery, oral maxillofacial surgery, and otolaryngology societies. The rates of surgical treatment, exploration of the orbital floor, and plating three or more buttresses were analyzed among the specialties. A total of 173 surgeons participated (46 plastic and reconstructive surgeons, 25 oral and maxillofacial surgeons, and 102 otolaryngologists). In Case 1, a significantly higher percentage of plastic surgeons recommend an operation (p < 0.01) compared with other specialties. More than 90% of surgeons would perform an operation on Case 2. Plastic surgeons explored the orbital floor (p < 0.01) and also fixated three or more buttresses more frequently (p < 0.01). More than 93% of surgeons would operate on Case 3, with plastic surgeons having the greatest proportion who fixed three or more buttresses (p < 0.01). In Case 4, there was no difference in treatment patterns between specialties. Across the specialties, more fixation was placed by surgeons with fewer years in practice (<10 years). Conclusion There is no consensus on standard treatment of ZMC fractures, as made evident by the survey. Significant variability in fracture type warrants an individualized approach to management. A thorough review on ZMC fracture management is provided.

Outpatient Alveolar Bone Grafting.

PURPOSE: Alveolar bone graft (ABG) has traditionally been performed with a postoperative inpatient stay secondary to donor site pain. Upon transitioning from an open iliac bone harvesting technique to an Acumed trephine, the authors observed that donor site pain was reduced eliminating an inpatient stay. This study examines the cost savings associated with outpatient ABG surgery. METHODS: A retrospective single-institution review was conducted on all patients who had an ABG performed from 2012 to 2015. Patients were categorized based upon hospital stay: inpatient, observation (23-hour), or outpatient. Cost data reported included: total direct cost, total variable direct cost, fixed direct cost, and the sum of total direct costs for both medical/surgical supplies and operating room costs. T tests were used to determine differences in various cost categories between groups of patients. RESULTS: Sixty-two procedures were performed: 7 procedures were inpatient, 16 observation, and 39 outpatient. The total direct costs averaged $4536 for inpatients, $3222 for the observation group, and $3340 for the outpatient group. Inpatient and outpatient costs were significantly different (P <0.01). Total variable direct costs (P <0.05) and fixed direct costs (P <0.01) were significantly lower in the outpatient/observation group. All costs for the observation group were significantly lower than inpatient costs, but were not significantly different than outpatient costs. There were no readmissions reported. CONCLUSIONS: Cost of an inpatient stay is significantly higher than outpatient or 23-hour observation for ABG procedures. The Acumed trephine technique allows for same-day discharge. In the face of declining reimbursement, safe and cost-efficient treatments are an appealing option.