Practice Trends in Plastic Hand Surgery: An Evaluation of Cases in the TOPS Database.

Background: Previous studies have sought to outline the clinical practice of hand surgeons with plastic surgery training backgrounds. Still, minimal data exist characterizing the scope of hand surgery among plastic surgeons, regardless of the subspecialty fellowship training. Methods: All hand procedures logged in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database from 2002 to 2016 were identified by the Common Procedural Technology (CPT) code and/or "upper extremity" anatomic classification. Trends in the total number and types of procedures, facility type, admission type, modes and providers of anesthesia, and patient demographics were reviewed. Results: A total of 182,137 hand procedures performed on 82,811 patients during the 15-year period were reviewed. Sixty-eight percent of procedures involved soft tissue only, and 22.7% involved only bone and/or joint. The most common procedure categories included the following: wound closure/coverage (15.8%), debridement/drainage (15.3%), nerve (13.2%), tendon (12.9%), and fracture/dislocation (12.9%). Ambulatory and office-based procedures increased over time, along with the use of local anesthetic, as well as a transition from the procedural surgeon providing anesthesia to the use of anesthesiologists and nurse anesthetists. In addition, hand procedures have remained a considerable proportion of all logged procedures but have seen a steady decline since 2014. Conclusion: Plastic surgeons play an important role in the field of hand surgery, performing a wide variety of procedure types, which has remained stable over time. The trends in facility type and anesthesia characteristics have, however, varied.

Safety of Outpatient Plastic Surgery: A Comparative Analysis Using the TOPS Registry with 286,826 Procedures.

BACKGROUND: Outpatient plastic surgery at office-based surgery facilities (OBSFs) and ambulatory surgery centers (ASCs) has become increasingly prevalent over the past 30 years. Importantly, historical data are inconsistent regarding the safety outcomes of these venues, with advocates for both citing supporting studies. This investigation's purpose is to provide a more definitive comparative evaluation of outcomes and safety for outpatient surgery performed in these facilities. METHODS: The most common outpatient procedures were identified using the Tracking Operations and Outcomes for Plastic Surgeons database between 2008 and 2016. Outcomes were analyzed for OBSFs and ASCs. Patient and perioperative information was also analyzed using regression analysis to identify risk factors for complications. RESULTS: A total of 286,826 procedures were evaluated, of which 43.8% were performed at ASCs and 56.2% at OBSFs. Most patients were healthy, middle-aged women categorized as American Society of Anesthesiologists class I. The incidence of adverse events was 5.7%, and most commonly included antibiotic requirement (1.4%), dehiscence (1.3%), or seroma requiring drainage (1.1%). Overall, there was no significant difference in adverse events between ASCs and OBSFs. Age, American Society of Anesthesiologists class, body mass index, diabetes, smoking history, general anesthesia, certified registered nurse anesthetist involvement, operative duration, noncosmetic indications, and body region were associated with adverse events. CONCLUSIONS: This study provides an extensive analysis of common plastic surgery procedures performed in an outpatient setting in a representative population. With appropriate patient selection, procedures are safely performed by board-certified plastic surgeons in ambulatory surgery centers and office-based settings, as evidenced by the low incidence of complications in both environments. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Characteristics and Treatment of Patients Diagnosed With Paradoxical Adipose Hyperplasia After Cryolipolysis: A Case Series and Scoping Review.

BACKGROUND: Paradoxical adipose hyperplasia (PAH), a rare side effect of CoolSculpting (cryolipolysis), is characterized by fatty enlargement of the treatment area occurring months after the procedure. OBJECTIVES: The purpose of this study was to report a retrospective case series of patients diagnosed with PAH at the authors' institution, increase the collective understanding of this complication and subsequent management, and raise the question of who should ethically perform cryolipolysis. METHODS: All participants diagnosed with PAH by a plastic surgeon at a large academic medical center were identified. Demographic information, medical history, procedure details, time to PAH diagnosis, and corrective surgical intervention details were collected. Mean duration of time from cryolipolysis treatment to diagnosis of PAH was calculated, along with other descriptive statistics. A scoping review of all PAH literature published in PubMed, Embase, and Web of Science was also conducted. RESULTS: Four patients diagnosed with PAH after cryolipolysis were identified for inclusion in this study. The calculated incidence of PAH at our center was 0.67%. All patients requested therapy for PAH and subsequently underwent either liposuction, abdominoplasty, or both. The mean duration of in-person follow-up time after final surgical treatment of PAH was 13.8 + 19.8 months (range, 2.8-43.5). Fortunately, no patients showed signs of PAH recurrence, and 3 out of 4 patients did not show signs of residual deformity. CONCLUSIONS: Findings from this patient cohort and scoping review provide evidence that although revisions may be required, conventional body contouring methods, not in the armamentarium of non-plastic surgeon practitioners, effectively alleviated PAH.

Opioid Prescribing Practices Among Plastic Surgeons: Results of the 2019 American Society of Plastic Surgeons Opioid Survey.

BACKGROUND: Health care providers play an important role in the national opioid crisis with 40% of opioid-related deaths being attributed to prescription medications (Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. 2018) and as many as half of the opioid pills prescribed after outpatient plastic surgery may go unused (Plast Reconstr Surg 2019;143:929-938). The purpose of this study was to provide broad foundational data regarding postoperative analgesic prescribing patterns among members of the American Society of Plastic Surgeons (ASPS) to facilitate inclusion of opioid data fields in the ASPS Tracking Operations and Outcomes for Plastic Surgeons database for longitudinal evaluation. METHODS: A survey regarding opioid prescribing practices was electronically distributed to a representative cohort of 2555 ASPS members. Two hundred seventy-nine responses (11% response rate) were received. RESULTS: The majority of respondents reported prescribing opioids following 1 or more types of cosmetic and reconstructive procedures (90.2% and 81.7%, respectively; p = 0.0057), most commonly oxycodone and hydrocodone. Most (61.9%) reported less than 5% of patients request an opioid refill. Nonopioid medications, most commonly acetaminophen and ibuprofen/naproxen, were also prescribed but less commonly so for cosmetic (80.7-85.8%) than reconstructive (86.3-91.5%) procedures. Local anesthetic was less commonly used for mastopexy (83.7%) than augmentation (91.8%, p = 0.02). CONCLUSIONS: Based on survey responses, potential areas of improvement to reduce opioid prescribing and use include provider education on the use of multimodal pain regimens including nonopioid medication and "as needed" rather than scheduled dosing, use of local anesthetic blocks, as well as patient education on opioid safety and proper disposal of unused medication.

Contemporary Analysis of Rhytidectomy Using the Tracking Operations and Outcomes for Plastic Surgeons Database with 13,346 Patients.

BACKGROUND: Rhytidectomy is a popular procedure for facial rejuvenation, but an up-to-date, comprehensive, and broadly representative appraisal is lacking. METHODS: A cohort of patients undergoing rhytidectomy between 2008 and 2016 was identified from the Tracking Outcomes in Plastic Surgery database. Perioperative data and patient characteristics were analyzed with respect to adverse events. Multivariate logistic regression was used to identify association of complications with various risk factors. RESULTS: A total of 13,346 patients with a mean age of 60 years underwent rhytidectomies and a total of 31,206 Current Procedural Terminology procedures. Most were healthy women with an American Society of Anesthesiologists class of 1 or 2 (98 percent). On average, 2.3 procedures were performed in 3.8 hours per patient, and blepharoplasty was the most common adjunctive procedure. Fifty percent of operations were performed in office-based settings, and general anesthesia utilized in 63 percent of cases. The incidence of adverse events was 5.1 percent, with hematomas and infections as the most frequent surgical complications. Male gender, obesity, current smoker, duration, combined procedures, general anesthesia, and office-based surgery were associated with increased odds of adverse events. CONCLUSIONS: This is the largest outcomes analysis of face-lift surgery in a patient population solely representative of board-certified plastic surgeons. Rhytidectomy is a very safe procedure when performed by board-certified plastic surgeons. Nevertheless, risk factors for complications are identified, several of which can be affected by surgeon choice of surgical venue, additive procedures, duration of operation, and type of anesthetic. The study provides a standard reference for professionals when counseling patients and in guiding clinical practices. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Is Thoracodorsal Nerve Transection Needed in Latissimus Dorsi Breast Reconstruction?

PURPOSE: Latissimus dorsi (LD) breast reconstruction is of proven efficacy. Advantages of thoracodorsal nerve transection are potential prevention of muscle spasticity/movement; disadvantages are possible long-term muscle atrophy and volume loss. This study's purpose is to provide data that would support or refute nerve transection. METHODS: A retrospective study of all LD breast reconstruction patients from 2011 to 2017 was done. Total number of flaps was identified, as was thoracodorsal nerve transection. Outcomes were noted for symptomatic muscle spasticity/involuntary movement, and complications inclusive of hematoma, seroma, and capsular contracture. RESULTS: A total of 125 patients had 170 flaps. Eighty-one flaps had nerve transection; 89 did not. These cohorts had no differences in comorbidities, indications of surgery (cancer vs prophylactic), irradiation, delayed/immediate reconstruction, and use of expanders. Symptomatic muscle movement/spasticity was not significantly different: 3 (3.7%) of 78 in transection and 5 (5.6%) of 84 in nontransection (P = 0.55, χ). Incidence of seroma in the transection group was notably higher (18/81; 22% vs 12%) but not statistically significant (P = 0.09, χ). No differences existed in all other outcomes. CONCLUSIONS: Symptomatic spasticity or involuntary muscle movement occurs in a small number of patients with LD breast reconstruction and is not affected by thoracodorsal nerve transection. Movement after transection is likely due to aberrant nerve innervation and reinnervation. The absence of movement without transection is due to disruption of muscle position and origin after transfer. Seroma formation may be affected by increased axillary dissection required for nerve transection. These data do not support nerve transection, and therefore, it is not recommended.

Analgesic Efficacy of Nerve Blocks After Abdominoplasty: A Systematic Review.

BACKGROUND: A variety of regional nerve blocks have been utilized in abdominoplasty procedures, including transversus abdominis plane (TAP), intercostal, rectus sheath (RS), pararectus + ilioinguinal/iliohypogastric, quadratus lumborum, and paravertebral blocks. No consensus exists regarding the most effective nerve block modality in optimizing postprocedural comfort levels. OBJECTIVES: The purpose of this systematic review was to explore the efficacy of the various abdominal nerve blocks employed in abdominoplasty surgery and to draw attention to any modality that may be superior in regards to effectiveness and/or administration. METHODS: Utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies that have employed regional nerve blocks in abdominoplasty procedures. Opioid consumption, pain scores, time to ambulation, time in the recovery room, and time to first analgesia request were extracted when available. RESULTS: A total of 191 articles were reviewed, of which 8 met inclusion criteria. The nerve blocks represented included TAP, RS, pararectus + ilioinguinal/iliohypogastric, intercostal, and quadratus lumborum. All modalities were effective in reducing opioid consumption except quadratus lumborum. CONCLUSIONS: TAP, RS, pararectus + ilioinguinal/iliohypogastric, and intercostal regional nerve blocks have been shown to optimize postoperative pain management in abdominoplasty procedures. The existing literature suggests that when studied against one another, TAP is more efficacious than RS and pararectus + ilioinguinal/iliohypogastric. When ultrasound guidance is unavailable, consideration should be given to TAP employing the direct visualization approach.

Comparison of Saline Expanders and Air Expanders for Breast Reconstruction.

INTRODUCTION: Postmastectomy breast reconstruction with saline tissue expanders requires frequent saline injections. Air expanders contain an air canister and patient-operated remote to control expansion. The aim of this study was to evaluate the effectiveness of air expanders, inclusive of cost. METHODS: An international review board-approved retrospective review was performed of women who underwent breast tissue expansion between January 1, 2005 and February 5, 2019. Data collected included demographics, distance from clinic, mastectomy type, breast cancer treatment, expander type, expansion duration, postoperative visits, expansion visits, and postoperative complications. We compared true, unrealized, and overall costs and efficiency measured by time for expansion completion. True cost was calculated by adding expander, saline, and needle prices. Unrealized cost was calculated by multiplying number of visits for expansion by the expense of roundtrip driving. T tests and z scores determined clinical significance. RESULTS: Postoperative complication rates were not significantly different between groups. The air expansion mean true cost was US $1006.11 more than saline expansion (P < 0.001), whereas the mean unrealized cost was US $551.81 less (P = 0.008). The air expansion mean overall cost was US $461.43 more than saline expansion (P = 0.063). There was no significant difference in time to expander-to-implant exchange. CONCLUSIONS: This study demonstrates that saline and air expanders have no difference in complications or ability to complete expansion. However, there is significantly higher unrealized cost of saline expansion due to needle and saline costs and travel for more frequent doctor visits. However, saline expansion overall cost is less than air expansion, but statistically insignificant. Air expanders are effective in properly selected patients.

The Minimal Access Cranial Suspension Lift.

The minimal access cranial suspension (MACS) facelift is a minimally invasive face and neck lift that uses the understanding of the changes in facial anatomy as it relates to facial aging. The MACS facelift uses a shorter incision with limited subcutaneous undermining. It achieves a resuspension of the underlying neck and midface soft tissues with the use of looped, purse-string sutures in the superficial musculoaponeurotic system and platysma. These attenuated structures are anchored to the deep temporal fascia. In the properly selected patient, the MACS facelift is an effective technique with high levels of physician and patient satisfaction.

Preoperative Hypoglycemia Increases Infection Risk After Trigger Finger Injection and Release.

BACKGROUND: Diabetes mellitus is a well-known risk factor for infection after trigger finger (TF) injection and/or release. However, the effect of preoperative hypoglycemia before TF injection or release is currently unknown. The purpose of this study is to determine the effects of preoperative hypoglycemia on infection incidence after TF injection or release. METHODOLOGY: A retrospective cohort review between 2007 and 2015 was conducted using a national private payer database within the PearlDiver Supercomputer. Preoperative, fasting, glucose levels were collected for each patient, and these ranged from 20 to 219 mg/dL. Surgical site infection (SSI) rates were determined using International Classification of Diseases, Ninth Revision codes. RESULTS: The query of the PearlDiver database returned 153,479 TF injections, of which 3479 (2.27%) and 6276 (4.09%) had infections within 90 days and 1 year after procedure, respectively. There were 70,290 TF releases identified, with 1887 (2.68%) SSIs captured within 3 months after surgery and 3144 (4.47%) within 1 year after surgery. There was a statistically significant increase in SSI rates in patients with hypoglycemia within 90-day (P = 0.006) and 1-year (P < 0.001) time intervals post-TF injection. Likewise, a statistically significant increase in SSI rate in patients with hypoglycemia undergoing TF release within 1 year after release was seen (P = 0.003). CONCLUSIONS: Hypoglycemia before TF injection or release increases the risk for SSI. Tight glycemic control may be warranted to mitigate this risk. Further studies are needed to investigate the effect of hypoglycemia as an independent risk factor for SSI.

Historical Roots of Modern Plastic Surgery: A Cited Reference Analysis.

BACKGROUND: Highly cited publications are referred to as citation classics and can signify important contributions to a discipline. Although citation classics in plastic surgery have been identified, none were published before 1960. Citation classics in earlier periods may contain the historical roots or intellectual origins of the field. We set out to identify such scholarly works and analyze their characteristics. METHODS: A novel technique of citation analysis, referred to as reference publication year spectroscopy, was used to analyze the literature. The spectrogram revealed distinct peaks before 1960, which corresponded to 20 citation classics. These 20 references were then analyzed with respect to historical context, topic of interest, anatomical region, originality, and if authors were named for their findings (eponyms). RESULTS: Twenty distinct citation classics (published from 1851 to 1959) were identified, accounting for 430 literature citations. Salmon's "Arteres de la Peau" was the most cited reference, followed by Gillies' "Principles of Plastic Surgery" and Neuber's "Fat Grafting." The theme of angiosomes was highly represented. Most citation classics dealt with reconstruction of acquired defects (37%) and primarily focused on the head and neck regions (45%). Thirty-five percent of clinical studies were noted for their originality, and 5 studies earned their authors' eponymous distinctions. CONCLUSION: The roots of modern plastic surgery began in the late 19th century with early efforts to describe cutaneous vasculature. Historical studies that either establish principles or lead to an advancement in our reconstructive methods have the best chance of achieving classical status.

The Use of Poly-4-Hydroxybutyrate (P4HB) Scaffold in the Ptotic Breast: A Multicenter Clinical Study.

BACKGROUND: Mastopexy and reduction mammaplasty are often limited by the patient's poor native soft tissue quality, resulting in ptosis recurrence and loss of rejuvenated surgical results. Surgical scaffolds and acellular dermal matrices are used in these procedures to provide physical and mechanical stabilization of weakened or compromised tissue. GalaFLEX scaffold, made from poly-4-hydroxybutyrate (P4HB), is a next-generation product for soft tissue reinforcement that resorbs gradually while aiding tissue regeneration to achieve excellent outcomes. OBJECTIVES: To assess the clinical performance of GalaFLEX scaffold in soft tissue reinforcement during elective mastopexy and reduction mammaplasty. METHODS: This multicenter, single-arm, observational study assessed product performance and outcomes of GalaFLEX scaffold when used in breast surgery. Outcomes included ptosis correction and maintenance, associated adverse events, patient and surgeon satisfaction, and mammographic and ultrasound imaging evaluation. RESULTS: At 6 centers in the US, 62 of 69 enrolled patients were treated. Of this population, 89.7% had successful ptosis correction and maintenance at 1 year, with high patient and surgeon satisfaction for breast shape, droop/sag of the breast, and maintenance of results at 1 year. There were 5 adverse events deemed related to the device (8.0%), including nerve pain, breast swelling, ptosis, and 2 instances of asymmetry. CONCLUSIONS: GalaFLEX scaffold safely and successfully supports and elevates breast tissue in mastopexy and reduction mammaplasty, with maintained support at 1 year. Surgeon and patient satisfaction were high. No mammogram or ultrasound interference was detected.

Facelift Practice Evolution: Objective Implementation of New Surgical Techniques.

BACKGROUND: Facial rejuvenation is an elective procedure commonly performed to combat the consequences of normal aging. The senior author's practice initially consisted of traditional facelifts with superficial muscular apopneurotic system plication and/or superficial muscular apopneurotic system flap. After the development of the minimal access cranial suspension (MACS) technique by Tonnard et al., the senior author transitioned to an almost exclusive MACS facelift practice. The purpose of this study was to determine the efficacy of the MACS technique versus the traditional facelift approach and objectively incorporate these results into practice. METHODS: A retrospective cohort study design was performed to identify all patients who underwent a facelift by the senior author between January 1, 2013, and December 31, 2015. Patient demographics, comorbidities, type of procedure, complications, revision surgery, and objective surgeon satisfaction were among the parameters recorded. This was compared with an historical cohort of the senior author's earlier experience. RESULTS: There was a statistically significant decrease in the use of the MACS facelift procedure between this study and the senior authors' seminal study. Within this study cohort, compared with conventional facelift, the MACS technique was done on younger patients, proved to have significantly shorter operative time, mean follow up, and allowed for additional concurrent non-facial procedures when compared with the traditional approach (all comparisons significant at P < 0.05). However, continued postoperative neck laxity, submental pleating, and periocular pleating were seen with the MACS technique. CONCLUSIONS: The current study shows that the MACS technique is better suited for young patients with lesser cervical bulk or laxity and provides an opportunity for concurrent nonfacial procedures. Objective assessment with recognition of the limitations of the MACS technique versus the traditional facelift approach has led to a change in the senior author's practice. Although the MACS lift incurs shorter procedure time and quicker recovery, it does demonstrate limitations when it comes to marked skin laxity and bulky necks/platysmal banding. Both techniques are used with in line with the respective limitations and advantages.

Identifying Risk Factors Leading to Unanticipated Postoperative Readmission.

INTRODUCTION: Unanticipated postoperative readmissions are a grading metric directly linked to both the quality of patient care and physician reimbursement. However, little data exist to define factors responsible for these readmissions in the plastic surgery patient population. This study aims to identify patient risk factors contributing to unanticipated postoperative readmissions to optimize perioperative patient care and mitigate negative financial impact upon providers. METHODS: We present an institutional review board-approved study retrospective review of 819 plastic surgery patients undergoing operative procedures performed at our institution between January 1, 2013, and December 31, 2014. All unanticipated readmissions within 30 days of an operation were identified and subjected to statistical analysis in an effort to determine whether these readmissions were associated with identifiable patient risk factors. RESULTS: One hundred forty-nine (18.1%) of the 819 investigated patients underwent readmission, reoperation, or both within 30 postoperative days. Seventy-four (9%) patients required hospital readmission, alone; 55 (6.7%) underwent readmission with operative intervention; and 20 (2.4%) required outpatient operative intervention without readmission. Readmitted patients were significantly more likely to have a positive smoking history (P = 0.009), hypertension (P = 0.0008), congestive heart failure (P = 0.0015), chronic obstructive pulmonary disease (P = 0.023), a higher mean age (P = 0.0001), and a higher Charlson Comorbidity Score (P = 0.0001). CONCLUSIONS: These results identify risk factors associated with unanticipated postoperative readmissions specific to a plastic surgery patient population. With this information, practitioners can allocate appropriate perioperative resources and planning for patients at increased risk for readmission, thereby improving delivery of patient care and satisfying quality metrics linked to practitioner reimbursement.

Comparative Outcomes and Quality Analysis of Inverted-T and Pure Vertical Scar Techniques in Superomedial Pedicle Reduction Mammaplasty.

INTRODUCTION: Multiple techniques exist for reduction mammoplasty, but no singular consensus exists as to which method is the most effective in providing an aesthetically pleasing breast. We reviewed our institution's reduction mammoplasty experience over a 2-year period to evaluate aesthetic and surgical outcomes comparing superiorly based pedicles with skin excisions resulting in either an inverted T or vertical scar. METHODS: An IRB-approved retrospective review of our institution's surgical database identified patient characteristics and outcomes of all breast reductions performed over a 2-year period (n = 104). A subgroup analysis of patients with complete preoperative and postoperative photographs (n = 56) evaluated postoperative aesthetics on a scale of 1 to 5 (1, poor; 5, excellent). RESULTS: Techniques included a superomedial pedicle with an inverted T-pattern skin excision (n = 81) and pure vertical reduction (n = 23). There was no significant difference in complications between techniques. Common patient risk factors (age, body mass index [BMI], and smoking status) did not correlate with postoperative complications. In the photograph analysis subgroup, inverted T scar pattern reductions had a significantly better scar quality score (3.5 vs 3.2, P < 0.05). In analysis of all subjects, volume of tissue resected was a significant factor in determining overall aesthetic score, with resections of less than 1300 g being significantly associated with an overall aesthetic score of 4 or higher. Logistic regression demonstrated patient age younger than 40 years was a significant contributor to aesthetic score of 4 or higher (P < 0.05). DISCUSSION: We reviewed our institution's experience with 2 common breast reduction techniques. Better scarring was associated with inverted T scar pattern versus vertical pattern. Additionally, rather than pedicle type or skin excision pattern, patient age and weight of tissue resected were the most important contributors to an aesthetically optimal outcome. This study suggests that a single superlative technique does not exist. Rather, inherent patient characteristics are most important in provision of the best aesthetic outcome.