Timing of Alveolar Bone Graft and Barriers to Care.

OBJECTIVE: The current standard timing for alveolar bone grafting (ABG) occurs during mixed dentition, typically between the ages of six and twelve. A delay in receiving this operation is associated with an increase in graft loss and an overall thinner maxilla. This study aims to determine whether socioeconomic barriers are associated with a delay in timely ABG. DESIGN: A retrospective analysis of patients who received ABG at our institution since 2012. Patient demographics, cleft classifications, operative details, and surgical dates were examined. A logistic regression model was created using socioeconomic variables to predict patients receiving delayed ABG. Significant variables were then included in a backwards selection logistic regression, followed by a final analysis of maximum likelihood estimates. SETTING: Single-institution, primary cleft care center. PATIENTS: 202 patients with cleft palates who underwent ABG. INTERVENTIONS: ABG. MAIN OUTCOME MEASURES: Timing in which patients received ABG: standard (6-12 years) and delayed (>12 years). RESULTS: Female sex was a protective factor in the timing of ABG in our initial univariate analysis (OR = 0.44; p = .015). Socioeconomic factors resulting in delayed presentation for ABG include median income (OR = 1.0; p = .018) and public insurance status (OR = 3.75; p < .001). Median income, sex, and driving distance to the cleft clinic were not significant following backward elimination, however, private insurance status remained significant (OR = 3.71; p = .0001). CONCLUSION: Patients with public insurance are approximately 3.75 times more likely to receive ABG during permanent dentition. Multidisciplinary teams should work closely with patients on public insurance to ensure timely delivery of ABG.Level of Evidence III, Retrospective.

Inpatient versus Outpatient Immediate Alloplastic Breast Reconstruction: Recent Trends, Outcomes, and Safety.

Background: Immediate alloplastic breast reconstruction was traditionally performed as an inpatient procedure. Despite several reports in the literature demonstrating comparable safety outcomes, there remains hesitancy to accept breast reconstruction performed as an outpatient procedure. Methods: A retrospective review of National Surgical Quality Improvement Program data from 2014 to 2018 was utilized to evaluate recent trends and 30-day postoperative complication rates for inpatient versus outpatient immediate prosthetic-based breast reconstruction. Propensity score matching was used to obtain comparable groups. Results: During the study period, 33,587 patients underwent immediate alloplastic breast reconstruction. Of those, 67.5% of patients were discharged within 24 hours, and 32.4% of patients had a hospital stay of more than 24 hours. Immediate alloplastic reconstruction had an overall growth rate of 16.9% from 2014 to 2018. After propensity score matching, intraoperative variables that correlated with significantly increased inpatient status included increased work relative value units (16.3 ± 2.3 versus 16.2 ± 2.6; P < 0.001), longer operative times (228 ± 86 versus 206 ± 77; P < 0.001), and bilateral procedure (44.0% versus 43.5%; P < 0.001). There were higher rates of pulmonary embolism, wound dehiscence, urinary tract infection, transfusions, sepsis, readmissions, and reoperations in the group with the longer hospital stay. Conclusion: Based on increased complication rates and costs in the inpatient setting, we propose outpatient reconstructive surgery as a safe and cost-effective alternative for immediate alloplastic breast reconstruction.

Legal Ramifications of Publishing Patient Photographs: A Review of Legal Cases.

The use of photography in plastic surgery has become standard of practice in recent years. Patient photographs have diverse utility and can be used to visualize medical progression, and as an educational and marketing tool. With increased publication of patient photographs outside the healthcare records, it is important to understand patient privacy rights and how they pertain to images. Additionally, it is valuable to understand the legal consequences associated with dissemination of patient photographs without proper consent. Methods: A retrospective analysis of the Lexis+ legal database was conducted to obtain cases that involved the improper dissemination of patient photographs or videos by surgeons. Inclusion criteria included civil cases in which the defendant was a surgeon being sued for the improper use of patient photographs. Criminal cases were excluded from analysis. Results: A total of 23 cases met the inclusion criteria for our study. On average, 2.13 defendants were listed per case, often including the accused surgeon and their employer. Prior photographic consent was obtained in 69.57% (n = 16) of cases. In the remaining seven cases, the defendant did not obtain consent. In all seven of these cases, either the court ruled in favor of the plaintiff or both parties reached a settlement outside court. Conclusions: To mitigate risk, surgeons should maintain two separate photographic consent forms for internal and external use. Additionally, a formal audit process should be established to ensure proper consent has been established before publishing patient photographs external to the electronic medical records.

Racial Disparities in the Timing of Alveolar Bone Grafting.

Standard bone grafting between ages 6 and 12 has become the preferred treatment of choice for alveolar clefts. Given the importance of surgical timing in complete cleft palate repairs, it is important to identify any populations at-risk for delayed alveolar bone grafting. The purpose of this study is to identify whether a racial disparity is present nationally in the timing of alveolar bone grafting.Retrospective analysis Setting: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).Inclusion criteria involved patients who underwent alveolar bone grafting identified by current procedure terminology (CPT) code 42210 between years 2012 and 2019. Patients were stratified by age at time of operation based on the following parameters: early bone grafting (before 6 years of age), standard bone grafting (between 6 and 12 years of age), and late bone grafting (after 12 years of age).Racial and ethnic differences in the age of patients at the time of alveolar bone grafting.Overall, 20.28% of the cohort received alveolar bone graft after 12 years of age. African American (29.33%) and Hispanic (24.42%) patients received late alveolar bone grafting more frequently than other racial and ethnic groups (P < .001).Racial and ethnic disparities are present in the frequency at which patients receive late alveolar bone grafting for complete cleft palates. Given the suboptimal surgical results of late compared to standard alveolar bone grafting it is important to further investigate the driving factors of these disparities.