Faculty Bibliography

INTRODUCTION/BACKGROUND:Incisional hernia (IH) represents a complex and costly surgical complication. We aim to address trends in open surgery to better understand potential drivers of hernia risk. MATERIAL AND METHODS/METHODS:Using the 2009-2013 NIS, a cross-sectional review of hospital discharges associated with an open abdominal surgery was performed. RESULTS:Between 2009 and 2013, there were nearly 10 million discharges associated with an open abdominal surgery. Overall, there were 2,140,616 patients receiving open surgery in 2009, decreasing to 1,760,549 in 2013 (18% decrease, p < 0.001). Open hernia procedures increased from 37,325 patients in 2009 to 41,845 in 2013 (12% increase, p = 0.001). The most prevalent comorbidities within this population included uncomplicated hypertension (25.26%), chronic pulmonary diseases (13.52%), obesity (10.24%), uncomplicated diabetes (11.06%), and depression (10.72%). CONCLUSIONS:Our analysis allowed for a unique view of surgical trends, health care population dynamics, and an opportunity to use evidence-driven analytics in the understanding of IH.

BACKGROUND:Incisional hernia remains a persistent and burdensome complication after colectomy. Through individualized risk-assessment and prediction models, we aimed to improve preoperative risk counseling for patients undergoing colectomy; identify modifiable preoperative risk factors; and encourage the use of evidence-based risk-prediction instruments in the clinical setting. STUDY DESIGN/METHODS:A retrospective review of the Healthcare Cost and Utilization Project data was conducted for all patients undergoing either open or laparoscopic colectomy as identified through the state inpatient databases of California, Florida, and New York in 2009. Incidence of incisional hernia repair was collected from both the state inpatient databases and the state ambulatory surgery and services databases in the 3 states between index surgery and 2011. Hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrapping techniques. Exclusion criteria included concurrent hernia, metastasis, mortality, and age younger than 18 years. Inflation-adjusted expenditure estimates were calculated. RESULTS:Overall, 30,741 patients underwent colectomy, one-third of these procedures performed laparoscopically. Incisional hernia repair was performed in 2,563 patients (8.3%) (27-month follow-up). Fourteen significant risk factors were identified, including open surgery (odds ratio = 1.49; p < 0.0001), obesity (odds ratio = 1.49; p < 0.0001), and alcohol abuse (odds ratio = 1.39; p = 0.010). Extreme-risk patients experienced the highest incidence of incisional hernia (19.8%) vs low-risk patients (3.9%) (C-statistic = 0.67). CONCLUSIONS:We present a clinically actionable model of incisional hernia using all-payer claims after colectomy. The data presented can structure preoperative risk counseling, identify modifiable patient-specific risk factors, and advance the field of risk prediction using claims data.

Reconstructing auricular deformities for bilateral microtia is a demanding challenge especially after failed autologous reconstruction. This case report presents a novel application of virtual surgical planning, computer-assisted design, and intraoperative surgical navigation to preplan and execute placement of custom-tailored silicone auricular prostheses and titanium osseointegrated implants for a bone-anchored hearing aid system in a patient with Treacher Collins syndrome in whom autologous reconstruction had previously failed. Through a collaborative approach between the reconstructive surgeon and anaplastologist, the implementation of advanced digital technologies may offer a superior esthetic and functional outcome to patients with previously failed reconstruction.

BACKGROUND:Congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and skeletal abnormalities (CLOVES) is a complex overgrowth syndrome with dramatic aesthetic and functional implications. The truncal masses characteristic of CLOVES syndrome are described as vascular malformations or lipomatous lesions with variable vascular components. Herein, we describe our single-institution experience with surgical excision of CLOVES-related truncal masses and discuss future directions in treatment of these complex anomalies. METHODS:A single-institution retrospective review was performed for patients diagnosed with CLOVES syndrome. Patients undergoing excision of truncal vascular malformations were included. Outcome measures included perioperative characteristics [estimated blood loss (EBL), specimen size/anatomic location, blood-product requirement], as well as length-of-stay [LOS], and complication profile. Mean follow-up was 23.4 months (range 4.2-44). RESULTS:. One patient with recurrence was subsequently treated with a combination of sclerotherapy and rapamycin, leading to significant mass reduction. CONCLUSIONS:Management of CLOVES syndrome requires a collaborative and multimodal approach. Although surgical debulking is one treatment option, non-invasive medical modalities and sclerotherapy should be considered prior to surgical resection. LEVEL OF EVIDENCE IV/METHODS:This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BACKGROUND:Incisional hernia (IH) is a complication following open abdominal hysterectomy. This study addresses the incidence and health care cost of IH repair after open hysterectomy, and identify perioperative risk factors to create predictive risk models. METHODS:We conduct a retrospective review of patients who underwent open hysterectomy between 2005 and 2013 at the University of Pennsylvania. The primary outcome was post-hysterectomy IH. Univariate/multivariate cox proportional hazard analyses identified perioperative risk factors. We performed cox hazard regression modeling with bootstrapped validation, risk stratification, and assessment of model performance. RESULTS:2145 patients underwent open hysterectomy during the study period. 76 patients developed IH, and all underwent repair. 31.3% underwent reoperation, generating higher costs ($71,559 vs. $23,313, p < 0.001). 8 risk factors were included in the model, the strongest being presence of a vertical incision (HR = 3.73 [2.01-6.92]). Extreme-risk patients experienced the highest incidence of IH (22%) vs. low-risk patients (0.8%) [C-statistic = 0.82]. CONCLUSIONS:We identify perioperative risk factors for IH and provide a risk prediction instrument to accurately stratify patients in effort to offer risk reductive techniques. SUMMARY/CONCLUSIONS:Open hysterectomies account for a magnitude of surgical procedures worldwide. This study presents an internally validated risk model of IH in patients undergoing open hysterectomy after a review of 2145 cases. With an increasing emphasis on prevention in healthcare, we create a risk model to improve outcomes after open hysterectomies in effort to identify high-risk patients, facilitate preoperative risk counseling, and implement evidence-based strategies to improve outcomes.

Throughout history, the technological advancements of conventional clinical photography in plastic surgery have not only refined the methods available to the plastic surgeon, but have invigorated the profession through technology. The technology of the once traditional two-dimensional photograph has since been revolutionized and refashioned to incorporate novel applications, which have since become the standard in clinical photography. Contrary to traditional standardized two-dimensional photographs, three-dimensional photography provides the surgeon with an invaluable volumetric and morphologic analysis by demonstrating true surface dimensions both preoperatively and postoperatively. Clinical photography has served as one of the fundamental objective means by which plastic surgeons review outcomes; however, the newer three-dimensional technology has been primarily used to enhance the preoperative consultation with surgical simulations. The authors intend to familiarize readers with the notion that three-dimensional photography extends well beyond its marketing application during surgical consultation. For the cosmetic surgeon, as the application of three-dimensional photography continues to mature in facial plastic surgery, it will continue to bypass the dated conventional photographic methods plastic surgeons once relied on. This article reviews a paradigm shift and provides a historical review of the fascinating evolution of photography in plastic surgery by highlighting the clinical utility of three-dimensional photography as an adjunct to plastic and reconstructive surgery practices. As three-dimensional photographic technology continues to evolve, its application in facial plastic surgery will provide an opportunity for a new objective standard in plastic surgery.