Faculty Bibliography

Background/UNASSIGNED:Lower eyelid blepharoplasty has continued to evolve with an ongoing debate regarding optimal techniques. Despite large case series publishing excellent results and minimal complications, the true longevity of these procedures remains unclear. Objective/UNASSIGNED:To determine how thoroughly the aesthetic surgery literature assesses the longevity of the lower blepharoplasty. Methods/UNASSIGNED:A 20-year comprehensive literature review from May 1997 to September 2017 was conducted. Titles and abstracts of 180 unique articles were reviewed yielding 86 potential publications. After reviewing the complete manuscripts, 49 studies met inclusion criteria and were analyzed. Results/UNASSIGNED:A total of 10,698 patients were included for analysis. Reported follow-up ranged between 1 week and 192 months. Mean follow-up was 14.8 months for the 29 studies (59.2%) that reported this data. Pooled analysis of complication rates demonstrated 0.77% (n=82) reoperation, 0.37% (n=39) scleral show, 0.25% (n=27) lid malposition, and 0.24% (n=25) ectropion rates, among others. Forty-four of 49 studies (89.8%) published postoperative photographs with a total of 141 unique postoperative time points that were supported with photographic evidence (mean, 15.3 months; range, 1 week - 192 months). In this series, only 10 patients (0.094%) had postoperative photographs at time points greater than 24 months. Conclusion/UNASSIGNED:Lower eyelid blepharoplasty is a powerful procedure with seemingly minimal morbidity despite its technical demand. Unfortunately, the longevity is poorly supported with photographic evidence in the literature. Studies do not adequately report or represent their follow up to capture long-lasting results. Standardized reporting of results is needed to ensure patients can be adequately counseled when pursuing lower eyelid blepharoplasty.

PURPOSE/OBJECTIVE:Phalangeal fractures represent a significant portion of upper extremity injuries but are not well studied as a single entity. We define our approach at a level 1 trauma center and determine whether plating or lag screws (ie, rigid fixation) have superior functional outcomes compared with Kirschner wire fixation for phalangeal or metacarpal fractures. METHODS:We performed a systematic review of all surgically managed hand fracture cases at Bellevue Hospital during 2012 and 2013. Demographics, type of fixation, length of operation, period of immobilization, range of motion, time to return to work, and complications including reoperation were noted. Comparisons were assessed for significance using Student t tests and Fisher exact test (P < 0.05 considered significant). RESULTS:One hundred ninety-two fractures (158 patients) were treated and followed for an average of 113 days. Rigid fixation was used for 17 (19%) of 90 metacarpal fractures and 5 (5%) of 102 phalangeal fractures. Operative times were significantly shorter (59 vs 135 minutes, 84 vs 149 minutes), and period of immobilization was longer (37 vs 15 days, 34 vs 18 days) when Kirschner wires were used for metacarpal and phalangeal fractures, respectively (P > 0.05). Total active motion and return to work were similar regardless of type of intervention in both fracture types. No patients treated with rigid fixation required reoperation. CONCLUSIONS:To our best knowledge, this is the first review to study phalangeal fractures concurrently but also separately from metacarpal fractures. Despite shorter periods of immobilization, rigid fixation does not appear to lead to improved total active motion or time to return to work.

BACKGROUND:Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. METHODS:Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. RESULTS:A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). CONCLUSIONS:Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

OBJECTIVES/OBJECTIVE:To investigate how muscle and fasciocutaneous flaps influence the progression of bone healing in acute Gustilo IIIB tibia fractures. DESIGN/METHODS:Retrospective Chart Review. SETTING/METHODS:Urban Academic Level I Trauma Center. PATIENTS/PARTICIPANTS/METHODS:Between 2006 and 2016, 39 patients from a database of operatively treated long bone fractures met the inclusion criteria, which consisted of adults with acute Gustilo IIIB tibia shaft fracture requiring flap coverage and having at least 6 months of radiographic follow-up. INTERVENTION/METHODS:Soft tissue coverage for patients with Gustilo IIIB open tibia fractures was performed with either a muscle flap or fasciocutaneous flap. MAIN OUTCOME MEASUREMENTS/METHODS:A radiographic union score for tibia (RUST) fractures, used to evaluate fracture healing, was assigned to patients' radiographs postoperatively, at 3, 6, and 12 months from the initial fracture date. Mean RUST scores at these time points were compared between those of patients with muscle flaps and fasciocutaneous flaps. Union was defined as a RUST score of 10 or higher. RESULTS:There was a significant difference (P = 0.026) in the mean RUST score at 6 months between the muscle group (8.54 ± 1.81) and the fasciocutaneous group (6.92 ± 2.46). There was no significant difference in the mean RUST score at 3 months (P = 0.056) and at 12 months (P = 0.947) between the 2 groups. There was also significance in the number of fractures reaching union, favoring muscle flaps, at 6 months (P = 0.020). CONCLUSIONS:Patients with acute Gustilo IIIB tibia fractures who received muscle flaps have significantly faster radiographic progression of bone healing in the first 6 months than do patients who received fasciocutaneous flaps. Furthermore, according to radiographic evaluation, more Gustilo IIIB tibia fractures receiving muscle flaps reach union by 6 months than those flapped with fasciocutaneous tissue. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program. METHODS:The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed. RESULTS:Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups. CONCLUSION/CONCLUSIONS:Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue-based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

Background/UNASSIGNED:The number of men undergoing cosmetic surgery is increasing in North America. Objectives/UNASSIGNED:To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males. Methods/UNASSIGNED:A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures. Results/UNASSIGNED:Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56). Conclusions/UNASSIGNED:Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures. Level of Evidence 2/UNASSIGNED/: