RESUMO

BACKGROUND: Our institution supports a chief resident aesthetic clinic with the goal of fostering autonomy and preparedness for independent practice in a safe environment. OBJECTIVES: The aim of this study was to compare safety profiles and costs for common aesthetic procedures performed in our resident versus attending clinics. METHODS: A retrospective review was conducted of all subjects presenting for aesthetic face, breast, and/or abdominal contouring surgery at our institution from 2008 to 2017. Two cohorts were identified: subjects undergoing surgery through the chief resident versus attending clinics. Aesthetic procedures queried included: (1) blepharoplasty, rhinoplasty, or rhytidectomy; (2) augmentation mammaplasty, reduction mammaplasty, or mastopexy; (3) abdominoplasty; and (4) combination. Demographics, perioperative characteristics, costs, and postoperative complications were analyzed. RESULTS: In total, 262 and 238 subjects underwent aesthetic procedures in the resident and attending clinics, respectively. Subjects presenting to the residents were younger (P < 0.001), lower income (P < 0.001), and had fewer comorbidities (P < 0.001). Length of procedure differed between resident and attending cohorts at 181 and 152 minutes, respectively (P < 0.001), although hospital costs were not significantly increased. Total costs were higher in the attending cohort independent of aesthetic procedure (P < 0.001). Hospital readmissions (P < 0.05) and cosmetic revisions (P < 0.002) were more likely to occur in the attending physician cohort. Postoperative complications (P < 0.50) and reoperative rates (P < 0.39) were not significantly different. CONCLUSIONS: The resident aesthetic clinic provides a mechanism for increased autonomy and decision-making, while maintaining patient safety in commonly performed cosmetic procedures.

Assuntos

RESUMO

INTRODUCTION: Head and neck free flap (HNFF) reconstructions have historically utilized a multidisciplinary approach between otolaryngology head and neck surgery (OHNS) and plastic surgery (PS). However, there seems to be a trend toward both the extirpative and reconstructive portions being performed by OHNS. We aimed to elucidate the volume trend in HNFF reconstruction over the last decade. METHODS: Data were collected by 3 modalities: electronic medical record search of patients who underwent HNFF surgery at our institution (2013-2018), survey data from microsurgery fellowship programs (2007-2017), and National Surgical Quality Improvement Program (NSQIP) query of cases receiving designated HNFF Current Procedural Terminology codes (2011-2016). Data were analyzed with trends in HNFF reconstruction as our primary outcome. RESULTS: At our institution, HNFF reconstructions increased 4-fold (59-227). Percentage of cases by PS decreased from 18.6% to 6.0%, whereas that of OHNS increased 81.4% to 94.0% (P = 0.009). Survey data, completed by microsurgery fellowship program directors (23/81 [27.2%]), revealed the number of OHNS programs in 2007 performing 100 or more HNFF cases compared with PS was 40% (6/15) to 12.5% (1/8) (P = 0.172). By 2016, that number increased significantly for OHNS to 73.3% (11/15), whereas that of PS remained stagnant at 12.5% (1/8) (P = 0.005). According to NSQIP data, the percentage of cases performed by PS in 2011 was 52%, which was greater than OHNS's share of 43%. The other 5% was allotted to either orthopedic, oral and maxillofacial surgery, or general surgery. In 2013, those numbers reached a peak for PS at 55% and a nadir for OHNS at 36%. However, by 2016, the percentage of HNFF cases reversed. where 58% of cases were performed by OHNS and only 38% by PS. When comparing the 2011 data to the 2016 data, OHNS had a 134% increase, whereas PS had a 27% decrease (P = 0.003). CONCLUSIONS: Head and neck free flap reconstruction has grown dramatically over the last 10 years. Plastic surgeons are performing fewer cases, whereas otolaryngology head and neck surgeons perform more as indicated by institutional, microsurgery fellowship program director survey, and NSQIP data.

Assuntos

RESUMO

BACKGROUND: Split-thickness skin grafting (STSG) is a commonly used tool in the plastic surgeon's reconstructive armamentarium. Fibrin glue (FG) consists of a combination of clotting factors and thrombin whose key properties include adherence and hemostasis. This preliminary study aimed to assess clinical outcomes and cost of FG for STSG fixation in a general wound reconstruction. METHODS: A retrospective review was conducted in all patients undergoing STSG placement by a single surgeon (JPF) from January 2016 to March 2018. Twenty patients were identified and matched by wound location and wound size. Patients were then divided into 2 groups based on the method of STSG fixation: FG (n = 10) or suture only (SO) (n = 10). RESULTS: In patients with FG fixation, we observed trends of decreased adjusted operative times (34.9 versus 49.4 minutes, P = 0.612), a similar length of stay (2.8 versus 3.5 days, P = 0.306), and liberation from the use of negative pressure wound therapy (0 versus 10 wounds, P < 0.0001). There were no observed differences between the 2 groups in terms of graft-related complications at 180 days (1 complication FG versus 0 complications SO). Time to 100% graft take was also not different (20.2 versus 29.4 days, P = 0.405). Additionally, total direct cost ($16,542 FG versus $24,266 SO; P = 0.545) and total charges ($120,336 FG versus $183,750 SO; P = 0.496) were not statistically different between the FG and SO groups. CONCLUSIONS: In this preliminary comparative assessment, FG for STSG fixation has shown no difference in clinical outcomes to SO fixation, trends of decreased operative time, and afforded complete liberation from negative pressure wound therapy dressings.

RESUMO

Abdominal-based autologous breast reconstruction remains a conflict between blood supply and donor site complication. Optimizing esthetics and minimizing recovery and postoperative pain add further complexity. We present a 2-stage technique of deep inferior epigastric artery perforator flap reconstruction to (1) reliably harvest single-vessel flaps while minimizing fat necrosis, (2) decrease abdominal wall morbidity, and (3) improve breast and donor site esthetics. METHODS: Female subjects presenting between August 2017 and January 2019 to the senior surgeon for abdominal-based breast reconstruction were included. After mastectomy, the subjects underwent subcutaneous placement of tissue expanders and in situ selection of a low, centrally located perforator based on preoperative computed tomographic angiography imaging through an infraumbilical "T" incision with ligation of all other perforators and superficial system. Subjects underwent tissue expander explant and flap transfer at a second stage. RESULTS: One hundred thirty-five subjects undergoing 215 free flaps met criteria. Mean age and body mass index were 52.1 years and 29.3 kg/m2, respectively. Seven perforator complications (3.3%) occurred with 2 (0.9%) total and 5 (2.3%) partial flap losses. There were 20 (14.8%) readmissions and 26 (19.3%) reoperations. Breast complications included arterial thrombosis (0.5%), venous congestion (1.9%), and fat necrosis (5.1%). The mastectomy skin flap necrosis rate decreased from 14.9% to 2.3% following staged reconstruction. Abdominal donor site complications included delayed healing (11.1%), seroma (5.9%), and hematoma (2.2%). CONCLUSIONS: The 2-stage delayed deep inferior epigastric artery perforator flap technique represents a safe, efficacious modality to allow for reliable harvest of single-vessel flaps with low rates of fat necrosis while improving donor site esthetics and morbidity.