Search

Background: Surgical cancellations that occur within 1 day of the procedure (ie, late cancellations) disrupt the efficiency of the operating room. The aim of the present study was to identify the factors associated with late cancellations in a tertiary pediatric surgical practice., Methods: We reviewed the medical records of patients treated by plastic and oral surgery services at our institution from 2010 to 2015. We collected data pertaining to the timing and reasons for cancellation. Reasons for cancellation were retrospectively classified by the investigators as either "preventable," "possibly preventable," "unpreventable," or "undocumented." We also measured the frequency of cancellations based on type of surgery., Results: Of 10,730 scheduled operating room cases, 444 (4.1%) were cancelled within 24 hours of the procedure. Sixty-seven percent (297/444 cases) were cancelled on the same day as the planned procedure, and the remaining cases were cancelled the day prior after 1 PM. Forty-two percent of cancellations were deemed preventable, and 45.3% of cases were deemed possibly preventable. The majority of procedures were cancelled because of illness (44%), inadequate fasting (9%), and parental inconvenience (7%). The highest frequency of cancellation was found in skin lesion (36%) followed by dentoalveolar (14%) and cleft lip and palate (12%) cases., Conclusions: In our study, most late surgical cancellations were preventable or possibly preventable. The timing of the cancellation is important because those that occur near the scheduled procedure time disallow adequate and timely redistribution of operating room resources and personnel. Analyzing and addressing the preventable and possibly preventable causes outlined in this study will significantly improve efficiency and patient access.

Background: Process management within a health care setting is poorly understood and often leads to an incomplete understanding of the true costs of patient care. Using time-driven activity-based costing methods, we evaluated the high-volume, low-complexity diagnosis of plagiocephaly to increase value within our clinic., Methods: A total of 59 plagiocephaly patients were evaluated in phase 1 (n = 31) and phase 2 (n = 28) of this study. During phase 1, a process map was created, encompassing each of the 5 clinicians and administrative personnel delivering 23 unique activities. After analysis of the phase 1 process maps, average times as well as costs of these activities were evaluated for potential modifications in workflow. These modifications were implemented in phase 2 to determine overall impact on visit-time and costs of care., Results: Improvements in patient education, workflow coordination, and examination room allocation were implemented during phase 2, resulting in a reduced patient visit-time of 13:25 (19.9% improvement) and an increased cost of $8.22 per patient (7.7% increase) due to changes in physician process times. However, this increased cost was directly offset by the availability of 2 additional appointments per day, potentially generating $7904 of additional annual revenue. Quantifying the impact of a 19.9% reduction in patient visit-time at an increased cost of 7.7% resulted in an increased value ratio of 1.113., Conclusions: This pilot study effectively demonstrates the novel use of time-driven activity-based costing in combination with the value equation as a metric for continuous process improvement programs within the health care setting.

"Value" has become a buzzword in current health-care discussions. This study demonstrates a provider-led strategy to measuring costs, an understudied component of the value equation, for a complex diagnosis for the purposes of improvement. A retrospective, microcosting methodology was used to measure costs for all hospital and physician services and costs to the patient over 18 months of multidisciplinary care for patients with cleft lip and palate. Short-term outcomes were also recorded. Overall costs to all parts of the system ranged from $35,826 to $56,611 for different subtypes, and insight was gained into major cost drivers and variations in care that will drive internal improvement efforts. It is critical that providers learn to work together and become familiar with their own costs in conjunction with outcomes as insurers increase pressure to reduce payments or accept alternative payments so that well-informed decisions can be made.

Plastic and reconstructive surgery has had a long history with international humanitarian efforts. As the field of global surgery continues to gain momentum in academic centers throughout the world, the role of the surgical subspecialist in the public health infrastructure of low-resource communities has also begun to gain a new sense of wonder and importance. Arthur Barsky, Jr was arguably one of the most influential forefathers of global plastic surgery. Throughout his notable career spanning most of the 20th century, Barsky remained dedicated to delivering plastic and reconstructive surgical care to the disadvantaged worldwide, as well as educating others to do the same. Although he was not the first surgeon with an interest in global health, Barsky's work was unique and influential in its originality, magnitude, and scope. An appreciation and understanding of Barsky's groundbreaking work will help inform the future development of sustainable surgical systems in resource-poor settings.

Access to essential surgical care in resource-poor settings is gaining recognition as a major component of international public health efforts. As evidence is mounting about the burden of surgically treatable disease in low- and middle-income countries, so too is the evidence for the significant need for plastic surgery treatment of disease rising in these areas. American plastic surgery has a long history with international surgical efforts in resource-poor regions around the world. Early experiences were not formalized until after World War II, when a foundation partnership provided a venue for interested plastic surgeons to volunteer. These efforts progressed and advanced throughout the 1960s-1970s, but were ultimately devastated by the Vietnam War. Subsequent international plastic surgical experiences by American surgeons over the last 40 years have been largely through several nongovernmental organizations. American plastic surgical involvement in global surgery has changed significantly over the last 70 years. Although quality care is being delivered to resource-poor regions around the world, many of the challenges of regionally appropriate, sustainable care persist today.

Unicoronal synostosis is frequently associated with strabismus. While the literature reports on the underlying bony dysmorphology and associated extraocular muscle dysfunction, the effect of the bony changes of fronto-orbital advancement has unpredictable effects on the strabismus associated with unicoronal synostosis. Previous authors have reported both resolution and new onset of strabismus following fronto-orbital advancement. The purpose of this study is to document the incidence of strabismus in patients with unicoronal synostosis and to assess the effect of fronto-orbital advancement on strabismus. A retrospective review of 20 patients with unicoronal synostosis was performed. The results demonstrated that 90% of our patients were noted to have strabismus preoperatively and this persisted postoperatively. Despite fronto-orbital advancement, strabismus persisted postoperatively. Seven (36.8%) required extraocular muscle surgery. In this series of patients with unicoronal synostosis there was a higher incidence of strabismus than previously reported elsewhere. Correction of the recessed frontal bone with bilateral fronto-orbital advancement does not fully address the orbital bony dysmorphology or correct the extraocular muscle dysfunction associated with unicoronal synostosis.

Nasal dermoid sinus cysts are uncommon congenital anomalies presenting either as cysts or sinuses. They are frequently associated with extension into the intracranial space, requiring craniotomy for adequate resection. At the Royal Children's Hospital in Melbourne, Australia, we have managed 25 patients with nasal dermoid sinus cysts over 8 years and present details of clinical features, preoperative assessment, and surgical management. Six patients presented with infection, including 1 with osteomyelitis. Four of our patients had intracranial extension of their lesions, and all were treated successfully with tailored investigation and appropriate surgical procedures. Insights into diagnosis, investigation, and surgery are offered to facilitate the management of these challenging lesions.

We present 2 contrasting cases of congenital interalveolar synechiae. The first occurred in the setting of Van der Woude syndrome and was associated with a cleft palate. In the second case, it was an isolated abnormality and there was no contributory family history or syndromic associations. We review the literature on interalveolar synechiae and discuss its management, implications, and genetics. Interalveolar synechiae is a condition with an excellent prognosis; its presence necessitates careful examination for associated abnormalities and syndromes.

Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. Recombinant human erythropoietin (RHE), a hormone that stimulates RBC production, increases the hematocrit when administered to infants. A retrospective chart review of all patients undergoing fronto-orbital advancement for craniosynostosis by the same plastic surgeon between January 2002 and December 2002 was conducted. A subgroup of patients (10/19) received RHE as a blood-conservation strategy. Transfusion requirements were lower in the RHE group (5/10) versus the control group (9/9). Total volume of blood products transfused was statistically lower in the RHE group (154 mL RHE group versus 421 mL control) (P < 0.03). RHE combined with blood-conservation techniques was associated with a decreased need for blood transfusion, thus exposing the patient to fewer risks associated with allogeneic transfusion.

Apert syndrome is characterized by craniosynostosis, central nervous system anomalies, midface hypoplasia, and syndactyly. Current research has focused on genetic and neurologic correlates. Cognitive assessment has been primarily limited to global intellectual evaluations, which can fail to detect the diverse cognitive attributes of these children at an individual level. This report describes in detail the neuropsychological profiles of 2 children with Apert syndrome, incorporating clinical, radiographic, molecular and surgical data. One child showed intellectual deficits consistent with a moderate intellectual disability. The second child, while of normal intelligence, displayed neuropsychological deficits associated with anterior-brain-region cognitive functions. These data highlight the diversity of neuropsychological outcomes in Apert syndrome in the same genetic mutation and underline the importance of detailed neuropsychological evaluations as integral to the management protocols of affected individuals.

Hemifacial microsomia is a craniofacial disorder involving structures derived from the first and second brachial arches. Bony structures, soft tissue, and the facial nerve can all be hypoplastic or absent. In this retrospective study of 70 patients at the Children's Hospital Los Angeles, craniofacial dysmorphology, temporal bone computed tomography, and audiological evaluations were examined. The purpose of this study was to identify further relationships between clinical findings, temporal bone anatomy, and audiological findings in these patients. Significant relationships were identified between total radiographic score and overall clinical findings (p<0.001). Clinical measurements of mandibular hypoplasia were also predictive of temporal computed tomographic findings (p<0.001), whereas clinical ear findings were related specifically to specific temporal bone abnormalities such as hypoplasia of the middle ear (p=0.008) and fusion or absence of ossicles (p<0.001). Interestingly, neither clinical findings nor temporal bone computed tomographic findings were related to either hearing loss type or degree. Audiology should not be deferred on the basis of relatively mild clinical findings.

Prenatal exposure to nitrofen is known to cause multiple malformations in mice. The reported malformations include lung hypoplasia, diaphragmatic hernia, cardiovascular defects, skeletal malformations, cleft palate, and renal abnormalities. The authors present detailed findings of craniofacial defects after prenatal exposure to nitrofen, and propose that together with the previously reported malformations, nitrofen exposure induces a Fryns phenotype in mice. Fryns syndrome is a rare human genetic syndrome that is an autosomal recessive disorder characterized by lung hypoplasia, diaphragmatic hernia, craniofacial malformations, skeletal malformations, cardiovascular malformations, and genitourinary malformations. Timed-pregnant Swiss Webster mice were gavage-fed 25 mg of nitrofen on day 8 of gestation. Control animals received olive oil. Osteogenesis and chondrogenesis were studied in fetuses recovered on day 17 after Alcian blue-Alizarin red staining. Approximately 26% of the nitrofen-exposed embryos had severe craniofacial defects, and there was generalized delay in chondrogenesis and osteogenesis throughout the skeleton. No such defects were noted in the control group. The authors propose that prenatal exposure to nitrofen induces a Fryns phenotype in mice, and thus speculate that nitrofen may target similar molecular mechanisms to those that lead to Fryns syndrome.

The tuberous breast deformity is one of the most challenging congenital breast anomalies. The nomenclature, classification, and treatment of this pathological condition have varied considerably. In this study, 16 patients with 23 tuberous breast deformities are evaluated. The breast deformities are classified according to the three-tier classification system used at the authors' institution. The treatment pattern is evaluated and a flexible algorithm is discussed for the treatment of the tuberous breast deformity.

The VACTERL association is an acronym for a constellation of abnormalities affecting the spinal column, anus, heart, trachea, esophagus, kidneys, and limbs that are seen in newborns. It has been shown that prenatal rats exposed to Adriamycin demonstrate a similar series of anomalies. It is the aim of this study to characterize the spectrum of limb anomalies in this model. Female Sprague-Dawley rats (N = 18; 14 experimental and 4 control) were used. After mating, pregnant animals received intraperitoneal injections of Adriamycin (2 mg per kilogram) on days 6, 7, 8, and 9 of gestation. Fetuses were recovered on day 21 of gestation. Ten experimental litters (42 fetuses) and two control litters (18 fetuses) underwent skeletal staining with Alizarin Red S stain. Four experimental litters (N = 18) and two control litters (N = 17) underwent histological study including staining for vascular and neural structures. Upper limb anomalies were found in 45% of the experimental animals, all including either hypoplasia or bending of the radius. The ulna was involved in 37% of the affected limbs. There were no isolated ulnar deformities. There were no histological differences noted. The spectrum of upper limb anomalies seen in the Adriamycin-exposed prenatal rat closely approximates, in incidence and morphology, the upper limb deformities seen with the VACTERL association in children. It is a reliable model for use in additional studies of the embryological mechanism by which these defects arise.

The great advantages of the radial forearm fasciocutaneous flap are offset by the dilemmas associated with its donor site. The most commonly encountered problems are the functional and cosmetic sequelae of skin graft loss with consequent exposure of volar forearm tendons, the superficial sensory branch of the radial nerve, and the radius. Techniques that minimize donor site morbidity are those that provide a well-vascularized bed for the protection of exposed tendon, nerve, and bone, and for the acceptance of skin grafts. A technique involving the mobilization of the flexor pollicis longus muscle belly in conjunction with the abductor pollicis longus with approximation to the flexor digitorum superficialis muscle belly provides stable, well-vascularized coverage of the radial forearm flap donor site, with reliable skin graft acceptance and no functional sequelae.

Giant congenital pigmented nevi pose a substantial reconstructive challenge for the treating physician. Due to the increased risk of malignant transformation in such lesions, complete excision with tissue expansion or skin grafting is the generally accepted treatment. These modalities can, however, leave the patient with secondary deformities that also require complex reconstructive procedures. The following case details a patient requiring secondary reconstruction with large-volume tissue expansion 12 years after excision of a giant nevus, and split-thickness skin grafting. This patient illustrates a severe secondary deformity and the usefulness of large-volume serial expansion in such patients.

Degloving injuries range from the occult, easily missed injury to obvious massive tissue damage. The serious nature of these wounds is exacerbated by mismanagement. It is generally accepted that the degloved tissue should be excised, defatted, fenestrated, and reapplied as a full-thickness skin graft. Dressings are required that provide gentle, evenly distributed pressure and avoid shear stress to the newly grafted skin. Numerous types of dressings have been devised but all are cumbersome and time-consuming. We have found the Vacuum-Assisted Closure device to be a rapid, effective, and easy-to-use alternative to traditional methods. The authors examine their experience using a vacuum-assisted closure device to treat nine degloving injuries in 5 patients and discuss the important aspects in using this technique.