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Background:The greater omentum is easily harvested for coverage of sternal wounds without muscle sacrifice. Its major disadvantage is a laparotomy incision with potential bowel injury, adhesions, or hernia. Over the past 20 years, the authors' technique has evolved to use a transdiaphragmatic openin

Background The lower abdomen is the most popular donor site for autologous tissue breast reconstruction. Several studies have reported abdominal morbidity following pedicled and free flap reconstructions using this donor site, yet few studies have compared the various types of free flaps and investigated specific operative and patient-related factors that are associated with higher rates of abdominal complications. Methods The authors conducted a retrospective review of all free flap breast reconstructions performed at University of California Los Angeles Medical Center between July of 2002 and July of 2005. Results A total of 279 patients underwent 211 unilateral and 68 bilateral reconstructions, totaling 347 flaps. Eleven percent were free transverse rectus abdominis myocutaneous (TRAM) flaps, 52 percent were muscle-sparing free TRAM flaps, and 37 percent were deep inferior epigastric perforator (DIEP) flaps. Mean follow-up was 29.9 months. There were 30 total abdominal complications (10.9 percent of patients), including 17 rectus bulges and five hernias. Free TRAM reconstructions had a significantly higher rate of donor-site complications than did DIEP reconstructions. Bilateral flap harvests and obesity (body mass index >30) were significant risk factors for (1) any donor-site complication and (2) rectus bulge/hernia formation. There was no significant increase in donor-site complications associated with various prior abdominal operations. Conclusions Donor-site complications are not uncommon, but paying careful attention to patient comorbidities when selecting an operative approach (bilateral versus unilateral, free TRAM versus DIEP, and so on) can minimize postoperative abdominal complications. Furthermore, the results corroborate the recent literature suggesting there is little functional difference in patients receiving muscle-sparing free TRAM versus DIEP reconstructions.

BACKGROUND Many health organizations sponsor overseas surgical outreach initiatives, yet none has published a standardized protocol to prevent and manage unforeseen emergencies. Surgeons, anesthesiologists, nurses, and administrators-working together on a brief overseas humanitarian initiative-benefit from education and training to maximize their collective emergency responsiveness. This article outlines the emergency response protocol instituted by the Global Smile Foundation, a 501(c)(3) nonprofit global outreach organization providing comprehensive cleft care for the past 25 years. METHODS The Global Smile Foundation emergency response protocol was constructed to provide all team members resources and training needed to emulate the high emergency response standards of developed nations. In this article, the authors share their education/training strategy, emergency "crash" cart inventory, site-specific safety checklist, and team member roles and responsibilities during various emergencies. RESULTS The authors' protocol emphasizes equipment portability, location-specific adaptability, clear workflow/communication, and standardized team roles. On-site training is likewise portable, standardized, reproducible, efficient, and adaptive to each setting. These characteristics make the authors' protocol widely adoptable. CONCLUSIONS Most morbidity and mortality during overseas surgical outreach initiatives result from unfamiliarity with the host hospital and other team members during operative (e.g., airway, bleeding, circulatory, anesthetic) or location-based (e.g., power outage, fire, oxygen shortage) emergencies. These complications are prevented and managed with aggressive team education and training. The Global Smile Foundation protocol adapts to the uncertainties of providing medical care in underresourced settings and reflects experience accumulated over the past quarter century. It is the authors' hope that other humanitarian outreach groups will adopt, customize, and build on these basic tenets.

Background: Neonatal upper airway obstruction demands urgent attention. Tracheostomy can prove to be lifesaving but has morbidities. Recently, the authors found reduced morbidity/mortality when using a distraction decision tree model compared with conventional "case-by-case" management. In this current study, the authors assess the long-term costs of (1) a decision tree model versus conventional treatment and (2) tracheostomy versus distraction osteogenesis. Methods: An inpatient cost-matrix analysis study on neonates with upper airway obstruction and micrognathia was performed (n = 149). In Part I, conventionally treated neonates managed on a case-by-case basis received home monitoring or a tracheostomy. Decision tree model-managed newborns had specialist consultations and diagnostic testing to determine whether home monitoring, tracheostomy, or distraction osteogenesis would be implemented. In Part II, tracheostomy treatment was compared directly to distraction osteogenesis. Results: In Part I (conventional versus decision tree model), taking into account the costs of the distraction, tracheostomy, hospital stay, diagnostic studies, physician fees, and emergency department visits, the total per patient treatment cost was 1.5 greater in the conventional treatment group ($332,673) compared with the decision tree model ($225,998) (p < 0.05). In Part II (tracheostomy versus distraction osteogenesis), the total per-patient treatment cost in the tracheostomy group was two times greater than in the distraction group ($382,246 versus $193,128) (p < 0.05). Conclusions: In treating newborns with micrognathia and upper airway obstruction, a decision tree model with mandibular distraction decreases long-term health care costs compared with conventional treatment. Furthermore, when comparing distraction to tracheostomy, similar decreases in long-term health care costs occurred.