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Office-based surgery has several potential benefits over hospital-based surgery, including cost containment, ease of scheduling, and convenience to both patients and surgeons. Scrutiny of office-based surgery by regulators and state-licensing agencies has increased and must be addressed by improved documentation of safety and efficacy. To evaluate the safety and efficacy of the authors' office-based plastic surgery, a review was undertaken of 3615 consecutive patients undergoing 4778 outpatient plastic surgery procedures under monitored anesthesia care/sedation in a single office. The charts of 3615 consecutive patients who had undergone office-based surgery with monitored anesthesia care/sedation between May of 1995 and May of 2000 were reviewed. In all cases, the anesthesia protocol used included sedation with midazolam, propofol, and a narcotic administered by a board-certified registered nurse anesthetist with local anesthesia provided by the surgeon. Charts were reviewed for patient profile, types of procedures, multiple procedures, duration of anesthesia, American Society of Anesthesiologists class, and complications related to anesthesia. Outcomes measured included death, airway compromise, dyspnea, hypotension, venous thrombosis, pulmonary emboli, protracted nausea and vomiting lasting more than 24 hours, and unplanned hospital admissions. Statistical analyses were performed using the Microsoft Excel program and the SAS package. Results were as follows: 92.3 percent of the patients were female and 7.7 percent were male, with a mean age of 42.7 years (range, 3 to 83 years). Patients underwent aesthetic (95.6 percent) and reconstructive (4.4 percent) plastic surgery procedures. Same-session multiple procedures occurred in 24.8 percent of patients. The vast majority of patients were healthy: 84.3 percent of patients were American Society of Anesthesiologists class I, 15.6 percent were class II, and 0.1 percent were class III. The operations required a mean of 111 minutes. There were no deaths, ventilator requirements, deep venous thromboses, or pulmonary emboli. Complications were as follows: 0.05 percent (n = 2) of patients had dyspnea that resolved, 0.2 percent (n = 6) of patients had protracted nausea and vomiting, and 0.05 percent (n = 2) of patients had unplanned hospital admissions (

PURPOSE: To analyze the demographics, hospital course, functional outcome, and reimbursement for elderly patients sustaining multisystem trauma. METHODS: The Trauma Registry was searched for patients > or = 65 years old with an Injury Severity Score (ISS) > or = 10 admitted with multisystem trauma from January 1991 through December 1991. Hospital data were obtained from the Trauma Registry; reimbursement data from the business office; and complete follow-up (mean, 12 months) data by telephone survey for all patients. RESULTS: Of the 1,931 trauma patients admitted during the study period, 601 (31%) were > or = 65 years old and 94 (5%) met the study criteria. Of these 94 patients, 52 were women and 42 were men; their mean age was 79 years (range, 65-100). Falls (59%) and motor vehicle crashes (36%) were the predominant causes of injury; closed head injury (CHI) and fractures were the most frequent injuries. The mean ISS was 18 (range, 10-57), and hospital stay averaged 10 days. Intensive care unit admission was necessary for 37%, and 38% required surgical intervention. Factors associated with mortality included previous myocardial infarction, chronic renal insufficiency, ventilatory or inotropic support (or both), shock (systolic BP < or = 90 mm Hg) at admission, bradycardia (HR < or = 60 bpm) at admission, and severe CHI (Glasgow Coma Scale score < or = 8). Mortality was 23% (22 of the 94 patients); three quarters of the deaths occurred in the first 24 hours--most from severe CHI. At discharge, 53% of patients (38 of 72) went home and 36% (26 of 72) went to nursing homes. At a mean follow-up of 12 months, an additional seven patients had died, and three quarters of the patients were at home with an independent functional status. The percentage of reimbursement for care was two thirds of cost. CONCLUSIONS: Mortality rates are high for elderly patients who sustain multisystem trauma. Most deaths occur within the first 24 hours, and most injuries are severe CHIs. More than half of survivors are discharged home, and most are independent at long-term follow-up. Reimbursement is not commensurate with the functional outcome achieved and the care provided.

Free-floating tumor debris or mucobilia as a cause of intermittent obstruction has been described infrequently. A patient with intermittent jaundice caused by tumor emboli from an intrahepatic polypoid mucinous cholangiocarcinoma is presented. Symptoms of intermittent jaundice and midepigastric pain persisted over 5 years despite an initial cholecystectomy and common bile duct exploration before definitive diagnosis and treatment of an hepatic trisegmentectomy (segments II, III, and IV). Intraductal mucin was confirmed intraoperatively and pathologically as the cause of the obstructive jaundice. The patient remains asymptomatic and without evidence of disease more than 5 years postoperatively. This report of a predominantly mucin-producing intrahepatic cholangiocarcinoma details a rare protracted clinical course of intermittent biliary obstruction from mucus emboli and highlights the possibility of long-term survival after complete resection.

Complex open wounds of the distal third of the leg and ankle remain a reconstructive challenge for the plastic surgeon. In many cases, these wounds are best addressed with a free tissue transfer. Although this group has performed more than 400 free flaps to the leg during the past 6 years, free tissue transfer can be an arduous operation that requires a team approach and substantial donor site morbidity for the patient. In recent years, the authors have favored the reverse sural artery fasciocutaneous flap in 11 patients for its ease of dissection, limited morbidity, and preservation of major vessels to the limb. Caveats for successful performance of the reverse sural artery flap include Doppler evidence of patent peroneal perforators, placement of a lazy T-shape skin paddle over the distal gastrocnemius muscle bellies, inclusion of the lesser saphenous vein to augment venous drainage, and, lastly, careful dissection to provide a wide adipofascial pedicle.

The surgical registry was reviewed for mandibular reconstruction from 1988 to 1992. During this time, 51 patients underwent mandibular reconstruction. Of this group, 17 patients had their microvascular bone grafts secured with lag-screw fixation. An AO technique, utilizing 2.7-mm cortical screws, was used to provide rigid fixation. Mandibular defects ranged from 6 to 20 cm. AO vascularized bone grafts were studied with bone scans and remained viable. Follow-up revealed no flap losses or oral cutaneous fistulae. Lag-screw fixation, in conjunction with mandibular reconstruction, results in rigid fixation, obviates the need for mandibulamaxillary fixation, has the advantage of ease of application, and is safe to use.