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Previous literature has documented craniometric changes of the bony calvaria, increases in intracranial volume, and resolution of Chiari malformations following posterior vault distraction osteogenesis. No studies have analyzed changes to the soft-tissue envelope after posterior vault distraction osteogenesis. In this study, the authors aimed to provide objective measurements of scalp thickness in patients undergoing posterior vault distraction osteogenesis, utilizing facial soft-tissue thickness as a proxy to control for growth. The authors hypothesized that the soft tissues of the scalp are not made thinner by the distraction process, either in the region of distraction or in neighboring areas. Subjects who underwent posterior vault distraction osteogenesis for a craniosynostosis diagnosis who had high-resolution predistraction and post-distractor removal computed tomographic scans within 100 days of each operation were included. The scans were analyzed on Materialise Mimics version 21 software (Materialise, Ghent, Belgium). Six key craniometric landmarks (glabella, pogonion, zygion, vertex, euryon, and opisthocranium) were identified on the three-dimensional bone masks in the Frankfort horizontal plane. The points were overlaid onto soft-tissue thickness masks and thicknesses were recorded. Percent change in postoperative facial soft-tissue thickness was used to control for growth of the craniofacial soft-tissue envelope during the study interval. The preoperative and postoperative posterior vault distraction osteogenesis cohorts did not differ significantly at the glabella, pogonion, opisthocranium, vertex, and zygion. The corrected median thickness at the euryon was significantly increased in the post-posterior vault distraction osteogenesis cohort [2.67 mm (IQR, 2.49 mm to 4.02 mm) versus 5.26 mm (IQR, 3.83 mm to 7.82 mm), p = 0.002]. This is the first study to quantify changes in soft-tissue thicknesses preoperatively and postoperatively in patients undergoing posterior vault distraction osteogenesis, demonstrating maintenance of scalp thickness. .Therapeutic, IV.

Background: Surgical site infections (SSIs) increase mortality and the economic burden associated with emergency surgery (ES). A reliable and sensitive scoring system to predict SSIs can help guide...

The authors observe significant bone gaps upon distractor removal in posterior vault distraction osteogenesis (PVDO). The purpose of this study was to quantify bone gaps upon distractor removal, determine whether they close over time, determine if they predispose to relapse, and investigate whether age affects rate and degree of re-ossification. The authors performed a retrospective review of PVDO patients and included those with computed tomography (CT) scans at 2 timepoints: 1 at completion of consolidation and another at least 4 months later. Using Mimics software, bone gaps were traced to calculate total surface area. A paired t test and linear regression were used to compare size of bone gaps, presence of relapse, and rates of re-ossification. Sixty-nine patients were identified, with 7 meeting inclusion criteria. Three were under 1 year. Consolidation began 28.3 ± 6.0 days after surgery and continued for 64.9 ± 14.5 days. Length of time between CT scans was 7.5 ± 2.7 months. A significant decrease in bone gaps occurred between scans (33.4 ± 14.6 cm2 versus 19.2 ± 17.2 cm2, P = 0.005). After consolidation, ossification occurred at a rate of 2.4 cm2/month (P = 0.046). The rate of bony regeneration in patients under and over 1 year was 4.3 cm3/month (P = 0.025) and 1.5 cm3/month (P = 0.552), respectively. Despite differential bony regeneration rates, no patient demonstrated relapse. From this study, the authors conclude the following. Calvarial bone gaps are present after PVDO consolidation. These gaps undergo re-ossification at a rate that appears to be faster in infants. Overall, they decrease in size over time. The presence of bone gaps does not correlate with relapse of cranial expansion.

Background Posterior vault distraction osteogenesis (PVDO) has been demonstrated to effectively increase intracranial volume, treat increased intracranial pressure, and improve head shape in syndromic patients. The purpose of this study is to compare changes along the posterior cranial base before and after distraction. Methods A retrospective review was completed of subjects who underwent PVDO with computed tomography scans at 2 time-points: within 3 months preoperatively and 1 to 6 months postoperatively. Using Mimics software, craniometric landmarks were identified and surface area of the foramen magnum was calculated. A comparison of pre- to postoperative measurements was completed using Wilcoxon matched-paired signed rank tests and linear regression. Results A total of 65 PVDO subjects were identified, 12 subjects met inclusion criteria. Mean operative age was 3.0 ± 4.0 years. The cranial vault was distracted on average 25.0 ± 6.0 mm, with those 12 months of age distracted 22.0 ± 4.9 mm (P = 0.0543). There was a significant increase in pre- to postoperative foramen magnum surface area (52.1 ± 63.2 mm, P = 0.002), length (0.9 ± 1.4 mm, P = 0.050), and width (0.6 ± 1.0 mm, P = 0.050). Similarly, linear distances between nasion and posterior cranial base landmarks such as foramen magnum (3.4 ± 4.2 mm, P = 0.010), and occipital protuberance (9.1 ± 9.6 mm, P = 0.003) were increased. Subjects under 12 months had a greater percentage increases in posterior vault length than those over 12 months. Conclusion Posterior vault distraction osteogenesis is associated with an increase in size of the foramen magnum, and lengthening of the posterior cranial base, both of which may be beneficial in patients with turribrachycephaly.

Midface advancement by distraction osteogenesis (DO) is commonly performed in patients with craniosynostosis for indications including midface hypoplasia, exorbitism, obstructive sleep apnea, class III malocclusion, and overall aesthetic facial deficiency. There is evidence to suggest that maxillary LeFort I advancement increases the risk of velopharyngeal dysfunction in the cleft palate population, yet few studies have investigated changes in speech following LeFort III or monobloc midface advancement in patients with syndromic craniosynostosis. The purpose of this study was to examine the effect of midface DO on speech as indicated by the Pittsburgh Weighted Speech Score in patients with Apert, Crouzon, and Pfeiffer Syndrome. Among 73 midface advancement cases performed during the study period, 19 cases met inclusion criteria. Overall, the highest post-advancement Pittsburgh Weighted Speech Score (PWSS) was significantly higher than the pre-advancement PWSS (0.52 versus 2.42, P = 0.01), indicating an acute worsening of VPI post-advancement. Specifically, the PWSS components nasal emission and nasality were significantly higher post-advancement than pre-advancement (nasal emission: 1.16 versus 0.21, P = 0.02) (nasality: 0.68 versus 0.05, P = 0.04). However, there was no significant difference between pre-advancement PWSS and the latest post-advancement PWSS (P = 0.31). Midface distraction is associated with an acute worsening of VPI post-operatively that is followed by improvement, and often resolution over time. Future work with additional patient accrual is needed to determine the effect of different advancement procedures and syndromes on VPI rates and profundity.

BACKGROUND The purpose of this study was to determine what craniometric changes occur to both orbits of unicoronal craniosynostosis patients undergoing fronto-orbital advancement and remodeling, and which of these changes are associated with new onset of postoperative strabismus. METHODS A retrospective analysis was performed of the preoperative and postoperative orbits of 24 unicoronal craniosynostosis patients and the orbits of 24 control subjects, totaling 144 orbits. Eight parameters were evaluated using multivariate logistic regression analysis. One of the parameters was modified orbital index, an indicator of severity of harlequin deformity. RESULTS Significant differences in orbital dimensions and angles were present bilaterally in unicoronal craniosynostosis orbits when compared to controls. Fronto-orbital advancement and remodeling increased the ipsilateral unicoronal craniosynostosis orbital volume from 13,184 ± 2003 mm to 16,220 ± 2323 mm (p < 0.001). Ipsilateral horizontal cone angles were increased from 48 ± 5 degrees to 54 ± 7 degrees (p = 0.004). Ipsilateral vertical cone angles were decreased from 73 ± 8 degrees to 66 ± 10 degrees (p = 0.003). Ipsilateral modified orbital index improved from 0.83 ± 0.06 to 0.88 ± 0.06 (p = 0.003). Three of the 19 unicoronal craniosynostosis patients developed transient postoperative strabismus. Logistic regression analysis displayed a strong significant association between new-onset strabismus and a change in modified orbital index with a coefficient of 30.84 ± 14.51 (p < 0.05). CONCLUSIONS The orbital dysmorphology in unicoronal craniosynostosis is bilateral in nature, and it is not wholly treated with conventional fronto-orbital advancement and remodeling. The severity of ipsilateral orbital dysmorphology is correlated with the incidence of postoperative strabismus following conventional fronto-orbital advancement and remodeling. Future research is needed to develop strategies to mitigate the risk of development of strabismus in this group of patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

BACKGROUND How hospital case-volume affects operative outcomes and cost continues to grow in importance. The purpose of this study was to examine the relationship of case volume with operative outcomes and cost in cleft palate repair. METHODS Subjects undergoing cleft palate repair between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two groups: those undergoing treatment at a high-volume institution, and those undergoing treatment at a low-volume institution. Primary outcomes were as follows: any complication, prolonged length of stay, and increased total cost. RESULTS Over 20,000 patients (n = 20,320) from 49 institutions met inclusion criteria. On univariate analysis, those subjects who underwent treatment at a high-volume institution had a lower rate of overall complications (3.4 percent versus 5.1 percent; p < 0.001), and lower rates of prolonged length of stay (4.5 percent versus 5.8 percent; p < 0.001) and increased total cost (48.6 percent versus 50.9 percent; p = 0.002). In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.678; p < 0.001) and were less likely to have an extended length of stay (OR, 0.82; p = 0.005). Subjects undergoing palate repair at a high-volume institution were no less likely to incur increased total cost (OR, 1.01; p = 0.805). CONCLUSION In institutions performing a high volume of cleft palate repairs, subjects had significantly decreased odds of experiencing a complication or prolonged length of stay. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

PURPOSE The aim of this study is to evaluate the effect of timing of surgery and spring characteristics on correction of scaphocephalic deformity in patients undergoing spring-mediated cranioplasty (SMC) for sagittal craniosynostosis. METHODS The authors conducted a review of patients with sagittal craniosynostosis who underwent SMC at a tertiary referral center between July 2011 and March 2017, with a primary outcome measure of head shape, both preoperatively and postoperatively, determined by cephalic index (CI). Patient demographics and operative details including timing of surgery and spring characteristics were collected. Differences in CI preoperation and postoperation were compared using Wilcoxon signed-rank test. Ordinary least-squares linear regression was used to assess the impact of timing, number of springs, maximum single spring force, and total spring force on postoperative change in CI. RESULTS Thirty-six subjects (12 males and 24 females) were included in the study. Mean age at spring placement was 3.9 months (range: 1.9-9.2) with a mean follow-up of 1.4 years (range: 0.3-5.2). The mean number of springs used was 3 (range: 2-4). The mean maximum single spring force was 9.9 Newtons (N) (range: 6.9-13.0) and the mean total spring force was 24.6 N (range: 12.7-37.0). Mean CI increased from 70 ± 0.9 preoperatively to 77 ± 1.0 postoperatively (P

Background The establishment of an effective clinical and academic culture within an institution is a multifactorial process. This process is cultivated by dynamic elements such as recruitment of an accomplished and diverse faculty, patient geographic outreach, clinical outcomes research, and fundamental support from all levels of an institution. This study reviews the academic evolution of a single academic plastic surgery practice, and summarizes a 10-year experience of microsurgical development, clinical outcomes, and academic productivity. Methods A 10-year retrospective institutional review was performed from fiscal years 2006 to 2016. Microsurgical flap type and operative volume were measured across all microsurgery faculty and participating hospitals. Microvascular compromise and flap salvage rates were noted for the six highest volume surgeons. Univariate and multivariable predictors of flap salvage were determined. Results The 5000th flap was performed in December of 2015 within this institutional study period. Looking at the six highest volume surgeons, free flaps were examined for microvascular compromise, with an institutional mean take-back rate of 1.53 percent and flap loss rate of 0.55 percent across all participating hospitals. Overall, 74.4 percent of cases were breast flaps, and the remaining cases were extremity and head and neck flaps. Conclusions Focused faculty and trainee recruitment has resulted in an academically and clinically productive practice. Collaboration among faculty, staff, and residents contributes to continual learning, innovation, and quality patient care. This established framework, constructed based on experience, offers a workable and reproducible model for other academic plastic surgery institutions. Clinical question/level of evidence Therapeutic, IV.

BACKGROUND The relationships between hospital/surgeon characteristics and operative outcomes and cost are being scrutinized increasingly. In patients with craniosynostosis specifically, the relationship between hospital volume and outcomes has yet to be characterized. METHODS Subjects undergoing craniosynostosis surgery between 2004 and 2015 were identified in the Pediatric Health Information System. Outcomes were compared between two exposure groups, those undergoing treatment at a high-volume institution (>40 cases per year), and those undergoing treatment at a low-volume institution (40 cases per year). Primary outcomes were any complication, prolonged length of stay, and increased total cost. RESULTS Over 13,000 patients (n = 13,112) from 49 institutions met inclusion criteria. In multivariate regression analyses, subjects treated in high-volume centers were less likely to experience any complication (OR, 0.764; p < 0.001), were less likely to have an extended length of stay (OR, 0.624; p < 0.001), and were less likely to have increased total cost (OR, 0.596; p < 0.001). Subjects undergoing strip craniectomy in high-volume centers were also less likely to have any complication (OR, 0.708; p = 0.018) or increased total cost (OR, 0.51; p < 0.001). Subjects undergoing midvault reconstruction in high-volume centers were less likely to experience any complications (OR, 0.696; p = 0.002), have an extended length of stay (OR, 0.542; p < 0.001), or have increased total cost (OR, 0.495; p < 0.001). CONCLUSION In hospitals performing a high volume of craniosynostosis surgery, subjects had significantly decreased odds of experiencing a complication, prolonged length of stay, or increased total cost compared with those undergoing treatment in low-volume institutions. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

BACKGROUND The effects of orthognathic surgery go beyond objective cephalometric correction of facial and dental disproportion and malocclusion, respectively. The authors hypothesized that there is tangible improvement following surgery that alters publicly perceived personality traits and emotions. METHODS The authors used Amazon.com's Mechanical Turk (MTurk), a crowdsourcing tool, to determine how preoperative and postoperative images of orthognathic surgery patients were perceived on six personality traits and six emotional expressions based on posteroanterior and lateral photographs. Blinded respondents provided demographic information and were randomly assigned to one of two sets of 20 photographs (10 subjects before and after surgery). RESULTS Data on 20 orthognathic surgery patients were collected from 476 individuals. The majority of participants were female (52.6 percent), 18 to 39 years old (67.9 percent), Caucasian (76.6 percent), had some college or technical training or graduated college (72.7 percent), and had an annual income between $20,000 and $99,999 (74.6 percent). A paired t test analysis found that subjects were perceived significantly more favorably after orthognathic surgery in 12 countenance categories: more dominant, trustworthy, friendly, intelligent, attractive, and happy; and also less threatening, angry, surprised, sad, afraid, and disgusted (p < 0.05). Raters with the highest annual income perceived a greater magnitude of dominance after surgery than those earning less (p < 0.001). CONCLUSIONS There is significant improvement in the countenance of patients after orthognathic surgery, with both perceived personality traits and emotions deemed more favorable. Additional work is needed to better understand the physiologic underpinnings of such findings. Crowdsourcing technology offers a unique opportunity for surgeons to gather data regarding laypeople's perceptions of surgical outcomes in areas such as orthognathic surgery.

While in-hospital outcomes and long-term results of craniosynostosis surgery have been described, no large studies have reported on postoperative readmission and emergency department (ED) visits. The authors conducted this study to describe the incidence, associated diagnoses, and risk factors for these encounters within 30 days of craniosynostosis surgery.Using 4 state-level databases, the authors conducted a retrospective cohort study of patients

The authors hypothesize that posterior sheath reconstruction to achieve retromuscular mesh placement provides outcomes comparable to traditional retromuscular mesh placement and superior to intraperitoneal repair.Patients were divided into three groups: (1) retromuscular mesh placement with repaired posterior sheath defects, (2) retromuscular repair with an intact posterior sheath, and (3) intraperitoneal repair. Primary outcomes included recurrence, surgical-site occurrences, and cost.Overall, 179 patients were included. Posterior sheath defects were repaired primarily with absorbable suture or biological mesh. Recurrence rates differed significantly between standard retromuscular repair and intraperitoneal repair groups (p0.009), trended toward significance between repaired posterior sheath and intraperitoneal repair groups (p0.058), and showed no difference between repaired posterior sheath and standard retromuscular repair (p0.608). Retromuscular repair was clinically protective and cost-effective.This analysis of posterior sheath reconstruction suggests outcomes comparable to traditional retromuscular repair and a trend toward superiority compared with intraperitoneal repair. Achieving retromuscular closure appears to demonstrate clinical and cost efficacy.Therapeutic, III.

Cranial base sutures are important drivers of both facial and cranial growth. The purpose of this study was to compare the incidence and location of cranial base suture fusion among three groups: nonaffected controls, patients with nonsyndromic craniosynostosis, and patients with syndromic craniosynostosis.Patients and computed tomographic scans were accrued from the authors' prospective craniofacial database. Computed tomographic scans were graded on the frequency of cranial vault and cranial base suture/synchondrosis fusion (0, open; 1, partially/completely fused) by an attending craniofacial surgeon and neuroradiologist. Statistical comparisons were conducted on location and rates of fusion, age, and diagnosis.One hundred forty patients met inclusion criteria: 55 syndromic, 64 nonsyndromic, and 21 controls. Average age at computed tomography of syndromic patients (3.6 ± 3.1 months) was younger than that of nonsyndromic patients (5.4 ± 3.1 months; p = 0.001) and control subjects (5.1 ± 3.2 months; p = 0.058). Syndromic craniosynostotic patients had over three times as many cranial base minor sutures fused (2.2 ± 2.5) as nonsyndromic craniosynostosis patients (0.7 ± 1.2; p0.001) and controls (0.4 ± 0.8; p = 0.002), whose rates of fusion were statistically equivalent (p = 0.342). Syndromic craniosynostosis patients had a greater frequency of cranial base suture fusion in the coronal branches, squamosal arch, and posterior intraoccipital synchondrosis (p0.05).Patients with syndromic craniosynostosis have higher rates of cranial base suture fusion in infancy, especially in the coronal arches, and this may have significant implications for both cranial and facial growth. In contrast, patients with nonsyndromic craniosynostosis have similar rates and sites of cranial base suture fusion as controls. Interestingly, there is a low, "normal," rate of cranial base suture/synchondrosis closure in infancy, the implications of which are unknown.Risk, III.

Background Posterior vault distraction osteogenesis (PVDO) is believed to improve frontal contour in infants with syndromic craniosynostosis and turribrachycephaly. This study provides an objective craniometric analysis to determine how PVDO affects anterior cranial morphology. Methods A retrospective chart review of patients who underwent PVDO was performed. Inclusion criteria included pre- and postoperative computed tomography (CT) scans within 3 months before surgery and another 1 to 6 months after device removal. Volumetric and craniometric data were derived using Mimics software and compared using paired t-test and Wilcoxon rank-sum test. Results About 65 patients underwent PVDO, and 13 patients met inclusion criteria. Mean age at intervention was 3.4 ± 4.2 years. Total cranial volume increased 249 ± 159 cm in all patients (P = 0.0001) and 380 ± 128 cm in patients younger than 1 year of age (n = 6, P =0 .0008). Supraorbital retrusion decreased from 5.44 ± 3.89 to 4.54 ± 3.91 mm postoperatively (P = 0.0004), decreasing significantly in patients without previous frontal surgery and not in those with previous frontal surgery (P = 0.2115; comparison P = 0.0047). Basofrontal angle decreased by 2.92 ± 2.16 degrees (P = 0.0004) with a greater decrease of 3.33±2.68 degrees in those younger than 12 months (P = 0.0289) and 2.58±1.74 degrees in those older (P = 0.0079). No change was found in anterior cranial height and anterofrontal angle (P > 0.05). Conclusion PVDO improves frontal contour by decreasing supraorbital retrusion and reducing frontal bossing in syndromic craniosynostosis patients with turribrachycephaly. When combined with its demonstrated efficacy for cranial expansion, these frontal changes likely reinforce PVDO's ability to influence the timing of, and to a degree, the need for frontal surgery in this group.

Purpose The purpose of this study was to evaluate the indications, safety, and short-term outcomes of posterior vault distraction osteogenesis (PVDO) in patients with no identified acrocephalosyndactyly syndrome (study) and to compare those to a syndromic cohort (controls). Methods Demographic and perioperative data were recorded and compared across the study and control groups for those who underwent PVDO between January 2009 and December 2016. Univariate analysis was conducted using χ and Fisher exact tests for categorical variables, and Mann-Whitney U test for continuous variables. Results Sixty-three subjects were included: 19 in the nonsyndromic cohort, 44 in the syndromic cohort. The cohorts had similar proportion of subjects exhibiting pansynostosis (42.1% of nonsyndromic versus 36.4% of syndromic, P = 0.667). The nonsyndromic cohort was significantly older (4.04 ± 3.66 years versus 2.55 ± 3.34 years, P = 0.046) and had higher rate of signs of raised intracranial pressure (68.4% versus 25.0%, P = 0.001) than the syndromic cohort. There was no significant difference in perioperative variables or rate of complications (P > 0.05). The mean total advancement distance achieved was similar, 27 ± 6 mm in the nonsyndromic versus 28 ± 8 mm in the syndromic cohort (P = 0.964). All nonsyndromic subjects with signs of raised intracranial pressure demonstrated improvement at an average follow-up of 22 months. Conclusion As in the syndromic patient, PVDO is a safe and, in the short-term, effective modality for cranial vault expansion in the nonsyndromic patient. The benefits and favorable perioperative profile of PVDO may therefore be extended to patient populations other than those with syndromic craniosynostosis.

BACKGROUND A large proportion of patients presenting for autologous breast reconstruction have a history of prior abdominal surgeries such as obstetric, gynecologic, or general surgical procedures. The impact of prior abdominal wall violation on the ability to perform free tissue transfer from the abdomen needs to be explored and characterized. The purpose of this study was to assess the impact of prior abdominal surgery on perfusion-related complications and donor-site morbidity in free tissue abdominal transfer. METHODS All patients who underwent abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at the Hospital of the University of Pennsylvania were included. In addition to collecting data on standard patient past medical histories, comorbidities, and case characteristics, we also noted specific types of prior abdominal surgeries, number of prior surgeries, and if the rectus sheath was violated. Outcomes assessed included thrombotic complications, flap loss, major surgical complications, minor surgical complications, delayed wound healing, and subsequent hernia formation. RESULTS Eight hundred twelve patients underwent 1257 free flap breast reconstructions during the study period. Four hundred seventeen (51.4%) women had undergone prior abdominal surgery. The most common prior abdominal surgeries included total abdominal hysterectomy and/or bilateral salpingo-oophorectomy (35.7%), cesarean delivery (33.8%), and appendectomy (12.7%). No significant differences were noted in the number of major intraoperative complications (P = 0.68), total thrombotic events (P = 0.339), or flap losses (P = 0.53). Patients who had undergone prior rectus sheath violation were found to experience a greater amount of delayed healing of the donor site (22.7% vs 16.5%, P = 0.03). Additionally, a higher rate of postoperative hernia formation was noted in patients who had undergone prior hernia repairs (13.6% vs 3.3%, P = 0.04). CONCLUSIONS A significant portion of patients presenting for breast reconstruction have had prior abdominal surgeries. This study demonstrates that these prior procedures represent an acceptable level of risk; although this issue should still be addressed during preoperative patient counseling. In patients with prior hernia repairs, however, additional care should be given to the fascial closure as these patients may be at higher risk for subsequent hernia formation after abdominally based breast reconstruction.

For patients with BRCA mutations, a simultaneous procedure that combines risk-reducing operation of the ovaries with mastectomy and breast reconstruction is an attractive option. The purpose of this study was to assess the outcomes and associated cost of performing simultaneous mastectomy, free flap breast reconstruction (FFR), and gynecologic procedure.A retrospective chart review was performed on patients who underwent bilateral FFR from 2005 to 2012. Four hundred twenty-two patients were identified who underwent bilateral breast reconstruction without a simultaneous gynecologic procedure. Forty-two patients were identified who underwent simultaneous FFR and gynecologic procedure. Clinical outcomes, medical and surgical complications, and hospital costs were analyzed and compared between the 2 groups.A total of 928 free flaps were performed on 464 patients. Forty-two patients had a simultaneous gynecologic procedure at the time of breast reconstruction. Twenty-three (54.8%) patients within the study group underwent simultaneous bilateral salpingo oophorectomy (BSO), whereas the other 19 (45.2%) underwent both total abdominal hysterectomy and BSO. Eighty-four free flaps were performed in this cohort (n = 48 muscle-sparing transverse rectus abdominis myocutaneous, n = 28 deep inferior epigastric perforator, n = 4 superficial inferior epigastric perforator, n = 4 transverse upper gracilis). Mean operative time was 573 minutes. Mean hospitalization was 5.3 days. Postoperatively, 4 patients experienced an anastomotic thrombosis; 2 patients had an arterial thrombosis and 2 patients had a venous thrombosis. There were 2 flap failures, 2 patients with mastectomy skin flap necrosis, 11 patients who developed breast wound healing complications, and 6 patients who developed abdominal wound healing complications. Surgical and medical complication rates did not differ significantly between those who had simultaneous procedures, and those who did not. There was a statistically significant difference in the average total cost when comparing the group of patients receiving prophylactic mastectomy/FFR/total abdominal hysterectomy and/or BSO versus the patients who did not have combined gynecologic procedures at the time of reconstruction ($22,994.52 vs $21,029.23, P = 0.0004).For the high-risk breast cancer patient, a combined mastectomy, free flap reconstruction, and gynecologic procedure represents an attractive and safe option.

Institutions are now incentivized to decrease rates of preventable readmissions. The purpose of this study was to examine readmissions following open ventral hernia repair (VHR), to ultimately create a model to preoperatively identify high-risk patients. Utilizing the 2011 and 2012 ACS-NSQIP datasets, patients undergoing open VHR were identified by CPT codes. Patients who were readmitted in 2011 within 30 days of the procedure were compared to those who were not with regard to preoperative and operative characteristics. A bootstrap analysis was performed to identify internally validated risk factors to be included in the final logistic regression, which was utilized to create a weighted model to predict the risk of readmission. This model was then validated with VHR patients in 2012. Overall, 10,745 patients were included for model generation. Of these, 850 (7.9 %) patients were readmitted within 30 days. The final bootstrap analysis demonstrated that active smoking, ASA ≥ 3, a history of bleeding disorder or anemia, long operative time, inpatient status, and concurrent panniculectomy were all independently associated with readmission following ventral hernia repair. Significant variables were assigned a weighted score, ranging from 1 to 3. Each patient was then placed into one of four cohorts according to their summed score. The internally validated model [Hernia Readmission Risk (HERR) Score] demonstrated that risk increased in a linear fashion, with the highest risk cohort having a 21 % risk of 30-day readmission. Perioperative predictors of readmission following VHR include smoking, ASA score, operative magnitude, concurrent panniculectomy, and preoperative anemia and bleeding disorders. The presented model based on these factors can aid in perioperative risk stratification for readmission.

BACKGROUND The authors hypothesized that patients with unicoronal craniosynostosis (UCS) have deviation of the vault, cranial base, and face resulting in significant differences in skull base morphology and segmental cranial vault volume relative to nonaffected controls. METHODS Unicoronal craniosynostosis patients were collected from the authors' IRB-approved, prospective, craniofacial registry; controls were from a trauma registry. Mimics software was used to compare those with UCS to controls for a series of standardized craniometric angles and distances. A segmented volumetric analysis of anterior, middle, and posterior cranial fossae was performed, as well. RESULTS The study included 18 patients with UCS and 19 controls. Nearly all angles measured were statistically different in UCS versus controls. Overall cranial vault volume did not differ between UCS and controls (P = 0.250). Three volumetric ratios comparing the synostosed side to the contralateral were significantly less than controls: anterior (0.44 ± 0.03 versus 0.5 ± 0.01, P

BACKGROUND The Whitaker classification is a simple and widely used system for describing aesthetic outcomes after craniosynostosis surgery. The purpose of this study is to evaluate its interrater reliability for patients who have undergone fronto-orbital surgery. METHODS A retrospective review of patients with craniosynostosis who underwent surgical intervention at a tertiary referral center was conducted. Inclusion criteria were as follows: single-suture craniosynostosis, surgical intervention before age 2 years, and photographs taken before revisions between 5 and 20 years of age. Thirteen craniofacial surgeons independently reviewed the subjects' photographs and assigned Whitaker classifications. Interrater reliability was assessed with the Cohen kappa statistic. RESULTS Twenty-nine subjects were included. Average ages at surgery and at the time of postoperative photography were 0.8 year and 12.8 years, respectively. The κ value for all 13 raters was 0.1567 (p < 0.0001), indicating "slight agreement." Pairwise comparisons demonstrated κ values ranging from 0.0384 to 0.5492. The average rating for the set of 29 photographs differed significantly across the 13 raters (p = 0.0020) and ranged from 1.79 ± 0.68 to 2.79 ± 0.77. Finally, we found that average Whitaker classification did not differ significantly between subjects who subsequently underwent cranioplasty and/or fronto-orbital advancement and those who did not (subsequent procedures, 2.45 ± 0.55; no subsequent procedures, 1.88 ± 0.78; p = 0.1087). CONCLUSIONS The Whitaker classification exhibits low interrater reliability and does not predict future treatment. It may benefit craniofacial surgeons to create new evaluation tools with greater precision, to improve the quality of patient care and craniofacial outcomes research.

PURPOSE Current operative techniques for correcting unicoronal craniosynostosis (UCS) leave the nasal bones untouched, resulting in an unclear long-term impact on nasal root deviation. The purpose of this study is to quantify nasal root deviation in the preoperative and late postoperative setting in patients who have undergone conventional single-staged UCS correction. METHODS The authors performed a retrospective, craniometric analysis of nasal root deviation comparing preoperative computed tomography scans, with those of the early, and late postoperative period. Three vectors were analyzed to measure nasal root deviation, one extending from the nasion to the rhinion (nasal bone vector), the second from the rhinion to the anterior nasal spine (nasal aperture vector), and the third from the nasion to the anterior nasal spine (nasal longitudinal vector). RESULTS Twenty-five subjects were included in the study. Average ages at the time of preoperative, early, and late postoperative imaging were 0.6 ± 0.3, 0.9 ± 0.6, and 9.3 ± 2.7 years, respectively. Improvement of angular deviation of both the nasal aperture vector and nasal longitudinal vector was observed. Mean angular deviation of the nasal aperture vector was 6.0 ± 1.9 degrees preoperatively, 6.0 ± 2.1 degrees early postoperatively (P = 0.952), and 2.4 ± 2.1 in the late postoperative period (P = 0.013). Mean angular deviation of the nasal longitudinal vector was 5.7+2.0 degrees preoperatively, 5.8 ± 2.3 degrees early postoperatively (P = 0.948), and 3.7 ± 1.6 degrees in the late postoperative period (P = 0.019). CONCLUSION Nasal root deviation decreased significantly only in the late postoperative period, lending credence to the notion that though UCS correction does not directly address nasal root deviation, this pathology improves significantly over time.

Background: The purpose of this study was to identify variables that may preoperatively predict successful outcomes in ambulatory cleft lip repair and to quantify the potential cost savings. Methods: A retrospective chart review of all patients who underwent cleft lip repair at a tertiary cleft care center from January of 2010 to May of 2013 was performed. Because inpatient stay is the authors’ current practice, overnight desaturations, poor oral intake, and failure to stop intravenous narcotics during the first day were considered indicators of a poor candidate. Charge data were also collected. Results: Twenty-nine of 111 patients were deemed likely to fail ambulatory surgery. American Society of Anesthesiologists score greater than 2 (p = 0.019), low birth weight (p = 0.022), bilateral cleft lip–cleft palate (p = 0.003), central nervous system or neurologic diagnosis (p = 0.046), syndromic and/or multiple congenital abnormalities (p = 0.024), prior emergency room visits (p = 0.021), failure to thrive (p = 0.046), and age older than 7 months (p = 0.028) were associated with poor candidacy. A diagnosis of cleft lip was protective (p = 0.015). Fifty-five patients had no risk factors for a poor ambulatory outcome and did not stay more than 1 day. The average savings per patient who met the authors’ criteria was $4261. Conclusions: The authors found that 49.5 percent of children may be safely eligible for ambulatory cleft lip repair. Patients with risk factors may be best served by a short hospital admission. This would lead to a national savings of $8,765,183 per year.

Choosing a breast reconstructive modality after mastectomy is an important step in the reconstructive process. The authors hypothesized that autologous tissue is associated with a greater success rate and cost efficacy over time, relative to implant reconstruction.A retrospective review was performed of patients undergoing free tissue (FF) transfer and expander implant (E/I) reconstruction between 2005 and 2011. Variables evaluated included comorbidities, surgical timing, complications, overall outcomes, unplanned reoperations, and costs. A propensity-matching technique was used to account for the nonrandomized selection of modality.A total of 310 propensity-matched patients underwent 499 reconstructions. No statistically significant differences in preoperative variables were noted between propensity-matched cohorts. Operative characteristics were similar between FF and E/I reconstructions. The E/I reconstruction was associated with a significantly higher rate of reconstructive failure (5.6% vs 1.2%, p0.001). Expander implant reconstructions were associated with higher rates of seroma (p = 0.009) and lower rates of medical complications (p = 0.02), but overall significantly higher rates of unplanned operations (15.5% vs 5.8%, p = 0.002). The total cost of reconstruction did not differ significantly between groups ($23,120.49 ± $6,969.56 vs $22,739.91 ± $9,727.79, p = 0.060), but E/I reconstruction was associated with higher total cost for secondary procedures ($10,157.89 ± $8,741.77 vs $3,200.71 ± $4,780.64, p0.0001) and a higher cost of unplanned revisions over time (p0.05).Our matched outcomes analysis does demonstrate a higher overall, 2-year success rate using FF reconstruction and a significantly lower rate of unplanned surgical revisions and cost. Although autologous reconstruction is not ideal for every patient, these findings can be used to enhance preoperative discussions when choosing a reconstructive modality.

The authors evaluated the complications, revisions, and long-term aesthetic outcomes of patients with isolated metopic synostosis.A retrospective chart review was performed on consecutive metopic craniosynostosis patients treated from June of 1987 to June of 2012 at The Children's Hospital of Philadelphia. Patient demographics, operative details, and postoperative data were collected. Outcomes were reported as Whitaker classification and postoperative clinical characteristics assessed before additional interventions. Reoperation in patients with greater than 5 years of follow-up was noted. Appropriate statistical analyses were applied.From 1987 to 2012, 178 patients underwent surgical correction of isolated metopic craniosynostosis, and 147 met inclusion criteria. Average age at surgery was 0.83 year (range, 0.3 to 4.7 years); average follow-up was 5.8 years (range, 1.0 to 17.8 years). There were 13 surgical complications (8.8 percent), three major (2.0 percent), and 10 minor (6.8 percent). At follow-up, 67 patients (56.8 percent) were classified as Whitaker class I, six (5.1 percent) as class II, 43 (36.4 percent) as class III, and two (1.7 percent) as class IV. Patients with greater than 5 years' follow-up (n = 57) were more likely to have temporal hollowing (OR, 2.9; 95 percent CI, 1.2 to 7.3; p = 0.021), lateral orbital retrusion (OR, 4.9; 95 percent CI, 1.9 to 12.7; p = 0.001), and Whitaker class III or IV classification (OR, 4.0; 95 percent CI, 1.5 to 10.6; p = 0.006) compared with those with less than 5 years' follow-up.This study reports low complication and reoperation rates in the treatment of isolated metopic craniosynostosis, but demonstrates a clear trend toward worsening aesthetic outcomes over time.Therapeutic, IV.

Background Ventral hernias are a common, challenging, and expensive problem for general and reconstructive surgeons. The authors assessed the impact of epidurals on morbidity following abdominal wall reconstruction for hernia. Methods A retrospective review of abdominal wall reconstruction patients operated on between 2007 and 2012 was performed with a specific focus on the use of epidurals. Bivariate and multivariate logistic regression analyses were used to assess independent predictors of morbidity. Subgroup analyses were also performed. Results The study included 134 consecutive reconstructions performed by a single surgeon over a 5-year period at an academic teaching center. Patient groups were similar in terms of demographics, preoperative characteristics, hernia grade, and intraoperative characteristics. Epidural use was associated with a lower incidence of major surgical complications (19.7 percent versus 36.1 percent; p = 0.04) and medical complications (26.8 percent versus 54.1 percent; p = 0.001). A significant and independent reduction in medical morbidity (OR, 0.09; p ≤ 0.001) and unplanned reoperations (OR, 0.23; p = 0.052), was found with patients receiving epidurals. Furthermore, a notable trend toward reduced major surgical complications (OR, 0.45; p = 0.141) and cost savings (-$22,184; p = 0.01) was found in patients who received epidurals. Subgroup analysis did not demonstrate statistically significant reductions in major surgical morbidity in reconstruction either with (p = 0.13) or without (p = 0.07) concurrent intra abdominal procedures when epidurals were not or were used, respectively. Conclusions Epidural use may be associated with reduced morbidity and cost savings in abdominal wall reconstruction. This effect appears to be related to reduced medical morbidity and shortened length of stay in patients undergoing more complex, concurrent intraabdominal hernia procedures. Clinical question/level of evidence Risk, II.

BACKGROUND This study explored factors associated with readmission following plastic surgery using a prospective, validated, national database. METHODS Patients who underwent primary plastic surgery procedures (n = 10,669) were identified from the 2011 American College of Surgeons National Surgical Quality Improvement Program databases. Those who were readmitted were compared with those who were not. Preoperative patient comorbidities, laboratory values, and intraoperative details derived from the data set were analyzed, and multivariate regression analysis was used to identify predictors of readmission. RESULTS A total of 10,669 patients were included, with a 4.5 percent readmission rate. Their average age was 49.5 years, 32.2 percent were obese, 15.2 percent were smokers, and 81.7 percent were women. The most commonly performed procedures included elective/cosmetic breast (23.4 percent), implant breast reconstruction (16.5 percent), revision breast procedures (14.9 percent), hand operations (9.7 percent), and body contouring (5.9 percent). The wound complication rate was 4.6 percent and the medical complication rate was 4.9 percent. The overall incidence of any postoperative complication was 10.9 percent, of which 4.8 percent were defined as major surgical complications. Independent risk factors associated with readmission included procedure type (p = 0.029); obesity (p = 0.011); anemia (p = 0.003); and medical (p < 0.001), major surgical (p < 0.001), and wound (p < 0.001) complications. CONCLUSIONS The most significant predictor of readmission was postoperative complications. Patients experiencing postoperative surgical complications were six times more likely to be readmitted. These findings can assist surgeons and health systems to better tailor preoperative risk counseling, resource allocation, and postoperative discharge services.

Background This study reports long-term aesthetic outcomes with fronto-orbital advancement and cranial vault remodeling in treating unicoronal synostosis over a 35-year period. Methods Retrospective review was performed on patients with isolated unicoronal synostosis from 1977 to 2012. Demographic, preoperative phenotypic, and long-term aesthetic outcomes data were analyzed with chi-squared and Fisher's exact test for categorical data and Wilcoxon rank-sum and Kruskal-Wallis rank for continuous data. Results A total of 238 patients were treated; 207 met inclusion criteria. None underwent secondary intervention for intracranial pressure. At definitive intervention, there 96 (55 percent) Whitaker class I patients, 11 (6 percent) class II, 62 (35 percent) class III, and six (3 percent) class IV. Nasal root deviation and occipital bossing each conferred an increased risk of Whitaker class III/IV [OR, 4.4 (1.4 to 13.9), p = 0.011; OR, 2.6 (1.0 to 6.8), p = 0.049]. Patients who underwent bilateral cranial vault remodeling with extended unilateral bandeau were less likely Whitaker class III/IV at latest follow-up compared with those undergoing strictly unilateral procedures [OR, 0.2 (0.1 to 0.7), p = 0.011]. Overcorrection resulted in decreased risk of temporal hollowing [OR, 0.3 (0.1 to 1.0), p = 0.05]. Patients with 5 years or more of follow-up were more likely to develop supraorbital retrusion [OR, 7.2 (2.2 to 23.4), p = 0.001] and temporal hollowing [OR, 3.7 (1.5 to 9.6), p = 0.006] and have Whitaker class III/IV outcomes [OR, 4.9 (1.8 to 12.8), p = 0.001]. Conclusion Traditional fronto-orbital advancement and cranial vault remodeling appears to mitigate risk of intracranial pressure but may lead to aesthetic shortcomings as patients mature, namely fronto-orbital retrusion and temporal hollowing. Clinical question/level of evidence Therapeutic, IV.

Within the diagnosis "craniosynostosis," there is a subset of patients who present with isolated, nonsyndromic, single-suture involvement. This study evaluates perioperative complications in this specific subset of patients over 4 decades at a single institution. To do so, we performed a retrospective review on consecutive patients undergoing correction of single-suture synostosis from May 1977 to January 2013 at a tertiary pediatric craniofacial center. Demographic information, operative details, and perioperative course were collected. Complications were categorized as either major or minor. A χ(2) test and Fisher exact test were used to compare all categorical variables. Continuous variables were analyzed using Wilcoxon rank-sum and Kruskal-Wallis tests.Seven hundred forty-six patients underwent surgical correction of nonsyndromic craniosynostosis. Of these, there were 307 (41.2%) sagittal, 201 (26.9%) metopic, and 238 (31.9%) unicoronal. Thirty-four patients had complications (4.6%). Eight were considered major (1.1%), including one postoperative mortality in a patient with hypoplastic left-sided heart syndrome. Minor complications occurred in 26 patients (3.5%) and included subgaleal hematoma (n = 3), seroma (n = 4), and superficial wound infection (n = 5). Metopic and sagittal suture involvement was significantly associated with a higher complication rate (P = 0.04). A child with isolated single suture synostosis and any comorbidity had a significantly greater risk of any complication (P < 0.001; odds ratio, 3.8) and specifically an increased risk of major complication (P = 0.031; odds ratio, 6.0). Subclassification of patients by time period yielded no statistically significant changes in perioperative morbidity. To conclude, these data allow us to counsel families more accurately with regard to morbidity and mortality and may potentially serve as a benchmark for future quality improvement work.

Previous studies assessing the costs associated with two stage expander/implant (E/I) reconstruction rarely include the cost of complications. The purpose of this study is to analyze the complication costs associated with a single institution experience with immediate E/I reconstruction. All immediate two stage E/I reconstructions at a single institution between March 2005-April 2011 were reviewed. The reconstruction database was retrospectively queried for reconstructive details, complications, and cost. Statistical analyses were performed to determine which complications significantly increased reconstructive cost. 327 E/I reconstructions in 195 patients were analyzed. The major complications analyzed included haematoma requiring evacuation (1.2% of reconstructions), major infection (6.1% of reconstructions), E/I exposure (3.1% of reconstructions), and E/I rupture (2.4% of reconstructions); 2.1% of patients experienced reconstructive failure. The mean reconstructive cost was $22,323 ± 9,072. Costs were increased $12,554 by E/I infection (p < 0.001) and $17,153 by prosthetic exposure (p < 0.001). Pre- or postoperative radiation or chemotherapy did not significantly affect reconstructive costs. Unplanned readmissions or unplanned visits to the operative room significantly increased total reconstructive costs (p < 0.001 and p < 0.001, respectively). In conclusion, prosthetic infection and prosthetic exposure significantly increased costs associated with immediate two-stage E/I reconstruction, as did unplanned readmissions and unplanned visits to the operative room. In the current state of the US healthcare system, it is becoming more important for surgeons to be conscious of the economic burden associated with poor reconstructive outcomes.

Complex abdominal wall reconstruction (AWR) is commonly performed, but with a significant rate of surgical complications and hernia recurrence. The aim of this experiential review is to assess risk factors for hernia recurrence after complex AWR. A retrospective review of AWR patients from 2007-2012 was performed. Rates of hernia recurrence were assessed. Univariate analyses and subsequent multivariate logistic regression analysis was used to assess independent predictors of early hernia recurrence. One hundred and thirty-four consecutive cases of AWR were performed over a 5-year period. Hernia recurrence developed in 14 (10.4%) patients. Hernias derived from trauma (OR = 19.76, p = 0.011) and those who experienced postoperative wound infections (OR = 18.81, p = 0.004) were at increased risk for hernia recurrence. In conclusion, increased vigilance must be paid to patients presenting after trauma with massive loss of domain and those who experience postoperative infection, as these cohorts are at added risk for failed reconstruction.

Panniculectomy (PAN) during ventral hernia repair (VHR) can be a challenging procedure associated with added risk. We utilized the ACS-NSQIP datasets to generate a risk model of morbidity following these combined interventions.The 2005-2012 ACS-NSQIP databases were queried to identify all patients undergoing VHR-PAN. Multivariate logistic regression analyses were used to assess perioperative factors associated with surgical and medical morbidity. Internal validation was performed using bootstrap analysis and risk stratification was performed using weighted β-coefficients.1974 patients underwent VHR-PAN with an average age of 53.6 ± 12.4 years and BMI of 36.4 ± 10.1 kg/m2. Surgical complications occurred in 23.8% of patients, whereas medical complications occurred in 11.5%. A multivariate logistic regression identified the presence of a renal comorbidity (OR = 1.62, P = 0.045), class II obesity (BMI = 34.9-40.0 kg/m2) (OR = 1.89, P0.001), class III obesity (BMI≥40 kg/m2) (OR = 2.66, P0.001), dirty/infected wound class (OR = 2.01, P = 0.003), smoking (OR = 1.41, P = 0.026), prolonged operative time (OR = 2.12, P = 0.001), and ASA physical status of ≥3 (OR = 1.69, P0.001) as independently associated with higher incidences of postoperative surgical complications. A multivariate regression analysis identified class II or III obesity (OR = 1.70, P = 0.003), contaminated or dirty/infected wounds (OR = 1.95, P0.001), diabetes (OR = 1.96, P = 0.001), pulmonary comorbidity (OR = 2.08, P = 0.005), and component separation (OR = 2.65, P0.001) as independently associated with higher incidences of postoperative medical complications. Simplified risk models of surgical and medical morbidity demonstrated good discrimination with C statistics of 0.69 and 0.70, respectively.We report a simple preoperative, internally-validated risk model of surgical and medical morbidity following VHR-PAN to guide patient selection.Prognostic/risk category, level II.

BACKGROUND Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a morbid and costly complication following surgical procedures. The authors aim to assess the added risk of venous thromboembolism in patients undergoing immediate breast reconstruction. METHODS The 2005 to 2011 American College of Surgeons National Surgical Quality Improvement Program data sets were used to identify patients undergoing mastectomy with or without immediate breast reconstruction. The dependent variable and our primary outcome was 30-day venous thromboembolism. Venous thromboembolism events were treated as a dichotomous variable. Subgroup analyses were performed with respect to procedure and body mass index stratifications. RESULTS A total of 48,634 patients were identified. Postoperative venous thromboembolism occurred in 184 patients (0.4 percent), including deep venous thrombosis (n = 118) and pulmonary embolism (n = 82). A multivariate regression analysis demonstrated that immediate breast reconstruction, either implant-based (OR, 1.65; p = 0.01) or autologous (OR, 2.14; p = 0.009), was associated with a greater odds of venous thromboembolism. Obesity was also identified as a risk factor for venous thromboembolism: class I (OR, 2.20; p < 0.001), class II (OR, 1.6; p < 0.092), and class III (OR, 2.88; p < 0.001). Impaired patient functional status (OR, 2.56; p = 0.035), recent irradiation (OR, 3.60; p = 0.03), and underlying renal comorbidities (OR, 5.60; p < 0.001) were associated with venous thromboembolism in adjusted analysis. Subgroup analysis of nonobese patients demonstrated that implant reconstruction (0.2 percent versus 0.3 percent; p = 0.383) did not confer an added risk of venous thromboembolism, whereas analysis of obese patients revealed a modality-specific increased risk of venous thromboembolism (0.4 percent versus 0.8 percent versus 1.8 percent; p < 0.001) between mastectomy compared to implant and autologous reconstruction, and for which all intergroup comparisons were significant (p < 0.05). CONCLUSIONS Immediate breast reconstruction is associated with an added risk of venous thromboembolism relative to mastectomy, but this risk is procedure and body mass index dependent. Overall, autologous reconstruction and states of obesity placed patients at significant added risk for venous thromboembolism, particularly when both factors are present. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.