BACKGROUND:Predictors for permanent nipple-areolar complex (NAC) insensitivity after reduction mammaplasty are sparsely defined. OBJECTIVES:We analyzed factors associated with NAC insensitivity over long-term follow-up. METHODS:A retrospective analysis of reduction mammaplasties on 1598 breasts performed by 4 surgeons from March 2015 to February 2023 was conducted. Data on patient demographics, intraoperative factors, and postoperative complications were collected from patient records. Analysis was conducted by breast, separated into breasts with NAC insensitivity (permanent and transient) and those without. Wilcoxon rank sum test for continuous variables and Fisher's exact test or Pearson's chi-square test for categorical variables evaluated differences between the groups. Univariate and multivariate logistic regression analyzed the association of pedicle choice with NAC insensitivity onset and permanence. RESULTS:Of 1598 breasts, 9.8% had loss of NAC sensation, of which 49.0% had permanent loss. A total of 51.0% regained sensitivity, taking an average of 116 days (median 64, range 6-798) to regain sensation. NAC-insensitive breasts had longer sternal notch to NAC (P < .001) and NAC to IMF (P < .001) measurements, greater weight removed (P < .001), and fat necrosis co-complication (P = .022). Greater weight removed (P = .044) and longer sternal notch to NAC measurements (P = .011) were associated with permanent insensitivity. The superomedial pedicle was associated with an increased rate of transient NAC insensitivity, whereas the inferior pedicle had a decreased rate. There was no significant association between pedicle choices and permanent insensitivity. CONCLUSIONS:Transient loss of NAC sensitivity is associated with pedicle choice, and breasts with permanent insensitivity were more likely to have longer breast measurements and a greater amount of tissue removed. LEVEL OF EVIDENCE: 4 (THERAPEUTIC):

Purpose Wound dressing following reduction mammoplasty can be conducted using surface 2-octyl cyanoacrylate (Dermabond; Ethicon, Inc., Somerville, N.J), but its effect on long-term wound healing in these patients is inconclusive. We present an updated review of Dermabond’s safety and efficacy in reduction mammoplasty patients. Methods An IRB-approved retrospective analysis was conducted on 532 patients (1048 breasts) who underwent reduction mammoplasty by a single surgeon between March 2015 and February 2023. Data on demographics, operative times, and postoperative complications were collected from patient records. Patient data were separated into Dermabond and non-Dermabond dressing groups. The Wilcoxon rank sum or student’s t-tests for continuous variables and Pearson’s chi-squared test for categorical variables were used to evaluate the differences between both groups. Univariate and multivariable logistic regression assessed the association of Dermabond application with complications. Results Among the 1048 total breasts, Dermabond was used in 525 (50.1%), while it was not used in 523 (49.9%). There were significantly increased rates of dehiscence (p < 0.001), hypertrophic scarring (p = 0.005), fat necrosis (p = 0.028), and major complications (p < 0.001) in the Dermabond cohort; however, no significant differences in rates of seroma, hematoma, infection, or nipple necrosis were observed. Dermabond was a significant predictor of higher rates of dehiscence (p < 0.001) and incidence of major complications (p < 0.001) with and without adjustment for demographic or intra- and postoperative characteristics. Conclusions Using Dermabond as wound dressing after reduction mammoplasty was associated with higher rates of dehiscence, hypertrophic scarring, and major complications, suggesting a negative impact on postoperative outcomes.

Background:. Accurate diagnosis of periprosthetic infections following breast reconstructions is paramount to reduce morbidity. Alpha defensin-1 (AD-1) is an antimicrobial peptide released by neutrophils. This study evaluates the relationship between quantitative AD-1 levels and infection severity in patients with suspected periprosthetic infection. Methods:. Retrospective review was conducted of patients with prior breast implant reconstruction undergoing surgery for either suspected infection or prosthesis exchange and revision. The AD-1 level in periprosthetic fluid was sent for quantitative analysis. Association between AD-1 levels with outcomes, management, systemic markers of infection, and overall infection severity was evaluated. Results:. Thirty-eight breasts were included. Infected breasts had higher AD-1 levels (3.91 versus 0.14, P < 0.01), greater odds of erythema [odds ratio (OR) 2.98 (1.53–5.82), P = 0.01], purulence [OR 2.84 (1.51–5.35), P = 0.01], fever [OR 1.84 (1.15–2.93), P = 0.01], threatened implant exposure [OR 2.97 (1.48–5.95), P < 0.01], and true implant exposure [OR 1.79 (1.04–3.08), P = 0.04]. Increasing AD-1 was an independent risk factor for washout (P < 0.01), and explant [OR 2.48 (1.47–4.2), P < 0.01]. AD-1 positively correlated with white blood cell count (β = 1.81 cells/µL, P < 0.01), and serum lactate (β = 0.19 meq/L, P < 0.04). Increasing AD-1 level was an independent predictor of infection severity (χ² = 22.77, P < 0.01). Conclusions:. AD-1 levels correlate with infection severity, highlighting its potential both when clinical examination is ambiguous and when treatment response is being monitored. Although further evaluation is warranted, AD-1 may demonstrate utility in novel breast implant salvage algorithms.

BACKGROUND:Cosmetic surgery tourism has become a significant global industry. Often patients who develop postoperative complications present for care in their US home state. OBJECTIVES:In this study we evaluated patients who either traveled abroad or to other states within the United States for cosmetic surgeries and later came with complications for treatment at the authors' center. We sought to compare rates of complications between patients who underwent cosmetic surgery internationally and domestically. METHODS:In this retrospective cross-sectional study we reviewed patients who presented from June 2014 to June 2022 with concerns related to cosmetic surgeries performed in another state or abroad. Binary logistic regressions were performed to assess differences in outcomes between domestic and international cases, including complications, interventions, and admissions. RESULTS:One-hundred twenty-three patients (97.6% female, mean age 34.0 ± 8.7 years, range 16-62 years) sought 159 emergency department consultations. The most common procedures included abdominoplasty (n = 72) and liposuction (n = 56). Complications included wound dehiscence (n = 39), infection (n = 38), and seroma (n = 34). Over one-half of patients required intervention. Twenty-nine patients (23.6%) required hospital admission. On multivariate regression analyses, incidence of seroma (P = .025) and oral (P = .036) and intravenous antibiotic prescriptions (P = .045) was significantly greater among the international cohort than the domestic, and all other complication variables were nonsignificant. There were no other significant differences in operative interventions or hospital admissions between international and domestic cohorts. CONCLUSIONS:Compared to domestic tourism cases, international tourism cases were associated with significantly higher rates of seroma formation and antibiotic use. There were no significant differences otherwise in overall complications, including infections, operative interventions, or hospital admissions. LEVEL OF EVIDENCE: 3:

Although research and innovation is a key within the field of plastic and reconstructive surgery, the impact of team structure, interpersonal dynamics, and/or standardized infrastructure on scholarly output has been infrequently studied. In this work, we present the formation and implementation of a novel plastic surgery research program that aims to unite previously disparate clinical and translational research efforts at our institution to facilitate critical inquiry. From July 2022 to June 2023, our department launched a pilot research program based on three pillars: (1) formalization of a research curriculum (monthly research meetings for agenda setting and discussion for project honing, formal research leadership for meeting facilitation and workflow regulation), (2) development of a centralized database to compile ongoing research (Google Drive repository to house all ongoing research documents, facilitate real-time editing, and provide resources/templates for assisting in the research process), and (3) bolstering of a core research identity built on mentorship and collaboration (more frequent interactions to shift previously siloed faculty-student mentorship into a robust milieu of intercollaboration). During the first year, we saw an increased number of publications and presentations, as well as robust participation and contribution from faculty, residents, and medical students. Future directions will focus on addressing resource limitation, such as project idea availability and funding, to sustain the success and growth of this novel research infrastructure.

Introduction Pediatric reduction mammoplasty has become increasingly common due to the obesity epidemic. While obesity remains the leading cause of macromastia leading to surgery, it may also be a risk factor for postoperative complications. This study examines the safety of pediatric reduction mammoplasty and the risk of obesity for complications following this procedure. Methods The American College of Surgeons National Surgical Quality Improvement Program Pediatrics was queried to obtain all reduction mammoplasty cases from 2012 to 2020. Univariate and multivariate logistic regression analyses controlling for confounders were carried out to assess the relationship between body mass index (BMI) and rates of complication. Results One thousand five hundred eighty-nine patients with the primary Current Procedural Terminology code 19318 were included in the final analysis. The mean age was 16.6 (SD, 1.1) years, and the mean BMI was 30.5 (SD, 6.2) lb/in2. Notably, 49% of the patients were obese, and 31% were overweight, while only 0.4% were underweight. Forty-three patients (2.7%) sustained a superficial surgical site infection (SSI) postoperatively. Other complications were less prevalent, including deep SSI (4 patients, 0.3%), dehiscence (11, 0.7%), reoperation (21, 1%), and readmission (26, 1.6%). Independent variables analyzed included age, sex, BMI, diabetes mellitus, American Society of Anesthesiologists (ASA) class, and operative time, of which only BMI and ASA class were found to be significantly associated with SSI on univariate analysis. On multivariate logistic regression while controlling for ASA class and the false discovery rate, there was a strong association between increasing rates of superficial SSI and increasing BMI (unit odds ratio, 1.05; 95% confidence interval, [1.01, 1.09]; P = 0.02). The OR indicates that for each 1-unit increase in BMI, the odds of SSI increase by 5%. Conclusions Complications following pediatric reduction mammoplasty are uncommon, demonstrating the safety of this procedure. High BMI was found to have a significantly higher risk for superficial SSI. Increased caution and infection prophylaxis should be taken when performing this operation on obese patients.

Background: Prompt diagnosis of breast implant infection is critical to reducing morbidity. A high incidence of false-negative microbial culture mandates superior testing modalities. Alpha defensin-1 (AD-1), an infection biomarker, has outperformed culture in diagnosing periprosthetic joint infection with sensitivity/specificity of 97%. After previously demonstrating its feasibility in breast implant-related infection (BIRI), this case-control study compares the accuracy of AD-1 to microbial culture in suspected BIRI. Methods: An institutional review board–approved, prospective, multicenter study was conducted of adults with prior breast implant reconstruction undergoing surgery for suspected infection (cases) or prosthetic exchange/revision (controls). Demographics, perioperative characteristics, antibiotic exposure, and implant pocket fluid were collected. Fluid samples underwent microbial culture, AD-1 assay, and adjunctive markers (C-reactive protein, lactate, cell differential); diagnostic performance was assessed by means of sensitivity, specificity, and accuracy from receiver operating characteristic curve analysis, with values of P < 0.05 considered significant. Results: Fifty-three implant pocket samples were included (cases, n = 20; controls, n = 33). All 20 patients with suspected BIRI exhibited cellulitis, 65% had abnormal drainage, and 55% were febrile. All suspected BIRIs were AD-1 positive (sensitivity, 100%). Microbial culture failed to grow any microorganisms in four BIRIs (sensitivity, 80%; P = 0.046); Gram stain was least accurate (sensitivity, 25%; P < 0.001). All tests demonstrated 100% specificity. Receiver operating characteristic curve analyses yielded the following areas under the curve: AD-1, 1.0; microbial culture, 0.90 (P = 0.029); and Gram stain, 0.62 (P < 0.001). Adjunctive markers were significantly higher among infections versus controls (P < 0.001). Conclusions: Study findings confirm the accuracy of AD-1 in diagnosing BIRI and indicate superiority to microbial culture. Although further study is warranted, AD-1 may facilitate perioperative decision-making in BIRI management in a resource-efficient manner. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Background: The advent of acellular dermal matrix (ADM) has revolutionized prosthesis-based breast reconstruction. However, paucity of human cadaveric tissue has resulted in limitation of supply and increased associated costs, prompting concerted effort to identify xenograft alternatives. Although studies have examined the safety of Artia, a porcine-derived ADM, few have evaluated its clinical efficacy as soft fissile reinforcement. This study uniquely evaluates the clinical efficacy of Artia in implant-based breast reconstruction. Methods: IRB-approved retrospective chart review was conducted to identify 243 consecutive TE-based procedures performed at a tertiary academic medical center between March 2017 and March 2021. Propensity snatching was conducted to minimize differences between cohorts. Efficacy metrics. defined as initial tissue expander (TE) fill volume, number of TE fills, and time interval between exchange of TE for final implant, were compared between xenograft (Artia) and allograft (AlloDerm) groups. Results: Patients who underwent Artia-based breast reconstruction achieved superior initial TE fill volume relative to those who underwent AlloDerm-based breast reconstruction via univariate analysis (317.3 +/- 185.8 ml. versus 286.1 +/- 140.4 mL, P < 0.01) when patient and operative characteristics were well-matched. However, linear regression analysis failed to demonstrate difference in efficacy metrics, such as initial TE fill volume (P= 0.31), ratio between initial FE fill volume and final implant size (P= 0.19), and number of TE tills (P= 0.76). Complication rates were comparable between groups. Conclusion: This study suggests that Artia can be used as a safe and efficacious alternative to human-derived ADM in immediate TE based breast reconstruction.

Background Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC’s ability to predict complications among patients having plastic surgery. Methods OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I 2 statistic, indicating heterogeneity, was judged low (I 2 < 50%) or borderline/unacceptably high (I 2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex). Results Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48–0.87], cardiac AUC = 0.66 [0.20–0.99], venous thromboembolism AUC = 0.55 [0.47–0.63]), (surgical: surgical site infection AUC = 0.55 [0.46–0.63], reoperation AUC = 0.54 [0.49–0.58], serious complication AUC = 0.58 [0.43–0.73], and any complication AUC = 0.60 [0.57–0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54–0.99]), heterogeneity was high with I 2 = 68%. Otherwise, heterogeneity was minimal (I 2 = 0%) or acceptably low (I 2 < 50%) for all other outcomes. Conclusions The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery–focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.

BACKGROUND: Preoperative surgical risk assessment is a major component of clinical decision-making. The ability to provide accurate, individualized risks of complications has become critical due to growing emphasis on quality metrics and outcome benchmarks. The ACS NSQIP Universal Risk Calculator was designed to quantify patient-specific risk across various types of surgery. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations.1 This study utilizes meta-analysis to evaluate the accuracy of the NSQIP Risk Calculator in predicting complications among patients having plastic surgery. METHODS: OVID Medline and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP Risk Calculator in plastic/reconstructive surgery, including oncologic defect reconstruction, ventral hernia repair, and body contouring. Only studies directly compared Risk Calculator predicted to observed complication rates were included. The primary outcome was Area Under the Curve (AUC), which measures the ability of the Surgical Risk Calculator to predict 30-day complications, ranging from 0.50 (prediction no better than random chance) to 1.0 (perfect prediction). Risk Calculator accuracy was assessed for each complication via DerSimonian and Laird random-effects analytic model. Data heterogeneity were evaluated with the I2 statistic, judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex.). RESULTS: Of the 296 studies identified from initial search, 10 studies with 2416 patients overall met criteria and were included for analysis. Studies were classified as follows: head and neck oncologic/reconstruction (head and neck: N = 5, breast: N = 1, extremity: N = 1), open ventral hernia repair (N = 2), panniculectomy (N = 1). Sufficient data were reported to meta-analyze eight NSQIP-defined complications. Predictive accuracy was poor for medical complications [pulmonary AUC = 0.67 (0.48–0.87), cardiac AUC = 0.66 (0.20–0.99), venous thromboembolism AUC = 0.55 (0.47–0.63)]. Similarly, predictive accuracy for surgical complications was unsatisfactory [surgical site infection AUC = 0.55 (0.46–0.63), reoperation AUC = 0.54 (0.49–0.58), serious complication AUC = 0.58 (0.43–0.73)]. Finally, any complication was poorly predicted by the NSQIP Risk Calculator [AUC = 0.60 (0.57–0.64)]. Although mortality was accurately predicted in two studies [AUC = 0.87 (0.54–0.99)], heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes. CONCLUSIONS: The NSQIP Universal Surgical Risk Calculator aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the Risk Calculator are perhaps most pronounced where complex, multidisciplinary reconstructions are needed2. Future efforts should identify targets for improving Risk Calculator reliability in order to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation. REFERENCES: 1. Basta MN, Bauder, AR, Kovach, SJ, et al. Assessing the predictive accuracy of the American College of Surgeons National Surgical Quality Improvement Project surgical risk calculator in open ventral hernia repair. Am. JSurg. 2016;212:272–281. 2. Fischer JP, Basta MN, Mirzabeigi, MN, et al. A comparison of outcomes and cost in VHWG grade II hernias between Rives-Stoppa synthetic mesh hernia repair versus underlay biologic mesh repair. Hernia 2014;18:781–789.

Background:. Prompt, accurate diagnosis of breast implant infection is critical to minimizing patient morbidity. Bacterial culture false negative rate approaches 25%–30%, and better costeffective testing modalities are needed. Alpha defensin-1 (AD-1) is a neutrophil-mediated biomarker for microbial infection. With sensitivity/specificity of 97% and 96%, it has replaced culture as the preferred diagnostic modality for orthopedic periprosthetic infection, but has yet to be investigated in breast reconstruction. This pilot study compares the diagnostic performance of AD-1 to bacterial culture in suspected periprosthetic breast infection. Methods:. Patients with prosthetic breast reconstruction and suspected periprosthetic infection were prospectively studied. Implant pocket fluid was analyzed with gram stain and culture, AD-1 assay, and adjunctive markers. Demographics, operative history, prosthetic characteristics, and antibiotic exposure were collected, and diagnostic performance of each test was compared. Results:. Fifteen breasts with suspected periprosthetic breast infection were included, 10 (66.7%) of which were acutely infected. Gram stain correctly identified only 1 of 10 infections, whereas culture failed to identify 1 infection and reported equivocal/false-positives in 2 noninfected samples. AD-1, however, correctly classified all 15 samples. AD-1 exhibited 100% sensitivity and specificity, comparing favorably to culture (sensitivity: 90%, specificity: 60%), although this did not reach significance (P=0.22). Infected breasts also demonstrated significantly higher adjunctive marker levels compared to noninfected breasts. Conclusions:. This study demonstrates the utility of AD-1 in diagnosing periprosthetic breast infection. Combining AD-1 with adjunctive inflammatory markers may allow more accurate, prompt detection of implant infection which may reduce morbidity and reconstructive failures.

GOALS/PURPOSE: In this age of globalization, patients may seek to have their aesthetic surgeries performed in foreign countries anticipating significant cost-savings compared to perceived prohibitive out-of-pocket costs in the US. Given the transient nature of their stay in the country of surgery, post-operative follow-up is often sub-optimal. These patients frequently seek care in the US for complications, the burden falling on the US healthcare system.1,2 Non-standardization of aseptic surgical facilities and technique leads to an increased risk of infectious complications. Management of these complications represents a resource burden to the healthcare system and poses a clinical danger to the general population. Travel and surgery in uncontrolled settings, with their disparate macro-biomes, facilitates translocation of potentially dangerous infectious microbiota. This study investigated the microbiological data from a series of patients who sustained infectious complications from their cosmetic tourism. METHODS/TECHNIQUE: A retrospective chart review was conducted on patients who underwent aesthetic surgery outside the US and were evaluated by the plastic surgery service from 1/1/2005 - 4/3/2016. Data included the patient demographics, type of surgery performed, country of surgery, complications, management of complications, cost of care, and microbiology data. RESULTS/COMPLICATIONS: Forty-one patients were evaluated for complications following their cosmetic tourism procedure. The most frequently documented countries of surgery were the Dominican Republic (25) and Colombia (7). The most common surgeries were abdominoplasty (11), abdominoplasty with liposuction(8), breast augmentation(5), and breast augmentation with mastopexy(4). Three patients received silicone injection into various sites including the lips, chin, breasts, hips, and buttocks. Nineteen patients suffered infectious complications which included cellulitis (4), cellulitis with abscess (12), and necrotizing soft tissue infections (2). Two patients with necrotizing infections required emergent debridement and protracted stays in the ICU. Two patients had undergone abdominoplasty with subsequent abscesses requiring serial operative debridements. The most commonly encountered infectious agents were atypical Mycobacterium species, including Mycobacterium abscessus and Mycobacterium chelonae, and Pseudomonas aeruginosa. Other atypical bacteria encountered included Peptostreptococcus magnus, Alcaligenes xylosoxidans, Enterococcus faecalis, Coryne bacterium, Acinetobacter baumannii, Bacillus sp, Prevotella bivia, and Candida parapsilosis. CONCLUSION: The growing pervasiveness of cosmetic tourism poses a significant resource burden to the US healthcare system and an atypical infectious risk. Atypical Mycobacterium infections were most common, followed by Pseudomonas aeruginosa. Introduction of novel flora may evolve into an epidemiological dilemma. More research is needed pertaining to the infection risks of foreign surgery to optimize antibiotic stewardship. Cosmetic tourism is a natural consequence of the commodification of aesthetic surgery, reducing the plastic surgeon and his craft to fungible goods. Education of the general public will help dispel the misplaced notion of equivalency between board-certified US plastic surgeons and providers of variable training in foreign countries by highlighting not only the qualitative aspects of aesthetic surgery, but also the safety concerns regarding the risk for postoperative complications, including infections that may lead to permanent disfigurement and possibly death. References: 1. Melendez MM, Alizadeh K. Complications from international surgery tourism. Aesthet Surg J. 2011;31:694–697. 2. Franzblau LE, Chung KC. Impact of medical tourism on cosmetic surgery in the United States. Plast Reconstr Surg Glob Open 2013;1:e63.

Basta, Marten N. MD; Jehle, Charles C. MD; Avanessian, Bella MD; Breuing, Karl H. MD, FACS; Liu, Paul Y. MD, FACS; Kwan, Daniel MD; Sullivan, Rachel MD; Zienowicz, Richard J. MD Author Information

BACKGROUND: Ambulatory surgery centers offer the advantages of greater efficiency and overall patient experience. As more procedures are performed in the outpatient setting, reliably identifying patients at higher risk for major complications will be critical. Abdominoplasty and panniculectomy represent a large component of ambulatory plastic surgery procedures. While recent studies have identified risk factors for complications in the outpatient setting, there is no clinically actionable tool available for use currently.1, 2 This study utilizes the ACS-NSQIP dataset to develop a risk-stratification model for complications requiring secondary clinical intervention after outpatient abdominal surgery. METHODS: Patients undergoing abdominoplasty or panniculectomy were identified from the NSQIP databases for 2012–2013. The primary outcome was need for secondary clinical intervention, defined as unplanned readmission or reoperation. Patient comorbidities and operative characteristics were correlated with complication risk. A step-wise multivariate logistic regression of all factors with p value< 0.1 was conducted and resulting significant factors were entered into a bootstrap technique. Adjusted multivariate beta-coefficients were used to generate weighted risk scores for each factor. Each patient was then assigned an aggregate complication risk score, yielding the risk-assessment tool. RESULTS: 1,429 patients underwent outpatient abdominal surgery and were included for analysis. Unplanned reoperation or readmissions were observed in 4.1% of surgeries (n=59). Independent patient factors predictive of secondary clinical intervention included malnutrition (OR=8.1), male gender (OR=3.4), diabetes (OR=2.8), smoking (OR=2.5), BMI 35 or higher (OR=2.2), and age over 45 (OR=2.2). Regarding operative characteristics, patients undergoing concurrent breast implant insertion were at increased risk (OR=4.4), while those undergoing trunk liposuction were less likely to require secondary clinical intervention (OR=0.48). Patients were stratified into 4 groups according to complication risk: low risk (complication=1.7%), average risk (complication=2.7%), high risk (complication=8.8%), and extreme risk (complication=21.0%). The model demonstrated high sensitivity and specificity for discriminating need for secondary intervention with a C-statistic=0.76. It was also applicable to secondary outcomes, and accurately predicted surgical complications, overall complications, and prolonged hospital stay during the index procedure. CONCLUSIONS: This study builds upon previous work by providing a quantifiable risk stratification system for clinically relevant complications experienced after abdominal surgery in the ambulatory setting. Malnutrition, male gender, and concurrent breast prosthetic implantation were strong independent predictors of risk. This tool may enhance preoperative counseling and improve patient selection in the ambulatory setting. DISCLOSURE/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. Funded by the Division of Plastic Surgery, Brown University and Rhode Island Hospital. REFERENCES: 1. Basta MN, Bauder AR, Kovach SJ, et al. Assessing the predictive accuracy of the American College of Surgeons National Surgical Quality Improvement Project Surgical Risk Calculator in open ventral hernia repair. Am J Surg. 2016; 2. Fischer JP, Basta MN, Wink JD, et al. Optimizing patient selection in ventral hernia repair with concurrent panniculectomy: an analysis of 1974 patients from the ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg. 2014; (67) 11: 1532–1540

Commercially available bioethanol-fueled fireplaces have become increasingly popular additions for interior home decoration in Europe and more recently in the United States. These fireplaces are advertised as smokeless, ecologically friendly, and do not require professional installation, formal gas lines, or venting. Although manufacturers and businesses promote their safety, recent presentations of injuries have alerted the authors to the relevant danger bioethanol fireplaces can pose for the incautious user. Are bioethanol fireplaces going to become the future threat in domestic burn accidents beside common barbeque burns? A Medline literature search on barbeque and domestic fireplace accidents was performed to compare and stratify the injury patterns reported and to identify a risk profile for contemporary bioethanol-fueled fireplaces. To exemplify, two representative clinical cases of severe burn accidents caused by bioethanol-fueled fireplaces, both treated in the burn unit of the authors, are being presented. Design fireplaces are being recognized as an increasing source of fuel and fire-related danger in the home. This risk may be underestimated by the uninformed customer, resulting in severe burn injuries. Because bioethanol-fueled fireplaces have become more commonplace, they may overtake barbecue-related injury as the most common domestic burn injury.

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.

BACKGROUND: Native breast skin flap necrosis is a complication that can result from ischemic injury following mastectomy and can compromise immediate breast reconstruction. The tumescent mastectomy technique has been advocated as a method of allowing sharp dissection with decreased blood loss and perioperative analgesia. This study was performed to determine whether the technique increases the risk for skin flap necrosis in an immediate breast: reconstruction setting.METHODS: Three hundred eighty consecutive mastectomies with immediate reconstruction over a 6-year period were reviewed and divided into 2 cohorts for comparison: 100 tumescent and 280 nontumescent mastectomy cases. The incidence of minor and major skin flap necrosis was evaluated.RESULTS: The use of tumescent mastectomy (odds ratio [OR], 3.93; P < .001), prior radiation (OR, 3.19; P = .011), patient age (OR, 1.59; P = .006), and body mass index (OR, 1.11; P = .004) were significant risk factors for developing postoperative major native skin flap necrosis.CONCLUSIONS: The use of the tumescent mastectomy technique appears to be associated with a substantial increase in the risk for postoperative major skin flap necrosis in an immediate breast reconstruction setting. (C) 2011 Elsevier Inc. All rights reserved.