Cost-Utility Analysis of Surgical Decompression Relative to Injection Therapy for Chronic Migraine Headaches

BACKGROUND

Common treatments for chronic migraine headaches include injection of corticosteroid and anesthetic agents at local trigger sites. However, the effects of therapy are short term, and lifelong treatment is often necessary. In contrast, surgical decompression of migraine trigger sites accomplishes the same goal yet demonstrates successful long-term elimination of chronic migraines.

OBJECTIVES

Our primary objective was to perform a cost-utility analysis to determine which patients would benefit most from available treatment options in a cost-conscious model.

METHODS

A cost-utility analysis was performed, taking into consideration costs, probabilities, and health state utility scores of various interventions.

RESULTS

Injection therapy offered a minor improvement in quality-adjusted life-years (QALYs) compared with surgical decompression (QALY Δ = 0.6). However, long-term injection therapy was significantly costlier to society than surgical decompression: injection treatment was estimated to cost $106,887.96 more than surgery. The results of our cost-utility analysis thus conferred a positive incremental cost-utility ratio of $178,163.27 in favor of surgical decompression.

CONCLUSIONS

Surgery provides a durable intervention and has been shown in this study to be extremely cost effective despite a very minor QALY deficit compared with injection therapy. If patients are identified who require treatment in the form of injections for less than 8.25 years, they may fall into a group that should not be offered surgery.

Value Improvement and Resource Utilization in Complex Abdominal Wall Reconstruction

Although recommendations help guide surgeons' mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.

Value Improvement and Resource Utilization in Complex Abdominal Wall Reconstruction

Although recommendations help guide surgeons’ mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.

Uncovering Lymphatic Transport Abnormalities in Patients with Primary Lipedema

Background Although lipedema is often clinically distinguished from lymphedema, there is considerable overlap between the two entities. The purpose of this study was to evaluate lymphoscintigraphic findings in patients with lipedema to better characterize lymphatic flow in this patient population.

Methods Patients with lipedema receiving lymphoscintigraphy between January 2015 and October 2017 were included. Patient demographics, clinical characteristics, and lymphoscintigraphic findings were extracted. Klienhan's transport index (TI) was utilized to assess lymphatic flow in patient's lower extremities (LEs).Scores ranged from 0 to 45, with values > 10 denoting pathologic lymphatic transport.

Results A total of 19 total patients with lipedema underwent lymphoscintigraphic evaluation. Mean age was 54.8 years and mean body mass index was 35.9 kg/m2. Severity of lipedema was classified as stage 1 in five patients (26.3%), stage 2 in four patients (21.1%), stage 3 in four patients (21.1%), and stage 4 in six patients (31.6%). The mean TI for all extremities was 12.5; 24 (63.2%) LEs had a pathologic TI, including 7 LEs with stage 1 (29.2%), 3 LEs with stage 2 (12.5%), 6 LEs with stage 3 (25.0%), and 8 LEs with stage 4 lipedema (33.3%). The mean TI was significantly greater for extremities with severe (stage 3/4) lipedema than those with mild or moderate (stage 1/2) lipedema (15.1 vs. 9.7, p = 0.049). Mean difference in TI scores between each LE for individual patients was 6.43 (standard deviation +7.96).

Conclusion Our results suggest that patients with lipedema have impaired lymphatic transport, and more severe lipedema may be associated with greater lymphatic transport abnormalities.

Thin Perforator Flaps for Reconstruction of the Lower Extremity

Thin flaps, a modification of traditional flaps that minimize the need for debulking and revision, offer unique advantages in the field of lower limb reconstruction. Advances in the field of microsurgery have made this streamlined method of reconstruction a viable solution for soft tissue coverage in patients with both trauma and nonhealing wounds. Better understanding of anatomy has allowed for flap harvest above the fascia level and the Scarpal plane. These modifications allow for flap transfer with thicknesses more comparable to the native anatomy of the lower leg, ankle, and foot. Flap survival is comparable to traditional techniques with greater potential for improved patient-centered outcomes.

The Public's Perception on Breast and Nipple Reconstruction: A Crowdsourcing-Based Assessment

BACKGROUND

Breast reconstruction outcomes have traditionally been measured by evaluating the opinions of patients and surgeons.

OBJECTIVES

Our goal was to assess the views of the general public.

METHODS

A survey was designed and distributed through a crowdsourcing website called Amazon Mechanical Turk. Questions assessed participant demographics, personal experience with breast reconstruction, perceptions on breast reconstruction, and opinions regarding aesthetics results. Responses were analyzed using chi-square test.

RESULTS

A total of 992 responses were collected. Most participants were female (56.1%), white (32.1%), aged 30 to 39 years (40.4%), and had a bachelor's degree (42.0%). A total of 44.2% had personal experience with breast reconstruction and 25.8% with nipple reconstruction. Several aesthetic and reconstructive factors were significantly favored over others across sex, ethnicity, age group, education level, and personal experience with breast reconstruction. For instance, women were more likely to prefer reconstructed nipples (P < 0.0001), view a breast without a nipple as complete (P = 0.024) and place less importance on nipple shape (P = 0.002). Additionally, those who personally experienced nipple reconstruction were willing to undergo more procedures for a complete nipple-areola complex (P < 0.0001), to increase aesthetic results (P = 0.018), and to increase chances of nipple survival (P = 0.002).

CONCLUSIONS

Crowdsourcing can be useful in plastic surgery and has helped identify several key findings. The importance of the nipple in reconstruction has been validated; almost three-quarters of respondents did not view a breast without a nipple as complete. The aesthetic preferences seem to support bilateral nipple-sparing reconstruction when possible. Most importantly, the respondents helped elucidate key differences in perception of aesthetic outcomes.

Breast implant-associated anaplastic large cell lymphoma, a systematic review and in-depth evaluation of the current understanding

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell neoplasm that arises in the capsule around breast implants. While an association with implants has been proposed, no causal link has been identified and the pathophysiology and natural history of BIA-ALCL remain unknown. A literature review of 391 articles was performed to assess the current understanding of BIA-ALCL and to provide a balanced and unbiased view of the current controversy surrounding the disease.

Nonmelanoma Facial Skin Cancer: A Review of Diagnostic Strategies, Surgical Treatment, and Reconstructive Techniques

Nonmelanoma skin cancer is the most common form of cancer in the United States, and the face is a common area for skin cancer development due to its frequent exposure to the sun. This article focuses on the surgical management of facial nonmelanoma skin cancers, including diagnostic considerations, biopsy techniques, and staging. In addition, we discuss surgical treatment options, including indications, techniques, outcomes, and facial reconstruction following tumor excision.

Ultrathin Free Flaps to the Foot and Ankle: New Options for Optimal Soft Tissue Coverage and Functional Contour

Soft tissue defects and chronic wounds around the foot and ankle can prove difficult to reconstruct using conventional techniques. Traditional flaps used for coverage in this region can result in the need for future debulking, shoe gear modifications, donor site morbidity, decreased function, and scarring. Successful reports of ultrathin free flaps harvested along suprafascial planes have yet to be described in the foot and ankle literature. We present 2 cases of ultrathin flaps used for foot and ankle defects that provide optimal contour while not limiting anatomic function. The resultant functional outcomes and contour shown by both flaps underscore the benefit of a thin and pliable flap in this region.

The First Reported Case of Gluteal Implant-Associated Anaplastic Large Cell Lymphoma (ALCL)

Anaplastic large-cell lymphoma (ALCL) is a very rare but life-threatening complication that has largely been demonstrated to be associated with breast implants (BIA-ALCL). Patients are at risk of BIA-ALCL with the placement of breast implants for either cosmetic or reconstructive purposes, with the highest risks associated with textured breast implants. In the past decade, an increasing number of publications have focused on BIA-ALCL, but there has yet to be a reported case outside of the breast. Here, we describe a unique instance of gluteal implant-associated ALCL (GIA-ALCL) in a middle-aged woman. The patient received bilateral textured silicone gluteal implants only a year prior to her diagnosis of GIA-ALCL. The patient later presented to the Plastic and Reconstructive Surgery Department at our institution with ulceration at the site of her gluteal implants. Unfortunately, her condition deteriorated before explanation could be performed. Biopsy of a left lung mass demonstrated "hallmark" cells of ALCL ("horseshoe"-shaped nuclei). The diagnosis was verified by immunohistochemical testing that revealed expression of CD30, CD4, CD43, BCL6, Perforin, and Ki67 in a population of abnormal cells. The goals of this case report are thus to demonstrate that all patients undergoing implantation of textured silicone implants are at risk of developing ALCL and to provide evidence for the possible new diagnosis of GIA-ALCL. Level of Evidence: 5.

Microtexture and the Cell/Biomaterial Interface: A Systematic Review and Meta-Analysis of Capsular Contracture and Prosthetic Breast Implants

BACKGROUND

The use of textured breast implants over smooth implants has been widely shown to have a lower incidence of capsular contracture. However, the impact of micropatterning techniques on the incidence of postoperative patient morbidity has not been comprehensively investigated.

OBJECTIVES

The authors sought to examine the incidence of capsular contracture, seroma, and implant rippling among the 3 major micropatterning techniques applied in the manufacturing of textured breast implants.

METHODS

Literature searches of PubMed/Medline and Embase between 1995 and 2017 were performed, and 19 studies were selected for analysis. Data from each study were extracted into a form including mean age, study design, population size, mean follow-up, number of capsular contracture cases, number of seroma cases, and number of rippling cases. Meta-analysis was performed separately for studies that included capsular contracture rates for foam textured implants, imprinted textured implants, and salt-loss textured implants.

RESULTS

The pooled rate of capsular contracture rates in primary augmentation patients was 3.80% (95% CI, 2.19-5.40) for imprinted textured implants, 4.90% (95% CI, 3.16-6.64) for foam textured implants, 5.27% (95% CI, 3.22-7.31) for salt-loss textured implants, and 15.56% (95% CI, 13.31-18.16) for smooth implants. The results of each meta-analysis were summarized on a forest plot depicting the distribution of capsular contracture rates from each study.

CONCLUSIONS

Micropatterning of prosthetic implants could drastically reduce postoperative patient morbidity given the advent of recent technologies that allow for more detailed texturing of implant surfaces.

LEVEL OF EVIDENCE: 4

The Public's Perception of Interventions for Migraine Headache Disorders: A Crowdsourcing Population-Based Study

Background

Migraine disorders are a leading cause of morbidity and decreased economic productivity in the United States among both men and women. As such, it is important to consider patient opinions, and have an accurate representation of the burden and sentiment toward currently available interventions among those suffering from migraines.

Objectives

The aim of the study was to assess patient options regarding adverse outcomes of the various treatment options available for migraine headaches.

Methods

A prospective cross-sectional study of volunteers recruited through an internet crowdsourcing service, Amazon Mechanical Turk©, was conducted. Surveys were administered to collect patient-reported opinions regarding adverse outcomes of both surgical and nonsurgical treatment options for migraine headaches.

Results

The prevalence of migraine headache across all study participants was 15.6% and varied slightly across participant demographics. Individuals ages 35–44 (2.73 migraines per month) experienced the fewest migraine and with the lowest severity. Those individuals ages 45+ experienced the most severe headaches (Visual Analog Scale = 44.23 mm). Additionally, the greatest migraine frequency and severity existed among those households with yearly income of $75,000–$100,000. The lowest injection therapy utility scores were obtained for adverse outcomes of hematoma (47.60 mm) and vertigo (54.40 mm).

Conclusions

Migraine headaches remains a significant problem among the US population, with an overall prevalence of 15.6% (approximately 50 million Americans). Additionally, physicians interesting in offering minimally invasive or surgical treatment for migraine headaches should focus on mitigating patient fears regarding clinical outcomes and cost of care.

Functional outcomes of traumatic lower extremity reconstruction

BACKGROUND

Lower extremity trauma accounts for over 300,000 injuries annually. While soft tissue transfer is a well-accepted practice for open fracture coverage, functional outcomes remain unclear.

HYPOTHESIS

This study investigates functional outcomes following soft tissue reconstruction for open tibial fractures.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database of open tibia fractures requiring soft tissue reconstruction was performed at an urban level 1 trauma center between October 2013 and March 2015.

OUTCOMES

were evaluated using Pearson's chi square test with significant p value < 0.05.

RESULTS

In 30 patients, fractures were graded Gustilo-Anderson type I (3.3%), 30% type II, 3.3% type IIIa, 53.3% type IIIb, and 10% type IIIc. Fixation was 56.7% plate and screw, 20% intramedullary nail, and 16.7% external fixator. Definitive closure was achieved in 43.3% through local rotational flap (38.5% gastrocnemius, 61.5% soleus), and in 56.7% by free tissue transfer (29.4% latissimus, 23.5% rectus, 17.6% ALT, 17.6% gracilis). In 10 patients, 70% returned to full ambulation, 30% required an assistance device, and 50% achieved union in 6 months. Local flap use was predictive of ambulation at discharge.

DISCUSSION

Following lower extremity fracture, 70% of patients returned to pre-injury function. Use of a local tissue flap was associated with early ambulation.

Emerging nonsurgical and surgical techniques to treat erectile dysfunction: A systematic review of treatment options and published outcomes

Erectile dysfunction (ED) is one of the most common causes of morbidity in male patients, with a prevalence of 50-60% in men aged 40-70 years. EDs may be caused by physical or psychological trauma, the former of which may be treatable through surgical intervention. Physical trauma may be further categorized as vasculogenic, neurogenic, or idiopathic in nature. Although many patients do not respond well to nonsurgical treatment options, few opt for surgical intervention. This is likely due to the difficulty of the procedures, as well as relatively low historical success rates. As such, a systematic review of the literature was performed to identify novel surgical interventions for ED. A total of 19 manuscripts were included in this review, representing data of three minimally invasive approaches to ED treatment and seven novel surgical techniques. The data revealed compelling evidence in support of microsurgical treatments for ED - namely, microvascular arterial bypass penile revascularization surgery (MABS) and cavernous nerve graft reconstruction. Nerve grafts varied, with the use of end-to-side ilioinguinal, genitofemoral, and sural grafts, all demonstrating high rates of success. Furthermore, minimally invasive botulinum toxin (BoNT-A) treatment and adipose-derived stem cell (ADSC) therapy have shown extreme promise in rat models; with BoNT-A treatment entering phase II human clinical trials this year. Many of the surgical methods investigated in this review are microsurgical interventions that demonstrate high rates of success in patients with neurogenic or vasculogenic ED. As such, microsurgeons are uniquely trained and positioned to be of value to ED treatment.

Risk Factors Associated with Reconstructive Complications Following Sacrectomy

BACKGROUND

Sacral pathology requiring partial or total sacrectomy is rare, and reconstructing the ensuing defects requires careful decision-making to minimize morbidity. The purpose of this study was to review the experience of a single institution with reconstructing large sacral defects, to identify risk factors for suboptimal outcomes.

METHODS

A retrospective chart review was conducted of all patients who underwent sacrectomy over a 10-year period. Univariate analysis of differences in risk factors between patients with and without various postoperative complications was performed. Multivariate logistic regression was used to identify predictive variables.

RESULTS

Twenty-eight patients were identified. The most common diagnosis leading to sacrectomy was chordoma (39%). Total sacrectomy was performed on 4 patients, whereas 24 patients underwent partial resection. Reconstructive modalities included 15 gluteal advancement flaps, 4 pedicled rectus abdominis myocutaneous flaps, and 9 paraspinous muscle or other flap types. There was an overall complication rate of 57.1% (n = 12) and a 28.6% (n = 8) incidence of major complications. There were significantly more flap-related complications in patients who underwent total sacrectomy (P = 0.02). Large defect size resulted in significantly more unplanned returns to the operating room (P < 0.01).

CONCLUSION

Consistent with other published series', the overall complication rate exceeded 50%. Defect volume and sacrectomy type were the strongest predictors of postoperative complications and return to the operating room, while reconstructive strategy showed limited power to predict patient outcomes. We recommend that patients anticipated to have large sacral defects should be appropriately counseled regarding the incidence of wound complications, regardless of reconstructive approach.

Lymph node transplantation for the treatment of lymphedema

Lymphedema is a complex disease process with deranged lymphatic transport, fluid accumulation and secondary lipedema and fibrosis. This is a challenging disease to treat with a surgical focus on debulking and physiologic strategies. One strategy is the use of vascularized lymph node transplant (VLNT) to improve physiologic lymph clearance. In this article, VLNT is discussed in detail, including mechanisms, combined strategies, and outcomes.

Introducing the subdermal free flap: Preserving the ultrathin-free skin flap option in morbidly obese patients

In the morbidly obese population (BMI > 35), distal extremity defects are difficult to reconstruct. Traditional skin flaps are several centimeters in thickness in obese patients; however, a new plane superficial to the scarpal plane has demonstrated success in these patients. In this report, we present a 62-year-old female (BMI = 44.81) with a chronic lower extremity wound. A suprascarpal thin flap (approximately 1 cm in thickness) was harvested from the thigh and transferred successfully with no wound-healing issues.

Vascularized Lymph Node Transfer for Lymphedema

Advances in our understanding of the lymphatic system and the pathogenesis of lymphedema have resulted in the development of effective surgical treatments. Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes into an extremity to restore physiological lymphatic function. It is most commonly performed by transferring combined deep inferior epigastric artery perforator and superficial inguinal lymph node flaps for postmastectomy breast reconstruction. For patients who do not require or are unable to undergo free abdominal breast reconstruction or have lymphedema affecting the lower extremity, several other VLNT options are available. These include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, and lymph node flaps from within the abdominal cavity. This article reviews the lymph node flap options and techniques available for VLNT for lymphedema.