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Sciegienka S, Slijepcevic A, Lipsey K, Spataro E, Chen C. Time to Mohs Reconstruction: A Systematic Review Comparing Complication Rates between Immediate and Delayed Repair. Facial Plast Surg 2024; 40:370-377. [PMID: 37336502 DOI: 10.1055/a-2112-7073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Several known factors affect outcomes of Mohs facial defect reconstruction; however, the effect of repair timing on outcomes is ill-defined. The aim of this study was to determine postoperative complication rates between immediate and delayed repair of Mohs facial defects. Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were used. Articles were selected using PICO format-population: Mohs facial defect patients, intervention: defect repair, comparator: immediate (<24 hours), or delayed (>24 hours) repair, outcome: complication rate. PubMed/Medline (1946-2020), EMBASE (1947-2020), Scopus (1823-2020), Web of Science (1900-2020), Cochrane Library, and Clinicaltrials.gov were searched. Two independent reviewers screened abstracts; those in English with human subjects reporting repair timing and complication rates were included. Search criteria yielded 6,649 abstracts; 233 qualified for review. Data were gathered from six studies; they alone contained comparative data meeting inclusion criteria. While many well-written studies were encountered, reported results varied widely. A statistically sound meta-analysis could not be completed due to large heterogeneity between studies, biasing the analysis towards the largest weighted study. Clinically important differences may exist between immediate and delayed Mohs reconstruction, but small study numbers, large heterogeneity, and lack of standardized outcome measures limit definitive conclusions. More studies are needed to perform appropriate meta-analyses, including studies using standardized methods of reporting Mohs outcome data.
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Affiliation(s)
- Sebastian Sciegienka
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St Louis, Missouri
| | - Allison Slijepcevic
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Kim Lipsey
- Bernard Becker Medical Library, Washington University in St. Louis, St Louis, Missouri
| | - Emily Spataro
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine, St Louis, Missouri
| | - Collin Chen
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Saint Louis University School of Medicine, St Louis, Missouri
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Allyn S, Bentov N, Dillon J. Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications. J Oral Maxillofac Surg 2024; 82:364-375. [PMID: 38103577 DOI: 10.1016/j.joms.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 12/19/2023]
Abstract
PURPOSE The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists. METHODS The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control. RESULTS The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period. CONCLUSION Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.
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Affiliation(s)
- Stuart Allyn
- Resident, Department of Oral & Maxillofacial Surgery, University of Washington, Seattle, WA
| | - Nathalie Bentov
- Pre-anesthesia Clinic Medical Director, Harborview Medical Center, Department of Family Medicine, University of Washington, Seattle, WA
| | - Jasjit Dillon
- Professor & Program Director, Department of Oral & Maxillofacial Surgery, University of Washington, Chief of Service, Harborview Medical Center, Seattle, WA.
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Chien L, Yver CM, Shohat S, Friedman O. Predictors of Success of Endonasal Septal Perforation Repair: A 10-Year Experience. Facial Plast Surg Aesthet Med 2024; 26:117-123. [PMID: 37782906 DOI: 10.1089/fpsam.2022.0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Background: There is no consensus on optimal repair technique for nasal septal perforations (NSPs). Objective: To measure success rate and evaluate predictors of success for NSP repair. Methods: Medical records of patients who underwent NSP repair from 2010 to 2020 were reviewed. Included patients had at least 60 days of postsurgical follow-up. Surgical technique involves an endonasal approach; subperichondrial dissection with local flap mobilization; and multilayer closure using cartilage interposition graft, fascia graft, and mucoperichondrial flaps. A chi-squared test or Fisher exact test was used for statistical analysis. Results: Eighty-one repairs were performed with a closure rate of 86%. The median patient age was 46 years (range 13-77); 34.6% of perforations were ≥2 cm. Conchal (77.8%), rib (7.4%), or septal (7.4%) cartilage was used as graft material. A complication rate of 8.6% was reported. Perforation size or graft material had no impact on successful closure rate. Of patients with failed repairs, 55% had perioperative complications or conditions associated with poor healing. Conclusion: An endonasal approach for NSP repair showed a high success rate across diverse presentations; however, NSP repair was significantly more likely to be successful in patients without perioperative complications or pre-existing conditions associated with poor wound healing.
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Affiliation(s)
- Lillian Chien
- Division of Facial Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christina M Yver
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shirly Shohat
- Department of Plastic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Oren Friedman
- Division of Facial Plastic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Manjunathan A, Thyparampil PJ. Re: "Perioperative Considerations for Antithrombotic Therapy in Oculofacial Surgery: A Review of Current Evidence and Practice Guidelines". Ophthalmic Plast Reconstr Surg 2023; 39:394. [PMID: 37413677 DOI: 10.1097/iop.0000000000002416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
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Perioperative Medication Management in Elective Plastic Surgery Procedures. J Craniofac Surg 2023; 34:1131-1136. [PMID: 36735455 DOI: 10.1097/scs.0000000000009183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Perioperative medication management is vital to maintain patient safety while under anesthesia, as well as to avoid postoperative complications. Plastic surgeons make daily decisions on whether to ask a patient to stop taking medication before their surgery. These important decisions can affect bleeding risk, wound healing, and interactions with anesthetics, which can range from minor to life-threatening. Current plastic surgery literature lacks a comprehensive review of perioperative medication management, with existing reports focusing on specific procedures and specific medication classes. METHODS A PubMed database search was conducted for articles through July 2021. The bibliographies of included studies were also examined for articles not acquired in the initial search queries. The authors included studies on medication usage and perioperative guidance in patients undergoing elective plastic surgery procedures. The authors excluded studies unrelated to plastic surgery and studies where the medications were used as an intervention. Abstracts, animal studies, studies involving the pediatric population, and book chapters were also excluded, as well as articles not published in English. RESULTS A total of 801 papers were identified by our search terms. After title and abstract screening, 35 papers were selected for full-text review. After full-text review, 20 papers were selected for inclusion, with an additional 6 papers from cited references added. Of the 26 papers, 6 papers discussed psychotropic drugs, 6 papers discussed medications affecting hemostasis, 4 papers discussed hormone-containing medications, 3 papers discussed antilipid medications, 2 papers discussed antihypertensive medications, 2 papers discussed herbal supplements, 1 paper discussed both psychotropic and herbal supplements, 1 paper discussed medications affecting wound healing, and 1 paper discussed rheumatologic medications. A summary of those recommendations was then compiled together. CONCLUSIONS The perioperative medication management in elective plastic surgery procedures remains a complex and multidisciplinary process. It is important to manage these patients in a case-by-case manner and to consult a specialist when necessary. Careful medication reconciliation is essential to decrease the likelihood of adverse outcomes and interactions with perioperative anesthetics.
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Yamasaki A, Dermody SM, Moyer JS. Reducing Risks of Graft Failure for Composite Skin–Cartilage Grafts. Facial Plast Surg Clin North Am 2023; 31:289-296. [PMID: 37001931 DOI: 10.1016/j.fsc.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Facial skin defects pose unique challenges for the reconstructive surgeon. Aesthetically complex areas involving a free margin-such as the ear, eyelid, columella, columella-lobule interface, soft tissue triangle, alar rim, and internal nasal lining-are particularly demanding, as secondary soft tissue contracture in these locations can lead to a very poor cosmetic outcome. In these cases, composite grafts offer an ideal combination of soft tissue coverage and structural rigidity, all accomplished in a single-stage surgery. Composite grafts are often underused in facial reconstructive surgery due to the tenuous blood supply and high reported rates of graft failure.
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Affiliation(s)
- Alisa Yamasaki
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, 1500 East Medical Center Drive SPC 5312, 1904 Taubman Center, Ann Arbor, MI 48109-5312, USA.
| | - Sarah M Dermody
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, 1500 East Medical Center Drive SPC 5312, 1904 Taubman Center, Ann Arbor, MI 48109-5312, USA
| | - Jeffrey S Moyer
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical Center, 1500 East Medical Center Drive SPC 5312, 1904 Taubman Center, Ann Arbor, MI 48109-5312, USA
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7
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Risk Factors and Consequences of Postoperative Bleeding in 12,580 Thyroid Surgeries. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03513-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Zeitz O, Wernecke L, Feltgen N, Sucker C, Koscielny J, Dörner T. [Anticoagulation and platelet aggregation inhibition : What needs to be considered in the ophthalmological practice]. Ophthalmologe 2021; 118:1287-1300. [PMID: 34279712 DOI: 10.1007/s00347-021-01438-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 10/20/2022]
Abstract
Several eye diseases requiring surgical intervention occur predominantly in elderly. Therefore, there is a significant co-incidence with systemic co-morbidities, which often do require anti-coagulation. There are several approaches to influence hemostasis pharmacologically. The number of options has increased substantially due to introduction of new drugs. This article provides an overview on the option range and gives insight, why this is of importance from the perspective of internal medicine. In addition, the basic principles of adjusting the therapy is being reviewed. Furthermore, the pharmacological inhibition of hemostasis in the context of eye surgery is being discussed. Available literature is analyzed to understand the necessity to interrupt or change the anti-coagulation for eye surgery.
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Affiliation(s)
- Oliver Zeitz
- Campus Benjamin Franklin, Augenklinik, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12202, Berlin, Deutschland.
| | - Laura Wernecke
- Campus Benjamin Franklin, Augenklinik, Charité Universitätsmedizin Berlin, Hindenburgdamm 30, 12202, Berlin, Deutschland
| | - Nicolas Feltgen
- Augenklinik, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Christoph Sucker
- MVZ Coagumed Gerinnungszentrum, Berlin, Deutschland.,Medizinische Hochschule Brandenburg, Brandenburg an der Havel, Deutschland
| | - Jürgen Koscielny
- Gerinnungsambulanz mit Hämophiliezentrum im ambulanten Gesundheitszentrum (AGZ), Universitätsmedizin Berlin, Charité, Berlin, Deutschland
| | - Thomas Dörner
- Klinische Hämostaseologie, Med. Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité, Universitätsmedizin Berlin & DRFZ Berlin, Berlin, Deutschland
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Bonadurer GF, Langeveld AP, Lalla SC, Roenigk RK, Arpey CJ, Otley CC, Baum CL, Trzasko LCO, Brewer JD. Hemorrhagic complications of cutaneous surgery for patients taking antithrombotic therapy: a systematic review and meta-analysis. Arch Dermatol Res 2021; 314:533-540. [PMID: 34132885 DOI: 10.1007/s00403-021-02250-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/12/2021] [Accepted: 05/22/2021] [Indexed: 11/27/2022]
Abstract
Cutaneous operations are generally safe procedures with minimal major risks. Excessive bleeding occasionally occurs, especially for patients taking antithrombotic medications. Conversely, stopping these medications before cutaneous surgery may increase the risk of a thromboembolic event. We aimed to synthesize the evidence regarding the risk of hemorrhage and thromboembolic events for patients undergoing cutaneous surgery while taking antithrombotic therapy. We performed a comprehensive search to identify randomized controlled trials and cohort studies that compared rates of hemorrhage and/or thromboembolic events between patients receiving antithrombotic therapy at cutaneous surgery and patients not receiving it. Odds ratio (OR) and risk difference for complications were calculated with random-effects models. Of 9214 patients taking anticoagulant or antiplatelet medications, 323 (3.5%) had hemorrhagic complications; of 21,696 control patients, 265 (1.2%) had hemorrhagic complications. Patients taking antithrombotic therapy had increased bleeding risk relative to control patients (OR 2.63 [95% CI 1.90-3.63]; P < 0.001) and an increased but less clinically important risk difference (OR 0.02 [95% CI 0.01-0.03]; P < 0.001) with high heterogeneity. No difference was observed in hemorrhage rates among patients whose antithrombotic therapy was stopped vs continued (OR 1.16 [95% CI 0.73-1.83]; P = 0.54). No difference was seen in rates of thromboembolic events among patients taking antithrombotic therapy vs control patients. However, two serious thromboembolic events were noted in a cohort of 59 patients whose antithrombotic therapy was stopped. Because of potentially devastating effects of thromboembolic events, the current accepted practice is indicated for continuation of antithrombotic therapy for patients undergoing cutaneous surgery.
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Affiliation(s)
- George F Bonadurer
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Andrea P Langeveld
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Soogan C Lalla
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,NYC Health and Hospitals, Central Office Division, 55 Water St, New York, NY, 10041, USA
| | - Randall K Roenigk
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christopher J Arpey
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Clark C Otley
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Christian L Baum
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Jerry D Brewer
- Department of Dermatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Beederman M, Jaffe J, Kuchta K, Warner J. Office-Based Forehead Flaps: A Safe and Reliable Reconstructive Option. Ann Plast Surg 2021; 86:287-291. [PMID: 33555682 DOI: 10.1097/sap.0000000000002478] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Forehead flaps are one of the workhorse flaps for nasal reconstruction, especially for large defects involving the nasal tip, ala, or multiple nasal subunits. Forehead flaps are often performed on older patients who have accompanying comorbidities and who may be at higher risk for anesthetic complications. The aim of this retrospective study was to compare the safety and success of forehead flap nasal reconstruction in 2 different clinical settings: those performed under local anesthesia in an office-based procedure room, compared with those performed in the operating room under either general anesthesia or intravenous sedation. METHODS A retrospective chart review was performed on all patients who underwent forehead flap reconstruction between the years of 2011 and 2018 by the senior author. Patient demographics, operative details, and postoperative complications were recorded and analyzed. Patients were followed for 1 year postoperatively or until the end of the study period. Patients were excluded if they had an accompanying unrelated cosmetic procedures performed during first-stage forehead flap reconstruction. RESULTS A total of 96 forehead flaps were performed, 35 of which (36.5%) were done in an office-based procedure room using local anesthesia only. Patient ages ranged from 45 to 92 years, with an average age of 71.9 years. The majority of flaps (n = 81, 85.3%) were divided at the second-stage procedure. There was no statistically significant difference in time elapsed between first- and second-stage procedures between groups (procedure room: 22.6 days; operating room: 23.8 days). There were 13 total postoperative complications (13.5%), but there was no statistically significant difference in complication rate between groups (office-based: 3 complications, 8.6%; operating room: 10 complications, 16.4%). CONCLUSIONS Our data suggest that forehead flap reconstruction can be done safely with acceptable postoperative results when performed under local anesthesia in an office-based outpatient setting.
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Affiliation(s)
- Maureen Beederman
- From the Section of Plastic and Reconstructive Surgery, The University of Chicago Medicine, Chicago, IL
| | | | - Kristine Kuchta
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL
| | - Jeremy Warner
- Warner Aesthetic & Reconstructive Institute, Winnetka, IL
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Miller MQ, Stevens JS, Park SS, Christophel JJ. Do Postoperative Antibiotics Affect Outcomes in Mohs Reconstructive Surgery? Laryngoscope 2020; 131:E434-E439. [PMID: 32401393 DOI: 10.1002/lary.28700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/28/2020] [Accepted: 04/03/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The prescribing of postoperative antibiotics for patients undergoing Mohs reconstructive surgery has increased in the last decade, while antibiotic resistance has been increasing. We hypothesized that routine prescribing of postoperative antibiotics after Mohs reconstruction does not decrease the risk of surgical site infection. STUDY DESIGN Retrospective, single-institution cohort study. METHODS This study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 29, 2019. The main outcomes assessed included postoperative surgical site infections, partial or full flap/graft necrosis, hematoma, and dehiscence. RESULTS A total of 900 defects in 800 patients (mean age [range] = 65.3 [21-96], 54.60% female) were identified over the 7-year period. Patient-specific variables reviewed included comorbidities, age, and smoking status. Surgery-specific variables analyzed included defect characteristics, time interval between Mohs micrographic surgery and reconstruction, reconstructive modalities, and use of postoperative antibiotics. All patients received peri-incisional antibiotics. On regression analysis, use of cartilage grafts (odds ratio [OR]: 6.53; 95% CI: 2.1-20.6; P = .001), current smoking status (OR: 6.67; 95% CI: 2.09-21.30; P = .001), full-thickness defects (OR: 1.2; 95% CI: 1.0-3.4; P = .045), and interpolated flap reconstruction (OR: 3.4; 95% CI: 1.0-11.5; P = .049) were associated with an increased risk of postoperative infections. Smoking and cartilage grafting remained significant on bivariable regression modeling. Use of perioperative antibiotics was not associated with a decreased risk of infection (OR: 1.82; 95% CI: 0.23-14.21; P = .568). CONCLUSIONS We found no association between postoperative infections after Mohs reconstructive surgery and the use of postoperative antibiotics. These data support a more targeted approach to antibiotic prescribing in Mohs reconstructive surgery. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E434-E439, 2021.
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Affiliation(s)
- Matthew Q Miller
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | | | - Stephen S Park
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - J Jared Christophel
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
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Albanese G, Kasbekar S, Abercrombie LC. Modified cheek advancement flap for medial lower eyelid, nasal sidewall and infraorbital cheek reconstruction: a case series. Orbit 2020; 39:123-127. [PMID: 31220981 DOI: 10.1080/01676830.2019.1626445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 05/29/2019] [Indexed: 06/09/2023]
Abstract
Aim: To describe and evaluate surgical outcomes of the Modified Cheek Advancement Flap (MCAF) to reconstruct defects involving medial lower eyelid, nasal sidewall and infraorbital cheek following Mohs micrographic surgery for basal cell carcinoma (BCC).Materials and Methods: All patients who underwent MCAF between 2012 and 2018 under the care of a single surgeon (LCA) were identified. The technique described in this report is a significant modification of the traditional cheek advancement flap. The MCAF was undertaken without subciliary or infraorbital incisions, less extensive dissection and use of flap advancement rather than rotation. A retrospective chart review was completed using a pro-forma which included risk factors for flap failure, early and late complications and additional reconstructive procedures. Patient satisfaction was rated using a five-point Likert-type scale.Results: 42 patients underwent the MCAF. Mean follow up was 28.4 months (±19.9 months). Early complications were found in 11.9% of the patients and resolved completely within the first four post-operative weeks. There were no long term complications secondary to the reconstruction. No lower eyelid ectropion was noted. 78.6% of the patients cited they were 'extremely satisfied' with the final cosmetic outcome.Conclusion: The MCAF proves a valuable and safe option in periocular reconstructive surgery with excellent cosmetic results and no post-operative ectropion. The necessity for eyelid tightening as part of the reconstructive process should encourage oculoplastic surgeons to use the MCAF when reconstructing defects involving medial lower eyelid, infraorbital cheek and nasal sidewall.
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Affiliation(s)
- Giorgio Albanese
- Oculoplastic and Orbital Surgery Service, Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Shivani Kasbekar
- Oculoplastic and Orbital Surgery Service, Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Lorraine C Abercrombie
- Oculoplastic and Orbital Surgery Service, Department of Ophthalmology, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
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David AP, Miller MQ, Park SS, Christophel JJ. Comparison of Outcomes of Early vs Delayed Graft Reconstruction of Mohs Micrographic Surgery Defects. JAMA FACIAL PLAST SU 2020; 21:89-94. [PMID: 30422211 DOI: 10.1001/jamafacial.2018.1204] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Reconstructing Mohs defects often requires grafting in the form of full-thickness skin grafts (FTSGs) and composite grafts. These grafts can be complicated by a variable and often indeterminable survival rate. Other researchers have found that delaying FTSG reconstruction improves graft outcomes, but the optimal interval between excision and reconstruction remains unclear, and no study has examined the association between delaying composite graft reconstruction and graft survival. Objective To review the outcomes of Mohs micrographic surgery defect reconstruction using FTSG and composite grafts with respect to patient- and surgery-specific variables, particularly early vs delayed reconstruction. Design, Setting, and Participants This retrospective, single-institution cohort study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 1, 2018. No patients had to be excluded for inadequate follow-up or incomplete medical records. Delayed reconstruction was defined as greater than 6 days after Mohs excision, the third quartile of the interval to reconstruction among our cohort. Main Outcomes and Measures Primary outcome was postoperative complications, including hematoma, infection, dehiscence, epidermolysis, and partial or full graft loss. Results A total of 320 defects were reconstructed with FTSG or composite grafts in 310 patients (median [range] age, 68 [21-96] years; 167 female [53.9%]) during the 6-year study period. The mean interval between the ablative and reconstructive operations was 4.73 days (range, 0-35 days). Univariate logistic regression was used to determine the significant indicators among patient and defect characteristics analyzed. A multivariate logistic regression model found delayed reconstruction to have a protective association (odds ratio, 0.52; 95% CI, 0.27-0.97; P = .046) and male sex to have a harmful association (odds ratio, 2.51; 95% CI, 1.52-4.20; P < .001) with postoperative complications. Conclusions and Relevance This study found that delaying reconstruction in FTSGs and composite grafts was associated with decreased rates of postoperative complications, and male sex was associated with an increased risk of postoperative complications. The findings suggest that this strategy can be considered in patients at increased risk for developing postoperative complications, such as current smokers, patients with large defects, and patients who require use of composite grafts. Level of Evidence 3.
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Affiliation(s)
- Abel P David
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco
| | - Matthew Q Miller
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - Stephen S Park
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - J Jared Christophel
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
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Abstract
Many patients undergoing ophthalmic surgery are elderly with comorbidities requiring antiplatelet therapy to prevent thromboembolic or atherothrombotic events. The use of antiplatelet therapy has expanded over the years, predisposing these patients to hemorrhagic complications perioperatively. The risk of hemorrhagic complications must be weighed against the risk of thromboembolic events with cessation of antiplatelet therapy. The decision to continue or interrupt antiplatelet therapy in the setting of ophthalmic surgery is based upon various factors, including the type of surgery and each patient’s comorbidities. This review examines the risks of thrombotic complications versus hemorrhagic complications in different types of ophthalmic surgeries with the use of antiplatelet medications and provides evidence-based recommendations regarding perioperative management of antiplatelet therapy
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Affiliation(s)
- Sana Idrees
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Jayanth Sridhar
- Bascom Palmer Eye Institute, University of Miami, Miami, FL, USA
| | - Ajay E. Kuriyan
- Flaum Eye Institute, University of Rochester Medical Center, Rochester, NY, USA
- Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
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15
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Miller MQ, David AP, McLean JE, Park SS, Christophel J. Association of Mohs Reconstructive Surgery Timing With Postoperative Complications. JAMA FACIAL PLAST SU 2019; 20:122-127. [PMID: 28880987 DOI: 10.1001/jamafacial.2017.1154] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Same-day Mohs reconstructive surgery is not always possible; moreover, a delay can offer benefits such as improved surgical planning and increased blood supply to the cauterized wound bed. However, recent work found that delaying reconstruction by more than 2 days increases the postoperative complication rate. Objective To review the outcomes of Mohs micrographic surgery (MMS) reconstruction with respect to patient- and surgery-specific variables, especially timing of repair. Design, Setting, and Participants Retrospective, single-institution cohort study of patients who underwent Mohs reconstructive surgery by 1 of the 2 senior authors from January 2012 to March 2017 for cutaneous squamous cell carcinoma or basal cell carcinoma. No patients had to be excluded for inadequate follow-up or incomplete medical records. Main Outcomes and Measures Postoperative complications including hematoma, infection, dehiscence, and partial or full graft or flap loss. Results A total of 633 defects in 591 patients (median [range] age, 65 [21-96] years; 333 [56.3%] female) were identified over the 5-year period. Reconstructions occurred from less than 24 hours to 32 days after MMS, with 229 (36.2%) delayed longer than 48 hours. Patient-specific variables reviewed included comorbidities, age, smoking status, and use of anticoagulant or antiplatelet medications. Surgery-specific variables analyzed included location and size of defect, time interval between MMS and reconstruction, and reconstructive modalities. Single-variable analysis was performed to determine whether each variable was associated with postoperative complications. On multivariable binary logistic regression, smoking status (odds ratio [OR], 2.46; 95% CI, 1.29-4.71; P = .007), defect size (OR exp(B), 1.04; 95% CI, 1.01-1.06; P = .006), full-thickness defects (OR, 1.56; 95% CI, 1.08-2.25; P = .02), interpolated flaps with cartilage grafting (OR, 8.09; 95% CI, 2.65-24.73; P < .001), and composite grafts (OR, 6.35; 95% CI, 2.25-17.92; P < .001) were associated with an increased risk of postoperative complications. Conclusions and Relevance We found no association between timing of Mohs reconstructive surgery and complications, indicating that a delayed repair did not increase the risk of infection or flap failure. Variables associated with an increased risk of postoperative complications include smoking status, size of the defect, full-thickness defects, interpolated flaps with cartilage grafting, and the use of composite grafts. Level of Evidence 3.
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Affiliation(s)
- Matthew Q Miller
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
| | - Abel P David
- University of Virginia School of Medicine, Charlottesville
| | - James E McLean
- University of Virginia School of Medicine, Charlottesville
| | - Stephen S Park
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville
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Fan KL, Black CK, Abbate O, Lu K, Camden RC, Evans KK. Venous thromboembolism in plastic surgery: the current state of evidence in risk assessment and chemoprophylactic options. J Plast Surg Hand Surg 2019; 53:370-380. [PMID: 31478782 DOI: 10.1080/2000656x.2019.1650057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The application of venous thromboembolism (VTE) prophylaxis has been the topic of intense debate in plastic surgery. The overall incidence of VTE is low in plastic surgery patients as compared to other surgical subspecialties but may be higher in the inpatient rather than outpatient plastic surgery populations. The Caprini Risk Assessment Model is the most highly studied and validated tool to assess VTE risk in plastic surgery patients. However, the Caprini model lacks procedure-specific risk assessment and patient-specific risk factor calculations. Due to these limitations, such as the low incidence and the heterogeneous nature of the specialty, trials lacked the power to capture proof of benefit, except in the highest-risk inpatient population. The emerging use of aspirin and novel oral anticoagulants may provide an alternative, as noninferiority in terms of efficacy and safety has been demonstrated in other fields. In this review, the authors intend to summarize the current state of evidence for prevention and explore the modalities available for prophylaxis, including novel oral anticoagulants.
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Affiliation(s)
- Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington DC, USA
| | - Cara K Black
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington DC, USA
| | - Olivia Abbate
- Harvard Plastic Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Karen Lu
- University of Central Florida School of Medicine, Orlando, FL, USA
| | - Rachel C Camden
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington DC, USA
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington DC, USA
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Tam S, Weber RS, Liu J, Ting J, Hanson S, Lewis CM. Evaluating Unplanned Returns to the Operating Room in Head and Neck Free Flap Patients. Ann Surg Oncol 2019; 27:440-448. [PMID: 31410610 DOI: 10.1245/s10434-019-07675-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Head and neck oncologic surgery with reconstruction represents one of the most complex operations in otolaryngology. Unplanned return to the operating room represents an objective measure of postoperative complications. The purpose of this study was to identify reasons and risk factors for unplanned return to the operating room in patients undergoing head and neck surgery with reconstruction. METHODS This retrospective cohort study of 467 patients undergoing head and neck surgery with free flap reconstruction used a previously-developed Head and Neck-Reconstructive Surgery-specific National Surgical Quality Improvement Program. Disease and site-specific preoperative, intraoperative, and postoperative data were gathered. Comparisons between those with and without an unexpected return to the operating room were completed with univariate and multiple logistic regression models. RESULTS The rate of unexpected return to the operating room was 18.8% (88 patients). Most common reasons for URTOR were flap compromise (24 patients, 5.1%), postoperative infection (21 patients, 4.5%), and hematoma (20 patients, 4.3%). Two risk factors were identified by multivariate analysis: coagulopathy (ORadjusted = 2.83, 95% CI = 1.24-6.19, P = 0.010), and use of alcohol (ORadjusted = 1.9, 95% CI = 1.14-3.33, P = 0.025). CONCLUSIONS Preexisting coagulopathy and increased alcohol consumption were associated with increased risk of unexpected return to the operating room. These findings can aid physicians in preoperative patient counseling and medical optimization and can inform more precise risk stratification of patients undergoing head and neck surgery with reconstruction. Strategies to prevent and mitigate unexpected returns to the operating room will improve patient outcomes, decrease resource utilization, and facilitate successful integration into alternative payment models.
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Affiliation(s)
- Samantha Tam
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Randal S Weber
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic and Reconstructive Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jose Ting
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Summer Hanson
- Department of Plastic and Reconstructive Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Guyot L, Saint-Pierre F, Bellot-Samson V, Chikhani L, Garmi R, Haen P, Jammet P, Meningaud JP, Savant J, Thomassin JM, Thiery G. Facial surgery for cosmetic purposes: Practice guidelines. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2019; 120:122-127. [PMID: 30685344 DOI: 10.1016/j.jormas.2019.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/11/2019] [Accepted: 01/20/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Facial surgery for cosmetic purposes aims to improve the physical appearance and self-image of normal individuals. The aim of the guidelines is to answer questions related to legislation, patient evaluation and motivations, relevance and risk assessment, patient information and patient follow-up. METHODOLOGY Analysis and synthesis of the medical literature through research of bibliographic databases in French and English from 2000 to 2017. Research and use of guidelines from evaluation agencies and academic societies. Drafting of guidelines with indications on levels of evidence. RESULTS 24 guidelines with levels of evidence B (scientific presumption), C (low level of evidence) or EO (expert opinion) were selected to answer the questions. Cosmetic facial surgery must be performed by certified, qualified professionals in authorized structures. It must follow certain specific rules as well as a charter and code of ethics so as to enforce the rules of practice.
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Affiliation(s)
- L Guyot
- Maxillofacial surgery unit, North university hospital, 13015 Marseille, France.
| | | | - V Bellot-Samson
- Maxillofacial surgery Private practice, 13008 Marseille, France
| | - L Chikhani
- Maxillofacial surgery, Private practice, 75016 Paris, France
| | - R Garmi
- Maxillofacial surgery unit, Caen university hospital, Caen, 14000 France
| | - P Haen
- Maxillofacial surgery unit, armed forces health Laveran Hospital, 13013 Marseille, France
| | - P Jammet
- Maxillofacial surgery unit, Lapeyronie university hospital, 34000 Montpellier, France
| | - J-P Meningaud
- Maxillofacial and plastic surgery unit, 94000 Creteil, France
| | - J Savant
- Maxillofacial surgery Private practice, 84000 Avignon, France
| | | | - G Thiery
- Maxillofacial surgery Private practice, 38043 Marseille, France
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Complications Arising From Perioperative Anticoagulant/Antiplatelet Therapy in Major Colorectal and Abdominal Wall Surgery. Dis Colon Rectum 2018; 61:1306-1315. [PMID: 30239396 DOI: 10.1097/dcr.0000000000001213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative hemorrhage and thromboembolism are recognized complications following colorectal and abdominal wall surgery, but accurate documentation of their incidence, trends, and outcomes is scant. This is relevant given the increasing number of surgical patients with cardiovascular comorbidity on anticoagulant/antiplatelet therapy. OBJECTIVE This study aims to characterize trends in the use of anticoagulant/antiplatelet therapy among patients undergoing major colorectal and abdominal wall surgery within the past decade, and to assess rates of, outcomes following, and risk factors for hemorrhagic and thromboembolic complications. DESIGN AND SETTING This is a retrospective cross-sectional study conducted at a single quaternary referral center. PATIENTS Patients who underwent major colorectal and abdominal wall surgery during three 12-month intervals (2005, 2010, and 2015) were included. MAIN OUTCOME MEASURES The primary outcomes measured was the rate of complications relating to postoperative hemorrhage or thromboembolism. RESULTS One thousand one hundred twenty-six patients underwent major colorectal and abdominal wall surgery (mean age, 61.4 years (SD 16.3); 575 (51.1%) male). Overall, 229 (21.7%) patients were on anticoagulant/antiplatelet agents; there was an increase in the proportion of patients on clopidogrel, dual antiplatelet therapy, and novel oral anticoagulants over the decade. One hundred seven (9.5%) cases were complicated by hemorrhage/thromboembolism. Aspirin (OR, 2.22; 95% CI, 1.38-3.57), warfarin/enoxaparin (OR, 3.10; 95% CI, 1.67-5.77), and dual antiplatelet therapy (OR, 2.99; 95% CI, 1.37-6.53) were most implicated with complications on univariate analysis. Patients with atrial fibrillation (adjusted OR 2.67; 95% CI, 1.47-4.85), ischemic heart disease (adjusted OR, 2.14; 95% CI, 1.04-4.40), and mechanical valves (adjusted OR, 7.40; 95% CI 1.11-49.29) were at increased risk of complications on multivariate analysis. The severity of these events was mainly limited to Clavien-Dindo 1 (n = 37) and 2 (n = 46) complications. LIMITATIONS This is a retrospective study with incomplete documentation of blood loss and operative time in the early study period. CONCLUSIONS One in ten patients incurs hemorrhagic/thromboembolic complications following colorectal and abdominal wall surgery. "High-risk" patients are identifiable, and individualized management of these patients concerning multidisciplinary discussion and critical-care monitoring may help improve outcomes. Prospective studies are required to formalize protocols in these "high-risk" patients. See Video Abstract at http://links.lww.com/DCR/A747.
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Hasselgren M, Runer T, Janson P, Ekström M. Antithrombotic treatment and risk of complications after head and neck full thickness skin graft surgery. J Plast Surg Hand Surg 2018; 52:333-337. [PMID: 30178690 DOI: 10.1080/2000656x.2018.1498789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Head and neck skin cancer surgery using a full thickness skin graft is a common procedure. Evidence concerning the effects of perioperative antithrombotic treatment on complications is limited. The aim of this study was to evaluate whether perioperative antithrombotic treatment is associated with risk of necrosis, bleeding or infection after full thickness skin graft surgery. Retrospective single-center cohort study with medical records review. Patients operated with a head and neck full thickness skin graft in 2010 and 2013-2015 had available data and were included. Any antithrombotic treatment was continued and all patients were routinely followed-up on days 7-10 after surgery. Data on demographics, concurrent disease, clinical characteristics, antithrombotic medications and postoperative necrosis, bleeding and infection were collected from electronic medical records. Associations with complications were examined using multivariate logistic regression adjusted for age, sex, reoperation, size of excision, site of surgery and concurrent disease. In total, 302 patients (53% women) were included. Antithrombotic treatment (n = 125 patients) was not associated with higher adjusted risk of total complications in multivariate analysis (OR 0.70; 95% CI: 0.34-1.46). In subgroup analyses, the total risk was not increased in patients on aspirin (OR 0.76; 95% CI: 0.39-1.48) or warfarin (OR 1.20; 95% CI: 0.47-3.10). In the warfarin subgroup (N = 26), there was a statistically non-significant trend towards increased risk of graft necrosis. This study supports that aspirin and warfarin should not be discontinued prior to head and neck full thickness skin graft surgery.
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Affiliation(s)
- Martin Hasselgren
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Thomas Runer
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Peter Janson
- a Department of Otolaryngology Head & Neck Surgery , Blekinge Hospital , Karlskrona , Sweden
| | - Magnus Ekström
- b Division of Respiratory Medicine and Allergology, Department of Clinical Sciences , Lund University , Lund , Sweden
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Ferrandino R, Garneau J, Roof S, Pacheco C, Poojary P, Saha A, Chauhan K, Miles B. The national landscape of unplanned 30-day readmissions after total laryngectomy. Laryngoscope 2017; 128:1842-1850. [PMID: 29152760 DOI: 10.1002/lary.27012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/11/2017] [Accepted: 10/20/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Examine rates of readmission after total laryngectomy and determine primary etiologies, timing, and risk factors for unplanned readmission. STUDY DESIGN Retrospective cohort study. METHODS The Nationwide Readmissions Database was queried for patients who underwent total laryngectomy between January 2013 and November 2013. Patient-, procedure-, admission-, and institution-level characteristics were compared for patients with and without unplanned 30-day readmission. Outcomes of interest included rates, etiology, and timing of readmission. Multivariate logistic regression was used to identify predictors of 30-day readmission. RESULTS There were 2,931 total laryngectomies performed in 2013 with an unplanned readmission rate of 17.5%. Postoperative fistula accounted for 13.7% of readmissions. The odds of readmission were elevated for patients undergoing concurrent procedures, including primary tracheoesophageal fistulization (adjusted odds ratio [aOR]: 2.44, 95% confidence interval [CI]: 1.15-5.18, P = .02) and/or pedicle graft or flap procedures (aOR: 1.73, 95% CI: 1.13-2.66, P = .01). Additionally, patients with comorbid coagulopathy (aOR: 3.04, 95% CI: 1.13-8.22, P = .03), liver disease (aOR: 2.48, 95% CI: 1.08-5.71, P = .03), and valvular heart disease (aOR: 3.18, 95% CI: 1.20-8.41, P = .02) had increased risk for unplanned 30-day readmission. Private insurance and longer lengths of stay were associated with decreased odds of readmission. CONCLUSIONS Nearly one-fifth of total laryngectomy patients are readmitted to the hospital within 30 days of discharge. Risk factors identified in this nationally representative cohort should be carefully considered during the postoperative period to reduce preventable readmissions after total laryngectomy. LEVEL OF EVIDENCE 2c Laryngoscope, 1842-1850, 2018.
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Affiliation(s)
- Rocco Ferrandino
- Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Jonathan Garneau
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Scott Roof
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Caitlin Pacheco
- Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Priti Poojary
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Aparna Saha
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Kinsuk Chauhan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
| | - Brett Miles
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A
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Liu J, Sun W, Dong W, Wang Z, Zhang P, Zhang T, Zhang H. Risk factors for post-thyroidectomy haemorrhage: a meta-analysis. Eur J Endocrinol 2017; 176:591-602. [PMID: 28179452 DOI: 10.1530/eje-16-0757] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 01/05/2017] [Accepted: 02/07/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Post-thyroidectomy haemorrhage is a rare but potentially life-threatening and unpredictable complication of thyroid surgery. In this study, we analysed the potential risk factors for the occurrence of post-thyroidectomy haemorrhage. METHODS The PubMed and SCIE databases were comprehensively searched for studies published before June 30, 2016. Studies on patients who underwent an open thyroidectomy with or without neck dissection were included, and RevMan 5.3 software was used to analyse the data. RESULTS Twenty-five studies and 424 563 patients were included in this meta-analysis, and post-thyroidectomy haemorrhage occurred in 6277 patients (incidence rate = 1.48%). The following variables were associated with an increased risk of post-thyroidectomy haemorrhage: older age (MD = 4.30, 95% CI = 3.09-5.52, P < 0.00001), male sex (OR = 1.73, 95% CI = 1.54-1.94, P < 0.00001), Graves' disease (OR = 1.76, 95% CI = 1.44-2.15, P < 0.00001), antithrombotic agents use (OR = 1.96, 95% CI 1.55-2.49, P < 0.00001), bilateral operation (OR = 1.71, 95% CI = 1.50-1.96, P < 0.00001), neck dissection (OR = 1.53, 95% CI = 1.11-2.11, P = 0.01) and previous thyroid surgery (OR = 1.62, 95% CI = 1.12-2.34, P = 0.01). Malignant tumours (OR = 1.07, 95% CI = 0.89-1.28, P = 0.46) and drainage device use (OR = 1.27, 95% CI = 0.74-2.18, P = 0.4) were not associated with post-thyroidectomy haemorrhage. CONCLUSION Our systematic review identified a number of risk factors for post-thyroidectomy haemorrhage, including older age, male sex, Graves' disease, antithrombotic agents use, bilateral operation, neck dissection and previous thyroid surgery. Early control of modifiable risk factors could improve patient outcomes and satisfaction.
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Affiliation(s)
- Jinhao Liu
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Wei Sun
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Wenwu Dong
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Zhihong Wang
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Ping Zhang
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Ting Zhang
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
| | - Hao Zhang
- Department of Thyroid SurgeryThe First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, People's Republic of China
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Kreicher KL, Bordeaux JS. Addressing Practice Gaps in Cutaneous Surgery: Advances in Diagnosis and Treatment. JAMA FACIAL PLAST SU 2017; 19:147-154. [PMID: 27768177 DOI: 10.1001/jamafacial.2016.1269] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Cutaneous surgery is performed by otolaryngologists, plastic surgeons, oculoplastic surgeons, dermatologic surgeons, and some primary care physicians. Practice gaps exist among cutaneous surgeons, as do differences in how different physicians approach preoperative, intraoperative, and postoperative decision-making. Objective To present the newest and best evidence to close common practice gaps in cutaneous surgery. Evidence Review We performed a detailed search of peer-reviewed publications that were identified through a search of PubMed/MEDLINE (January 1, 2000, through June 30, 2016) using the literature search terms "cutaneous surgery," "Mohs micrographic surgery," "plastic surgery," in combination with "safety," "cost," "anesthesia," "anti-coagulation," "bleeding," "pain," "analgesia," "anxiety," or "infection," among others. Bibliographies from these references, as well as meta-analyses, were also reviewed. Findings A total of 73 peer-reviewed studies, including randomized clinical trials, were selected to support the conclusions of the article. Levels of evidence were analyzed for selected studies using recommendations from the American Association of Plastic Surgeons based on guidelines from the Oxford Centre for Evidence-Based Medicine. Large cutaneous surgical resections can be done effectively and safely, taking steps to assure patient comfort under local anesthesia. Medically necessary anticoagulant and antiplatelet medication should be continued during cutaneous surgery. In preparation for surgery, patient anxiety and pain must be addressed. Music and anxiolytics limit anxiety, prevent cardiovascular compromise, and improve patient satisfaction. Cutaneous surgeons and support staff should carefully consider the dose and injection angle of local anesthetic. Postoperative opioids and topical antibiotics might cause harm to patients and should be avoided. Acetaminophen and ibuprofen provide adequate pain control with fewer adverse effects than opioid medications. Conclusions and Relevance Clinicians performing cutaneous surgery should understand the importance of patient safety and comfort, as guided by recent evidence.
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Affiliation(s)
- Kathryn L Kreicher
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jeremy S Bordeaux
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, Ohio
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Patel SA, Liu JJ, Murakami CS, Berg D, Akkina SR, Bhrany AD. Complication Rates in Delayed Reconstruction of the Head and Neck After Mohs Micrographic Surgery. JAMA FACIAL PLAST SU 2016; 18:340-6. [DOI: 10.1001/jamafacial.2016.0363] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Sapna A. Patel
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
| | - Jack J. Liu
- Department of Otolaryngology, Kaiser Permanente, Irvine, California
| | - Craig S. Murakami
- Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington
| | - Daniel Berg
- Seattle Skin Cancer Center, Seattle, Washington
| | - Sarah R. Akkina
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
| | - Amit D. Bhrany
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
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Oltmann SC, Alhefdhi AY, Rajaei MH, Schneider DF, Sippel RS, Chen H. Antiplatelet and Anticoagulant Medications Significantly Increase the Risk of Postoperative Hematoma: Review of over 4500 Thyroid and Parathyroid Procedures. Ann Surg Oncol 2016; 23:2874-82. [PMID: 27138383 DOI: 10.1245/s10434-016-5241-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE Antiplatelet and/or anticoagulant medication use is common. Abstinence a week before surgery may still result in altered hemostasis. The study aim was to report on perioperative antiplatelet and anticoagulant use in thyroidectomy and parathyroidectomy patients, and to determine the association with postoperative hematoma (POH) rates. METHODS Retrospective review of a prospective endocrine surgery database was performed. Procedure extent was defined as unilateral, bilateral, or extensive. Antiplatelets were categorized as none, 325 mg aspirin (ASA), <325 mg ASA, clopidogrel, or other. Anticoagulants were categorized as none, oral, or injectable. RESULTS A total of 4514 patients were identified. POH developed in 22 patients (0.5 %). Rates were similar between age, gender, and reoperative status. POH were seven times more common after thyroidectomy (0.8 vs. 0.1 %, p < 0.01). Unilateral procedures had lower POH rates than bilateral or extensive (0.1 vs. 0.9 vs. 0.8 %, p < 0.01). POH rates in patients receiving 325 mg ASA (0.8 %) or clopidogrel (2.2 %) were much higher than patients not receiving antiplatelets (0.5 %) or receiving <325 mg ASA (0.1 %, p = 0.04). Oral anticoagulants (2.2 %) and injectable anticoagulants (10.7 %) had much higher POH rates than patients not receiving anticoagulants (0.4 %, p < 0.01). Target organ, patient gender, procedure extent, antiplatelet use, and anticoagulant use were included on logistic regression to determine association with POH. Bilateral procedures, thyroidectomy, clopidogrel, oral, and injectable anticoagulants were all independently associated with POH. CONCLUSIONS POH occur more frequently after thyroidectomy and during bilateral procedures. Patients requiring clopidogrel or any anticoagulant coverage are at much higher risk for POH. These higher-risk patients should be considered for observation to ensure prompt POH recognition and intervention.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Amal Y Alhefdhi
- Department of Surgery, The King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | | | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Acute pain management in dermatology. J Am Acad Dermatol 2015; 73:543-60; quiz 561-2. [DOI: 10.1016/j.jaad.2015.04.050] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 04/08/2015] [Accepted: 04/08/2015] [Indexed: 02/02/2023]
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Perioperative management of anticoagulants and antiplatelet agents in oculoplastic surgery. Curr Opin Ophthalmol 2015; 26:422-8. [DOI: 10.1097/icu.0000000000000187] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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De Boulle K, Heydenrych I. Patient factors influencing dermal filler complications: prevention, assessment, and treatment. Clin Cosmet Investig Dermatol 2015; 8:205-14. [PMID: 25926750 PMCID: PMC4404720 DOI: 10.2147/ccid.s80446] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
While rare, complications do occur with the esthetic use of dermal fillers. Careful attention to patient factors and technique can do much to avoid these complications, and a well-informed practitioner can mitigate problems when they do occur. Since cosmetic surgery is usually an elective process, requested by the patient, clinical trials are complex to organize and run. For this reason, an international group of practicing physicians in the field of esthetics came together to share knowledge and to try and produce some informed guidance for their colleagues, considering the literature and also pooling their own extensive clinical experience. This manuscript aims to summarize the crucial aspects of patient selection, including absolute contraindications as well as situations that warrant caution, and also covers important considerations for the pre- and posttreatment periods as well as during the procedure itself. Guidance is given on both immediate and long-term management of adverse reactions. The majority of complications are related to accepting patients inappropriate for treatment or issues of sterility, placement, volume, and injection technique. It is clear that esthetic practitioners need an in-depth knowledge of all aspects of treatment with dermal fillers to achieve optimal outcomes for their patients.
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