Evidence-Based Patient Safety Advisory: Patient Selection and Procedures in Ambulatory Surgery:

Complications From Fat Grafting and Gluteal Augmentation in Outpatient Plastic Surgery: An Analysis of American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF, QUAD A) Data

BACKGROUND

Gluteal augmentation with autologous fat grafting, colloquially referred to as Brazilian butt lift (BBL), is an increasingly common procedure with a highly reported complication profile.

OBJECTIVES

In this study we aimed to analyze the prevalence and characteristics of complications that accompanied these surgeries at ambulatory surgery facilities.

METHODS

Adults patients who experienced fat grafting complications from 2019 to 2021 were identified in QUAD A, formerly known as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF, Highland Park, IL, USA), database. Patients and complications were analyzed based on sociodemographic, surgery-, and facility-specific variables with descriptive statistics and logistic regression.

RESULTS

Overall, 436 fat grafting procedures with complications were reported to QUAD A, with an overall complication rate of 0.94%. Of these complications, 164 (37.6%) were confirmed to be from gluteal augmentation procedures. Notably, the number of gluteal augmentation with fat grafting complications decreased from the year 2019 (48) to 2020 (36), then nearly doubled from 2020 to 2021 (69). The majority of patients were female (96.7%), with a mean age of 42.0 years and a mean BMI of 28.3 kg/m2. Wound infection was the most commonly documented complication (22.3%). Of the patients who experienced complications, 35.9% presented to a hospital for their complications and 12.6% required reoperation. Four deaths were described. There was no association between sociodemographic or surgical variables and increased odds of readmission or reoperation (P > .05), except for increasing surgeon number and reoperation (P = .02).

CONCLUSIONS

Gluteal augmentation accounts for a large proportion of complications from fat grafting procedures. Increased reporting requirements may aid in future determination of incidences of complications and improve patient safety.

LEVEL OF EVIDENCE: 3

Prolonged operative time is a risk factor for adverse postoperative outcomes in the unilateral deep inferior epigastric perforator (DIEP) flap surgery: A retrospective cohort study

BACKGROUND

Currently, one published study documented operative time (OT) as a predictor for postoperative outcomes in bilateral deep inferior epigastric perforator (DIEP) flap breast reconstructions. No literature has investigated this in unilateral DIEP flaps. We aimed to determine the relationship between unilateral OT, postoperative complications, unplanned reoperations (UR), and extended length-of-stay (eLOS).

METHODS

Patients who underwent elective unilateral DIEP reconstruction from 2018 to 2023 at a tertiary centre in London, United Kingdom, were retrospectively analysed. Patients were divided into four groups depending on OT quartiles to define a critical cut-off period. Data on extensive covariates, including procedural complexity, was recorded and used in univariable and multivariable regression models.

RESULTS

The final cohort contained 173 patients. After risk-adjustment, ≥421-minute operations led to a significantly higher overall complication rate (HR: 2.14, 95% CI: 1.26, 3.64, p = 0.005) relative to <421 min. Significantly higher odds of eLOS were observed in the ≥460-minute group (OR: 2.07, 95% CI: 1.07, 3.99, p = 0.03) compared to <460 min. There was no significant effect on the rate of postoperative UR across any OT group.

CONCLUSIONS

We confirmed OT was an independent predictor for postoperative outcomes in the DIEP flap, and demonstrated this in unilateral reconstructions. A clinical maximum threshold of 7 h was derived based on this cohort to help guide future surgical practice. Efficiency can be achieved by meticulous preoperative planning and process standardisation, multiple senior surgeons working per flap, and smooth teamwork between specialities and intraoperative staff.

Liposuction Complications in the Outpatient Setting: A National Analysis of 246,119 Cases in Accredited Ambulatory Surgery Facilities

Background

Suction lipectomy (liposuction) is a popular cosmetic surgical procedure performed in the United States, but little has been documented regarding perioperative complications due to its outpatient nature.

Objectives

This cross-sectional study aims to analyze the most common complications that accompany liposuction-related procedures and importantly estimate the total complication rate occurring at ambulatory surgical facilities.

Methods

Adult patients who experienced liposuction-related complications from 2019 to 2021 were identified in the reporting database of the global surgery accreditation authority, the American Association for Accreditation of Ambulatory Surgery Facilities (QUAD A). Patients were then divided by complication type and procedure location. Demographics and facility-specific variables were analyzed. Descriptive statistics were performed.

Results

Overall, 984 patients were included, with a mean age of 44 years (interquartile range [IQR] 37-53) and a median BMI of 28.7 kg/m2 (IQR 25.7-32.2). The overall confirmed complication rate was found to be 0.40% (984/246,119). Unplanned emergency department presentation was the most common complication overall (24%). Wound disruption was associated with the longest median procedure length (261 min), and venous thromboembolism was associated with the highest median BMI (30.1 kg/m2). The Southeast had the most complications (431), which accounted for 13/21 deaths (61.9%). Out of all complications, death was associated with the highest average annual case volume (241).

Conclusions

Procedures that involve liposuction are associated with a variety of medical and surgical complications. Given the high frequency and variability in how liposuction is performed, a thorough assessment of complications is critical to improve the safety of this procedure.

Level of Evidence 3

Asystolic Cardiac Arrest Associated With Unstable Bradycardia During Augmentation Mammaplasty: A Case Report

Cardiac arrest is a rare but reported complication during breast augmentation surgery. It is even more rare in a reportedly healthy patient without preexisting cardiac disease. The authors present the case of a healthy 34-year-old female who underwent elective bilateral augmentation mammaplasty and experienced unanticipated asystolic cardiac arrest intraoperatively following general anesthesia supplemented by a regional pectoral (pec I) nerve block. The performing plastic surgeon provided cardiopulmonary resuscitation while the anesthesiologist initiated a rescue protocol per Advanced Cardiac Life Support (ACLS) guidelines. Fortunately, the patient was resuscitated in a timely manner and had a successful return of spontaneous circulation within 1 minute. This case report serves to briefly review the literature and recommendations on proper resuscitation of cardiac arrest per ACLS protocols as well as discuss unstable bradycardia in otherwise healthy patients undergoing breast augmentation surgery. Plastic surgeons and anesthesiologists who perform this procedure should be aware of the possible, rare but serious progression to asystole as well as the proper resuscitative measures to take should they be required.

LEVEL OF EVIDENCE 5

Joint-Venture Ambulatory Surgery Centers: The Perfect Partnership

BACKGROUND

Ambulatory surgery growth has increased in the last few decades as ambulatory surgery centers have been shown to succeed in cost efficiencies through their smaller size and breadth, specialization of care, and ability to quickly participate in perioperative process improvement and education.

METHODS

A 5-year retrospective fiscal review was performed for all Northwell Health-physician ambulatory surgery center joint ventures. The outcome measures studied included model of ownership, specialty types, and gross revenue. Additional facility characteristics were studied, including growth trajectory, facility size, and cost to build a de novo facility.

RESULTS

Eleven free-standing ambulatory surgery centers were identified at Northwell Health during the 5-year study period. The total gross revenue for all Northwell clinical joint ventures for 2019 alone was $102,854,000. Northwell Health is a majority stakeholder in eight of their joint venture ambulatory surgery centers, with an average Northwell ownership of 53 percent and an average number of physician owners per facility of 11. The number of hospital-physician joint-venture ambulatory surgery centers grew from two to 11 facilities during the study period (450 percent). Surgical volume followed a similar trajectory, increasing 295 percent over the same time period.

CONCLUSIONS

The ambulatory surgery center setting provides a vast number of possibilities for key stakeholders, including patients themselves, to benefit from financial and clinical efficiencies. Ambulatory surgery centers have been popular, as they meet patient expectations for convenience of elective surgery, reduce payer and clinical pressures to minimize length of stay in hospitals, and achieve similar or higher quality care with less intense resources.

Safety and Cost Effectiveness of Outpatient Surgery in Acute Burn Care

INTRODUCTION

Outpatient burn surgery is increasingly utilized in acute burn care. Reports of its safety and efficacy are limited. This study aims to evaluate the safety and cost reduction associated with outpatient burn surgery and to describe our centre's experience.

METHODS

This was a single centre, retrospective cohort study of consecutive patients who underwent outpatient burn surgery requiring split thickness skin graft or dermal regenerative template from January 2010 - December 2018. Patient demographics, comorbidities, burn etiologies, operative data and postoperative care were reviewed. The primary outcome is complications involving major graft loss requiring reoperation.

RESULTS

One hundred and sixty-five patients and 173 procedures met the inclusion criteria. The average age was 44 years and 60.6% (100/165) were male. Annual outpatient procedure volume increased 48% from 23 to 34 cases over the 9-year period. The median (IQR) grafted percentage total body surface area was 1.0 (1.0)%. Rate of major graft loss requiring reoperation was 5.2% (9/172) and the most common site was the lower extremity (8/9, 88.9%). Age, sex, co-morbidities, total body surface area, and procedure types were not significantly associated with postoperative complication rates. The outpatient burn surgery model was estimated to save CA$8,170 per patient from inpatient costs.

CONCLUSION

Demonstration of the safety and cost savings associated with outpatient acute burn surgery is compelling for further utilization. Our experience found the adoption of improved dressing care, appropriate patient selection, increased patient education, adequate pain control, and regimented outpatient multidisciplinary care to be fundamental for effective outpatient surgical burn care.

Finesse in Mastopexy and Augmentation Mastopexy

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe surgical techniques associated with mastopexy and mastopexy augmentation. 2. Understand the evolution of mastopexy and augmentation mastopexy. 3. Address patient goals. 4. Achieve a favorable cosmetic outcome.

SUMMARY

The surgical techniques associated with mastopexy and mastopexy augmentation have continued to evolve. Traditional mastopexy techniques have included periareolar, circumvertical, and inverted-T patterns; however, adjuncts to these have included the use of various surgical mesh materials, implants, and fat grafting. This evidence-based article reviews how the techniques of mastopexy and augmentation mastopexy have evolved to best address patient goals and provide a favorable cosmetic outcome.

[Liposuctions in the ambulatory setting]

BACKGROUND

 Liposuctions are among the most frequently performed operations in plastic surgery worldwide. They are offered as inpatient as well as outpatient procedures. In the outpatient setting, tumescent anaesthesia is used in various forms. There is ambiguity about the amount of lipoaspirate that can be removed safely in an outpatient setting, and also about the monitoring of parameters and the duration of postoperative care.

MATERIAL AND METHODS

 A systematic literature review was conducted with the help of the MEDLINE data base of the U. S. National Library of Medicine (NLM) and the bibliographic search engine Google Scholar (https://scholar.google.com) of Google LLC. The key words "Liposuction Anesthesia" and "Liposuction Guidelines" were used. All items resulting from the search were checked for thematic concordance and further analysed by their level of evidence, significance and availability.

RESULTS

 After the literature review, a total of 197 items were identified for further analysis. The analysis of the international and German literature yielded a systematic overview of recommendations.

CONCLUSIONS

 Tumescence anaesthesia in an outpatient setting has various advantages, e. g. cost reduction for provider and patient as well as avoidance of the risk profile of general anaesthesia. Also patients can change their position autonomously, which can be beneficial for surgery. However, there are limitations in terms of the lipoaspirate volume that can be removed safely. With increasing lipoaspirate volumes, more local anaesthetic is needed, which also increases the postoperative monitoring time. In the authors view, tumescent anaesthesia should only be used for small-volume and localised liposuctions. Liposuction in general anaesthesia offers more advantages, especially with increasing lipoaspirate volumes.

Venous Thromboembolism Prophylaxis in Aesthetic Surgery: A Survey of Plastic Surgeons' Practices

BACKGROUND

Deep venous thrombosis and pulmonary embolism, collectively known as venous thromboembolism (VTE), are among the most feared yet preventable surgical complications. Although many recommendations exist to reduce the risk of VTE, the actual VTE prophylaxis practices of aesthetic plastic surgeons remain unknown.

OBJECTIVES

The primary aim of this study was to elucidate plastic surgeons' experiences with VTE, preferred VTE prophylaxis practices, and areas in which VTE prevention may be improved.

METHODS

Members of The Aesthetic Society were queried via a 55-question electronic survey regarding their experience with VTE as well as their VTE prophylaxis practices. Anonymous responses were collected and analyzed by the Mayo Clinic Survey Research Center.

RESULTS

The survey was sent to 1729 of The Aesthetic Society members, of whom 286 responded. Fifty percent, 38%, and 6% of respondents reported having had a patient develop a deep venous thrombosis, pulmonary embolism, or death secondary to VTE, respectively. Procedures performed on the back or trunk were associated with the highest rate of VTE. Lower extremity procedures were associated with a significantly higher rate of VTE than expected. Over 90% of respondents reported utilizing a patient risk stratification assessment tool. Although at least one-half of respondents reported that the surgical facility in which they operate maintains some form of VTE prophylaxis protocol, 39% self-reported nonadherence with these protocols.

CONCLUSIONS

Considerable variability exists in VTE prophylaxis practices among The Aesthetic Society responders. Future efforts should simplify guidelines and tailor prophylaxis recommendations to the aesthetic surgery population. Furthermore, education of plastic surgeons performing aesthetic surgery and more diligent surgical venue supervision is needed to narrow the gap between current recommendations and actual practices.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

BACKGROUND

There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors.

METHODS

A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation.

RESULTS

We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood.

CONCLUSIONS

The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

Getting the Most Out of Augmentation-Mastopexy

LEARNING OBJECTIVES

After reviewing the article, the participant should be able to: 1. Understand the tenets of proper patient selection. 2. Be familiar with the assessment of patients for augmentation-mastopexy. 3. Be able to plan an operative approach and execute the critical steps. 4. Be able to recognize common complications and have a basic understanding of their management. 5. Be aware of emerging adjunctive techniques and technologies with respect to augmentation-mastopexy.

SUMMARY

Despite being a multivariable and complex procedure, augmentation-mastopexy remains a central and pivotal component of the treatment algorithm for ptotic and deflated breasts among plastic surgeons. Careful preoperative planning, combined with proper selection of approach and implant, can lead to success. Physicians need to understand that there is a high frequency of reoperation cited in the literature with regard to this procedure, and discussions before the initial operation can help alleviate common misunderstandings and challenges inherent in this operation.

Venous Thromboembolism in Aesthetic Surgery: Risk Optimization in the Preoperative, Intraoperative, and Postoperative Settings

The purpose of this Continuing Medical Education (CME) article is to provide a framework for practicing surgeons to conceptualize and quantify venous thromboembolism risk among the aesthetic and ambulatory surgery population. The article provides a practical approach to identify and minimize venous thromboembolism risk in the preoperative, intraoperative, and postoperative settings.

Total Joint Arthroplasty in Ambulatory Surgery Centers: Analysis of Disqualifying Conditions and the Frequency at Which They Occur

BACKGROUND

The frequency of total joint arthroplasties (TJAs) performed in ambulatory surgery centers (ASCs) is increasing. However, not all TJA patients are healthy enough to safely undergo these procedures in an ambulatory setting. We examined the percentage of arthroplasty patients who would be eligible to have the procedure performed in a free-standing ASC and the distribution of comorbidities making patients ASC-ineligible.

METHODS

We reviewed the charts of 3444 patients undergoing TJA and assigned ASC eligibility based on American Society of Anesthesiologists (ASA) status, a set of exclusion criteria, and any existing comorbidities.

RESULTS

Overall, 70.03% of all patients undergoing TJA were eligible for ASC. Of the ASA class 3 patients who did not meet any exclusion criteria but had systemic disease (51.11% of all ASA class 3 patients), 53.69% were deemed ASC-eligible because of sufficiently low severity of comorbidities. The most frequent reasons for ineligibility were body mass index >40 kg/m² (32.66% of ineligible patients), severity of comorbidities (28.00%), and untreated obstructive sleep apnea (25.19%).

CONCLUSION

A large proportion of TJA patients were found to be eligible for surgery in an ASC, including over one-third of ASA class 3 patients. ASC performed TJA provides an opportunity for increased patient satisfaction and decreased costs, selecting the right candidates for the ambulatory setting is critical to maintain patient safety and avoid postoperative complications.

Variables Influencing the Depth of Conscious Sedation in Plastic Surgery: A Prospective Study

Background

Conscious sedation has been widely utilized in plastic surgery. However, inadequate research has been published evaluating adequate drug dosage and depth of sedation. In clinical practice, sedation is often inadequate or accompanied by complications when sedatives are administered according to body weight alone. The purpose of this study was to identify variables influencing the depth of sedation during conscious sedation for plastic surgery.

Methods

This prospective study evaluated 97 patients who underwent plastic surgical procedures under conscious sedation. Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), creatinine, and glucose levels were measured. Midazolam and ketamine were administered intravenously according to a preset protocol. Bispectral index (BIS) recordings were obtained to evaluate the depth of sedation 4, 10, 15, and 20 minutes after midazolam administration. Associations between variables and the BIS were assessed using multiple regression analysis.

Results

Alcohol intake and female sex were positively associated with the mean BIS (P<0.01). Age was negatively associated with the mean BIS (P<0.01). Body mass index (P=0.263), creatinine clearance (P=0.832), smoking history (P=0.398), glucose (P=0.718), AST (P=0.729), and ALT (P=0.423) were not associated with the BIS.

Conclusions

Older patients tended to have a greater depth of sedation, whereas females and patients with greater alcohol intake had a shallower depth of sedation. Thus, precise dose adjustments of sedatives, accounting for not only weight but also age, sex, and alcohol consumption, are required to achieve safe, effective, and predictable conscious sedation.

Is Office-Based Surgery Safe? Comparing Outcomes of 183,914 Aesthetic Surgical Procedures Across Different Types of Accredited Facilities

BACKGROUND

There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned.

OBJECTIVES

This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals.

METHODS

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed.

RESULTS

Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01).

CONCLUSIONS

Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3.

Plastic Surgery after Massive Weight Loss

Bariatric surgery rates have increased in the United States concurrent with the rise in obesity. As a result of the massive weight loss from these surgeries, patients are left with a different set of functional and cosmetic issues related to excess skin. Plastic surgery has evolved to treat these unique issues faced by this patient population and has demonstrated beneficial effects. This article will provide an overview of the options available to massive weight loss patients to treat specifically affected area of the body.

Rivaroxaban for Venous Thromboembolism Prophylaxis in Abdominoplasty: A Multicenter Experience

BACKGROUND

Abdominoplasty, a commonly performed aesthetic procedure, is considered to have an increased risk of venous thromboembolism (VTE) events. At present, routine VTE chemoprophylaxis following abdominoplasty remains controversial.

OBJECTIVES

This study evaluates the authors' experience with rivaroxaban, an oral Factor Xa inhibitor, for VTE prophylaxis in abdominoplasty patients.

METHODS

A retrospective case series was conducted. All patients who underwent abdominoplasty and received rivaroxaban were included. The prophylactic dose was 10 mg daily for 7 days, beginning 12 hours postoperatively. Patient demographics, comorbidities, and type of surgery were recorded. The primary outcome measured was hematologic complication, including VTE, hematoma requiring operative evacuation, and need for blood transfusion.

RESULTS

From September 2012 until July 2014, 132 patients (122 women and 10 men) underwent abdominoplasty surgery and received rivaroxaban postoperatively. Mean patient age was 43.7 years, and mean body mass index was 27.1. One hundred twenty-five patients also underwent abdominal muscle plication. Eleven patients underwent a fleur de lis vertical skin resection component. One hundred patients underwent concomitant abdominal liposuction, while 79 patients also had back liposuction. Only 1 patient had a symptomatic VTE event. Three patients had a hematoma requiring operative evacuation, and all went on to heal without sequelae. Two patients received a blood transfusion for anemia during their course of rivaroxaban.

CONCLUSIONS

Oral rivaroxaban administration for chemoprophylaxis in abdominoplasty patients is safe, with low rates of symptomatic VTE and hematoma formation. The authors continue routine use of the medication for patients at increased risk for VTE events. LEVEL OF EVIDENCE 4: Risk.

Quality and safety outcomes of ambulatory plastic surgery facilities in California

BACKGROUND

Although most cosmetic surgery procedures are performed at outpatient surgery facilities, there is little published literature on the quality and safety of such facilities. Furthermore, regulation of such facilities varies widely and may leave room for poor outcomes. The authors sought to determine whether all outpatient surgery facilities that are licensed by the California Department of Public Health have similar rates of postoperative complications.

METHODS

A retrospective review was performed of all data collected from 2005 to 2010 by the California Office of Statewide Health Planning and Development. All outpatient surgery facilities licensed by the Department of Public Health must report encounter-level data to that office. Patients' subsequent inpatient admissions and emergency department visits were identified. Several cosmetic procedures were studied. Outcomes analyzed were the 30-day venous thromboembolism, hospital admission, and emergency department visit rates.

RESULTS

A total of 160,847 patients and 635 facilities were included. By facility, the range for 30-day venous thromboembolism rates was 0 to 3.4 percent, the range for 30-day admission rates was 0 to 7.7 percent, and the range for 30-day emergency department visits was 0 to 22.8 percent.

CONCLUSIONS

Analysis showed a significant variability in the rate of 30-day venous thromboembolism incidents, admissions, and emergency department visits. Some facilities had complication rates that were a significant deviation from the mean, whereas others had no complications. To ensure optimal quality and patient safety, it is necessary to analyze why outliers exist and identify ways to improve on the current system of licensure and outcomes reporting.

Risk of adverse outcomes when plastic surgery procedures are combined

BACKGROUND

The ability to study population-level outcomes of outpatient cosmetic procedures has been limited by a lack of longitudinal data. This study aimed to describe the rates of adverse events in patients who underwent an isolated cosmetic surgery procedure compared with those who had a combination of two procedures.

METHODS

Retrospective longitudinal analysis was performed of the 2005 to 2010 California Office of Statewide Health Planning and Development Ambulatory Surgery Database. Patients were included if they had undergone an abdominoplasty or any other procedure that was identified as frequently performed concurrently with abdominoplasty. Patients' subsequent in-patient admissions and emergency department visits were identified. Outcomes analyzed were the 30-day and 1-year venous thromboembolism rates, 30-day hospital admission rate, 30-day emergency department visit rate, and 30-day mortality rate.

RESULTS

A total of 477,741 patients were analyzed, of whom 16,893 had undergone two concurrent procedures. The 12-month venous thromboembolism rate was 0.57 percent for patients undergoing abdominoplasty, 0.20 percent for liposuction, 0.12 percent for breast procedures, 0.32 percent for hernia repair, 0.28 percent for face procedures, and 0.28 percent for thigh lift/brachioplasty. Greater than additive 30-day and 1-year venous thromboembolism rates were observed among patients who underwent an abdominoplasty and liposuction (0.68 percent and 0.81 percent, respectively) and those who underwent an abdominoplasty and hernia repair (0.93 percent).

CONCLUSIONS

Some combinations of elective outpatient procedures conferred an additive, and sometimes more than additive, venous thromboembolism risk. This is an important consideration when informing patients of potential postoperative complications and for venous thromboembolism prophylaxis.

Venous Thromboembolism following Elective Aesthetic Plastic Surgery: A Longitudinal Prospective Study in 1254 Patients

Background. Venous thromboembolism (VTE) is a disorder with short-term mortality and long-term morbidity. Healthy patients submitted to elective aesthetic plastic surgeries (EAPS) have risk factors to develop VTE not well established yet. The objective of this study was to examine the incidence and risk factors for VTE in these patients. Methods. Longitudinal, prospective (minimum follow-up of 3 months), observational study. Comprehensive information on patient characteristics and surgeries performed was obtained. Preoperative, intraoperative, and postoperative risk factors were analyzed for their association with VTE. Results. A total of 1254 patients were included in the study. Postoperative VTE occurred in 17 (1,35%) of patients. VTE was more frequent in patients more than 40 years old (82.3%). Smoking, patients with 2 or 3 pregnancies, and hormone replacement therapy, and oral contraceptives use presents higher levels of VTE. In this study we have not found any correlation between liposuction, augmentation mammoplasty, mastopexy, and rhinoplasty as an isolated risk factor for VTE. Conclusions. The incidence of VTE in patients undergoing EAPS was 1.35%. Patients with more than 40 years of age, tobacco users, patients with 2 or more pregnancies, and hormone replacement therapy or oral contraceptives use presents higher levels of VTE.

Initial results from the National Anesthesia Clinical Outcomes Registry and overview of office-based anesthesia

Safe office-based anesthesia practices dictate proper patient and procedure selection, appropriate provider qualifications, adequately equipped facilities, and effective administrative infrastructure. Analysis of patient outcomes can help reduce mortality and morbidity by identifying high-risk patients and procedures. We analyzed data from the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry. Analysis included patient demographics and outcomes, procedure and anesthesia type and duration, and case coverage by provider. Increased regulation and standardization of care, such as the use of checklists and professional guidelines, can advance safe practices. There is increasing emphasis on continuous quality improvement, electronic health records, and outcomes data reporting.

Outpatient surgery and sequelae: an analysis of the AAAASF Internet-based quality assurance and peer review database

Although Internet-based quality assurance and peer review data have demonstrated the safety of procedures performed in the outpatient setting through the analysis of outcomes, the future of patient care will be directed by evidence-based medicine. Large inpatient surgical databases have long existed to provide quality assurance and improvement data for the inpatient cohort of patients. The acquisition of large data sets related to surgical care can best be achieved through the Internet. When outcomes are analyzed in conjunction with the indications for a procedure and the manner that care was delivered, evidence-based medicine is the end product.

A comparative analysis of readmission rates after outpatient cosmetic surgery

BACKGROUND

Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures.

OBJECTIVES

The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures.

METHODS

The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients.

RESULTS

The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08-1.81; P=.010).

CONCLUSIONS

Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.

How to Link outcomes data to quality initiatives in plastic surgery?

In recent decades, the expansion of health services research has created an opportunity to crate salient, evidence-based guidelines for diagnosis, treatment, and prognosis. However, for many aspects of care, incorporation of new scientific knowledge into clinical practice often lags, particularly among the surgical subspecialties. This article highlights the development of evidence-based medicine, the principles of innovation diffusion, and successes and challenges in developing plastic surgery quality initiatives.

Difficult airway management in an ambulatory surgical center?

PURPOSE OF REVIEW

This review will focus on two key aspects of difficult airway management in an ambulatory surgical center (ASC). First, the selection process of patients with known difficult airways suitable for this environment, and second, the requirements of a difficult airway cart to manage unexpected airway problems.

RECENT FINDINGS

The decision whether to manage a patient with a previously documented difficult airways in an ASC requires a multidisciplinary approach. Many factors will influence this decision including the cause and severity of the airway problem, the type of procedure, the experience of the perioperative staff, and the availability of difficult airway management devices.Unexpected difficult airways will always occur in anesthesia. Difficult airway carts are, therefore, a requirement for any area in which anesthesia is to be conducted. The contents of these carts should reflect the need to maintain patient oxygenation to avoid morbidity and mortality. Regular training sessions should include both technical training in the use of equipment and nontechnical training to improve interpersonal communication during crises.

SUMMARY

The management of ambulatory surgical practices must provide suitable difficult airway management equipment as well as technical and nontechnical training. Patients may present to an ASC with expected and unexpected difficult airways. Appropriate management of these patients requires advance planning to avoid poor outcomes.

Asystole in young athletic women during breast augmentation: a report of three cases

Reported herein are three cases of spontaneous bradycardia progressing to asystole during routine breast augmentation in healthy, adult female patients with a history of endurance training and resting bradycardia (heart rate <60 beats per minute). The incidence of this phenomenon is minimally reported and virtually unexplained in literature. Our goal is to alert the plastic surgery community of the possibility of these events occurring without warning in athletic patients, attempt to explain these findings, and provide a plan of action to minimize morbidity and mortality in these patients. The most severe case was that of a 38-year-old female who became severely bradycardic progressing to asystole during routine breast augmentation. She had no history of any medical problems, but did have a resting heart rate of <60. Glycopyrrolate, an antimuscarinic agent, was given and chest compressions started. After 10-20 s of chest compressions the patient's normal sinus rhythm resumed. Two other cases are also reported, although these patients responded to antimuscarinic agents without requiring chest compressions. Both were endurance athletes with a resting heart rate of <60. Bradycardia caused by a vagal response during surgery is not uncommon and routinely treated successfully with administration of atropine-like agents. Bradycardia progressing to frank asystole is rare and has not been reported in young, otherwise healthy, aesthetic surgery patients. This report should serve to alert the plastic surgeon to the possibility of this situation occurring and how to treat it successfully, especially in the outpatient or office-based surgery setting. Level of Evidence V This journal requires that authors assign a level of evidence to each article.

Pediatric nasoorbitoethmoid fractures

The pediatric craniofacial trauma literature largely focuses on the management of mandible fractures, with very little information focusing on pediatric midface fractures, specifically nasoorbitethmoid (NOE) fractures. Because the diagnosis and surgical treatment plan for adult NOE fractures is well established in the literature, the treatment algorithms for NOE are essentially a transfer of adult practices to pediatric patients. This article reviews the differences between the pediatric and adult facial skeleton and the pathology and presentation of NOE fractures in the pediatric craniomaxillofacial skeleton. It also presents the effects of NOE fractures on the growth and development of the pediatric facial skeleton and describes the current surgical management for NOE fractures.

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

Breast reshaping following massive weight loss: principles and techniques

SUMMARY

Management of the breast following massive weight loss for both reconstructive and aesthetic reasons poses unique challenges that are often inadequately addressed with traditional techniques. The breast mound is often unstable and deflated, with a loose inelastic skin envelope and ill-defined boundaries that blend into similar lateral chest wall, arm, and upper abdominal contour irregularities. Because this has become more common recently with the increasing prevalence of massive weight loss patients desiring body contouring, the purpose of this review was to discuss modifications to traditional breast techniques that have been proposed for these patients. It has become apparent that mammaplasty techniques in the massive weight loss patient should rely more on extensive glandular manipulation for shape preservation rather than relying on the skin envelope for shaping. Such techniques include parenchymal plication, suspension, and autoaugmentation. This will improve the likelihood of maintained shape and symmetry in an otherwise difficult patient population.