Patient safety in plastic surgery: identifying areas for quality improvement efforts

Reasons for Silicone Breast Implant Removal After Long-Term Implantation in Chinese Patients Without Complications: A Questionnaire-Based Study

BACKGROUND

There are few studies of Chinese patients who request silicone breast implant removal after at least 10 years of implantation without any complications. This study aimed to study the characteristics of these patients, explore their reasons for breast implant removal and associate factors that affect their choice, so as to provide valuable information on clinical decision making.

METHODS

A total of 55 eligible female patients (110 breasts) were enrolled from 2016 to 2022. A preoperative questionnaire survey before removal surgery and a telephone follow-up 1 year after removal surgery were conducted to collect data.

RESULTS

The mean age of the patients was 40.6±8.8 years with the average time from breast augmentation to implant removal or replacement ranged from 10 to 15 years. Concerns about the aging of silicone gel-filled breast implant and the adverse effects of its long-term placement on body health were the top two reasons for breast implant removal. 63% of patients refused implant replacement, who were nearly 10 years older than those accepted implant replacement (p<0.05). Older age at implant removal (OR=0.67; 95%CI: 0.44-0.89) and a history of basic diseases (OR=0.02; 95%CI: 0.00-0.39) were statistically associated with lower rate of implant replacement.

CONCLUSIONS

Concerns about the aging of silicone gel-filled breast implant were the main reason for uncomplicated patients to remove their breast implants. A comprehensive analysis based on patient's subjective choice and physical condition was suggested when an uncomplicated patient asks for implant removal.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk of Complications in Combined Plastic Surgery Procedures Using the Tracking Operations and Outcomes for Plastic Surgeons Database

BACKGROUND

Combining multiple surgical procedures into a single operative session is widespread in the field of plastic surgery; however, the implications of this practice are not fully understood.

OBJECTIVES

This study compared 30-day complication rates associated with combined plastic surgery procedures with the rates for index procedures.

METHODS

This retrospective cohort analysis utilized the Tracking Operations and Outcomes for Plastic Surgeons database from 2016 to 2020 to identify the 3 most frequent combinations of augmentation mammaplasty, reduction mammaplasty, trunk liposuction, mastopexy, and abdominoplasty.

RESULTS

The 30-day overall complication rate was 5.0% (1400 of 26,771 patients), with a higher complication rate for combined procedures compared with index (7.6% vs 4.2%, adjusted odd ratio [aOR], 1.91 [95% CI, 1.61-2.27], P < .001). There were no significant differences in complication rates for abdominoplasty or mastopexy combinations compared with index. Complication rates for reduction mammaplasty combinations compared with index were not statistically different after controlling for demographics (aOR, 1.02 [95% CI, 0.61-1.64], P = .93). Higher rates of minor and major complications were observed for combinations of trunk liposuction (aOR, 4.84 [95% CI, 3.31-7.21), P < .001) and augmentation mammaplasty (aOR, 1.60 [95% CI 1.13-2.22], P = .007) compared with index.

CONCLUSIONS

Combinations with trunk liposuction or augmentation mammaplasty present with increased risk of complications compared with index, controlling for demographics. Abdominoplasty and mastopexy may be combined with other plastic surgery procedures without increased risk to patients. The complication risk of reduction mammaplasty combinations is mediated by other variables, suggesting the need for shared surgical decision-making when recommending these combinations to patients.

LEVEL OF EVIDENCE: 4

Systematic Review of Patient Safety and Quality Improvement Initiatives in Breast Reconstruction

BACKGROUND

Improving patient care and safety requires high-quality evidence. The objective of this study was to systematically review the existing evidence for patient safety (PS) and quality improvement initiatives in breast reconstruction.

METHODS

A systematic review of the published plastic surgery literature was undertaken using a computerized search and following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Publication descriptors, methodological details, and results were extracted. Articles were assessed for methodological quality and clinical heterogeneity. Descriptive statistics were completed, and a meta-analysis was considered.

RESULTS

Forty-six studies were included. Most studies were retrospective (52.2%) and from the third level of evidence (60.9%). Overall, the scientific quality was moderate, with randomized controlled trials generally being higher quality. Studies investigating approaches to reduce seroma (28.3% of included articles) suggested a potential benefit of quilting sutures. Studies focusing on infection (26.1%) demonstrated potential benefits to prophylactic antibiotics and drain use under 21 days. Enhanced recovery after surgery protocols (10.9%) overall did not compromise PS and was beneficial in reducing opioid use and length of stay. Interventions to increase flap survival (10.9%) demonstrated a potential benefit of nitroglycerin on mastectomy skin flaps.

CONCLUSIONS

Overall, studies were of moderate quality and investigated several worthwhile interventions. More validated, standardized outcome measures are required, and studies focusing on interventions to reduce thromboembolic events and bleeding risk could further improve PS.

System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection

BACKGROUND

Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.

METHODS

Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.

RESULTS

The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI, 1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).

CONCLUSIONS

Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes

BACKGROUND

Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.

METHODS

Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.

RESULTS

The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.

CONCLUSIONS

Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter?

ABSTRACT

Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Surgical reconstruction of pressure ulcers in spinal cord injury individuals: A single- or two-stage approach?

INTRODUCTION

There are two surgical approaches to reconstruct a pressure ulcer (PU): one-stage reconstruction or two-stage reconstruction. One stage reconstruction consists of surgical debridement and flap reconstruction during one operation. Two-stage surgery consist of a surgical debridement and a final reconstruction in two different sessions, with approximately six weeks between both sessions.

OBJECTIVE

The aim of this study was to compare the results of single stage surgery and two-stage surgery on the PU recurrence rate and other important post operative complications.

METHOD

A retrospective, comparative study in Spinal Cord Injured (SCI) individuals with a single- or two stage surgical reconstruction between 2005 and 2016 was designed. A total of 81 records were included for analysis.

RESULTS

The primary outcome, the difference in occurrence of a recurrent PU in the reconstructed area (33.3% versus 31.6%), is not statistically significant between one-and two-stages reconstruction. Also, the mean duration to develop a recurrent PU between both surgical reconstructions is not statistically significant. Other surgical complications in the reconstructed area like wound hematoma, hemorrhage, seroma or (partial) flap failure did not differ significantly between both groups, apart and in total. We calculated the additional costs in case of a two-stage approach compared with a single-stage reconstruction at EUR 16,362.

CONCLUSIONS

There are no statistical significant differences in PU recurrence rate or other post operative complications between SCI patients who have undergone one- or two stage PU reconstructive surgery. The most obvious choice for a one-stage approach in case of PU reconstructive surgery has great positive implications for the patient, family, health care providers and the health care system.

Levels of Evidence in Plastic and Reconstructive Surgery Research: Have We Improved Over the Past 10 Years?

Levels of evidence (LOE) aid in the critical appraisal of evidence by ranking studies based on limitation of its design. Analyzing LOE provides insight into application of evidence-based medicine. The aim of this study is to determine if the quality of evidence in plastic surgery research has improved over the past 10 years. Systematic review of research published in Plastics and Reconstructive Surgery journal over the years, 10-year period (2008, 2013, 2018), was performed. LOE for each article was determined using the American Society of Plastic Surgeons (ASPS) guidelines. Each level was calculated as percentage of publications per year and compared yearly and between different topics. Eight hundred eighty-four studies were included in the final analysis. The LOE of the research improved over the study period. Level 4 evidence was the most frequent published (50.6%, 447/884), with a decline from 63.2% in 2008 to 41.3% in 2018. Level 1 evidence improved each year and accounted for 2.1% of all research in 2018. Aesthetic surgery was the most frequent published topic with upper limb research demonstrating an 18.5% increase in high-quality evidence over the study period. Increased awareness of evidence-based medicine has improved the quality of plastic surgery research over the past decade. It is vital this continues to provide gold standard patient care.

The impact of hospital volume on patient safety indicators following post-mastectomy breast reconstruction in the US

INTRODUCTION

Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors.

METHODS

Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality's designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes.

RESULTS

The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced ≥ 1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p < 0.01) and Elixhauser score ≥ 4 (p < 0.01) for the free flap group, and delayed reconstruction (p < 0.01) for the prosthetic group. Annual reconstructive facility volume was not associated with increased odds of PSIs in either prosthetic or free flap reconstruction (p > 0.05).

CONCLUSION

PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.

Development of a Plastic Surgery Supply Cart: Patient Outcomes and Quality of Care

Background

Plastic surgeons experience unique quality issues related to the specialty nature of patient procedures. Lack of accessibility to specialty supplies is a rate-limiting variable that impacts treatment efficiency and hospital resources. This study had the following goals: (1) to develop a mobile plastic surgery cart and (2) to assess the impact of a plastic surgery cart on time to treatment of consults.

Methods

Two plastic carts were developed using preexisting hospital supplies. Cart composition was designed and approved by hospital staff. A prospective study was conducted to assess overall time to treatment of patient consults throughout the hospital comparing a plastics cart versus a traditional hunt and gather methodology. One surgeon recorded time to treatment with and without the plastics cart for each consult during on-call duty hours over a 6-month period.

Results

A total of 40 patients were treated for either head or neck (60%) or hand-related (40%) cases. The average time (minutes) to treatment across all procedures with the plastics cart was 3.7 ± 1.9 versus 46.3 ± 60.0 without the plastics cart. The maximum time to treatment was 9.5 minutes with the plastics cart and 3 hours without the plastics cart. Usage of the plastics cart resulted in a significant reduction in total time to treatment of 42.5 ± 60.3 minutes (P < 0.0001).

Conclusions

A specialty supplies cart has quality improvement implications for patients, physicians, and hospitals. Increased accessibility of specialty supplies may significantly reduce the time to treatment for plastic surgery patient consults throughout a hospital.

Evaluating patient safety indicators in orthopedic surgery between Italy and the USA

OBJECTIVE

To compare patient safety in major orthopedic procedures between an orthopedic hospital in Italy, and 26 US hospitals of similar size.

DESIGN

Retrospective analysis of administrative data from hospital discharge records in Italy and Florida, USA, 2011-13. Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Quality and Research were used to identify inpatient adverse events (AEs). We examined the factors associated with the development of each different PSI, taking into account known confounders, using logistic regression.

SETTING

One Italian orthopedic hospital and 26 hospitals in Florida with ≥ 1000 major orthopedic procedures per year.

PARTICIPANTS

Patients ≥ 18 years who underwent 1 of the 17 major orthopedic procedures, and with a length of stay (LOS) > 1 day.

INTERVENTION

Patient Safety management between Italy and the USA.

MAIN OUTCOME MEASURE

Patient Safety Indicators.

RESULTS

A total of 14 393 patients in Italy (mean age = 59.8 years) and 131 371 in the USA (mean age = 65.4 years) were included. US patients had lower adjusted odds of developing a PSI compared to Italy for pressure ulcers (odds ratio [OR]: 0.21; 95% confidence interval [CI]: 0.10-0.45), hemorrhage or hematoma (OR: 0.42; CI 0.23-0.78), physiologic and metabolic derangement (OR: 0.08; CI 0.02-0.37). Italian patients had lower odds of pulmonary embolism/deep vein thrombosis (OR: 3.17; CI 2.16-4.67) compared to US patients.

CONCLUSIONS

Important differences in patient safety events were identified across countries using US developed PSIs. Though caution about potential coding differences is wise when comparing PSIs internationally, other differences may explain AEs, and offer opportunities for cross-country learning about safe practices.