Surgical Complexity and Physician Compensation: An Analysis of Relative Under-Valuation for Pediatric Brachial Plexus Surgery

BACKGROUND

Brachial plexus reconstruction (BPR) is a rapidly advancing field within hand surgery. BPR procedures are complex, time-intensive, and require microsurgical expertise. As physician reimbursement rates for BPR are poorly defined, relative to more common hand procedures, we sought to analyze compensation for BPR across different payor groups and understand the factors contributing to their reimbursement.

METHODS

A retrospective review was performed of surgeries by a single senior staff member in a 4-year period to evaluate Current Procedural Terminology (CPT) codes from BPR cases. For comparison, all finger fracture fixations and skin graft reconstructions performed by the same surgeon over the same time period were analyzed as well.

RESULTS

A total of 57 BPR cases, 94 finger fracture fixation cases, and 69 skin grafting cases met inclusion criteria. Among the top 5 insurance providers, average work relative value unit (wRVU)/hour was 6.55, 3.49, and 12.67 for BPR, fracture fixation, and skin grafts, respectively. Reimbursements were an average $685.76/hour for BPR, compared to $590.10/hour for fracture fixation and $1,197.94/hour for skin grafts.

CONCLUSIONS

BPR demonstrates a relative undervaluation, in terms of reimbursement per hour, given the time and surgical skill required for such cases, particularly compared to shorter, less complex cases such as skin grafting and fracture fixation. We find that this discrepancy is amplified across multiple levels of coding, billing, and reimbursement. We suggest specific strategies for physician leadership to more directly participate in the financial decisions that affect themselves, their patients, and their specialty.

A newly developed container for safe, easy, and cost-effective overnight transportation of tissues and organs by electrically keeping tissue or organ temperature at 3 to 6°C

BACKGROUND

As there is only one skin procurement organization in Japan the Japan Skin Bank Network (JSBN), all skin grafts procured in Japan are sent by a commercialized delivery system. Preliminarily, bottles containing saline were transported in a cardboard box using a so-called "cooled home delivery service" using a truck with a refrigerated cargo container. During transportation the temperature in the cardboard box increased to 18°C in summer and decreased to -5°C in winter. For these reasons, we investigated whether a newly developed container "Medi Cube" would be useful to transport skin grafts.

OBJECTIVES

Four bottles with a capacity of 300 mL containing 150 mL of saline in a Medi Cube container were transported from Osaka to the JSBN in Tokyo between 4 PM and 10 AM using a commercialized cooled home delivery service. Two bottles were transported in a Medi Cube container without phase change materials (PCM) in winter and summer, respectively. Another two bottles were transported in the Medi Cube with PCMs in winter. The temperatures inside saline, inside a transportation container, and outside the container, and air temperature were monitored continuously with a recordable thermometer.

RESULTS

The temperatures inside saline and inside a Medi Cube container were maintained between 3 and 6°C, even when the temperature outside the container increased during parking. The temperature inside a Medi Cube container without PCM decreased to -3°C when the inside of the cargo container was overcooled in winter. However, the temperatures inside saline and inside a Medi Cube container with PCM were between 3 and 6°C, even when the temperature outside the container decreased to below 0°C in winter.

CONCLUSION

A Medi Cube container with PCM provided a safe, easy, and cost-effective method for overnight transportation of skin grafts.

[Cost-effective change in treatment after split skin grafting to lower leg defects]

We present a clinical comparison of short stretch bandage versus a two-layer compression bandage and early mobilization after split skin grafting to lower leg defects. A total of 38 patients were included. The first group were immobilized for four days and given a short stretch support bandage. Group 2 were mobilized one day after the operation with a two-layer compression bandage (Pro-Guide). There was no difference in healing or frequency of complications. The patients treated with Pro-Guide had significantly fewer admission days and out-patient consultations. Larger randomized trials are warranted.

A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients

INTRODUCTION

Split-thickness skin grafting (SSG) is a technique used extensively in the care of burn patients and is fraught with suboptimal graft take when there is a less-than-ideal graft bed and/or grafting conditions. The technique of Negative Pressure Dressing (NPD), initially used for better wound healing has been tried on skin-grafts and has shown to increase the graft take rates. However, comparative studies between the conventional dressing and vacuum assisted closure on skin grafts in burn patients are unavailable. The present study was undertaken to find out if NPD improves graft take as compared to conventional dressing in burns patients.

MATERIALS AND METHODS

Consecutive burn patients undergoing split-skin grafting were randomized to receive either a conventional dressing consisting of Vaseline gauze and cotton pads or to have a NPD of 80 mm Hg for four days over the freshly laid SSG. The results in terms of amount of graft take, duration of dressings for the grafted area and the cost of treatment of wound were compared between the two groups.

RESULTS

A total of 40 split-skin grafts were put on 30 patients. The grafted wounds included acute and chronic burns wounds and surgically created raw areas during burn reconstruction. Twenty-one of them received NPD and 19 served as controls. Patient profiles and average size of the grafts were comparable between the two groups. The vacuum closure assembly was well tolerated by all patients. Final graft take at nine days in the study group ranged from 90 to 100 per cent with an average of 96.7 per cent (SD: 3.55). The control group showed a graft take ranging between 70 and 100 percent with an average graft take of 87.5 percent (SD: 8.73). Mean duration of continued dressings on the grafted area was 8 days in cases (SD: 1.48) and 11 days in controls (SD: 2.2) after surgery. Each of these differences was found to be statistically significant (p<0.001).

CONCLUSION

Negative pressure dressing improves graft take in burns patients and can particularly be considered when wound bed and grafting conditions seem less-than-ideal. The negative pressure can also be effectively assembled using locally available materials thus significantly reducing the cost of treatment.

[Comparison of cost between two ways of skin grafting in the treatment of patients with extensive deep burn]

OBJECTIVE

To evaluate the economic significance of Meek skin grafting and automicrografting combined with large piece of allogenous skin (micrografting in brief) in the treatment of patients with extensive deep burn.

METHODS

Twenty-four patients with extensive deep burn admitted to the First Affiliated Hospital of Wenzhou Medical College were divided into Meek skin grafting group and micrografting group, with 12 patients in each group. Statistical comparison between Meek skin grafting group and micrografting group in respect of wound healing time, consumption of each special dressing, total cost of hospitalization, rehabilitation cost during convalescence was made. Then the cost and effect value was compared between two groups.

RESULTS

The wound healing time, consumption of each special dressing, total cost of hospitalization and rehabilitation cost in Meek skin grafting group was (14.4 +/- 1.9) d, yen(16 590 +/- 521), yen(421 628 +/- 145), yen(39 571 +/- 225), respectively, and that in micrografting group was (25.6 +/- 4.2) d, yen (136 441 +/- 356), yen(539 526 +/- 686), yen(55 853 +/- 794), respectively. The difference between two groups were statistically significant (P < 0.01).

CONCLUSIONS

In a definite range of burn size, Meek skin grafting has a lower therapeutic cost and better therapeutic effects as compared with micrografting.

Comparison of commonly used mesher types in burns surgery revisited

Meshed skin grafts are commonly used in the treatment of burns. Machines for meshing skin are expensive and therefore choosing the correct machine is important. We describe the two available groups of meshers, those that use carriers and those that do not, with advantages and disadvantages of each group. A cost comparison of the use of each type of mesher has been formulated. This information should aid the purchasers in making a more informed choice.

Suprathel®, a new skin substitute, in the management of donor sites of split-thickness skin grafts: Results of a clinical study

OBJECTIVE

A prospective, randomized, two center clinical study was conducted to evaluate the impact on wound healing of Suprathel in donor sites of split-thickness skin grafts. Suprathel represents an absorbable, synthetic wound dressing with properties of natural epithelium.

METHODS

22 burn patients who were treated with split-thickness skin grafts, and with a mean age of 39.6 years were included in the study. Donor sites of skin grafts were randomly selected; partly treated with Jelonet and partly treated with Suprathel. First gauze change was carried out the fifth day postoperatively followed by regular wound inspection until complete re-epithelization. The study focused on patient pain score, healing time, analysis of wound bed, ease of care, and treatment costs.

RESULTS

There was no significant difference between the two materials tested regarding healing time and re-epithelization. There was a significantly lower pain score for patients treated with Suprathel (p=0.0002). Suprathel became transparent when applied and allowed close monitoring of wound healing. In contrast to Jelonet, Suprathel showed excellent plasticity with better attachment and adherence to wound surfaces. Throughout the healing process it detached from wounds without damaging the new epithelial surface. In addition, wound areas treated with Suprathel required less frequent dressing changes. It also demonstrated excellent ease of care. This, altogether with the significant pain reduction, presented a positive feedback by patients and healthcare professionals who both rated Suprathel as their treatment preference. Though Jelonet is more cost effective as dressing material, the study revealed an overall reduction in total treatment costs achieved with Suprathel.

CONCLUSION

Suprathel represents a solid, reliable epidermal skin substitute with impact on wound healing, patient comfort and ease of care. The material effectiveness contributes to the reduction of overall treatment costs.

A retrospective cohort study of Acticoat™ versus Silvazine™ in a paediatric population

We wished to determine whether changing our centre's practice of using Acticoat instead of Silvazine as our first-line burns dressing provided a better standard of care in terms of efficacy, cost and ease of use. A retrospective cohort study was performed examining 328 Silvazine treated patients from January 2000 to June 2001 and 241 Acticoat treated patients from July 2002 to July 2003. During those periods the respective dressings were used exclusively. There was no significant difference in age, %BSA and mechanism of burn between the groups. In the Silvazine group, 25.6% of children required grafting compared to 15.4% in the Acticoat group (p=0.001). When patients requiring grafting were excluded, the time taken for re-epithelialisation in the Acticoat group (14.9 days) was significantly less than that for the Silvazine group (18.3 days), p=0.047. There were more wounds requiring long term scar management in the Silvazine group (32.6%) compared to the Acticoat group (29.5%), however this was not significant. There was only one positive blood culture in each group, indicating that both Silvazine and Acticoat are potent antimicrobial agents. The use of Acticoat as our primary burns dressing has dramatically changed our clinical practice. Inpatients are now only 18% of the total admissions, with the vast majority of patients treated on an outpatient basis. In terms of cost, Acticoat was demonstrated to be less expensive over the treatment period than Silvazine . We have concluded that Acticoat is a safe, cost-effective, efficacious dressing that reduces the time for re-epithelialisation and the requirement for grafting and long term scar management, compared to Silvazine.

Prevalence of skin allograft discards as a result of serological and molecular microbiological screening in a regional skin bank in Italy

BACKGROUND

Postmortem skin is widely used in the treatment of patients with severe burns. Skin specimens must be screened for transmissible agents including human immunodeficiency virus (HIV), hepatitis B (HBV) and C (HCV) virus, human T-cell lymphotropic virus (HTLV), cytomegalovirus (CMV) and Treponema pallidum.

METHODS

Four hundred and sixty-one cadaveric donors underwent serological and molecular microbiological (polymerase chain reaction, PCR) screening at Siena Skin Bank between 2000 and 2004.

RESULTS

74/461 donors (16.1%) were found ineligible under current regulations.

CONCLUSIONS

These results are interesting in a local context and underline the importance of screening involving both routine serological procedures and molecular microbiological investigation. The latter has not been uniformly introduced in many countries and very limited data is available to assess its cost-benefit ratio in the field of skin donor screening.

Correction of pincer-nail deformities with autograft or homograft dermis: modified surgical technique

The pincer-nail deformity is characterized by an excessively curved and distorted nail across the transverse dimension. Forty-nine sides (paronychial folds) were dissected off the distal phalanx periosteum with scissors and/or a small elevator. The dermis was placed between the paronychial fold and the plalanx to flatten the germinal and sterile matrix. Direct comparison of autograft dermis to homograft dermis did not show any significant differences in postcorrection appearance of the nail or relief of symptoms. Surgical time averaged 22 minutes less in those patients having reconstruction on both sides of one nail with homograft dermis.

Unexpected Economics of Ulcer Care Protocols

The cost of managing chronic ulcers, both venous leg and decubiti (sacral pressure), was reviewed using 36 randomized, controlled studies with a focus on saline, hydrocolloid, and a human skin construct. When one includes the labor intensiveness of dressing changes three to four times per day, the application of hydrocolloid dressings becomes the most cost-effective.

The influence of reconstructive modality on cost of care in head and neck oncologic surgery

OBJECTIVE

To determine the differential costs of 3 reconstructive modalities in patients undergoing head and neck oncologic surgery.

DESIGN

Cost-identification analysis.

SETTING

Academic tertiary care medical center.

METHODS

Retrospective review of 104 major head and neck resections involving primary tumors of the upper aerodigestive tract requiring a tracheotomy (primary hospital discharge, diagnosis related group 482 from the International Classification of Diseases, Ninth Revision, Clinical Modification) from July 2, 1999, through June 30, 2000. Patients were stratified by reconstruction modality: (1) microvascular free tissue transfer (MFFT), (2) pedicle myocutaneous flaps (PMF), and (3) primary reconstruction and/or skin graft (PR). Dependent variables included length of hospitalization, direct and indirect hospital costs, total hospital costs, the percentage of total costs attributable to direct costs, and the percentage of total costs attributable to indirect costs.

RESULTS

No significant age differences existed among the 3 patient groups. Significant differences (Kruskal-Wallis) were observed for all variables. The PR group was compared with the PMF and MFFT groups. Total patient charges were greatest in the MFFT group (mean, $22 821.04) and least for the PR group (mean, $13 125.70). Length of stay was greatest in the PMF group (mean, 7.53 days) and shortest in the PR group (mean, 5.53 days).

CONCLUSIONS

Intricate reconstructions are frequently more times consuming than primary closure, and the additional surgical procedures are more likely to use more hospital resources. Efforts at providing superior functional outcomes must be balanced against increasing restrictions on the use of health care dollars. Careful evaluation of functional outcomes and quality of life will be required to justify the increased expenditure incurred when providing complex reconstructions.

A prospective controlled clinical study of skin donor sites treated with a 1-4,2-acetamide-deoxy-B-D-glucan polymer: a preliminary report

The effect of Hyphecan (1-4,2-acetamide-deoxy-B-D-glucan) on skin donor site healing was compared with the standard skin donor site dressing Kaltostat (calcium sodium alginate) in 35 burn patients with 70 skin donor sites prospectively. The median time of wound healing for the Hyphecan group was 12 days with an average of 13.1+/-4.0 days (ranged from 9 to 28 days) while the Kaltostat group had a median healing time of 12 days (ranged from 8 to 28 days) with a mean of 13.0+/-4.1 days. The difference in healing time between these two groups was statistically insignificant with a P-value of 0.95. The infection rate was 2.9% for both Hyphecan and Kaltostat. These 35 patients had been followed up from 10 to 16 months and no difference in long-term donor site morbidity between Hyphecan and Kaltostat had been observed. This finding was encouraging because the cost of Hyphecan is less than 50% of Kaltostat and it may be worthwhile to explore the clinical application of Hyphecan in other area of burns treatment.

Pinch grafting in hospital and primary care: a cost analysis

The cost of treating venous leg ulcers with pinch grafting was evaluated for 58 consecutive patients: 29 in hospital care and 29 in primary care. The mean age was 76.8 and 74.3 years and the mean ulcer size 15.1 and 13.5 cm2, respectively. The operation technique, pinch grafting, was the same for all patients but primary care patients were not immobilised postoperatively. Healing rate within 12 weeks was the same for patients in hospital care and primary care (31%). Treatment costs for one week pre-operatively and three weeks postoperatively amounted to 5109 Pounds per patient in hospital care and 870 Pounds per patient in primary care (p < 0.001), and the costs for one week pre-operatively and 12 weeks postoperatively were 6738 Pounds and 1806 Pounds, respectively (p < 0.001). Costs for patients whose ulcers healed within 12 weeks were 5552 Pounds for those receiving hospital care and 1676 Pounds for those receiving primary care (p < 0.001). Pinch grafting in primary care was shown to cost 3.3 to 5.9 times less, with the same healing outcome, than pinch grafting in hospital care.

Evaluation of a combined calcium sodium alginate and bio-occlusive membrane dressing in the management of split-thickness skin graft donor sites

The optimal treatment of the split-thickness skin graft (STSG) donor site remains an unresolved issue. This study was conducted to evaluate the combined use of calcium sodium alginate and a bio-occlusive membrane dressing in the management of STSG donor sites. This study was a prospective evaluation of all patients requiring an STSG over a 6-month period ending October 1998. There were 57 patients with a mean age of 61 years. All skin grafts were harvested with an electric dermatome from the anterior thigh and were 0.012 to 0.016 inches thick. Donor sites were dressed with calcium sodium alginate followed by a bio-occlusive dressing. Postoperatively, the skin graft donor site dressing was removed and replaced. The mean skin graft area was 114 cm2. The first dressing change occurred, on average, 3 days postoperatively. All dressings were taken down and the wounds reevaluated 7 days postoperatively. Fifty-two patients (91%) had achieved complete reepithelialization by this time. Five patients (9%) required an additional dressing. All wounds were healed completely by postoperative day 10. Donor site discomfort was minimal and limited to the time of dressing change. There were no wound-related complications. The average cost of dressing supplies was $48.00 per patient and $23.00 per dressing. This method of managing STSG donor sites allowed for unimpeded reepithelialization without wound complication. The bio-occlusive dressing eliminated the pain typically associated with fine mesh gauze dressings. The absorptive property of the calcium sodium alginate eliminated the problem of seroma formation and leakage seen routinely with the use of a bio-occlusive dressing alone. These results confirm that this technique is both efficacious and cost-effective.

Cultured epithelial autografts in extensive burn coverage of severely traumatized patients: a five year single-center experience with 30 patients

OBJECTIVE

We report recent five-year experience in a large, single center series of severely burned and otherwise traumatized patients given cultured epithelial autografts (CEA) from a single commercial laboratory.

SUMMARY BACKGROUND DATA

Initial optimism over CEA application has been tempered by subsequent reports asserting that this modality is unreliable and expensive. Discussion continues over its clinical role.

METHODS

From 1991 to 1996, CEA were applied to a mean 37+/-17% of total body surface area (TBSA) of 30 patients. These patients had 78+/-10% average burn size, 65+/-16% average third-degree burn size, 90% prevalence of endoscopically confirmed inhalation injury and 37% prevalence of other serious conditions.

RESULTS

CEA achieved permanent coverage of a mean 26+/-15% of TBSA, an area greater than that covered by conventional autografts (a mean 25+/-10% of TBSA). Survival was 90% in these severely burned and otherwise traumatized patients. Final CEA take was a mean 69+/-23%. In subset analyses, only younger age was significantly associated with better CEA take (p = 0.0001 in univariate analysis, p<0.04 in multivariate analysis, Student's t-test).

CONCLUSIONS

Epicel CEA successfully provided extensive, permanent burn coverage in severely traumatized patients, proving an important adjunct to achievement of a high survival rate in a patient population whose prognosis previously had been poor. In our experience CEA appear to have a very high beneficial value in the management of bur ns >60% TBSA. In some cases studied it is very likely that CEA was a life-saving treatment.

[Ambulatory skin grafting in leg ulcers: a feasibility study of 34 patients]

OBJECTIVES

Despite the advent of modern dressings, management of leg ulcers remains a long costly process, particularly if no etiological treatment is possible. Autologous skin grafting is more and more widely used in this indication. The aim of this open single center noncomparative study was to analyze the feasibility of ambulatory procedures for skin grafting and the incidence of ambulatory care in a medical nursing clinic as an alternative to traditional hospitalization on total cost in this pathological condition.

PATIENTS AND METHODS

Thirty-nine grafts were performed in 34 consecutive patients. No selection was made for etiology or duration of the leg ulcers. Three grafting techniques were used after debridement-cleansing: flap grafts for medium sized ulcers (29 cases), mesh grafts for large ulcers (6 cases) and patch grafts for small ulcers or ulcers with irregular contours (4 cases). The dressing was opened on day 5, nursing care was provided every 2 days and daily in case of infection. Percentage of healing was evaluated clinically on days 5, 15 and 30 then at months 3, 6 and 12. Photographs were taken.

RESULTS

Four patients were lost to follow-up and one died. Among the 34 grafts assessed at 6 months, we obtained total healing in 56 p. 100, 75 p. 100 healing in 6 p. 100, 50 p. 100 healing in 9 p. 100 and failure in 29 p. 100. Healing rates were those expected for arterial ulcers and necrotic angiodermas. For venous leg ulcers, the rate of total healing was only 30 p. 100 at 6 months and 43 p. 100 at 1 year. Outcome depended on duration of the lesion and not on the type of skin graft or patient age.

DISCUSSION

This prospective study reports outcome of ambulatory skin grafting in a large representative sample of patients with leg ulcers of various etiologies. The less favorable outcome for venous ulcers can be explained by the duration of the ulcerations and infection in these often neglected lesions. The risk of graft displacement, contact eczema, and infection must be recognized for early treatment. There were no cases with general complications. This ambulatory technique has the enormous advantage of limiting the risk of hospital-related problems in this elderly population and of reducing overall cost of care for leg ulcers, and finally of limiting the risk of recurrence by regular post-graft follow-up in a specialized center and by treatment of the causal disease.

Treatment of leg ulcers with split skin grafts: early and late results

Sixty patients (mean age 73.5 years) with 88 leg ulcers that had not responded to conservative treatment had split skin grafts applied at the Department of Plastic Surgery, Linköping, Sweden. Of 51 venous leg ulcers 45 (88%) healed after a mean of 15 days (range 5-30); and 13 (62%) of the 21 arterial ulcers healed after a mean of 18 days (range 8-30). Additional skin grafting was done on nine of the venous and on three of the arterial ulcers. Twenty-two (49%) of the healed venous ulcers recurred after a mean of four months while only two (15%) of the healed arterial ulcers recurred after a mean of 10 months. At late follow up after a mean of four years 18 of the patients were dead and 10 had had the leg in question amputated. Of the 34 patients still alive who had not had amputations, 31 were investigated at open ward or interviewed by telephone and 23 patients were examined with colour duplex scan. Seven of these patients had open leg ulcers. At duplex scan six patients had no venous or arterial insufficiency that could cause a leg ulcer. Of 16 patients with venous insufficiency 10 patients had only an inadequate superficial system. The mean cost for treating one leg ulcer by skin grafting is estimated at SEK 89000 (US$11125). We conclude that leg ulcers often heal with skin grafting but that venous ulcers often recur. To reduce the recurrence rate we suggest a better preoperative aetiological evaluation and improved postoperative treatment with a compression bandage.

Outcome and cost analysis for outpatient skin grafting

BACKGROUND

To reduce cost, outpatient surgery is advocated when feasible; however, the potential of compromising outcome is a concern. The purpose of this review is to assess patient outcome and cost for managing operative burn injuries without hospitalization.

METHODS

During the past 18 months, 54 patients were identified with burns amenable to operative debridement and skin grafting without hospitalization. Twenty patients chose to be hospitalized and underwent prompt skin grafting. Operative skin grafting as an outpatient was chosen by the remaining 34 patients. Of these, four patients were subsequently hospitalized postoperatively (two for pain, one for cellulitis, and one for vomiting).

RESULTS

Hospitalized patients and outpatients were similar in age and extent of burn; however, those hospitalized underwent skin grafting sooner after injury (2.1 +/- 0.4 days for inpatients vs. 11.5 +/- 0.8 days for outpatients; mean +/- SEM). Inpatients also had a significantly larger area skin-grafted (286 +/- 24 cm2 for inpatients vs. 178 +/- 14 cm2 for outpatients). Graft take was very good in each group. Cost, as indexed by patient charge, was substantially less for outpatients ($2,397 +/- $222) than for inpatients ($17,220 +/- $410).

CONCLUSION

These results demonstrate a significant cost reduction with nonhospitalized operative care of burn injuries without any overt detriment in outcome, thus endorsing outpatient skin grafting when amenable. This review also illustrates that delaying operative intervention reduces the burn area required for grafting.

A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps

A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.

Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects

Thirty-nine patients underwent reconstruction of composite mandibular defects following resection for squamous cell carcinoma. Thirty-four underwent immediate reconstruction, while 5 were reconstructed secondarily. Twenty-one received soft-tissue reconstruction only with a pectoralis major myocutaneous flap, 14 underwent osteocutaneous free-tissue transfer, and 4 received a reconstruction plate with free-tissue transfer for soft-tissue coverage. The mandibular defects in the pectoralis major myocutaneous flap group tended to be posterolateral, while free-tissue transfer defects were more severe, usually involving the anterior mandible. Length of surgery and duration of intensive care unit care were significantly longer for free-tissue transfer patients, while flap complications were more common in the pectoralis major myocutaneous flap patients. Facial appearance scores were higher for the free-tissue transfer group by both patient and physician assessment. Social function, speech, and oral function did not differ significantly. Patients reconstructed secondarily with free-tissue transfer reported significant improvement in appearance, oral continence, and social function, with little change in speech intelligibility, deglutition, or diet tolerance. The cost of the main hospitalization was significantly higher in the free-tissue transfer group than in the pectoralis major myocutaneous flap group, although when the costs of subsequent hospitalizations are included, the difference in total cost narrows. Despite more adverse defects, free-tissue transfer provided more predictable aesthetic results and expeditious return to normal social function than did pectoralis major myocutaneous flap reconstruction. The fiscal impact of these complex reconstructions is, however, significant. Cost-containment issues are presented and recommendations are made.

Experience with the modified Meek technique

In 1958 Meek described the so called Meek-Wall dermatome to cut postage stamp skin grafts. This method was eclipsed by the introduction of mesh skin grafts. In 1993 Kreis and colleagues reintroduced a modified Meek technique using a dermatome running on compressed air. This technique has been used in our burn unit since August 1994. The aim of this paper is to compare the modified Meek technique with the mesh graft technique. Within a period of 20 months 41 patients were grafted using the modified Meek technique. The mean TBSAB was 54.4% with 50.0% full thickness burns. All patients were excised early. The expansion ratio was 1:4 and 1:6. In 20 patients the Meek technique was used exclusively for grafting of the trunk and the extremities with the exception of face, neck and hands. In 3 patients with a mean TBSAB of 68.3% a combination of postage stamp autologous skin grafts and cultured epithelial autografts (CEA) was applied. Compared with the mesh graft technique the Meek technique showed the following advantages: 1. The Meek method provides the true expansion ratio. 2. Small graft remnants can be utilized. 3. Grafting of full thickness burns up to 70 to 75% TBSAB becomes possible with one harvest of the donor sites. 4. The reliability of graft take is equal or better. 5. Epithelialization is achieved within 3 to 4 weeks depending on the expansion ratio. 6. The combination of widely expanded postage stamp split thickness grafts and CEA provides an excellent take rate and durable wound closure within a short time and avoids the problems associated with the engraftment of CEA on fascia. The method is simple but more demanding than the mesh technique. Compared with the mesh graft technique the preparation of Meek grafts is more time consuming and requires more staff than the Mesh technique. The cost of materials is higher. In our experience complete coverage of the Meek grafts with an overlay of meshed allografts after removal of the gauze as recommended by Kreis is not necessary using the 1:4 expansion ratio. Greater expansion ratios necessitate an overlay with meshed allografts. Regarding the scar formation no significant differences were observed compared with the mesh graft technique. In conclusion the modified Meek technique is reliable and simple to perform. This technique provides a sufficient expansion ratio enabling to graft patients with burns up to 75% TBSA with only one harvest of donor sides and without the necessity of CEA. In our opinion the Meek technique is reliable and simple to perform. This technique provides a sufficient expansion ratio enabling to graft patients with burns up to 75% TBSA with only one harvest of donor sides and without the necessity of CEA. In our opinion the Meek technique is advantageous in patients with burns greater than 45% TBSAB. In smaller burns mesh grafts should be used because of lower material cost and staff requirements. Especially in extensively burned patients the Meek technique may be cost effective avoiding the need of CEA.

Comparative clinical study of the sure-closure device with conventional wound closure techniques

The Sure-Closure device, designed for wound closure, harnesses the viscoelastic properties of the skin. It has been used in clinical studies in the past. We have evaluated the role of this device in complex wound problems and compared it to closure achieved by conventional wound closure methods such as skin grafts and flaps. A total of 40 patients with multiple wound etiologies were examined. We used the device under local and general anesthesia. In addition, we performed cost analysis on the use of the device and compared this to traditional methods. We found a cost reduction trend associated with the Sure-Closure method (p < .05). All of the 24 patients in whom the device was used to close the wounds had complete primary closure. The device is also easy to use. When used for delayed stretching, as in some of our patients, the compliance rate was high.

Use of cultured epidermal autografts in the treatment of large burns

Mortality in patients with large areas of full skin thickness burns is, in part, due to complications developing during the period of prolonged delay required to obtain enough wound healing to permit skin grafting from limited donor sites. Cultured epithelial autograft (CEA) has become available as an alternative measure to the use of expanded skin autografts and regrafting. Small biopsies are taken and transported to the laboratories of BioSurface Technology where keratinocytes are grown to cover large areas during a 3-week period. The cultured keratinocytes are then available on petroleum jelly gauze which is applied to the patient. The gauze is used as a temporary dressing. To date, 37 patients have been biopsied. Grafts have been applied in 15. Graft 'take' averaged 71.5 per cent at our institution. Two of the patients grafted with CEA died of sepsis. One patient had a 100 per cent loss of the CEA grafts. In 12 patients, the use of CEA probably contributed significantly to wound coverage and survival. Such grafts are more susceptible to mechanical loss than routine autograft, although long-term coverage after several years is considered to be satisfactory. The cost of the process is high.

One hundred consecutive cases of flap lacerations of the leg in ageing patients

AIM

To define the cost of inpatient treatment of flap laceration to the leg in ageing patients.

METHODS

One hundred consecutive admissions over a 19 month period were reviewed retrospectively.

RESULTS

The mean age of flap laceration of the leg patients was 77.5 years (50-93). The mean bed stay was 14.53 days (1-36). Most patients (84%) were treated with debridement and split skin grafting. The total cost of treatment was $551,390.00. The mean delay before surgery was 41.2 hours. 92% of patients returned to the same preoperative social circumstances.

CONCLUSIONS

Flap laceration of the leg is expensive to treat in hospital. There are a number of strategies in which bed stay and costs can be reduced. These include early and aggressive surgery, the use of meshed skin graft, early mobilisation and early involvement of social support services.

Current trends in the use of allograft skin for patients with burns and reflections on the future of skin banking in the United States

Cadaveric allograft skin can play a critical role in the care of patients with massive burns. It is difficult, however, to estimate current use and levels of enthusiasm for allograft skin in the United States. We report on a survey of 40 skin banks and 140 United States burn center medical directors as listed in the American Burn Association's Directory of Burn Care Resources for North America 1991-1992. Response rate was 45% for skin banks and 38% for burn directors. Overall, 12% of admitted patients were treated with allograft skin at the responding burn centers. Sixty-nine percent of burn center directors preferred to use fresh skin, although only 47% of skin banks were able to supply fresh cadaver skin. Tabulated survey results and a review and discussion of future directions in skin banking and replacement research are discussed in this paper and were presented to the Tissue Bank Special Interest group at the 1993 American Burn Association annual meeting.

Costs and complications in mandibular reconstruction

Because of increasing concerns about the high cost of complex medical care, we compared the combined cost of ablation and reconstruction incurred using five different management strategies for patients undergoing mandibular resection. We also compared the rates of complication and failure for the methods used. The records of 69 patients undergoing segmental or total mandibulectomy between January 1, 1986, and June 30, 1990, were reviewed. Of these, 15 had reconstruction with soft tissue only (average cost, $36,137; complication rate, 33%), whereas 20 had immediate reconstruction with vascularized bone (average cost, $46,894; complication rate, 50%), and 15 had reconstruction with only a metal plate (average cost, $47,678; complication rate, 73%). Nine patients had plate reconstructions initially but subsequently underwent reconstructions with bone (average cost, $54,346; complication rate, 78%), whereas 10 patients had no initial reconstruction but subsequently underwent delayed reconstruction with bone (average cost, $52,486; complication rate, 70%). If reconstruction was performed with bone, immediate reconstruction was more cost effective than delayed reconstruction and had a lower complication rate as well.

New economical skin graft expansion wheel

A simple and economical mesh graft expansion wheel is described. The instrument does not need any consumables--carriers for example--and is very low priced compared with other expanders. A small institution or a private practising surgeon in this country can afford it. It is possible to increase or reduce the number of wheels to individual surgeon's requirements. Different expansion ratios can be obtained by simple changes in design.

Comparison of cultured epidermal autograft and massive excision with serial autografting plus homograft overlay

The chief determinant of mortality in severe burn injuries has been the size and severity of the wound. Early massive excision of the wound has increased the median lethal dose to 98% of total body surface area burn but presents the problem of wound closure. Autograft substitutes must be used for a large burn. We report our experience with early massive excision in the treatment of 47 pediatric patients with burns who had greater than 80% total body surface area burn and greater than 80% full-thickness burn. Four patients died within hours of admission. Fifteen patients died of sepsis and multiorgan failure; the primary source of bacterial contamination was the open wound. The 28 survivors received approximately 2.0 m2 2:1 homograft until autograft became available. A case report of a 10-year-old boy illustrates the use of two types of cultured epidermal autograft, one "homegrown" and one commercially produced.