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ABSTRACT: The latissimus dorsi myocutaneous flap and implant breast reconstruction procedure has undergone many refinements over its lifetime. In fact, the authors have made many aesthetic and technical refinements to their own approach to breast reconstruction.
The authors review the historical progression of latissimus flap and breast reconstruction techniques and compare these to their own 15-year experience.
A retrospective chart review was conducted for all latissimus and implant breast reconstructions performed by the senior author (MAC) from July 1994 to June 2009, for a total of 52 procedures in 31 patients. Surgical and oncological data, complications, and outcomes data were recorded.
The mean age of the patients at time of surgery was 47.6 years. Average mastectomy weight was 283 grams and average final implant volume was 364 cc. Average follow-up was three years, four months. Of the 52 total procedures, 34.6% were immediate breast reconstructions utilizing skin-sparing mastectomy (SSM); 13.5% of the reconstructed breasts also had preservation of the areola (areolar-sparing mastectomy [ASM]). The most common complication was donor site seroma (40.4%). Aesthetic and surgical refinements identified over the time period included the adoption of SSM and ASM techniques, immediate nipple reconstruction, the placement of an adjustable saline implant to allow for postoperative size adjustment, and implant placement in the prepectoral position. The overall latissimus dorsi implant reconstruction success rate was 94.2% (49/52).
The data demonstrated a successful outcome for latissimus dorsi and implant breast reconstruction for patients with a low or normal body mass index and a small (A to C cup) breast size. The aesthetic outcome of latissimus dorsi breast reconstruction has been improved over the past 15 years by the adoption of SSM and ASM techniques. Immediate nipple reconstruction and the placement of an adjustable saline implant potentially render this procedure a true single-stage reconstruction. Prepectoral implant position provides good aesthetics while preserving the subpectoral space for future management of capsular contracture if required.
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 02/2011; 31(2):190-9.
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ABSTRACT: Brow lift and blepharoplasty are among the most commonly requested procedures in facial aesthetic surgery. The purpose of this article is to provide an overview of current concepts, including goals, surgical options, and outcomes for aesthetic improvement of the forehead and periorbital region. Preoperative patient assessment, anatomical and surgical concepts, advantages and disadvantages, and prevention and management of complications and expected results are discussed. Surgical results of endoscopic and lateral brow lift, upper lid blepharoplasty with supratarsal fixation, and lower lid blepharoplasty with correction of the tear trough are presented. Details of the perioperative techniques are presented in accompanying video format. A critical understanding of patient expectation, surgical anatomy, and operative technique is important for avoiding complications and achieving aesthetic results in brow and eyelid rejuvenation.
Plastic and reconstructive surgery 07/2010; 126(1):1e-17e. · 2.74 Impact Factor
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ABSTRACT: SUMMARY: Blepharoplasty remains one of the most popular operations in facial aesthetic surgery. Serious complications, which include blindness, retrobulbar hematoma, and ectropion, although relatively rare, are well reported in the literature. As techniques evolve in aesthetic eyelid surgery, minor complications continue to be very common. Nonetheless, management of these complications can be challenging and may require extended management or surgical revision. The authors discuss several of the most common minor complications, including hematoma, dry-eye syndrome, infections, atypical lesions, lid malposition, and scarring. In addition, preoperative assessment of risk factors, treatment, and management of these minor complications are presented.
Plastic and reconstructive surgery 02/2010; 125(2):709-18. · 2.74 Impact Factor
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ABSTRACT: Transconjunctival blepharoplasty remains a popular and safe technique to treat periorbital aging. In the lower lid, it can be used successfully for orbital fat excision, redistribution, or septal tightening. In the upper lid, transconjunctival blepharoplasty has a role in removal of the nasal fat pad via an isolated, direct approach.
The authors review anatomy, indications, and surgical approaches for upper and lower lid transconjunctival blepharoplasty.
Potential complications, patient results, and the senior author's personal series are discussed.
In the lower lid, this technique can be advocated in an effort to avoid lower lid complications such as sclera show or lid malposition. In the upper lid, it can be effective in treating isolated fat pads with minimal skin excess.
Plastic and reconstructive surgery 01/2010; 125(1):384-92. · 2.74 Impact Factor
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Plastic and reconstructive surgery 06/2009; 123(5):1414-7. · 2.74 Impact Factor
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ABSTRACT: The transaxillary approach to breast augmentation provides patients with an option for augmentation that avoids any visible scars on the breast. The versatility of the endoscopic technique allows the surgeon to reliably dissect the submuscular pocket under direct visualization and to control the position of the inframammary fold while still enabling the use of any of a wide variety of both saline and silicone implants. This article addresses issues related to patient selection and preoperative assessment of this technique as well as technical aspects of performing this operation. In addition, the article reviews postoperative management of the endoscopic augmentation patient and describes potential complications associated with this technique.
Clinics in plastic surgery 02/2009; 36(1):49-61, vi. · 0.95 Impact Factor
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Plastic and reconstructive surgery 10/2008; 122(3):930-1. · 2.74 Impact Factor
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ABSTRACT: The authors examined the economic patterns of outpatient aesthetic and reconstructive plastic surgical procedures performed within an academic health center.
For fiscal years 2003 and 2004, the University of Michigan Health System's accounting database was queried to identify all outpatient plastic surgery cases (aesthetic and reconstructive) from four surgical facilities. Total facility charges, cost, revenue, and margin were calculated for each case. Contribution margin (total revenue minus variable direct cost) was compared with total case time to determine average contribution margin per operating suite case minute for subsets of aesthetic and reconstructive procedures.
A total of 3603 cases (3457 reconstructive and 146 aesthetic) were identified. Payer mix included Blue Cross (36.7 percent), health maintenance organization (28.7 percent), other commercial payers (17.4 percent), Medicare/Medicaid (13.5 percent), and self-pay (3.7 percent). The most profitable cases were reconstructive laser procedures ($66.20; n = 361), scar revision ($36.01; n = 25), and facial trauma ($32.17; n = 64). The least profitable were hand arthroplasty ($13.93; n = 35), arthroscopy ($17.25; n = 15), and breast reduction ($17.46; n = 210). Aesthetic procedures (n = 144) yielded a significantly higher contribution margin per case minute ($24.21) compared with reconstructive procedures ($22.28; n = 3093) (p = 0.01). Plastic surgical cases performed at dedicated ambulatory surgery centers ($28.60; n = 1477) yielded significantly higher contribution margin per case minute compared with those performed at hospital-based facilities ($25.58; n = 2123) (p < 0.01).
Use of standardized accounting (contribution margin per case minute) can be a strategically effective method for determining the most profitable and appropriate case mix. Within academic health centers, aesthetic surgery can be a profitable enterprise; dedicated ambulatory surgery centers yield higher profitability.
Plastic and reconstructive surgery 04/2008; 121(4):1479-88. · 2.74 Impact Factor
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Salvatore J Pacella
Plastic and reconstructive surgery 10/2006; 118(3):822-3; author reply 823. · 2.74 Impact Factor
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ABSTRACT: The purpose of this investigation was to determine the impact of hospital clinical volume on patient outcomes (i.e., in-hospital mortality, length of stay) and discharge disposition of burn patients using a large nationally representative database.
Patient data were obtained from the 1999-2001 National Inpatient Sample using burn diagnosis-related group codes 504 through 511. Hospitals were segregated into high-volume hospitals (treating more than 100 patients per year), medium-volume hospitals (treating 20 to 99 patients per year), and low-volume hospitals (treating fewer than 20 patients per year). Mortality, length of stay, and discharge disposition were catalogued for each diagnosis-related group code and hospital type.
In diagnosis-related group pair 504/505 (most severe), the mortality rate in patients admitted to high-volume hospitals (33.5 percent) was significantly higher than in patients admitted to both medium-volume hospitals (28.8 percent) and low-volume hospitals (11.5 percent) (p = 0.002). Within lower severity diagnosis-related groups, where the mortality rate was lower across all admissions, medium-volume hospitals and high-volume hospitals had a higher proportion of routine discharges to home, a lower need for home care, and a lower proportion of transfers compared with low-volume hospitals. Despite shorter length of stay, across most burn diagnosis-related groups, patients admitted to low-volume hospitals had lower rates of routine discharges and a higher proportion of admissions "with complications."
Higher-volume facilities, despite receiving the most severe burn patients, may provide better patient outcomes than lower-volume facilities. The patterns of discharges found at lower-volume facilities may result in higher diagnosis-related group reimbursement "capture" by lower-volume facilities and higher postdischarge resource use.
Plastic and reconstructive surgery 05/2006; 117(4):1296-305; discussion 1306-7. · 2.74 Impact Factor
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ABSTRACT: For plastic surgeons, independent development of outpatient surgical centers and specialty facilities is becoming increasingly common. These facilities serve as important avenues not only for increasing access and efficiency but in maintaining a sustainable, competitive specialty advantage. Certificate of Need regulation represents a major hurdle to plastic surgeons who attempt to create autonomy in this fashion. At the state level, Certificate of Need programs were initially established in an effort to reduce health care costs by preventing unnecessary capital outlays for facility expansion (i.e., managing supply of health care resources) in addition to assisting with patient safety and access to care. The purpose of this study was to examine the effect of Certificate of Need regulations on health care costs, patient safety, and access to care and to discuss specific implications of these regulations for plastic surgeons. Within Certificate of Need states, these regulations have done little, if anything, to control health care costs or affect patient safety. Presently, Certificate of Need effects coupled with recent provisions in the Medicare Modernization Act banning development of specialty hospitals may restrict patient access to ambulatory surgical and specialty care. For the plastic surgeon, these effects not only act as an economic barrier to entry but can threaten the efficiencies gained from providing surgical care in an ambulatory setting. An appreciation of these effects is critical to maintaining specialty autonomy and access to fiscal policy.
Plastic and reconstructive surgery 10/2005; 116(4):1103-11; discussion 1112-3. · 2.74 Impact Factor
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ABSTRACT: The purpose of this investigation was to examine burn-patient referral patterns and severity of burn distribution, as well as to determine the impact these patterns may have on the education of surgeons in training. Data from the 1998-1999 National Inpatient Sample (NIS) and the Michigan Hospital Association (MHA) were analyzed based upon burn diagnostic-related groups (DRGs; 504-511) and their referral distribution was documented. Providers were segregated into high-volume hospitals (HVHs) treating >100 patients per year, moderate-volume hospitals treating 25 to 99 patients per year, and low-volume hospitals (LVHs) treating <25 patients per year. Surgical training programs were identified within the state of Michigan and examined for an educational affiliation with a burn center. Across the United States, 47.5% of burn patients receive care at HVHs. Patients with the highest severity (ie, DRGs 504 and 505) were usually (77%) treated in HVHs. Within the state of Michigan, 4 HVHs were identified, which represent 50.8% of the total burn admissions. At least 1 HVH received over 80% of its admissions from adjacent or distant counties and subsequently represented a higher proportion of higher-severity burn DRG admissions. Twenty-three percent of general surgical programs within the state of Michigan do not have a formal burn rotation or affiliation with a regional burn center for educational training. Several programs have affiliations with low-volume burn providers. The most severe burns are reaching high-volume centers, but many burns continue to remain within LVHs. A wide variation in patient distribution occurs throughout the United States. Matching the patient and resident distribution is essential for effective training of surgical residents.
Annals of Plastic Surgery 04/2005; 54(4):412-9. · 1.32 Impact Factor
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ABSTRACT: Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors' study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.
Plastic & Reconstructive Surgery 11/2003; 112(5):1257-65. · 3.38 Impact Factor
