Browsing by Subject "Plastic Surgery Procedures"
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Item Open Access Comparison of Structural Disease Burden to Health-related Quality of Life Scores in 264 Adult Spinal Deformity Patients With 2-Year Follow-up: Novel Insights into Drivers of Disability.(Clinical spine surgery, 2017-03) Bakhsheshian, Joshua; Scheer, Justin K; Gum, Jeffrey L; Horner, Lance; Hostin, Richard; Lafage, Virginie; Bess, Shay; Protopsaltis, Themistocles S; Burton, Douglas C; Keefe, Malla; Hart, Robert A; Mundis, Gregory M; Shaffrey, Christopher I; Schwab, Frank; Smith, Justin S; Ames, Christopher P; International Spine Study Group (ISSG)Study design
This is a review of a prospective multicenter database.Objective
To investigate the relationship between preoperative disability and sagittal deformity in patients with high Oswestry Disability Index (ODI) and no sagittal malalignment, or low ODI and high sagittal malalignment.Summary of background data
The relationship between ODI and sagittal malalignment varies between each adult spinal deformity (ASD) patient.Methods
A prospective multicenter database of 365 patients with ASD undergoing surgical reconstruction was analyzed. Inclusion criteria entailed: age 18 years or above and the presence of spinal deformity as defined by a coronal Cobb angle≥20 degrees, sagittal vertical axis (SVA)≥5 cm, pelvic tilt (PT) angle≥25 degrees, or thoracic kyphosis≥60 degrees. Radiographic and health-related quality of life (HRQOL) variables were examined and compared, preoperatively and at 2-year postoperative follow-up. Group 1 (low disability high sagittal-LDHS) consisted of ODI<40 and SVA≥5 cm or PT≥25 degrees or pelvic incidence-lumbar lordosis≥11 degrees and group 2 (high disability low sagittal-HDLS) consisted of ODI>40 and SVA<5 cm and PT<25 degrees and pelvic incidence-lumbar lordosis<11 degrees.Results
Of 264 patients with follow-up, 58 (22.0%) patients were included in LDHS and 30 (11.4%) were included in HDLS. Both groups had similar demographics and preoperative coronal angles. HDLS had worse baseline HRQOL for all measures (P<0.05) except leg and back pain. HDLS had a higher rate of self-reported leg weakness, arthritis, depression and neurological disorder. Both groups had similar 2-year improvements in HRQOL (P>0.05), except only HDLS had a significant Scoliosis Research Society Mental improvement and a significantly higher rate of reaching minimal clinically important differences in Scoliosis Research Society Mental scores (P<0.05).Conclusions
There is an association of worse baseline HRQOL measures, weakness, arthritis, and mental disease in HDLS. Furthermore, HDLS patients demonstrated similar improvements to LDHS. However, HDLS had greater improvements in the mental domains, perhaps indicating the responsiveness of the mental disability to surgical treatment.Level of evidence
Level III.Item Open Access Congenital Kyphosis: Progressive Correction With an Instrumented Posterior Epiphysiodesis: A Preliminary Report.(Journal of pediatric orthopedics, 2021-03) Rocos, Brett; Lebel, David E; Zeller, ReinhardPurpose
Congenital kyphosis is a rare condition. In this case series we sought to identify the outcomes and complications of posterior instrumented fusion and the resultant epiphysiodesis effect in uniplanar congenital kyphosis in pediatric patients.Method
Pediatric patients were included if treated for a uniplanar congenital kyphotic deformity treated with posterior instrumented spinal fusion between October 2006 and August 2017, with a minimum of 2 years of follow-up. Patients were excluded if a coronal deformity >10 degrees was present.Results
Six patients met the inclusion criteria. Mean age at surgery was 3.6 years. The mean kyphotic deformity before surgery was 49.7 degrees. All patients underwent posterior instrumented fusion with autogenous iliac crest graft and a cast or brace postoperatively. One patient showed a loss of motor evoked potential on prone positioning which returned to normal on supine positioning. No patient showed any postoperative neurological deficits. One patient was diagnosed with a wound infection which was successfully treated with oral antibiotics.By a follow-up of 5.4 years (range, 2.2 to 10.9 y) there was no failure of instrumentation. An epiphysiodesis effect (a difference of ≥5 degrees in the kyphotic deformity measured between the immediate postoperative and final follow-up lateral whole spine XR) of 16.2 degrees (range, 7.2 to 30.9 degrees) was seen in 5 patients. The mean annual epiphysiodesis effect was 2.7 degrees (95% confidence interval, 1.4-4.1 degrees). No kyphosis proximal to the instrumentation was observed for the duration of follow-up.Conclusion
Posterior instrumented fusion and epiphysiodesis is safe and effective. The epiphysiodesis effect occurs in 5/6 of cases, and our data suggests that the procedure is associated with an acceptable blood loss and a low incidence of neurological complications.Item Open Access Coronal realignment and reduction techniques and complication avoidance.(Neurosurgery clinics of North America, 2013-04) Fu, Kai-Ming G; Smith, Justin S; Shaffrey, Christopher I; Ames, Christopher P; Bess, ShayScoliosis is a broad term encompassing multiple pathologies with different etiologies. Patients may range from the infant with congenital deformity, to the adolescent with idiopathic scoliosis, to the elderly patient with severe degenerative scoliosis. Treatment must be tailored to individual circumstances and the pathoanatomy of each deformity. Various coronal reduction techniques have been described and will be discussed within this article. While scoliosis is generally considered a deformity in the coronal plane, often deformity is present in the sagittal and axial planes also. Treatment of these deformities can require osteotomies or vertebral column resections, techniques further discussed in accompanying articles.Item Open Access Development and Validation of a Model for Predicting Surgical Site Infection After Pelvic Organ Prolapse Surgery.(Urogynecology (Hagerstown, Md.), 2022-10) Sheyn, David; Gregory, W Thomas; Osazuwa-Peters, Oyomoare; Jelovsek, J EricImportance
Surgical site infection (SSI) is a common and costly complication. Targeted interventions in high-risk patients may lead to a reduction in SSI; at present, there is no method to consistently identify patients at increased risk of SSI.Objective
The aim of this study was to develop and validate a model for predicting risk of SSI after pelvic organ prolapse surgery.Study design
Women undergoing surgery between 2011 and 2017 were identified using Current Procedural Terminology codes from the Centers for Medicare and Medicaid Services 5% Limited Data Set. Surgical site infection ≤90 days of surgery was the primary outcome, with 41 candidate predictors identified, including demographics, comorbidities, and perioperative variables. Generalized linear regression was used to fit a full specified model, including all predictors and a reduced penalized model approximating the full model. Model performance was measured using the c-statistic, Brier score, and calibration curves. Accuracy measures were internally validated using bootstrapping to correct for bias and overfitting. Decision curves were used to determine the net benefit of using the model.Results
Of 12,334 women, 4.7% experienced SSI. The approximated model included 10 predictors. Model accuracy was acceptable (bias-corrected c-statistic [95% confidence interval], 0.603 [0.578-0.624]; Brier score, 0.045). The model was moderately calibrated when predicting up to 5-6 times the average risk of SSI between 0 and 25-30%. There was a net benefit for clinical use when risk thresholds for intervention were between 3% and 12%.Conclusions
This model provides estimates of probability of SSI within 90 days after pelvic organ prolapse surgery and demonstrates net benefit when considering prevention strategies to reduce SSI.Item Open Access Indicators for Nonroutine Discharge Following Cervical Deformity-Corrective Surgery: Radiographic, Surgical, and Patient-Related Factors.(Neurosurgery, 2019-09) Bortz, Cole A; Passias, Peter G; Segreto, Frank; Horn, Samantha R; Lafage, Virginie; Smith, Justin S; Line, Breton; Mundis, Gregory M; Kebaish, Khaled M; Kelly, Michael P; Protopsaltis, Themistocles; Sciubba, Daniel M; Soroceanu, Alexandra; Klineberg, Eric O; Burton, Douglas C; Hart, Robert A; Schwab, Frank J; Bess, Shay; Shaffrey, Christopher I; Ames, Christopher PBackground
Nonroutine discharge, including discharge to inpatient rehab and skilled nursing facilities, is associated with increased cost-of-care. Given the rising prevalence of cervical deformity (CD)-corrective surgery and the necessity of value-based healthcare, it is important to identify indicators for nonroutine discharge.Objective
To identify factors associated with nonroutine discharge after CD-corrective surgery using a statistical learning algorithm.Methods
A retrospective review of patients ≥18 yr with discharge and baseline (BL) radiographic data. Conditional inference decision trees identified factors associated with nonroutine discharge and cut-off points at which factors were significantly associated with discharge status. A conditional variable importance table used nonreplacement sampling set of 10 000 conditional inference trees to identify influential patient/surgical factors. The binary logistic regression indicated odds of nonroutine discharge for patients with influential factors at significant cut-off points.Results
Of 138 patients (61 yr, 63% female) undergoing surgery for CD (8 ± 5 levels; 49% posterior approach, 16% anterior, and 35% combined), 29% experienced nonroutine discharge. BL cervical/upper-cervical malalignment showed the strongest relationship with nonroutine discharge: C1 slope ≥ 14°, C2 slope ≥ 57°, TS-CL ≥ 57°. Patient-related factors associated with nonroutine discharge included BL gait impairment, age ≥ 59 yr and apex of CD primary driver ≥ C7. The only surgical factor associated with nonroutine discharge was fusion ≥ 8 levels. There was no relationship between nonhome discharge and reoperation within 6 mo or 1 yr (both P > .05) of index procedure. Despite no differences in BL EQ-5D (P = .946), nonroutine discharge patients had inferior 1-yr postoperative EQ-5D scores (P = .044).Conclusion
Severe preoperative cervical malalignment was strongly associated with nonroutine discharge following CD-corrective surgery. Age, deformity driver, and ≥ 8 level fusions were also associated with nonroutine discharge and should be taken into account to improve patient counseling and health care resource allocation.Item Open Access Mini-Open Lateral Corpectomy for Thoracolumbar Junction Lesions.(Operative neurosurgery (Hagerstown, Md.), 2020-06) Huangxs, Shengbin; Christiansen, Peter A; Tan, Haitao; Smith, Justin S; Shaffrey, Mark E; Uribe, Juan S; Shaffrey, Christopher I; Yen, Chun-PoBackground
Neoplastic, traumatic, infectious, and degenerative pathologies affecting the thoracolumbar junction pose a unique challenge to spine surgeons. Posterior or anterior approaches have traditionally been utilized to treat these lesions. Although minimally invasive surgeries through a lateral approach to the thoracic or lumbar spine have gained popularity, lateral access to the thoracolumbar junction remains technically challenging due to the overlying diaphragm positioned at the interface of the peritoneum and pleura.Objective
To describe a mini-open lateral retropleural retroperitoneal approach for pathologies with spinal cord/cauda equina compression at the thoracolumbar junction.Methods
A mini-open lateral corpectomy is described in detail in a patient with an L1 metastatic tumor.Results
Satisfactory decompression and spinal column reconstruction were achieved. The patient obtained neural function recovery following the procedure with no intra- or postoperative complications.Conclusion
The morbidities associated with traditional posterior or anterior approaches to thoracolumbar junction pathologies have led to a growing interest in minimally invasive alternatives. The mini-open lateral approach allows for a safe and efficacious corpectomy and reconstruction for thoracolumbar junction pathologies. Thorough understanding of the anatomy, particularly of the diaphragm, is critical. This approach will have expanded roles in the management of patients with thoracolumbar neoplasms, fractures, infections, deformities, or degenerative diseases.Item Open Access Outcomes of the Keystone Island Perforator Flap: A Systematic Review.(Journal of reconstructive microsurgery, 2022-11) Weinberg, Maxene; Heiman, Adee J; DeSanti, Rebecca; Lanni, Michael A; Kouwenberg, Emily Van; Patel, AshitBackground
The Keystone Design Perforator Island Flap (KDPIF), first described by Behan in 2003, has been demonstrated as a versatile, safe, and straightforward reconstructive option for various soft tissue defects. The purpose of this systematic review is to evaluate the indications, variations, and overall complication profile of the keystone flap in reconstructive surgery.Methods
A literature review was conducted in accordance with PRISMA guidelines using MeSH term "surgical flaps" with the keyword "keystone flap." Empirical studies with at least 15 patients who underwent keystone flap reconstruction were assessed for quantitative analysis. Outcomes of interest included patient demographics, indications, anatomic location, flap design, and complications.Results
Database search produced 135 articles, of which 25 were selected for full-text review. Out of 23 studies selected qualitative analysis and 22 met criteria for quantitative analysis. Overall success rate of this flap was 98%. Wound complications were highest in extremity flaps. Several modifications of this flap were described.Conclusion
Keystone reconstruction demonstrates excellent success rates and versatility. However, further studies with more standard reporting are needed to determine guidelines for patient specific surgical planning.Item Open Access Prophylactic Muscle Flaps Decrease Wound Complication Rates in Patients with Oncologic Spine Disease.(Plastic and reconstructive surgery, 2024-01) Dalton, Tara; Darner, Grant; McCray, Edwin; Price, Meghan; Baëta, Cesar; Erickson, Melissa; Karikari, Isaac O; Abd-El-Barr, Muhammad M; Goodwin, C Rory; Brown, David ABackground
Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established.Methods
A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data.Results
A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053).Conclusions
Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention.Clinical question/level of evidence
Therapeutic, III.Item Unknown Systematic Review and Guidelines for Perioperative Management of Pediatric Patients Undergoing Major Plastic Surgery Procedures, with a Focus on Free Tissue Transfer.(Plastic and reconstructive surgery, 2022-08) Mountziaris, Paschalia M; Rudolph, Christina M; Fournier, Craig T; Haykal, Siba; Ricci, Joseph A; Rezak, Kristen M; Patel, AshitBackground
Microsurgical free tissue transfer has been successfully implemented for various reconstructive applications in children. The goal of this study was to identify the best available evidence on perioperative management of pediatric patients undergoing free tissue transfer and to use it to develop evidence-based care guidelines.Methods
A systematic review was conducted in the PubMed, Embase, Scopus, and Cochrane Library databases. Because a preliminary search of the pediatric microsurgical literature yielded scant data with a low level of evidence, pediatric anesthesia guidelines for healthy children undergoing major operations were also included. Exclusion criteria included vague descriptions of perioperative care, case reports, and studies of syndromic or chronically ill children.Results
Two hundred four articles were identified, and 53 met inclusion criteria. Management approaches specific to the pediatric population were used to formulate recommendations. High-quality data were found for anesthesia, analgesia, fluid administration/blood transfusion, and anticoagulation (Level I Evidence). Lower quality evidence was identified for patient temperature (Level III Evidence) and vasodilator use (Level IV Evidence). Key recommendations include administering sevoflurane for general anesthesia, implementing a multimodal analgesia strategy, limiting preoperative fasting, restricting blood transfusions until hemoglobin level is less than 7 g/dl unless the patient is symptomatic, and reserving chemical venous thromboembolism prophylaxis for high-risk patients.Conclusions
Pediatric-specific guidelines are important, as they acknowledge physiologic differences in children, which may be overlooked when extrapolating from adult studies. These evidence-based recommendations are a key first step toward standardization of perioperative care of pediatric patients undergoing plastic surgical procedures, including free tissue transfer, to improve outcomes and minimize complications.Item Unknown The evolution of facial reanimation techniques.(American journal of otolaryngology, 2023-05) Pan, Debbie R; Clark, Nicholas W; Chiang, Harry; Kahmke, Russel R; Phillips, Brett T; Barrett, Dane MThis review article provides an updated discussion on evidence-based practices related to the evaluation and management of facial paralysis. Ultimately, the goals of facial reanimation include obtaining facial symmetry at rest, providing corneal protection, restoring smile symmetry and facial movement for functional and aesthetic purposes. The treatment of facial nerve injury is highly individualized, especially given the wide heterogeneity regarding the degree of initial neuronal insult and eventual functional outcome. Recent advancements in facial reanimation techniques have better equipped clinicians to approach challenging patient scenarios with reliable, effective strategies. We discuss how technology such as machine learning software has revolutionized pre- and post-intervention assessments and provide an overview of current controversies including timing of intervention, choice of donor nerve, and management of nonflaccid facial palsy with synkinesis. We highlight novel considerations to mainstay conservative management strategies and examine innovations in modern surgical techniques with a focus on gracilis free muscle transfer. Innervation sources, procedural staging, coaptation patterns, and multi-vector and multi-muscle paddle design are modifications that have significantly evolved over the past decade.