Kometh Thawanyarat

Introduction: We seek to evaluate the financial impact of the COVID-19 pandemic on pediatric craniomaxillofacial surgeries for cleft lip and/or palate. These surgeries are carefully timed for optimal outcomes, but the pandemic necessitated postponement or cancellation of elective procedures. Our study quantifies the decline in cases and associated charges at a single academic medical center before and after the pandemic.Methods: After receiving Institutional Review Board approval, we analyzed the financial billing data of 83 patients who underwent cleft lip and/or palate repair at an academic medical center. The caseload and charges incurred in the year before the COVID-19 pandemic (March 2019 to February 2020) were compared to the 2 years following the pandemic’s onset (March 2020 to February 2022). Statistical analysis was conducted using paired t-tests and the Wilcoxon signed-rank.Results: In the year following the onset of the pandemic, we observed a significant decrease in the number of cleft lip and/or palate repairs performed per month (from 2.75 to 1.42 per month, P-value .021) and a decrease in per-month charges for these procedures ($13 334.75 to $7237.17 per month, P-value .036). However, when examining data over the 2 years post-COVID, these differences no longer remain statistically significant ( P-value .25 for cases and P-value .32 for charges), indicating a return to pre-COVID baseline.Conclusion: There was a statistically significant decrease in cleft lip/palate repair surgeries in the 12 months following the start of the COVID-19 pandemic. Both the caseload and total charges decreased after March 2020, with a subsequent return to baseline after 2 years. These findings emphasize that the pandemic had a transient impact on pediatric craniomaxillofacial surgical volume at our institution. While acknowledging our study’s external validity, we advocate for a nuanced approach, with flexible staffing crucial in facilitating a swift return to normal elective volumes.

The novel use of the omental flap in breast reconstruction has been increasing in research popularity within the last few decades. This technique has its roots in the early 20th century as surgeons explored the use of the omentum for a variety of reconstructive purposes across various surgical subspecialties. The current literature shows evidence of the benefits of using the omentum in autologous breast reconstruction compared to the more traditional abdominal, flank, thigh, and gluteal donor flap reconstruction. This method introduces a viable option for patients that do not meet the criteria for the traditional autologous reconstruction techniques allowing for the restoration of more natural appearing breasts without the added complication of donor-site mortality. Additionally, the omentum, with its rich source of vascularized lymph nodes, has been studied as a potential source for lymph node transfer in the treatment of mastectomy-associated lymphedema. In this review, we highlight the most recent research on the current practices of omental-based breast reconstruction techniques and their use in postmastectomy lymphedema. We discuss the history and natural progression of the development of omental-based reconstruction as an autologous breast reconstruction technique, highlight the latest advances and challenges for the utility of the omental flap in current surgical procedures, and present future directions for the potential role of omental-based breast reconstruction in postmastectomy breast surgery.

Background Studies have shown that Black patients are more likely to experience complications following breast reconstruction compared to other racial groups. Most of these studies have been conducted on patient populations focusing on either autologous or implant-based reconstruction without possible predictive indicators for complication disparities for all types of reconstruction procedures. The aim of this study is to elucidate disparities among patient demographics by identifying predictors of complications and postoperative outcomes among different racial/ethnic patients undergoing breast reconstruction utilizing multi-state, multi-institution, and national level data. Methods Patients in the Optum Clinformatics Data Mart that underwent all billable forms of breast reconstruction were identified via CPT codes. Demographics, medical history, and postoperative outcome data were collected by querying relevant reports of CPT, ICD-9, and ICD-10 codes. Outcomes analysis was limited to the 90-day global postoperative period. A multivariable logistic-regression analysis was performed to ascertain the effects of age, patient reported ethnicity, coexisting conditions, and reconstruction type on the likelihood of any common postoperative complication occurring. Linearity of the continuous variables with respect to the logit of the dependent variable was confirmed. Odds ratios and corresponding 95% confidence intervals were calculated. Results From over 86 million longitudinal patient records, our study population included 104,714 encounters for 57,468 patients who had undergone breast reconstruction between January 2003 and June 2019. Black race (relative to White), autologous reconstruction, hypertension, type II diabetes mellitus, and tobacco use were independent predictors of increased likelihood of complication. Specifically, the odds ratios for complication occurrence for Black, Hispanic, and Asian ethnicity (relative to White) were 1.09, 1.03, and 0.77, respectively. Black patients had an overall breast reconstruction complication rate of 20.4%, while the corresponding rate for White, Hispanic, and Asian patients were 17.0%, 17.9%, and 13.2%, respectively. Conclusion Our analysis of a national-level database shows that Black patients undergoing implant-based or autologous reconstruction have increased risk of complications, likely due to multifactorial components that play a role in the care of this patient population. While higher rates of comorbidities have been cited as a possible cause, providers must consider racial influences involving cultural context, historical mistrust in medicine, and physician/health institution factors that may drive this disparity of outcomes among our patients.

Professional health care organizations including the American Society of Plastic Surgeons (ASPS) historically provide guidance to medical providers in the wake of major medical news and events. Consider, for example, the ASPS guidance published in response to the December 17, 2020 Food and Drug Administration (FDA) briefing document of the Vaccines and Related Biological Products Advisory Committee for the Moderna COVID-19 (coronavirus disease 2019) Vaccine.[1] This information provides a framework for physicians to guide patient-physician conversations in formalized health care settings. However, it provides little insight into tangible patient concerns during the contemplation stage of decision-making prior to formalized patient consultations. We suggest utilizing Google Trends (GT) as a real-time tool to aid in identifying patient concerns. There have been several previously published case reports commenting on the immunogenicity of hyaluronic fillers as well as COVID-19 vaccine hypersensitivity and dermal manifestations.[2] [3] [4] [5] In theory, statements from professional organizations have a broader audience base than research articles from independent bodies including research institutions and universities. Few tools are available to both analyze how the public perception changes and capture significant concerns in the wake of these statements. In this virtual era where health-related information is readily accessible to patients via Internet searches, patients often form biases and premature decisions regarding treatment options prior to ever setting foot—or meeting virtually—in a provider's office.[6] [7] Additionally, there is an ever-growing body of literature supporting the use of social media and its utility in communicating with patients, particularly within the field of plastic and reconstructive surgery.[8] [9] [10] In order for physicians to address patient concerns on their Web-based platforms in the absence of in-person patient consultations, we advocate for the use of free analytical tools, particularly GT, to predict and mitigate patient concerns. We used a GT analysis to examine whether public interest in and concern over dermal fillers and related injectable products, namely botulinum toxin, increased in the wake of FDA adverse event reports, specifically the aforementioned December 2020 FDA Briefing. In our analysis, the following search terms ([Table 1]) were queried on GT (Google LLC., Mountain View, CA). These search terms were grouped by the following categories: general terms, adverse reaction terms, safety consideration terms, procedural terminology, brand names of botulinum toxin, and brand names of dermal fillers. These search terms were chosen to capture the various aspects of patient concerns regarding these products, their uses, and safety with respect to the COVID-19 vaccine. The search terms were gathered from November 1, 2019 to November 1, 2021. These dates provided a year's worth of data before and after the inflection point—November 1, 2020—which was chosen to capture the media coverage leading up to the official FDA statement released in December 2020. GT normalizes the volume of the search terms to compare them against one another. Thus, the data extracted is assigned a value from 0 to 100 to represent the relative search volume for each term. Once the data had been extracted from the GT platform for each search term, a bivariate regression analysis of panel data was utilized to explore whether or not the search term volumes were significantly increased after the chosen inflection point of November 1, 2020, as compared with the search volume prior to the inflection point. The data inputs were grouped by search volume for each term up to the inflection point of November 1, 2020, and search volumes for each term following the inflection point. Significant increases or decreases were statistically determined with a p-value of < 0.05 at a 95% confidence interval. [Table 2] demonstrates that general terms (p < 0.001), safety consideration terms (p = 0.034), procedural terminology (p < 0.001), brand names for botulinum toxin (p < 0.001), and brand names for dermal fillers (p = 0.049) had significantly different relative search volume before versus after the chosen inflection point of November 1, 2020. Our GT analysis demonstrated a significant increase in search terms, and therefore public interest, related to injectable products, the COVID-19 vaccine, and their adverse effects following the December 2020 FDA Briefing. GT analysis allows providers to accurately query public interest in, and concern over, medical procedures in the absence of face-to-face, individual patient meetings. Using free, publicly available analytical tools allows physicians the ability to tailor patient education on social media or other Web-based platforms to anticipate and mitigate patient concerns. M.A.R. and K.T. were involved in conception, writing, and editing. J.K.S. was involved in data collection, analysis, and writing. R.N. was involved in conception and editing. Received: 27 January 2022 Accepted: 30 June 2022 Article published online: 28 March 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Thieme Medical Publishers, Inc. 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

Introduction Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes. Methods Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated. Results From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications. Conclusions This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.

Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve both clinical outcomes and cost savings in various perioperative settings. Our study focuses on the effects of ERAS protocol in craniomaxillofacial surgery in a single institution within 2 years leading up to and following implementation. The purpose of this research is to quantify the changes in effective pain management in pediatric patients undergoing craniomaxillofacial procedures before and after our ERAS protocol, which did not include IV acetaminophen. We hypothesize that ERAS protocol, even without IV acetaminophen, will provide effective pain management while decreasing the opioid use4 in the perioperative and postoperative period without associated complications from NSAID therapy. Methods: A retrospective chart review was conducted on 137 pediatric patients that underwent craniofacial surgery between July 1, 2014, and June 30, 2020. Patients were divided into 2 cohorts: Pre-ERAS and Post-ERAS with the implementation of ERAS on July 1, 2017. Results: Post-ERAS cohort showed increased NSAID use in the preoperative and postoperative period for both IV and PO ( P = .006 and P = .0064). Morphine use showed no immediate changes until a year after implementation with a statistically significant reduction ( P = .0051). When stratified by procedure type, IV NSAID (Ketorolac) use increased in Palatoplasty procedures ( P = .0154) while PO NSAID (Ibuprofen) use increased in Cleft Lip Repair ( P = .0224). Conclusion: ERAS protocol implementation can provide benefit for pediatric patients undergoing craniomaxillofacial surgery by decreasing opioid use, even in the absence of IV acetaminophen. Outcomes may potentially be delayed in the immediate post-implementation period. This study can add to the expanding literature for the use of ERAS protocol in craniomaxillofacial surgical settings. Further studies can include analyzing potential barriers to implementation and future complications related to ERAS long term outcomes.

Instagram (Menlo Park, CA) has become a popular means of advertisement for aesthetic surgery procedures, influencing patients’ likelihood of undergoing a procedure. This study aims to explore public interest in aesthetic procedures before and after the Instagram platform began to obtain popularity via Google Trends (Google, Mountain View, CA), a platform with previously demonstrated utility for tracking interest in surgical procedures. We hypothesize that as a result of increased medical marketing on Instagram, there is an increase in public interest in plastic surgery elective procedures. Trends in the United States for given search terms and volumes were gathered via Google Trends between April 2004 to January 2022. Search terms included popular aesthetic procedures based on the 2020 Aesthetic Plastic Surgery National Data Bank Statistics. The search volumes were normalized, and a bivariate regression analysis of panel data was then applied to the aggregate trendlines to determine if a statistically significant change in search volume occurred following the increase in user traffic of the Instagram platform. We found significant variations in search volume for plastic surgery procedures before and after April 2012. Blepharoplasty, Botox, brachioplasty, breast implant removal, breast reduction, brow lift, butt lift, hair transplantation, lip augmentation, male breast surgery, mastopexy, mentoplasty, otoplasty, platysmaplasty, rhinoplasty, and thighplasty (pp = 0.003) had a statistically significant decrease in search volume after April 2012. We observed a significant increase in public interest in both surgical and non-surgical aesthetic procedures after Instagram gained popularity in April of 2012.