Vyas, Krishna S.

Background Postsurgical complications have been an increasing concern for hospitals, particularly in light of payment reform. The costs to the health care system are increasing in light of Medicare penalties for readmissions for certain conditions. Surgical site infection following implant-based breast reconstruction (IBR) remains challenging. The rates of positive cultures and isolated microorganisms in IBR are unknown. This systematic review summarizes the reported microorganisms and positive culture rates in the existing literature. Methods A systematic review was performed using the guidelines outlined in Preferred Reporting Items for Systematic Reviews and Meta-analyses. Articles were included if breast implant infection rates and culture results were reported. Further subgroup analysis of culture positive infections was performed. Results A total of 25 studies were included, encompassing 25,177 IBR. Implant infections were reported in 1356 reconstructions (5.4%). Cultures were positive in 74.5% of infections. Gram-positive bacteria were the most common (68.6%), of which Staphylococcus species (51%) was the most isolated pathogen, followed by Pseudomonas. A subgroup analysis showed that early infections (63% vs 88%), radiotherapy (82% vs 93%), and acellular dermal matrix use (90% vs 100%) were associated with lower positive culture rates than their respective counterparts. Patients who received chemotherapy had higher positive culture results (94% vs 83%). Isolated microorganisms also varied among the subgroups. Conclusions This systematic review outlines reported microorganisms in IBR. Staphylococcus species and Pseudomonas were the most frequently reported microorganism. Negative cultures were reported in up to 25.5% of infections. Patients with early infections, radiotherapy, and acellular dermal matrix demonstrated higher negative culture rates. This review can help guide the use of empirical antimicrobial therapy in IBR.

Background: Pediatric calvarial reconstruction is challenging because of the unique anatomical and growth considerations in this population. Comparative studies evaluating current cranioplasty materials are lacking. This review addresses the knowledge gap in pediatric cranioplasty outcomes with emphasis on current materials used. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome data comparing fresh bone, banked bone, titanium, poly(methyl methacrylate), and polyetheretherketone were abstracted. Results: Twenty studies met the authors’ selection criteria. The mean patient age ranged from 4 to 17.4 years. Autologous cranioplasty was performed in 439 patients, and 201 patients underwent alloplastic reconstruction. Fresh bone grafts and titanium mesh were associated with the lowest infection rates (0.4 percent and 3.3 percent, respectively; p < 0.001), graft failures (2.9 percent and 3.3 percent, respectively; p < 0.001), and surgical-site occurrence rates (8.8 percent and 6.7 percent, respectively; p < 0.001). Banked bone flaps had the highest overall complication rates (51 percent; p < 0.001), bone resorption (39.7 percent; p < 0.001), and failure rates (40.2 percent; p < 0.001), whereas polyetherether ketone had the highest rates of infection (16.1 percent; p < 0.001). Conclusions: Based on the available evidence to date, fresh bone grafts and titanium mesh demonstrated the lowest surgical-site infection, surgical-site occurrence, and graft failure rates. Banked bone flaps had the highest overall surgical-site complications and graft failures. Pediatric cranioplasty outcomes studies are needed to evaluate current and novel cranioplasty materials.

ObjectiveThis study was performed to outline and analyze the overall Medicare landscape with respect to otolaryngologists and beneficiaries, services, and reimbursements.MethodsThis is a retrospective analysis of publicly available Medicare utilization and payment data for all otolaryngologists in facility and nonfacility practice settings who provided services to Medicare beneficiaries between January 1, 2012, and December 31, 2016.ResultsIn 2016, a total of $701,195,375 was distributed to 8572 otolaryngology physician providers for 815 unique Healthcare Common Procedure Coding System codes for 13,942,536 procedure claims. Of specialty care, otolaryngology ranks 20th among 54 subspecialties for total Medicare payments. The average number of services coded per provider was 1627. The average otolaryngologist was paid $81,800.67. Thirty‐two percent of otolaryngologists did not receive reimbursement for services from Medicare in 2016.DiscussionIn 2016, the most significant contributors to Medicare payments to otolaryngologists were large‐scale, low‐cost events that are relatively short procedures done in clinic. Utilization of nasal endoscopy was up trending from 2012 to 2016. Some of the Current Procedural Terminology codes with the greatest discrepancies between submitted charge and Medicare payment among nonfacility otolaryngology providers are more involved than simple office procedures.Implications for PracticeIt is increasingly valuable for physicians to know factors that affect reimbursement for procedures and operations in different settings and to be aware of the trends in variation in their specialty. Otolaryngologists should communicate with policy makers in efforts toward sustainable reimbursement models.

AbstractBackgroundThe Goldilocks mastectomy procedure involves local contouring of completely autologous breast tissue created by preserving and de‐epithelializing the residual mastectomy flaps. The purpose of this study was to provide outcomes data for 96‐Goldilocks mastectomy procedures analyzing indications, complications, relevant comorbidities, and adjuvant cancer treatment impacting reconstructive and aesthetic outcomes.MethodsComprehensive review of every patient who underwent Goldilocks mastectomy from 2012 to 2018 included relevant medical and surgical comorbidities, as well as complication profiles. Aesthetic outcomes were also assessed in those with postoperative imaging available.ResultsA total of 53 patients (96 breasts) were included in this study. Bilateral cases consisted of 81.1% of the total cohort (n = 86 cases), and 18.9% (n = 10 cases) were unilateral procedures. Mean age at the time of reconstruction was 55.8 (33‐77) years. Mean body mass index (BMI) at the time of reconstruction was 33.7 (19.2‐54.6). The overall complication rate was 9.38% (seroma = 2, hematoma = 1, cellulitis = 2, wound dehiscence = 3, and operating room take back = 1).ConclusionsGoldilocks breast reconstruction is a safe, effective option in patients with higher than average BMI or excess local breast tissue, or in patients meeting these criteria preferring a single‐stage reconstruction. This study qualifies its use in patients with higher than average risk factors for more extensive reconstructive modalities.

ABSTRACT Background Penile prostheses are commonly used to achieve erectile rigidity after phalloplasty in trans masculine patients. Implantation poses significant challenges because of the delicate nature of the neophallus and lack of native erectile tissue. Many groups have developed novel phalloplasty and prosthesis insertion techniques, but none have proven superior. Aim To analyze and aggregate reported characteristics and outcomes of penile prosthesis implantation in the trans masculine patient. Methods A comprehensive literature search of Medline, EMBASE, and Cochrane Registry databases was conducted for studies published through February 19, 2019, with multiple search terms related to penile prosthesis use in gender-affirming surgical procedures. Outcomes Studies were included and tabulated if they reported prosthesis outcomes in patients who received a neophallus as part of a gender-affirming procedure. Results 23 journal articles met inclusion criteria from 434 references identified. All selected articles were either retrospective or case series/reports. A total of 1,056 patients underwent phalloplasty, and 792 received a penile prosthesis. Most (83.6%) of the prostheses were inflatable, whereas 16.4% were non-inflatable. The number of cylinders used for each prosthesis was 61.0% single-cylinder and 39.0% double-cylinder. The mean follow-up duration was 3.0 years. Of patients who received a prosthesis, 36.2% reported a prosthesis complication; at follow-up 60.0% of patients had their original implant present, and 83.9% reported achieving penetration. Clinical Implications Prosthesis implantation in gender-affirming operations poses significant risk of complication, but it is still a reasonable and useful method to achieve rigidity necessary for sexual intercourse. Strength & Limitation This is the first study to aggregate all reported penile prosthesis characteristics and outcomes in trans masculine patients. This study was significantly limited by inconsistent reporting of demographics, sensation, urinary health, patient satisfaction, and penetrative sex. The lack of comparative studies precluded any meaningful meta-analytical comparison. Conclusions There is a great need for a prosthesis designed to meet the specific needs of the trans masculine patient after phalloplasty. Standardized methods of reporting implant outcomes including sexual function, sensation, and patient satisfaction should be refined for future studies. This study can assist patients and surgeons about the risks and benefits of this procedure.