A Multivariate Regression Analysis of Panniculectomy Outcomes: Does Plastic Surgery Training Matter?

The impact of simultaneous panniculectomy in ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

Ventral hernia repair (VHR) is often performed in patients with obesity. While panniculectomy improves cosmetic outcomes, it may increase complications, particularly wound-related adverse events. Despite its widespread use, the impact of concurrent panniculectomy on postoperative complications in VHR remains unclear. This study aimed to assess whether concurrent panniculectomy increases postoperative complications in VHR.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane databases for studies published up to April 2024 comparing surgical outcomes in patients undergoing VHR with and without concurrent panniculectomy. We assessed recurrence, seroma, hematoma, surgical site infections (SSI), wound dehiscence, skin necrosis, chronic wound, length of stay (LOS), readmissions, duration of surgery, and deep venous thromboembolism (DVT). Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were pooled for dichotomous and continuous endpoints, respectively. We used RStudio for statistics and heterogeneity was assessed with I2 statistics.

RESULTS

We screened 890 studies, fully reviewed 40, and included 11 observational studies and 2 randomized controlled trials, comprising 23,354 patients. Of these, 2,972 (13%) patients underwent VHR with concurrent panniculectomy (VHR-PAN). The mean age ranged from 37 to 59 years, and 73% of the sample were women. The mean BMI varied from 29 to 45 kg/m2, and 75% of the patients underwent mesh repair. The mean defect area ranged from 36 to 389 cm2. Most repairs were performed using mesh (75%) in an underlay position (68%) and 24% underwent component separation. VHR-PAN was associated with a decrease in recurrence rates (RR 0.74; 95% CI 0.62 to 0.89; p < 0.001; I2 = 1%) with a follow-up ranging from 1 to 36 months. Furthermore, subgroup analysis of recurrence in studies with a mean follow-up of at least one year also showed a reduction in recurrence (RR 0.72; 95% CI 0.60 to 0.88; p < 0.001; I2 = 12%), with a follow-up ranging from 12 to 36 months. Moreover, concurrent panniculectomy was associated with increased SSI (RR 1.31; 95% CI 1.13 to 1.51; p < 0.001; I2 = 0%), SSO (RR 1.49; 95% CI 1.26 to 1.77; p < 0.001; I2 = 11%), skin necrosis (RR 2.94; 95% CI 1.26 to 6.85; p = 0.012; I2 = 0%) and reoperation (RR 1.73; 95% CI 1.32 to 2.28; p < 0.001; I2 = 0%), and longer LOS (MD 0.90 day; 95%CI 0.40 to 1.40; p < 0.001; I2 = 56%). There was no significant difference in ocurrence of DVT, enterocutaneous fistula, hematoma, seroma, or wound dehiscence, neither on operative time or readmission rates.

CONCLUSION

VHR-PAN is associated with lower recurrence rates. However, it increases the risk of wound morbidity and reoperation and prolongs hospital stay. Surgeons should carefully weigh the risks and benefits of performing VHR-PAN.

STUDY REGISTRATION

A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024542721).

The Impact of Body Mass Index on Adverse Outcomes Associated with Panniculectomy: A Multimodal Analysis

BACKGROUND

Overhanging pannus may be detrimental to ambulation, urination, sexual function, and social well-being. Massive weight loss patients often have high residual body mass index (BMI) and comorbidities presenting a unique challenge in panniculectomy patient selection. This study aims to better characterize the role of BMI in postoperative complications following panniculectomy.

METHODS

A meta-analysis attempted to assess the impact of BMI on complications following panniculectomy. Cochrane Q and I2 test statistics measured study heterogeneity, with subsequent random effects meta-regression investigating these results. After this, all panniculectomy patients in the National Surgical Quality Improvement Program database in the years 2007 to 2019 were analyzed. Univariate and multivariable tests assessed the relative role of BMI on 30-day postoperative complications.

RESULTS

Thirty-four studies satisfied inclusion criteria, revealing very high heterogeneity (Cochrane Q = 2453.3; I2 = 99.1%), precluding further meta-analysis results. Receiver operating characteristic curves demonstrated BMI was a significant predictor of both all causes (area under the curve, 0.64; 95% CI, 0.62 to 0.66) and wound complications (area under the curve, 0.66; 95% CI, 0.63 to 0.69). BMI remained significant following multivariable regression analyses. Restricted cubic spines demonstrated marginal increases in complication incidence above 33.2 and 35 kg/m 2 for all-cause and wound complications, respectively.

CONCLUSIONS

Reported literature regarding postoperative complications in panniculectomy patients is highly heterogeneous and may limit evidence-based care. Complication incidence positively correlated with BMI, although the receiver operating characteristic curve demonstrated its limitations as the sole predictive variable. Furthermore, restricted cubic splines demonstrated diminishing marginal predictive capacity of BMI for incremental increases in BMIs above 33.2 to 35 kg/m 2 . These findings support a reevaluation of the role of BMI cutoffs in panniculectomy patient selection.

Who Posts on Instagram? Using Natural Language Processing to Assess the Relationship Between Training Background and Content of 700,000 Posts

Background

Instagram (Menlo Park, CA) is a major platform for the dissemination of plastic surgery (PS) information, but the training background of users is difficult to ascertain.

Objectives

We sought to better characterize the source and content of PS-related posts on Instagram.

Methods

Metadata from publicly available Instagram posts containing PS relevant hashtags was collected from December 2018 to August 2020 using Node.js (Node.js Foundation, San Francisco, CA). The data was characterized by account type, and post topics were analyzed using a custom dictionary of PS procedures applied with natural language processing. All data analyses were performed with R (The R Foundation, Vienna, Austria).

Results

Board-certified plastic surgeons account for 38% of posts on Instagram, followed by organizations (31%), nonplastics-trained physicians (19%), facial plastics (5%), oculoplastics (1%), and nonphysician providers (5%). Oculoplastics had the highest engagement rate with their posts (3.7 ± 5.1), whereas plastic surgeons had the lowest (2.7 ± 4.2). Breast aesthetics was the predominant topic posted by plastic surgeons (42%, P < .001), and board certification phrases distinguished their posts from other account types (23%, P < .001). Nonphysician posts focused on nonsurgical aesthetics like Botox and fillers (80%). However, nonplastics-trained physicians and organizations significantly contributed to procedural subcategories in a similar distribution to plastic surgeons.

Conclusions

Board-certified plastic surgeons are not the predominant source of PS content on Instagram. Furthermore, posts by plastic surgeons have the lowest rate of engagement out of all account types studied. Although declarations of board certification distinguish content from plastics disciplines, they are only used in 21% of posts.

Level of Evidence 4

How Do You Like Me Now? The Influence of "Likes" and Followers on Social Media in Plastic Surgery

BACKGROUND

The number of "likes" and followers on social media is a surrogate marker for peer acceptance and popularity, but the influence of likes and followers on prospective plastic surgery patients has not been studied. The aim of this study was to evaluate whether the number of followers or likes on social media has an impact on perceived surgeon competence or likelihood of recruiting new patients.

METHODS

A fictitious Instagram page was created with different permutations displaying different numbers of followers on the page. Similarly, fictitious Instagram posts were created displaying before-and-after results of ideal and suboptimal breast augmentation and gynecomastia surgery results, with the number of likes being the only variable. Using a crowdsourcing platform, survey responders rated surgeon competence and likelihood of patient recruitment based on the Instagram post.

RESULTS

A total of 4284 responses were collected. The number of followers or likes did not impact perceived surgeon competence or patient recruitment scores. Optimal surgical results consistently scored higher than suboptimal results, regardless of the number of likes. Almost half the responders were unable to identify the American Board of Plastic Surgery as the appropriate board certification for performing aesthetic breast or body surgery.

CONCLUSIONS

A high number of followers or likes, by itself, is unlikely to translate into higher likelihood of recruiting new patients. Overall, aesthetic results seem to be the most important driving force in receiving high competence scores and recruiting new patients, rather than social media presence or board certification.

Abdominal Panniculectomy: An Analysis of Outcomes in 238 Consecutive Patients over 10 Years

Panniculectomy is a commonly performed body contouring procedure to address skin laxity and its related complications. This study aimed to assess clinical outcomes of abdominal panniculectomy and identify predictors of complications at a tertiary academic healthcare center.

Methods

A retrospective review of patients who underwent panniculectomy between January 2010 and January 2020 at our institution was performed. Exclusion criteria were a history of prior panniculectomy or abdominoplasty. Patient characteristics and clinical outcomes were collected. Univariate and multivariable analyses were performed to assess the risk factors of complications.

Results

The mean age in the included 238 patients was 51.7 ± 12.7 years, and the mean body mass index (BMI) at the time of panniculectomy was 33 ± 7.5 kg/m². Median resection weight was 2.7 kg (range: 0.15-14.6) and median length of hospital stay was 2 days (range: 0-24). Mean follow-up time was 50 ± 37 months. The rate of major complications was 22.3%. Revision surgery was performed in 3.4% of the cases. Multivariable analyses demonstrated that increase in BMI (P = 0.007) and active smoking (P = 0.026) were significantly associated with increased odds of major complication, and increase in BMI (P = 0.0004), history of venous thromboembolism (P = 0.034) and having a concomitant ventral hernia repair (P = 0.0044) were significantly associated with having a length of hospital stay of 3 days or more.

Conclusions

Panniculectomy is generally safe to perform, with major postoperative complication rate of 22.3% in our series. Increase in BMI and active smoking were significantly associated with having a major complication. Higher BMI, concomitant hernia repair, and a history of venous thromboembolism were associated with length of hospital stay of 3 days or more.

Evaluating Outcomes and Weight Loss After Panniculectomy

OBJECTIVE

The objective of this study was to evaluate long-term outcomes and weight loss after panniculectomy.

METHODS

A retrospective chart review study was performed on 225 consecutive patients who had undergone panniculectomy from 2002 and 2020. Demographic variables including smoking status, medical comorbidities, and prior history of weight loss/bariatric surgery were collected for 173 patients. Preoperative and postoperative body mass index (BMI) were calculated in addition to postoperative outcomes.

RESULTS

The study population was 85% female with a mean age of 57 years and an average follow-up of 3.9 years. Relevant comorbidities included obesity (88%), hypertension (65%), diabetes (37%), and smoking (8%), and the majority (53%) of patients had undergone prior bariatric surgery. The overall complication rate was 40%. Twenty percent of patients required reoperation or readmission, and 20% had minor complications addressed in an outpatient setting. Patients who had higher preoperative BMI experienced a significant long-term reduction in BMI. In addition, patients who did not undergo prior bariatric surgery tended to lose weight more often and by larger amounts than patients who had prior bariatric surgery (71.6% vs 57.6, P = 0.023). Complications were not uncommon and included infection (17%), delayed wound healing (16%), seroma (8%), and hematoma (3%). Patients who had prior bariatric surgery were at reduced risk of any complication (P = 0.012). Smoking increased the incidence of infection (38.5% of smokers vs 15.6% of nonsmokers, P = 0.039). Concomitant hernia repair increased the risk of overall complications (64.3% vs 35.9%, P = 0.003) and delayed wound healing (39.2% vs 11.7%, P < 0.001). In the subgroup of patients who did not lose weight, a panniculus weight greater than 5 kg was associated with an increased complication rate (61.5% vs 27%, P = 0.03).

CONCLUSIONS

Patients who underwent a panniculectomy tended to lose weight postoperatively, particularly those who had not undergone previous bariatric surgery. Complications were not uncommon, especially in patients with a smoking history. Prior bariatric surgery patients had a significant decrease in postoperative complications but tended to lose less weight after panniculectomy than those without prior bariatric surgery. Concomitant hernia repair put patients at an increased risk of complications.

Photographic Misrepresentation on Instagram After Facial Cosmetic Surgery: Is Increased Photography Bias Associated With Greater User Engagement?

BACKGROUND

Before-and-after images are commonly used on Instagram (Menlo Park, CA) to advertise aesthetic surgical treatments and are a powerful means of engaging prospective patients. Consistency between before-and-after images accurately demonstrating the postoperative result on Instagram, however, has not been systematically assessed.

OBJECTIVES

The aim of this study was to systematically assess facial cosmetic surgery before-and-after photography bias on Instagram.

METHODS

The authors queried 19 Instagram facial aesthetic surgery-related hashtags on 3 dates in May 2020. The "top" 9 posts associated with each hashtag (291 posts) were analyzed by 3 plastic surgeons by means of a 5-item rubric quantifying photographic discrepancies between preoperative and postoperative images. Duplicate posts and those that did not include before-and-after images of facial aesthetic surgery procedures were excluded.

RESULTS

A total of 3,477,178 posts were queried. Photography conditions were observed to favor visual enhancement of the postoperative result in 282/291 analyzed top posts, with an average bias score of 1.71 [1.01] out of 5. Plastic surgeons accounted for only 27.5% of top posts. Physicians practicing outside their scope of practice accounted for 2.8% of top posts. Accounts with a greater number of followers (P = 0.017) and posts originating from Asia (P = 0.013) were significantly associated with a higher postoperative photography bias score.

CONCLUSIONS

Photographic misrepresentation, with photography conditions biased towards enhancing the appearance of the postoperative result, is pervasive on Instagram. This pattern was observed across all physician specialties and raises significant concerns. Accounts with a greater number of followers demonstrated significantly greater postoperative photography bias, suggesting photographic misrepresentation is rewarded by greater user engagement.

Panniculectomy Outcomes by Body Mass Index: an Analysis of 12,732 Cases

Purpose

With an increasing rate of obesity in the USA, bariatric surgery has become widespread, resulting in a greater number of patients seeking panniculectomy. The authors aim to determine the complication profile of panniculectomies by body mass index (BMI).

Methods

The 2012–2018 National Surgical Quality Improvement Program database was queried for all panniculectomy cases. Patients were assigned to a category by their calculated BMI. Rates of complications were compared across BMI ranges. Demographics, comorbidities, and perioperative factors were compared between those with and without complications. Multivariable analyses were performed to analyze the associations between BMI ranges and post-surgical complications.

Results

Twelve thousand seven hundred thirty-two cases were analyzed, of which 1759 (13.8%) had at least one postoperative complication. As BMI increased, patients were more likely to experience postoperative complications (p<0.001). Patients experiencing complications were more likely to be male, older, of a higher BMI group, have a higher American Society of Anesthesiologists Personal Status classification, be an inpatient, have various comorbidities, or be undergoing a concurrent procedure. On multivariable analysis, patients who were overweight (OR=1.24, p=0.039), with class 1 (OR=1.72, p<0.001), class 2 (OR=2.10, p<0.001), or class 3 (OR=3.01, p<0.001) obesity were more likely to have a postoperative complication. Wound complications were particularly prevalent in patients who were overweight (OR=1.77, p=0.001) or with class 1 (OR=2.59, p<0.001), class 2 (OR=4.05, p<0.001), or class 3 (p=5.84, p<0.001) obesity compared to non-overweight patients.

Conclusion

A higher BMI is associated with more postoperative complications, particularly wound healing complications, following panniculectomy in a dose-dependent manner.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05468-w.

The incisional hernia epidemic: evaluation of outcomes, recurrence, and expenses using the healthcare cost and utilization project (HCUP) datasets

BACKGROUND

Incisional hernias (IH) following abdominal surgery persist as morbid, costly, and multi-disciplinary surgical challenges. Using longitudinal, multi-state, administrative claims data (HCUP State Inpatient Databases (SID)); (HCUP State Ambulatory Surgery and Services Databases (SASD)), we aimed to characterize the epidemiology, outcomes, recurrence, and costs of IH.

STUDY DESIGN

529,108 patients undergoing abdominal surgery in 2010 across six specialties (colorectal, general/bariatric, hepatobiliary, obstetrics/gynecology, urology, and vascular) were identified within inpatient and ambulatory databases for Florida (FL), Iowa (IA), Nebraska (NE), New York (NY), and Utah (UT). IH repairs, complications, and expenditures were assessed through 2014. Predictive regression modeling was validated using a training set of 1000 bootstrapped repetitions.

RESULTS

16,169 (3.1%) patients developed hernias requiring repair (4.3-year mean follow-up), 3176 (20%) underwent recurrent repair, and 731 (23%) underwent re-recurrent repair. Patients with IH had increased readmissions (6.6 vs. 2.4), morbidity (39 vs. 8% surgical and 22 vs. 7% medical), and costs ($46,000 vs. $25,000) when compared to patients without IH (p < 0.001). IH expenditures totaled $875 million: initial ($687 million), recurrent ($155 million), and re-recurrent hernias ($33 million). IH predominated in colorectal (10%), hepatobiliary (8%), and vascular (5%) procedures. Of 31 significant independent IH risk factors (p < 0.001), obesity, age, smoking, open surgery, and prior surgery were pervasive across surgical specialties.

CONCLUSION

IH represents an unremitting surgical epidemic associated with considerable morbidity, costs, and features consistent with a chronic disease state. We define critical pervasive risk factors (obesity, age, smoking open surgery, and prior surgery) independently associated with IH across surgical disciplines. With failed repairs, subsequent success becomes less likely, increasing morbidity and costs-underscoring the critical importance of optimal treatment and prevention.

The Potential Impact of Plastic Surgery Expertise on Body Contouring Procedure Outcomes

BACKGROUND

With the increasing demand for body contouring procedures in the United States over the past 2 decades, more surgeons with diverse specialty training are performing these procedures. However, little is known regarding the comparative outcomes of these patients.

OBJECTIVES

The purpose of this study was to compare outcomes of body contouring procedures based on the specialty training of the surgeon.

METHODS

Data from the American College of Surgeons National Surgical Quality Improvement Program (2005-2015) were reviewed for all body contouring procedures. Patients were stratified by surgeon training (plastic surgery [PS] vs general surgery [GS]). Descriptive statistics and regression analyses were used to evaluate differences in outcomes.

RESULTS

A total of 11,658 patients were included; 9502 PS cases and 2156 GS cases. Most were women (90.4%), aged 40 to 59 (52.7%) and white (79.5%). Compared with PS patients, GS patients were more likely to be obese (61.4% vs 40.6%), smokers (13.6% vs 9.8%), and with ASA classification ≥3 (35.3% vs 18.6%) (all P < 0.001). Abdominal contouring procedures were the most common (76%) cases. Multivariate regression revealed that compared with PS cases, those performed by GS practitioners were associated with increased wound and infectious complications (adjusted odds ratio [aOR], 1.81; 95% confidence interval [CI], 1.44-2.27), reoperation (aOR, 1.85; 95% CI, 1.31-2.62), and predicted mean length of stay (1.12 days; 95% CI, 0.64-1.60 days).

CONCLUSIONS

The variable outcomes in body contouring procedures performed by PS compared with GS practitioners may imply procedural-algorithmic differences between the subspecialties, leading to the noted outcome differential.

LEVEL OF EVIDENCE: 2

Panniculectomy at the time of bariatric surgery: a propensity score-matched analysis of outcomes in the MBSAQIP database

BACKGROUND

Body contouring in the postbariatric surgery patient improves quality of life and daily function.

OBJECTIVES

To determine the risk profile of panniculectomy when performed in select patients at the time of bariatric surgery.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating centers.

METHODS

We examined the MBSAQIP database (2016-2017), in which data on 379,544 bariatric surgeries are reported. Concurrent panniculectomy procedures were identified by Current Procedural Technology (CPT) codes. Patient characteristics and in-hospital as well as 30-day complications were compared between the body contouring group and propensity score-matched bariatric surgery controls.

RESULTS

One hundred twenty-four patients met inclusion criteria and were matched to 248 controls. An infra-umbilical panniculectomy was performed in the majority of patients (n = 94, 75.8%). Most patients received an open rather than laparoscopic bariatric surgery (n = 87, 70.2%). There were no statistically significant differences between 30-day mortality (1.9%), wound complications (11.5%), readmission (12.5%) and reoperation (5.8%) between the 2 groups (P > .05). Wound complications occurred in 11.5% of patients and were associated with prolonged hospital stay (odds ratio 4.65, 95% confidence interval 1.99-10.86, P < .001) and a body mass index (BMI) > 50 (odds ratio 3.19, 95% confidence interval 1.02-9.96, P = .046).

CONCLUSION

In select patients, panniculectomy at the time of bariatric surgery was not associated with increased in-hospital or 30-day adverse outcomes compared with matched bariatric surgery controls. This procedure may be performed in select patients, with awareness that revision surgery may be needed once weight loss stabilizes.

Modified Frailty Index Predicts Postoperative Complications following Panniculectomy in the Elderly

Due to the high complication rate of panniculectomies, preoperative risk stratification is imperative. This study aimed to assess the predictive value of the 5-item modified frailty index (mFI-5) for postoperative complications in the elderly following panniculectomy.

Advanced Age Is a Risk Factor for Complications Following Abdominal Panniculectomy

BACKGROUND

Widespread adoption of bariatric surgery in the treatment of obesity has led to greater numbers of patients seeking panniculectomy, including aged patients, who represent a rapidly growing proportion of the U.S population. Although the quality of life and functional benefits of abdominal panniculectomy have been established, its safety in patients 65 years and older has not been evaluated.

METHODS

The American College of Surgeons National Surgical Quality Improvements (ACS-NSQIP) database was used to identify patients undergoing panniculectomy between 2010 and 2015. Age 65 years and older was the risk factor of interest, and primary outcomes included 30-day wound complications, overall complications, reoperation, readmission, and mortality. Multivariate regression was performed to control for confounders.

RESULTS

Review of the database identified 7030 patients who underwent abdominal panniculectomy. When stratified by age, 6455 (91.8%) of patients were younger than 65, and 575 (8.2%) were 65 or older. Multivariate regression analysis demonstrated that age over 65 was a significant independent risk factor for wound complications (OR = 1.81; 95% CI 1.35-2.42; p < 0.001) and all complications (OR = 1.46; 95% CI 1.15-1.87; p = 0.002). BMI, smoking, diabetes, and partial or total dependence were also identified as significant independent risk factors for wound and all complications.

CONCLUSION

Our analysis demonstrates that advanced age is an independent risk factor for wound and overall complications following abdominal panniculectomy. These results highlight the importance of preoperative evaluation and optimization of modifiable preoperative risk factors as well as close postoperative follow-up for safe outcomes in patients 65 and older.

Postoperative Outcomes in Obese Patients That Undergo Ventral Hernia Repair versus Ventral Hernia Repair with Concurrent Panniculectomy

BACKGROUND

The safety of concurrent panniculectomy during ventral hernia repair remains a widely debated topic. This study aims to compare outcomes in obese patients who undergo ventral hernia repair with concurrent panniculectomy versus ventral hernia repair alone.

METHODS

An 8-year retrospective cohort study was performed on obese patients who underwent ventral hernia repair. Patients were divided into those who underwent concurrent panniculectomy and those who did not. Postoperative complications were compared between these groups.

RESULTS

A total of 223 patients were analyzed: 122 in the ventral hernia repair with concurrent panniculectomy group and 101 in the ventral hernia repair-only group. Median follow-up duration was 141 days. Patients in the ventral hernia repair with concurrent panniculectomy group had more surgical-site occurrences (57 percent versus 40 percent; p = 0.012). Both groups had similar rates of surgical-site occurrences that required an intervention (39 percent versus 31 percent; p = 0.179) and similar rates of hernia recurrence (23 percent versus 29 percent; p = 0.326). Multivariate analysis showed that concurrent panniculectomy increased the risk of surgical-site occurrences by two-fold; however, it did not increase the risk of surgical-site occurrences that required an intervention.

CONCLUSIONS

The addition of a panniculectomy to ventral hernia repair increases surgical-site occurrences but does not increase complications that require an intervention. As such, ventral hernia repair with concurrent panniculectomy can be considered in obese patients with a symptomatic panniculus who wish to have a single-stage operation and the lifestyle benefits of a panniculectomy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Google Ranking of Plastic Surgeons Values Social Media Presence Over Academic Pedigree and Experience

BACKGROUND

Patients increasingly rely on online resources to make healthcare decisions. Google dominates the search engine market; first-page results receive most of the web traffic and therefore serve as an important indicator of consumer reach.

OBJECTIVES

Our objective was to analyze the respective importance of physician academic pedigree, experience, and social media presence on plastic surgeon Google first-page search result placement.

METHODS

A Google.com search was conducted in the top 25 United States metropolitan areas to identify the top 20 websites of board-certified plastic surgeons. Social media presence was quantified by tracking the number of followers on Facebook, Twitter, and Instagram for every surgeon as well as medical school and year of graduation. The primary outcome was website ranking in the first page of Google search results. To identify the independent predictors of presence on the front page, we performed a multivariate logistic regression.

RESULTS

Total number of social medial followers was associated with Google front-page placement (P < 0.001), whereas medical school ranking and years in practice were not (P = 0.17 and 0.39, respectively). A total 19.6% of plastic surgeon practices in our study cohort still had no social media accounts whatsoever.

CONCLUSIONS

For the past few decades, plastic surgery practices relied on referrals, word of mouth, and the surgeon's reputation and academic pedigree to attract new patients. It is now clear that this practice-building model is being rapidly supplanted by a new paradigm based on social media presence to reach potential patients.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

BACKGROUND

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

METHODS

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

RESULTS

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

CONCLUSION

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Surgical Training and Standardised Management Guidelines Improved the 30-Day Complication Rate After Abdominoplasty for Massive Weight Loss

Background

An increasing number of patients need reconstructive surgery after massive weight loss. The hypothesis was that surgical experience together with standardised management guidelines significantly decreases early complication rates after abdominoplasty for massive weight loss. The primary aim was to assess the 30-day complication rate after abdominoplasty following increased surgical training and experience. The secondary aim was to assess whether optimised management guidelines have an impact on the complication rate and patient safety.

Methods

The outcome of 69 consecutive abdominoplasties operated by surgeons in 2011 (Group A) and 70 consecutive patients operated by plastic surgeons in 2010–2012 (Group B) was compared. Another Group of 70 consecutive patients operated by surgeons in 2013–2014 (Group C) was assessed since standardised guidelines for pre- and post-operative treatments and refinement of surgical technique had been introduced. The same surgeons participated in operations of Groups A and C. χ²-test and Fisher’s exact test were applied to dichotomous data. Logistic regression test and ANOVA were used.

Results

Group C had more comorbidities and was significantly older. 48 patients in Group A (70%), 31 in Group B (44%) and 13 patients in Group C (19%) had early complications. A significantly decreased rate of complications occurred with improved guidelines and surgical training and experience. (A vs. C p < 0.001 and A vs. B p = 0.008).

Conclusions

Our results indicate that the rate of early complications after abdominoplasty for massive weight loss can be significantly reduced with improved surgical experience and standardised management guidelines.

Registered at Clinical Trial.gov (ID: NCT02679391).

Prolonged operative duration is associated with complications: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically synthesize the large volume of literature reporting on the association between operative duration and complications across various surgical specialties and procedure types.

METHODS

An electronic search of PubMed, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews from January 2005 to January 2015 was conducted. Sixty-six observational studies met the inclusion criteria.

RESULTS

Pooled analyses showed that the likelihood of complications increased significantly with prolonged operative duration, approximately doubling with operative time thresholds exceeding 2 or more hours. Meta-analyses also demonstrated a 14% increase in the likelihood of complications for every 30 min of additional operating time.

CONCLUSIONS

Prolonged operative time is associated with an increase in the risk of complications. Given the adverse consequences of complications, decreased operative times should be a universal goal for surgeons, hospitals, and policy-makers. Future study is recommended on the evaluation of interventions targeted to reducing operating time.

Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing

BACKGROUND

Recent data suggest patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media. Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery.

OBJECTIVES

We set out to answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using?

METHODS

Our study queried 21 Instagram plastic surgery-related hashtags. Content analysis was used to qualitatively evaluate each of the nine "top" posts associated with each hashtag (189 posts). Duplicate posts and those not relevant to plastic surgery were excluded.

RESULTS

A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria. Plastic surgeons eligible for membership in American Society for Aesthetic Plastic Surgery (ASAPS) accounted for only 17.8% of top posts, whereas noneligible physicians accounted for 26.4%. All nonplastic surgery trained physicians marketed themselves as "cosmetic surgeons." Nine top posts (5.5%) were by nonphysicians, including dentists, spas with no associated physician, and a hair salon. The majority of these posts were self-promotional (67.1%) as opposed to educational (32.9%). Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02).

CONCLUSIONS

ASAPS eligible board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram.

Abdominal Contouring Outcomes in Class III Obesity: Analysis of the ACS-NSQIP Database

BACKGROUND

Obesity may increase the risk of complications following abdominal contouring. The aim of this study is to evaluate panniculectomy outcomes in patients with class III obesity (BMI > 40 kg/m²).

METHODS

The American College of Surgeon's National Surgical Quality Improvement Program ACS-NSQIP (2010-2014) was used to identify patients who underwent panniculectomy. Class III obesity patients were identified. Demographics, comorbidities and postoperative outcomes were evaluated. Risk-adjusted multivariate logistic regression analyses were performed to assess impact of class III obesity on panniculectomy outcomes.

RESULTS

A total of 4497 panniculectomies were identified. Of these, 545 (12.1%) were performed in patients with class III obesity. This group was older (mean age 50.3 vs. 45.9, p < 0.01) with a higher proportion of men (23.4 vs. 12.4%, p < 0.01). Class III obesity group also had higher rates of comorbidities (p < 0.01). Postoperatively, class III obesity patients experienced much higher rates of wound complications (17.8 vs. 6.8%), sepsis (3.3 vs. 0.8%), venous thromboembolism (1.5 vs. 0.7%) and medical complications (6.4 vs. 1.8%), p < 0.05. Additionally, this group had higher rates of unplanned reoperation (9.2 vs. 3.7%) and 30-day readmissions (3.5 vs. 1.0%), p < 0.01. On risk-adjusted multivariate regression analyses, class III obesity was independently associated with increased risk of wound complications (OR 2.22, p < 0.01), sepsis (OR 3.53, p < 0.01), medical adverse events (OR 1.98, p < 0.05), unplanned reoperation (OR 1.62, p < 0.05) and 30-day readmission (OR 2.30, p < 0.05).

CONCLUSION

Class III obesity patients are at significantly increased risk of adverse outcomes following abdominal contouring. Plastic surgeons should consider these risks for counseling and preoperative risk optimization.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of Metabolic Syndrome on the Morbidity and Mortality of Patients Undergoing Panniculectomy

BACKGROUND

Metabolic syndrome (MetS) is defined as the concomitant disease process of obesity and at least two of the following variables: diabetes, hypertension, hypertriglyceridemia, or reduced high-density lipoprotein. These entities are well established as risk factors for complications following surgery. Obese patients are particularly prone to the development of MetS. The authors therefore aimed at elucidating the impact of MetS on the perioperative panniculectomy outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was analyzed for all primary procedures of panniculectomy from 2010 through 2015. The cases were stratified based on the presence or absence of MetS and evaluated for demographic data, intraoperative details, and their morbidity and mortality within 30 days after surgery.

RESULTS

A total of 7030 cases were included in this study. Patients with MetS (6.2%) were of significantly worse health, required more emergency admissions (p = 0.022), longer hospitalization (p < 0.001), and more frequently inpatient procedures (p < 0.001) compared to the control group without MetS (3.8%). Plastic surgery was the predominant specialty operating on 79.5% of all cases. Surgical (23.3 vs. 8.7%) complications, readmission (8.7 vs. 3.0%), and reoperations (6.9 vs. 3.1%) rates were all significantly higher in patients with MetS that those without (p < 0.001). One fatality occurred in each cohort (0.23 vs. 0.02%, p = 0.010).

CONCLUSION

Comorbidities are not uncommon in patients undergoing panniculectomy, especially in those diagnosed with MetS. Health-care providers need to be aware of the increased morbidity and mortality in this high-risk subgroup and need to consider preoperative optimization and management before proceeding with surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Combining abdominal and cosmetic breast surgery does not increase short-term complication rates: a comparison of each individual procedure and pretreatment risk stratification tool

BACKGROUND

Combined abdominal and breast surgery presents a convenient and relatively cost-effective approach for accomplishing both procedures.

OBJECTIVES

This study is the largest to date assessing the safety of combined procedures, and it aims to develop a simple pretreatment risk stratification method for patients who desire a combined procedure.

METHODS

All women undergoing abdominoplasty, panniculectomy, augmentation mammaplasty, and/or mastopexy in the TOPS database were identified. Demographics and outcomes for combined procedures were compared to individual procedures using χ(2) and Student's t-tests. Multiple logistic regression provided adjusted odds ratios for the effect of a combined procedure on 30-day complications. Among combined procedures, a logistic regression model determined point values for pretreatment risk factors including diabetes (1 point), age over 53 (1), obesity (2), and 3+ ASA status (3), creating a 7-point pretreatment risk stratification tool.

RESULTS

A total of 58,756 cases met inclusion criteria. Complication rates among combined procedures (9.40%) were greater than those of aesthetic breast surgery (2.66%; P < .001) but did not significantly differ from abdominal procedures (9.75%; P = .530). Nearly 77% of combined cases were classified as low-risk (0 points total) with a 9.78% complication rates. Medium-risk patients (1 to 3 points) had a 16.63% complication rate, and high-risk (4 to 7 points) 38.46%.

CONCLUSIONS

Combining abdominal and breast procedures is safe in the majority of patients and does not increase 30-day complications rates. The risk stratification tool can continue to ensure favorable outcomes for patients who may desire a combined surgery.

LEVEL OF EVIDENCE

4 Risk.

Post-mastectomy reconstruction: a risk-stratified comparative analysis of outcomes

INTRODUCTION

Although breast reconstruction following mastectomy plays a role in the psychological impact of breast cancer, only one in three women undergo reconstruction. Few multi-institutional studies have compared complication profiles of reconstructive patients to non-reconstructive.

METHODS

Using the National Surgical Quality Improvement database, all patients undergoing mastectomy from 2006 to 2010, with or without reconstruction, were identified and risk-stratified using propensity scored quintiles. The incidence of complications and comorbidities were compared.

RESULTS

Of 37,723 mastectomies identified, 30% received immediate breast reconstruction. After quintile matching for comorbidities, complications rates between reconstructive and non-reconstructives were similar. This trend was echoed across all quintiles, except in the sub-group with highest comorbidities. Here, the reconstructive patients had significantly more complications than the non-reconstructive (22.8% versus 7.0%, p < 0.001).

CONCLUSION

Immediate breast reconstruction is a well-tolerated surgical procedure. However, in patients with high comorbidities, surgeons must carefully counterbalance surgical risks with psychosocial benefits to maximize patient outcomes.

LEVEL OF EVIDENCE

Level 3.

Assessing safety and outcomes in outpatient versus inpatient thyroidectomy using the NSQIP: a propensity score matched analysis of 16,370 patients

BACKGROUND

With increasing economic healthcare constraints and an evolving understanding of patient selection criteria and patient safety, outpatient thyroidectomy is now more frequently employed. However, robust statistical analyses evaluating outcomes and safety after outpatient thyroidectomy with matched comparisons to inpatient cohorts are lacking.

METHODS

The 2011-2012 NSQIP datasets were queried to identify all patients undergoing thyroidectomy. Inpatient and outpatient procedures cohorts were matched 1:1 using propensity score analysis to assess outcomes. Outcomes of interest included surgical and medical complications, reoperation, mortality, and readmission. Univariate and multivariate analyses were utilized to identify predictors of these events. Relative risk ratios were calculated for adverse events between inpatient and outpatient cohorts.

RESULTS

In total, 21,508 patients were identified to have undergone a thyroidectomy in 2011-2012. Inpatients and outpatients were matched 1:1 with respect to preoperative and operative characteristics, leaving 8,185 patients in each treatment arm. After matching, overall 30-day morbidity was rare with only 250 patients (1.53 %) experiencing any perioperative morbidity. 476 patients (2.91 %) were readmitted within 30-days of the operation. Both pre- and post-matching, inpatient thyroidectomy was associated with increased risks of readmission, reoperation, and any complication.

CONCLUSIONS

Based on this comprehensive population-based study, outpatient thyroidectomy appears to be at least as safe as inpatient thyroidectomy. However, there are still differences in outcomes between inpatient and outpatient cohorts, despite statistical matching of preoperative and intraoperative variables. Future research needs to be spent identifying these as-of-yet unknown risk factors to resolve this discrepancy.