Dr. Cliff Sheckter is a California native, growing up in the rural Eastern Sierra. He graduated from UCLA with a BS in Anthropology and earned summa cum laude and Phi Beta Kappa honors. He attended USC (Keck) for medical school on an academic scholarship and graduated valedictorian with Alpha Omega Alpha honors. He fell in love with burn care while at USC/LA General Medical Center and completed his surgical training at Stanford. While in residency, he pursued a fellowship/postdoc in Health Systems Design at Stanford’s Clinical Excellence Research Center (CERC). He received additional training in Surgical Critical Care and Burn Surgery at the University of Washington.

Dr. Sheckter is a health services and health policy researcher. His work focuses on burn prevention, health economics in surgical care, and health equity outcomes in burn care. He has authored over 120 articles and numerous book chapters. His research has been published in JAMA, JAMA Network Open, JAMA Surgery, Annals of Surgery, Journal of Plastic & Reconstructive Surgery, Burns, and Journal of Burn Care & Research. His work has been featured in USA Today and the New York Times. He was the recipient of a career development award from the NIH and has funding from the Plastic Surgery Foundation. Dr. Sheckter was awarded the American Burn Association (ABA) Traveling Fellow for 2023 and has won top abstract at the ABA Annual Meeting multiple times. He is an active member of the ABA Burn Prevention and Research Committees.

Dr. Sheckter is one of a few surgeons double-board certified in Surgical Critical Care and Plastic & Reconstructive Surgery. He practices critical care medicine as an intensivist in the Stanford Surgical ICU. He is the Director of the Regional Burn Center at Santa Clara Valley Medical Center which is the only burn/trauma center for the San Francisco Bay Area. He performs scar reconstruction using surgical and laser techniques.

Clinical Focus

  • Burn
  • Scar
  • Surgical Critical Care

Academic Appointments

All Publications

  • Burn Care Funding in the Era of Price Transparency-Does Verification Signal Bargaining Power? Journal of burn care & research : official publication of the American Burn Association Stanton, E., Pedreira, R., Rizk, N., Swaminathan, A., Sheckter, C. 2024


    The Price Transparency Rule of 2021 forced payors and hospitals to publicly disclose negotiated prices to foster competition and reduce cost. Burn care is costly and concentrated at less than 130 centers in the US. We aimed to analyze geographic price variations for inpatient burn care and measure the effects of American Burn Association (ABA) verification status and market concentration on prices. All available commercial rates for 2021-2022 for burn-related Diagnosis Related Groups (DRG) 927, 928, 929, 933, 934, and 935 were merged with hospital-level variables, ABA verification status, and Herfindahl-Hirschman Index (HHI) data. For the DRG 927 (most intensive burn admission) a linear mixed effects model was fit with cost as the outcome and the following variables as covariates: HHI, plan type, safety net status, profit status, verification status, rural status, teaching hospital status. Random intercepts allowed for individual burn centers. There were 170,738 rates published from 1541 unique hospitals. Commercial reimbursement rates for the same DRG varied by a factor of approximately three within hospitals for all DRGs. Similarly, rates across different hospitals varied by a factor of three for all DRGs, with DRG 927 having the most variation. Burn center status was independently associated with higher reimbursement rates adjusting for facility-level factors for all DRGs except for 935. Notably, HHI was the largest predictor of commercial rates (p<0.001). Negotiated prices for inpatient burn care vary widely. ABA-verified centers garner higher rates along with burn centers in more concentrated/monopolistic markets.

    View details for DOI 10.1093/jbcr/irae078

    View details for PubMedID 38733210

  • A national analysis of burn injuries among homeless persons presenting to emergency departments. Burns : journal of the International Society for Burn Injuries Shah, J. K., Liu, F., Cevallos, P., Amakiri, U. O., Johnstone, T., Nazerali, R., Sheckter, C. C. 2024


    Burn injuries among the homeless are increasing as record numbers of people are unsheltered and resort to unsafe heating practices. This study characterizes burns in homeless encounters presenting to US emergency departments (EDs).Burn encounters in the 2019 Nationwide Emergency Department Sample (NEDS) were queried. ICD-10 and CPT codes identified homelessness, injury regions, depths, total body surface area (TBSA %), and treatment plans. Demographics, comorbidities, and charges were analyzed. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate modeling.Of 316,344 weighted ED visits meeting criteria, 1919 (0.6%) were homeless. Homeless encounters were older (mean age 44.83 vs. 32.39 years), male-predominant (71% vs. 52%), and had more comorbidities, and were more often White or Black race (p < 0.001). They more commonly presented to EDs in the West and were covered by Medicaid (51% vs. 33%) (p < 0.001). 12% and 5% of homeless burn injuries were related to self-harm and assault, respectively (p < 0.001). Homeless encounters experienced more third-degree burns (13% vs. 4%; p < 0.001), though TBSA % deciles were not significantly different (34% vs. 33% had TBSA % of ten or lower; p = 0.516). Homeless encounters were more often admitted (49% vs. 7%; p < 0.001), and homelessness increased odds of admission (OR 4.779; p < 0.001). Odds of transfer were significantly lower (OR 0.405; p = 0.021).Homeless burn ED encounters were more likely due to assault and self-inflicted injuries, and more severe. ED practitioners should be aware of these patients' unique presentation and triage to burn centers accordingly.

    View details for DOI 10.1016/j.burns.2024.02.030

    View details for PubMedID 38492979

  • Access to Burn Care in the US. JAMA surgery Hur, D. G., Yao, J., Yue, T. M., Sheckter, C. C., Choi, J. 2024


    This cross-sectional study examines burn incidence rates and accessibility of American Burn Association-verified or self-designated burn centers from 2013 to 2019.

    View details for DOI 10.1001/jamasurg.2023.7763

    View details for PubMedID 38353985

  • Inpatient Complications and Outcomes for Burn Patients Admitted with Methamphetamine Intoxication. Journal of burn care & research : official publication of the American Burn Association Stanton, E., Karanas, Y., Pham, T., Gillenwater, J., Sheckter, C. C. 2024


    Methamphetamine intoxication frequently complicates inpatient burn admissions. While single-institution studies describe adverse outcomes during resuscitation, little is known about the risks of amphetamine intoxication on inpatient complications and perioperative management. The US National Trauma Data Bank was queried for burn encounters between 2017-2021. Amphetamine intoxication was identified on admission. Primary outcomes included death, stroke, and myocardial infarction (MI). Secondary outcomes included organ failure and surgical management. Multivariable regressions modeled outcomes adjusting for available covariates including demographics, total body surface area (TBSA) burned, and inhalation injury. Bonferroni adjustments were applied. Our study identified a total of 73,968 primary burn encounters with toxicology screens. Among these, 800 cases (1.1%) were found to have positive methamphetamine drug screens upon admission. Methamphetamine users were significantly older (41.7 versus 34.9 years, p<.001), had a greater percentage of males (69.6 vs. 65.4, p=.045), were more likely to have inhalation injury (p<.001) and had larger %TBSA burns (16% vs. 13%, (p<.001). Methamphetamine users were no more likely to die, experience MI, or experience stroke during admission. In contrast, methamphetamine users were significantly more likely to have alcohol withdrawal (p=.019), AKI (p<.001), deep vein thrombosis (DVT) (p=.001) , pulmonary embolism (PE) (p=.039), sepsis (p=.026), and longer ICU stays (p<.001). Methamphetamine use was associated with a longer number of days to first procedure (p=.005). Of all patients who required surgery (15.0%), methamphetamine users required significantly more total debridements and reconstructive procedures (p<.001). While not associated with mortality, methamphetamine intoxication was associated with an increased risk of many complications including PE, DVT, AKI, sepsis, and longer ICU stays. Methamphetamine intoxication was associated with delays in surgical care.

    View details for DOI 10.1093/jbcr/irae014

    View details for PubMedID 38285638

  • Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019. Annals of plastic surgery Shah, J. K., Amakiri, U. O., Cevallos, P., Yesantharao, P., Ayyala, H., Sheckter, C. C., Nazerali, R. 2024


    INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States.METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease, Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling.RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Delta = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Delta = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR (P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay (P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242).CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

    View details for DOI 10.1097/SAP.0000000000003764

    View details for PubMedID 38320006

  • US air pollution is associated with increased incidence of non-syndromic cleft lip/palate. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Krakauer, K. N., Cevallos, P. C., Amakiri, U. O., Saldana, G. M., Lipman, K. J., Howell, L. K., Wan, D. C., Khosla, R. K., Nazerali, R., Sheckter, C. C. 2023; 88: 344-351


    Maternal cigarette use is associated with the fetal development of orofacial clefts. Air pollution should be investigated for similar causation. We hypothesize that the incidence of non-syndromic cleft lip with or without palate (NSCLP) and non-syndromic cleft palate (NSCP) would be positively correlated with air pollution concentration.The incidence of NSCLP and NSCP per 1000 live births from 2016 to 2020 was extracted from the Centers for Disease Control and Prevention Vital Statistics Database and merged with national reports on air pollution using the Environmental Protection Agency Air Quality Systems annual data. The most commonly reported pollutants were analyzed including benzene, sulfur dioxide (SO2), particulate matter (PM) 2.5, PM 10, ozone (O3), and carbon monoxide (CO). Multivariable negative binomial and Poisson log-linear regression models evaluated the incidence of NSCLP and NSCP as a function of the pollutants, adjusting for race. All p-values are reported with Bonferroni correction.The median NSCLP incidence was 0.22/1000 births, and isolated NSCP incidence was 0.18/1000 births. For NSCLP, SO2 had a coefficient estimate (CE) of 0.60 (95% CI [0.23, 0.98], p < 0.007) and PM 2.5 had a CE of 0.20 (95% CI [0.10, 0.31], p < 0.005). Among isolated NSCP, no pollutants were found to be significantly associated.SO2 and PM 2.5 were significantly correlated with increased incidence of NSCLP. The American people and perinatal practitioners should be aware of the connection to allow for risk reduction and in utero screening.

    View details for DOI 10.1016/j.bjps.2023.11.012

    View details for PubMedID 38064913

  • Increased Time Spent in the Emergency Department Is Associated with Adverse Inpatient Outcomes in Burn Patients Requiring Resuscitation Wong, S., Pham, T. N., Sheckter, C. C. LIPPINCOTT WILLIAMS & WILKINS. 2023: S531
  • Health Equity Ratings of US Burn Centers-Does For-Profit Status Matter? Journal of burn care & research : official publication of the American Burn Association Rizk, N., Rochlin, D., Sheckter, C. C. 2023


    Achieving health equity is forefront in national discussions on health care structuring. Burn injuries transcend racial and socioeconomic boundaries. Burn center funding ranges from safety-net to for-profit without an understanding of how funding mechanisms translate into equity outcomes. We hypothesized that health equity would be highest at safety-net facilities and lowest at for-profit centers. All verified and non-verified American Burn Association burn centers were collated in 2022. Safety-net status, for-profit status, and health equity rating were extracted from national datasets. Equity ratings were compared across national burn centers and significance was determined with comparative statistics and ordinal logistic regression. On an equity grade of A to D (A is the best), 27.6% of centers were rated A, 27.6% rated B, 41.5% rated C, and 3.3% rated D. 17.1% of all burn centers were designated as for-profit compared to 21.1% of centers that were safety-net. 73.1% of safety-net centers scored an A rating, and 14.3% of for-profit centers scored an A rating. Safety-net centers were 21.8 times more likely (p<0.001) to have the highest equity score compared to non-safety-net centers. There was an 80% decrease in the odds of having a rating of A for for-profit centers compared to non-profit centers (p=0.04). Safety-net centers had the highest equity ratings while for-profit burn centers scored the lowest. For-profit funding mechanisms may lead to the delivery of less equitable burn care. Burn centers should focus on health equity in the triage and management of their patients.

    View details for DOI 10.1093/jbcr/irad162

    View details for PubMedID 37930806

  • Increased Time Spent in the Emergency Department Is Associated with Adverse Inpatient Outcomes in Burn Patients Requiring Resuscitation Wong, S., Pham, T. N., Sheckter, C. C. LIPPINCOTT WILLIAMS & WILKINS. 2023: S531
  • Amphetamine Positivity Prior to Burn Surgery Does not Adversely Affect Intraoperative Outcomes. Journal of burn care & research : official publication of the American Burn Association Rizk, N., Crawford, D., Karanas, Y., Barnes, C., Pham, T. N., Sheckter, C. C. 2023


    The treatment of burn patients using amphetamines is challenging due hemodynamic labilty and altered physiology. Wide variation exists in the operative timing for this patient population. We hypothesize that burn excision in patients admitted with amphetamine positivity is safe regardless of timing. Data from two verified burn centers between 2017-2022 with differing practice patterns in operative timing for amphetamine positive patients. Center A obtains toxicology only on admission and proceeds with surgery based on hemodynamic status and operative urgency, whereas Center B sends daily toxicology until a negative test results. The primary outcome was the use of vasoactive agents during the index operation, modeled using logistic regression adjusting for burn severity and hospital days to index operation. Secondary outcomes included death and inpatient complications. A total of 270 patients were included, and there were no significant differences in demographics or burn characteristics between centers. Center A screened once and Center B obtained a median of 4 screens prior to surgery. The adjusted OR of requiring vasoactive support intraoperatively was not associated with negative toxicology result (p=0.821). Having a body surface area burned >20% conferred a significantly higher risk of vasoactive support (adj. OR 13.42 [3.90 - 46.23], p<0.001). Mortality, number of operations, stroke, and hospital length of stay were similar between cohorts. Comparison between 2 verified burn centers indicates that waiting until a negative amphetamine toxicology result does not impact intraoperative management or subsequent burn outcomes. Serial toxicology tests are unnecessary to guide operative timing of burn patients with amphetamine use.

    View details for DOI 10.1093/jbcr/irad165

    View details for PubMedID 37875155

  • The Association of Structural Fires with Heating Complaints and Race in New York City. Journal of burn care & research : official publication of the American Burn Association Stanton, E., Biedry, J., Rochlin, D., Sheckter, C. 2023


    The devastating fire on January 9, 2022, led to the death of eight children and nine adults in New York City's Bronx borough. Previous reports have suggested that heating complaints in low socioeconomic Black/Latinx communities are frequently ignored. This trend suggests the existence of housing inequities and landlord negligence, which may lead to higher rates of residential fires in the Bronx and other low-income neighborhoods. However, this assertion has yet to be scientifically investigated. Two datasets (New York City Open Data Portal Fire Incident Dispatch and 311 Heat/Hot Water Complaints) were merged to determine the frequency of heating complaints and structural fires per month among community districts in New York City between 2017 and 2022. The primary outcome was structural fires per month which was modeled using a mixed effects multivariable regression allowing random intercepts for individual community districts. Within New York City's 59 community districts, 3,877 heating complaints were filed against 3,989 structural fires during the study period. The mixed effects model demonstrated a significant relationship between heat complaints and frequency of structural fires (coefficient 0.013, 95% confidence interval .012-.014 p< .001). For the decennial census year 2020, the mixed effects model demonstrated a significant association between heat complaints and proportion of non-Hispanic, Black residents (coefficient 0.493, 95% confidence interval 0.330-0.657, p<0.001). This highlights a trend in marginalized racial/ethnic communities, where unresolved heating complaints may force residents to resort to dangerous heating practices, inadvertently leading to fires and morbidity/mortality.

    View details for DOI 10.1093/jbcr/irad138

    View details for PubMedID 37718559

  • Negotiated Rates for Surgical Cancer Care in the Era of Price Transparency-Prices Reflect Market Competition. Annals of surgery Rochlin, D. H., Rizk, N. M., Matros, E., Wagner, T. H., Sheckter, C. C. 2023


    To measure commercial price variation for cancer surgery within and across hospitals.Surgical care for solid organ tumors is costly and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule, enacted in 2021, requires all hospitals list their negotiated rates on their website, thus opening the door for an examination of pricing for cancer surgery.This was a cross-sectional study using 2021 negotiated price data disclosed US hospitals for the ten most common cancers treated with surgery. Price variation was measured using within- and across-hospital ratios. Commercial rates relative to cancer center designation and the Herfindahl-Hirschman Index at the facility level were evaluated with mixed effects linear regression with random intercepts per procedural code.495,200 unique commercial rates from 2,232 hospitals resulted for the ten most common solid-organ tumor cancers. Gynecologic cancer operations had the highest median rates at $6,035.8/operation compared to bladder cancer surgery at $3,431.0/operation. Compared to competitive markets, moderately and highly concentrated markets were associated with significantly higher rates (HHI 1501-2500, coefficient $513.6, 95% CI, $295.5 - $731.7; HHI >2500, coefficient $1,115.5, 95% CI, $913.7-$1,317.2). National Cancer Institute designation was associated with higher rates, coefficient $3,451.9 (95% CI, -$2,853.2-$4,050.7).Commercial payer-negotiated prices for the surgical management of 10 common, solid-tumor malignancies varied widely both within and across hospitals. Higher rates were observed in less competitive markets. Future efforts should facilitate price competition and limit health market concentration.

    View details for DOI 10.1097/SLA.0000000000006091

    View details for PubMedID 37678179

  • Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer. Journal of the American College of Surgeons Sheckter, C. C., Rochlin, D. H., Rubenstein, R., Shamsunder, M. G., Morris, A. M., Wagner, T. H., Matros, E. 2023; 237 (3): 473-482


    High-deductible health plans (HDHPs) have been shown to delay timing of breast and colon cancer screening, although the relationship to the timing of cancer surgery is unknown. The objective of this study was to characterize timing of surgery for breast and colon cancer patients undergoing cancer operations following routine screening.Data from the IBM MarketScan Commercial Claims Database from 2007 to 2016 were queried to identify patients who underwent screening mammogram and/or colonoscopy. The calendar quarters of screening and surgery were analyzed with ordinal logistic regression. The time from screening to surgery (time to surgery, TTS) was evaluated using a Cox proportional hazard function.Among 32,562,751 patients who had screening mammograms, 0.7% underwent breast cancer surgery within the following year. Among 9,325,238 patients who had screening colonoscopies, 0.9% were followed by colon cancer surgery within a year. The odds of screening (OR 1.146 for mammogram, 1.272 for colonoscopy; p < 0.001) and surgery (OR 1.120 for breast surgery, 1.219 for colon surgery; p < 0.001) increased each quarter for HDHPs compared to low-deductible health plans. Enrollment in an HDHP was not associated with a difference in TTS. Screening in Q3 or Q4 was associated with shorter TTS compared to screening in Q1 (hazard ratio 1.061 and 1.046, respectively; p < 0.001).HDHPs were associated with delays in screening and surgery. However, HDHPs were not associated with delays in TTS. Interventions to improve cancer care outcomes in the HDHP population should concentrate on reducing barriers to timely screening.

    View details for DOI 10.1097/XCS.0000000000000737

    View details for PubMedID 38085770

  • Association of High-Deductible Health Plans and Time to Surgery for Breast and Colon Cancer JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS Sheckter, C. C., Rochlin, D. H., Rubenstein, R., Shamsunder, M. G., Morris, A. M., Wagner, T. H., Matros, E. 2023; 237 (3): 473-482
  • Free Flap Reconstruction in the Era of Commercial Price Transparency - What are We Paying For? Plastic and reconstructive surgery Rochlin, D. H., Rizk, N. M., Mehrara, B., Matros, E., Sheckter, C. C. 2023


    Commercial rates for free flap reconstruction were not known publicly prior to the 2021 Hospital Price Transparency Final Rule. The purpose of this study was to examine commercial facility payments to characterize nationwide variation for microsurgical operations and identify opportunities to improve market effectiveness.A cross-sectional study was performed using 2022 commercial insurance pricing merged with hospital performance data. Facility payment rates were extracted for nine CPT codes for free flap operations. Price variation was quantified via across-hospital ratios (AHRs) and within-hospital ratios (WHRs). Mixed effects linear models evaluated commercial rates relative to value, outcomes, and equity performance metrics, in addition to facility-level factors that included healthcare market concentration.20,528 commercial rates across 675 hospitals were compiled. AHRs ranged from 5.85-7.95, while WHRs ranged from 1.00-1.71. Compared to the lowest scoring hospitals (grade D), hospitals with an outcome grade of A and equity grades of B or C were associated with higher commercial rates (p<0.04); there were no significant differences in rate based on value. Higher commercial rates were also associated with nonprofit status and more concentrated markets (p<0.006). Lower commercial rates were correlated with safety-net and teaching hospitals (p<0.001).Commercial rates for free flaps varied substantially both across and within hospitals. Associations of higher commercial rates with less competitive markets, and the lack of consistent association with value and equity, identify pricing failures. Additional work is needed to improve market efficiency for free flap operations.

    View details for DOI 10.1097/PRS.0000000000011021

    View details for PubMedID 37621006

  • What Do Patients Look for When Scheduling Their Initial Elective Aesthetic Plastic Surgery Consultation? Aesthetic plastic surgery Fung, E., Cevallos, P., Thawanyarat, K., Rowley, M., Navarro, Y., Sheckter, C., Nazerali, R. 2023


    Multiple factors influence patients when deciding on where to seek plastic surgery consultations. Our objective was to determine the most important factors when booking the initial consultation.A 23 question survey was distributed online via Amazon Mechanical Turk targeting participants who had prior plastic surgery consultations or were planning to have one in the future. Participant demographic data were collected, and participants were asked to rank the importance of factors related to cost, surgeon reputation, social media, technology, amenities, accessibility, and appointment details on a 1-5 Likert scale. Rankings were reported by mean and standard deviation.A total of 593 responses were gathered. 48.1% of participants were 25-34 years of age, 54.6% were female, 66.3% identified as White, 78.4% were located in the U.S, and 54.5% had a bachelor's degree. Participants rated the importance of a surgeon's online reviews (mean 4.15, SD 0.81), surgeon presence at follow-up visits (mean 4.01, SD 0.91), and availability of pricing prior to appointment (mean 4.01, SD 0.91) the highest. The least important factors were waiting room amenities and social media advertising. Individuals younger than 45 were more likely to rate a surgeon's social media presence higher than those 45 years and older (OR 2.02; 95%CI [1.37-2.96]; p < 0.001).Patients considered surgeon's online reviews, presence at follow-up visits, and the availability of pricing information the most important when booking a plastic surgery consultation. These findings may assist physicians in structuring plastic surgery consultations based on factors important to patients.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 .

    View details for DOI 10.1007/s00266-023-03609-3

    View details for PubMedID 37620567

    View details for PubMedCentralID 4127729

  • The risks of sedation and pain control during burn resuscitation: Increased opioids lead to over-resuscitation and hypotension. Burns : journal of the International Society for Burn Injuries McClellan, J. M., Stanton, E., O'Neal, J., Anderson, J., Sheckter, C., Mandell, S. P. 2023


    INTRODUCTION: Pain management and sedation are necessary in severely burned persons. Balancing pain control, obtundation, and hemodynamic suppression can be challenging. We hypothesized that increased sedation during burn resuscitation is associated with increased intravenous fluid administration and hemodynamic instability.METHODS: A retrospective review of a single burn center was performed from 2014 to 2019 for all admissions to the burn unit with >20% total body surface area (TBSA) burns. Within 48h of admission, we compared total amounts of sedation/pain medications (morphine milligram equivalents (MME), propofol, dexmedetomidine, benzodiazepines) with total resuscitation volumes and frequency of hypotensive episodes. Resuscitation volumes and frequency of hypotension were modeled with multivariable linear regression adjusting for burn severity and weight.RESULTS: 208 patients were included with median age of 43 years (IQR 29-55) and median %TBSA of 31 (IQR 25-44). Median 48-hour resuscitation milliliters per weight per %TBSA were 3.3 (IQR 2.28-4.92). Pain/sedative medications included a combination of opioids in 99%, benzodiazepines in 73%, propofol in 31%, and dexmedetomidine in 11% of patients. MMEs were associated with greater resuscitation volumes (95% CI: 0.15-0.54, p=0.01) as well as number of hypotensive events (95% CI: 1.57-2.7, p<0.001). No associations were noted with other sedative medications when comparing the number of hypotensive events and resuscitation volumes.CONCLUSIONS: Increased opioid administration has physiological consequences and should be carefully monitored during resuscitation as higher volume administrations lead to worse outcomes. Opioids and sedating medications should be titrated to the least amount needed to achieve reasonable comfort and sedation.

    View details for DOI 10.1016/j.burns.2023.08.005

    View details for PubMedID 37833146

  • The Financial Impact of S Code Termination for Autologous Breast Reconstruction: Considerations for Patient Access. Plastic and reconstructive surgery Rochlin, D., Matros, E., Lee, C., Sheckter, C. 2023

    View details for DOI 10.1097/PRS.0000000000010983

    View details for PubMedID 37566527

  • Discussion: Comparing 200,000 Breast Implants and 85,000 Patients over Four National Breast Implant Registries. Plastic and reconstructive surgery Rochlin, D. H., Sheckter, C. C., Matros, E. 2023; 152 (2): 319-320

    View details for DOI 10.1097/PRS.0000000000010209

    View details for PubMedID 37498923

  • Discussion: Racial Disparities in the Cost of Unplanned Hospitalizations after Breast Reconstruction. Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2023; 152 (2): 291-292

    View details for DOI 10.1097/PRS.0000000000010415

    View details for PubMedID 37498921

  • Plastic surgery market share of breast reconstructive procedures: An analysis of two nationwide databases. Journal of surgical oncology Rochlin, D. H., Matros, E., Shamsunder, M. G., Rubenstein, R., Nelson, J. A., Sheckter, C. C. 2023


    Given advances that streamline breast reconstruction (e.g., prepectoral placement, acellular dermal matrix [ADM], oncoplastic surgery), there is concern that nonplastic surgeons are performing a growing proportion of breast reconstructive procedures. The purpose of this study was to evaluate US trends in the market share of breast reconstruction performed by plastic compared to general surgeons.IBM® MarketScan® Commercial Claims 2006-2017 and NSQIP 2005-2020 were queried to identify women who underwent mastectomy with alloplastic (tissue expander or implant-based) or free flap reconstruction, or lumpectomy with oncoplastic reconstruction (breast reduction, mastopexy, or local/regional flap). MarketScan included immediate and delayed reconstructions, while all NSQIP reconstructions were immediate. Poisson regression with incident rate ratios (IRRs) modeled trends in surgeon type over time.The cohort included 65 168 encounters from MarketScan and 73 351 from NSQIP. Plastic surgeons performed 95.8% of free flap, 93.8% of alloplastic, and 64.9% of oncoplastic reconstructions. Plastic surgeons performed an increasing proportion of immediate oncoplastic reduction and mastopexy (MarketScan IRR: 1.077, 95% confidence interval [CI]: 1.060-1.094, p < 0.001; NSQIP IRR: 1.041, 95% CI: 1.030-1.052, p < 0.001). There were no clinically significant trends for delayed oncoplastic, alloplastic, or free flap reconstructions. Plastic surgeons were more likely to use ADM compared to general surgeons in NSQIP (p < 0.001).Plastic surgeons gained market share in immediate oncoplastic breast reduction and mastopexy over the past two decades without any loss in alloplastic or free flap breast reconstruction. Plastic surgeons should continue collaboration with breast surgical oncologists to reinforce the shared surgeon model for management of breast cancer.

    View details for DOI 10.1002/jso.27398

    View details for PubMedID 37439094

  • How Postoperative Infection Affects Reoperations after Implant-based Breast Reconstruction: A National Claims Analysis of Abandonment of Reconstruction. Plastic and reconstructive surgery. Global open Francis, S. D., Thawanyarat, K., Johnstone, T. M., Yesantharao, P. S., Kim, T. S., Rowley, M. A., Sheckter, C. C., Nazerali, R. S. 2023; 11 (6): e5040


    Infection after implant-based breast reconstruction adversely affects surgical outcomes and increases healthcare utilization. This study aimed to quantify how postimplant breast reconstruction infections impact unplanned reoperations, hospital length of stay, and discontinuation of initially desired breast reconstruction.We conducted a retrospective cohort study using Optum's de-identifed Clinformatics Data Mart Database to analyze women undergoing implant breast reconstruction from 2003 to 2019. Unplanned reoperations were identified via Current Procedural Terminology (CPT) codes. Outcomes were analyzed via multivariate linear regression with Poisson distribution to determine statistical significance at P < 0.00625 (Bonferroni correction).In our national claims-based dataset, post-IBR infection rate was 8.53%. Subsequently, 31.2% patients had an implant removed, 6.9% had an implant replaced, 3.6% underwent autologous salvage, and 20.7% discontinued further reconstruction. Patients with a postoperative infection were significantly associated with increased incidence rate of total reoperations (IRR, 3.11; 95% CI, 2.92-3.31; P < 0.001) and total hospital length of stay (IRR, 1.55; 95% CI, 1.48-1.63; P < 0.001). Postoperative infections were associated with significantly increased odds of abandoning reconstruction (OR, 2.92; 95% CI, 0.081-0.11; P < 0.001).Unplanned reoperations impact patients and healthcare systems. This national, claims-level study shows that post-IBR infection was associated with a 3.11× and 1.55× increase in the incidence rate of unplanned reoperations and length of stay. Post-IBR infection was associated with 2.92× increased odds of abandoning further reconstruction after implant removal.

    View details for DOI 10.1097/GOX.0000000000005040

    View details for PubMedID 37325376

    View details for PubMedCentralID PMC10263246

  • The Geographical Impact of Plastic Surgery Residency to Fellowship and Residency/Fellowship to First Job Placement. Annals of plastic surgery Maheta, B., Eggert, G. R., Thawanyarat, K., Patel, A. A., Sheckter, C. C., Nazerali, R. 2023; 90 (6): 603-610


    The location of trainees' plastic surgery residency or fellowship has implications on their subsequent careers, which can inform future trainees and faculty decisions, and may affect access to care nationwide. This study explores historic geographic trends of the location where trainees complete residency or fellowship and where they pursue a fellowship program or first job.Graduates from US integrated plastic surgery residency or fellowship programs from 2015 to 2021 were identified along with their proximity to fellowship or first job. Location was categorized based on whether the graduate's fellowship/first job location to residency/fellowship was within 100 miles, the same state, the same geographic region, the United States, or international. A χ2 value was calculated to determine the significance of relative geographical location after training.Three hundred sixty-five graduates that attended fellowship were included, representing 76.5% (65/85) of integrated plastic surgery residency programs. There were 47.7% (n = 174) that stayed within the same geographic region and 3.6% (n = 13) pursued training internationally. The location of the residency or fellowship program appears to have an influence on the location of the graduate's fellowship or first job.Graduates who completed integrated residency or fellowship in a certain geographic location were more likely to stay in that area for their fellowship or first job. This may be explained by graduates continuing training with their original program, the established network, and personal factors such as family and friends.

    View details for DOI 10.1097/SAP.0000000000003572

    View details for PubMedID 37311316

  • Targeting Vulnerability in the Homeless-A National Analysis of Burn Injuries Presenting to the Emergency Department Shah, J., Liu, F., Cevallos, P., Amakiri, U., Johnstone, T., Sheckter, C., Nazerali, R. OXFORD UNIV PRESS. 2023: S6
  • Methamphetamine Positivity Prior to Burn Surgery Does not Adversely Affect Intraoperative or Inpatient Outcomes Sheckter, C., Rizk, N., Crawford, D., Karanas, Y., Barnes, C., Pham, T. OXFORD UNIV PRESS. 2023: S35
  • The Effect of Postoperative Infection after Implant Breast Reconstruction on Additional Revision Procedures Francis, S., Shah, J. K., Thawanyarat, K., Rowley, M., Kim, T., Sheckter, C., Nazerali, R. LIPPINCOTT WILLIAMS & WILKINS. 2023: S12
  • Higher Out-of-pocket Expenses are Associated with Worse Health-Related Quality of Life in Burn Survivors-a Northwest Regional Burn Model System Investigation. Journal of burn care & research : official publication of the American Burn Association Sheckter, C. C., Holan, C., Carrougher, G., Orton, C., Gibran, N., Stewart, B. T. 2023


    The care required to recover serious burn injuries is costly. In the US, these costs are often borne by patients. Examining the relationship between out-of-pocket (OOP) costs and health-related quality of life (HRQL) is important to support burn survivors. Financial data from a regional burn center were merged with data in the Burn Model System (BMS) National Database. HRQL outcomes included VA-Rand 12 (VR-12) physical component summary (PCS) and mental component summary (MCS) scores. Participant surveys were conducted at 6-, 12-, and 24-months post-injury. VR-12 scores were evaluated using generalized linear models and adjusted for potential confounders (age, sex, insurance/payer, self-identified race/ethnicity, measures of burn injury severity). 644 participants were included, of which 13% (84) had OOP costs. The percentage of participants with OOP costs was 34% for commercial/private, 22% for Medicare, 8% for other, 4% for self-pay, and 0% for workers' compensation and Medicaid. For participants with OOP expenses, median payments were $875 with an IQR of $368 - 1,728. In addition to markers of burn injury severity, OOP costs were negatively associated with PCS scores at 6-months (coefficient -0.002, p<0.001) and 12-months post-injury (coefficient -0.001, p=0.004). There were no significant associations with PCS scores at 24 months post-injury or MCS scores at any interval. Participants with commercial/private or Medicare payer had higher financial liability than other payers. Higher OOP expenses were negatively associated with physical HRQL for at least 12 months after injury. Financial toxicity occurs after burn injury and providers should target resources accordingly.

    View details for DOI 10.1093/jbcr/irad058

    View details for PubMedID 37094279

  • Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus. Plastic and reconstructive surgery Rochlin, D. H., Sheckter, C. C., Brazio, P. S., Coriddi, M. R., Dayan, J. H., Mehrara, B. J., Matros, E. 2023


    Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [(lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern.We performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 Current Procedural Terminology (CPT) codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates.270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2,863 hospitals. Lymphangiography codes varied most in commercial price (WHR 1.76 - 3.89, AHR 8.12 - 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3,635.84) were higher than for physiologic procedures ($2,560.40; p<0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, though regression coefficients varied by code.Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

    View details for DOI 10.1097/PRS.0000000000010591

    View details for PubMedID 37092977

  • Is Plastic Surgery Training Equitable? An Analysis of Health Equity across US Plastic Surgery Residency Programs. Plastic and reconstructive surgery. Global open Cevallos, P., Amakiri, U. O., Johnstone, T., Kim, T. S., Maheta, B., Nazerali, R., Sheckter, C. 2023; 11 (4): e4900


    Achieving health equity includes training surgeons in environments exemplifying access, treatment, and outcomes across the racial, ethnic, and socioeconomic spectrum. Increased attention on health equity has generated metrics comparing hospitals. To establish the quality of health equity in plastic and reconstructive surgery (PRS) residency training, we determined the mean equity score (MES) across training hospitals of US PRS residencies.Methods: The 2021 Lown Institute Hospital Index database was merged with affiliated training hospitals of US integrated PRS residency programs. The Lown equity category is composed of three domains (community benefit, inclusivity, pay equity) generating a health equity grade. MES (standard deviation) was calculated and reported for residency programs (higher MES represented greater health equity). Linear regression modeled the effects of a program's number of training hospitals, safety net hospitals, and geographical region on MES.Results: The MES was 2.64 (0.62). An estimated 5.9% of programs had an MES between 1-2. In total, 56.5% of programs had an MES between 2 and 3, and 37.7% had an MES of 3 or more. The southern region was associated with a higher MES compared with the reference group (Northeast) (P = 0.03). The number of safety net hospitals per program was associated with higher MES (P = 0.02).Conclusions: Two out of three programs train residents in facilities failing to demonstrate high equity healthcare. Programs should promote health equity by diversifying care delivery through affiliated hospitals. This will aid in the creation of a PRS workforce trained to provide care for a socioeconomically, racially, and ethnically diverse population.

    View details for DOI 10.1097/GOX.0000000000004900

    View details for PubMedID 37035124

  • Association of Structural Fires in New York City With Inequities in Safe Heating for Immigrant Communities. JAMA network open Stanton, E., Biedry, J., Rochlin, D., Sheckter, C. C. 2023; 6 (3): e231575


    This cross-sectional study assesses the association of heating complaints with structural fires in New York, New York.

    View details for DOI 10.1001/jamanetworkopen.2023.1575

    View details for PubMedID 36867409

  • The Reality of Commercial Payer-Negotiated Rates in Cleft Lip and Palate Repair. Plastic and reconstructive surgery Rochlin, D. H., Rizk, N. M., Flores, R. L., Matros, E., Sheckter, C. C. 2023


    INTRODUCTION: Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates.METHODS: A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were utilized to assess the relationship between median commercial rate and facility-level variables, and between commercial and Medicaid rates.RESULTS: There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0-2.9, while across-hospital ratios ranged from 5.4-13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5,492.2 vs. $1,739.0), secondary cleft lip and palate repair ($5,429.1 vs. $1,917.0), and cleft rhinoplasty ($6,001.0 vs. $1,917.0) (p<0.001). Lower commercial rates were associated with hospitals that were smaller (p<0.001), safety-net (p<0.001), and non-profit (p<0.001). Medicaid rate was positively associated with commercial rate (p<0.001).CONCLUSIONS: Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, and/or non-profit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not utilize cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement.

    View details for DOI 10.1097/PRS.0000000000010329

    View details for PubMedID 36847669

  • Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction. Annals of plastic surgery Thawanyarat, K., Johnstone, T., Rowley, M., Kim, T., Francis, S., Barrera, J., Cheeseborough, J., Sheckter, C., Nazerali, R. 2023


    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.

    View details for DOI 10.1097/SAP.0000000000003420

    View details for PubMedID 36880783

  • Foot Burns and Diabetes: A Systematic Review of Current Clinical Studies and Proposal of a New Treatment Algorithm. Journal of burn care & research : official publication of the American Burn Association Sharma, A., Perrault, D., Makarewicz, N. S., Pham, T., Sheckter, C., Gurtner, G. 2023


    This study aims to systematically identify studies that evaluate lower extremity burn injury in the diabetic population, evaluate their clinical course and patient outcomes, and present a treatment algorithm tailored to diabetic burn patients. Our systematic review of the PubMed and Web of Science databases yielded 429 unique articles. After exclusion and inclusion criteria were applied, 59 articles were selected for evaluation. In diabetic patients, thermal injury was largely a result of decreased awareness and education regarding heat therapies in the context of peripheral neuropathy. All non-case studies found that metrics such as hospital length of stay, ICU admission rates, rates of comorbidity, complication rates, scald injuries, infection rates, and cost of treatment was significantly increased in the diabetic burn population as compared to their nondiabetic counterparts. Where infection was present, microorganisms colonizing diabetic burn wounds were different than those found in the burn wounds of immunocompetent individuals. Operative intervention including split-skin graft, amputation, and debridement were more often utilized in diabetic burn patients. Foot burns in diabetic patients pose unique clinical risks to patients, and as such need to be an alternate treatment protocol to reflect their pathology. Education and training programs are crucial in the prevention of diabetic foot burns to avoid complications, protracted healing, and adverse outcomes. A unique algorithm can guide the unique treatment of this clinical entity.

    View details for DOI 10.1093/jbcr/irad019

    View details for PubMedID 36786194

  • Impact of High-Deductible Health Plans on Breast Reconstruction: Considerations for Financial Toxicity PLASTIC AND RECONSTRUCTIVE SURGERY Shamsunder, M. G., Sheckter, C. C., Sheinin, A., Rubin, D., Parikh, R. P., Rose, J., Momoh, A. O., Offodile II, A. C., Matros, E. 2023; 151 (2): 245-253


    High-deductible health plans (HDHPs) are used within the United States to curb unnecessary health care spending; however, the resulting increased out-of-pocket (OOP) costs may be associated with financial toxicity. The aim was to assess the impact of HDHPs on use and seasonality of mastectomy and breast reconstruction procedures. The hypothesis is that the high OOP costs of HDHPs will lead to decreased overall service use and greater fourth-quarter use after the deductible has been met.MarketScan was queried from 2014 to 2017 for episodes of mastectomy, breast reconstruction (immediate and delayed), breast revision, and reduction. Only patients continuously enrolled for the full calendar year after the index operation were included. HDHPs and low-deductible health plans (LDHPs) were compared based on OOP cost sharing. Outcomes included surgery use rates, seasonality of operations, and median/mean OOP costs.Annual mastectomy and breast reconstruction use rates varied little between LDHPs and HDHPs. Mastectomies, delayed breast reconstruction, and elective breast procedures (P < 0.001) all showed significant increases in fourth-quarter use, whereas immediate breast reconstruction did not. Regardless of timing and reconstruction method, HDHPs had significantly greater median OOP costs compared to LDHPs (all P < 0.001).Mastectomy and breast reconstruction rates did not differ between LDHPs and HDHPs, but seasonality for all breast procedures was measured with the exception of immediate breast reconstruction, suggesting that women are rational economic actors. Regardless of service timing and reconstruction modality, HDHP patients had greater OOP costs compared to LDHP patients, which serves as a good starting point for provider engagement in financial toxicity.

    View details for DOI 10.1097/PRS.0000000000009823

    View details for Web of Science ID 000923643100009

    View details for PubMedID 36696302

  • Discussion: Breast Reconstruction Decision Aids Decrease Decisional Conflict and Improve Decisional Satisfaction: A Randomized Controlled Trial. Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2023; 151 (2): 289-290

    View details for DOI 10.1097/PRS.0000000000009898

    View details for PubMedID 36696308

  • Impact of Adding Carpal Tunnel Release or Trigger Finger Release to Carpometacarpal Arthroplasty on Postoperative Complications". Plastic and reconstructive surgery Trinh, P., Luan, A., Tawfik, V. L., Sheckter, C., Rochlin, D., Fox, P., Curtin, C. 2023


    BACKGROUND: This study assessed whether adding trigger finger or carpal tunnel release at the time of thumb carpometacarpal (CMC) arthroplasty would increase postoperative opioid use, readmissions, complications, and development of CRPS.METHODS: Using the IBM MarketScan Research Databases from 2012 to 2016, we identified a two groups of CMC arthroplasty patients. The "CMC only" group only had a CMC arthroplasty on the day of operation. The "multiple procedures" group had a CMC arthroplasty and concurrent carpal tunnel and / or trigger finger release. Between the two groups, we compared persistent opioid use, 30-day readmissions, 30-day complications, and diagnosis of complex regional pain syndrome (CRPS).RESULTS: The CMC only group consisted of 18,010 patients. The multiple procedures group consisted of 4,064 patients. These patients received a CMC arthroplasty and a carpal tunnel release (74%), a trigger finger release (20%), or both (6%). CMC only patients had lower rates of persistent opioid use compared to patients who underwent multiple procedures (16% vs 18%). Readmission rates were also lower for CMC only patients (3% vs 4%). CMC only patients had decreased odds of persistent opioid use (OR=0.85; 95% CI, 0.75-0.97, p=0.013) and readmissions (OR=0.80; 95% CI, 0.67-0.96, p=0.016). The most common reason for readmission was pain (16%).CONCLUSIONS: Adding another procedure to a CMC arthroplasty slightly increases the odds of adverse outcomes such as persistent opioid use and readmission. Patients and providers should weigh the efficiency of doing these procedures concurrently against the risk of performing multiple procedures at once.CLINICAL QUESTION / LEVEL OF EVIDENCE: Risk, II.

    View details for DOI 10.1097/PRS.0000000000010144

    View details for PubMedID 36728633

  • The Hypermetabolic Response to Burns and its Treatment: A Literature Review CURRENT NUTRITION & FOOD SCIENCE Houschyar, M., Borrelli, M. R., Tapking, C., Puladi, B., Ooms, M., Maan, Z. N., Sheckter, C. C., Rein, S., Reumuth, G., Weissenberg, K., Weil, C., Duscher, D., Pfoerringer, D., Siemers, F., Behr, B., Lehnhardt, M., Houschyar, K. S. 2023; 19 (7): 682-691
  • Commercial Price Variation for Breast Reconstruction in the Era of Price Transparency. JAMA surgery Rochlin, D. H., Rizk, N. M., Matros, E., Wagner, T. H., Sheckter, C. C. 2022


    Importance: Breast reconstruction is costly, and negotiated commercial rates have been hidden from public view. The Hospital Price Transparency Rule was enacted in 2021 to facilitate market competition and lower health care costs. Breast reconstruction pricing should be analyzed to evaluate for market effectiveness and opportunities to lower the cost of health care.Objective: To evaluate the extent of commercial price variation for breast reconstruction. The secondary objective was to characterize the price of breast reconstruction in relation to market concentration and payer mix.Design, Setting, and Participants: This was a cross-sectional study conducted from January to April 2022 using 2021 pricing data made available after the Hospital Price Transparency Rule. National data were obtained from Turquoise Health, a data service platform that aggregates price disclosures from hospital websites. Participants were included from all hospitals with disclosed pricing data for breast reconstructive procedures, identified by Current Procedural Terminology (CPT) code.Main Outcomes and Measures: Price variation was measured via within- and across-hospital ratios. A mixed-effects linear model evaluated commercial rates relative to governmental rates and the Herfindahl-Hirschman Index (health care market concentration) at the facility level. Linear regression was used to evaluate commercial rates as a function of facility characteristics.Results: A total of 69 834 unique commercial rates were extracted from 978 facilities across 335 metropolitan areas. Commercial rates increased as health care markets became less competitive (coefficient, $4037.52; 95% CI, $700.12 to $7374.92; P = .02; for Herfindahl-Hirschman Index [HHI] 1501-2500, coefficient $3290.21; 95% CI, $878.08 to $5702.34; P = .01; both compared with HHI ≤1500). Commercial rates demonstrated economically insignificant associations with Medicare and Medicaid rates (Medicare coefficient, -$0.05; 95% CI, -$0.14 to $0.03; P = .23; Medicaid coefficient, $0.14; 95% CI, $0.07 to $0.22; P < .001). Safety-net and nonprofit hospitals reported lower commercial rates (coefficient, -$3269.58; 95% CI, -$3815.42 to -$2723.74; P < .001 and coefficient, -$1892.79; -$2519.61 to -$1265.97; P<.001, respectively). Extra-large hospitals (400+ beds) reported higher commercial rates compared with their smaller counterparts (coefficient, $1036.07; 95% CI, $198.29 to $1873.85, P=.02).Conclusions and Relevance: Study results suggest that commercial rates for breast reconstruction demonstrated large nationwide variation. Higher commercial rates were associated with less competitive markets and facilities that were large, for-profit, and nonsafety net. Privately insured patients with breast cancer may experience higher premiums and deductibles as US hospital market consolidation and for-profit hospitals continue to grow. Transparency policies should be continued along with actions that facilitate greater health care market competition. There was no evidence that facilities increase commercial rates in response to lower governmental rates.

    View details for DOI 10.1001/jamasurg.2022.6402

    View details for PubMedID 36515928

  • Temperature Derangement on Admission is Associated with Mortality in Burn Patients-a Nationwide Analysis and Opportunity for Improvement. Journal of burn care & research : official publication of the American Burn Association Stanton, E., Gillenwater, J., Pham, T. N., Sheckter, C. C. 2022


    While single-institution studies have described the relationship between hypothermia, burn severity, and complications, there are no national estimates on how temperature on admission impacts hospital mortality. This study aims to evaluate the relationship between admission temperature and complications on a national scale to expose opportunities for improved outcomes. The US National Trauma Data Bank (NTDB) was analyzed between 2007-2018. Mortality was modeled using multivariable logistic regression including burn severity variables (% total burn surface area (TBSA), inhalation injury, emergency department (ED) temperature), demographics, and facility variables. Temperature was parsed into three categories: hypothermia (<36.0°C), euthermia (36.0-37.9°C), and hyperthermia (≥38.0°C). 116,796 burn encounters were included of which 77.9% were euthermic, 20.6% were hypothermic and 1.45% were hyperthermic on admission. For every 1.0C drop in body temperature from 36.0°C, mortality increased by 5%. Both hypothermia and hyperthermia were independently associated with increased odds of mortality when controlling for age, gender, inhalation injury, number of comorbidities, and %TBSA burned (p<.001). All temperatures below 36.0°C were significantly associated with increased odds of mortality. Patients with ED temperatures between 32.5-33.5°C had the highest odds of mortality (22.0, 95% CI 15.6-31.0, p<.001). ED hypothermia and hyperthermia are independently associated with mortality even when controlling for known covariates associated with inpatient death. These findings underscore the importance of early warming interventions both at the prehospital stage and upon ED arrival. ED temperature could become a quality metric in benchmarking burn centers to improve mortality.

    View details for DOI 10.1093/jbcr/irac168

    View details for PubMedID 36335477

  • Transversus abdominus plane blocks do not reduce rates of postoperative prolonged opioid use following abdominally based autologous breast reconstruction: a nationwide longitudinal analysis. European journal of plastic surgery Chattopadhyay, A., Shah, J. K., Yesantharao, P., Ho, V. T., Sheckter, C. C., Nazerali, R. 2022: 1-11


    Background: The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use.Methods: The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable-TAP block-was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery.Results: Of the 4091 patients, (mean age 51.2±9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p=0.142; p=0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score>3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription.Conclusions: In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy.Level of evidence: Level III, risk/prognostic study.

    View details for DOI 10.1007/s00238-022-01996-5

    View details for PubMedID 36212234

  • Unwinding the False Paradigm of Acute Versus Reconstructive Management of Burn Injuries. Plastic and reconstructive surgery Sheckter, C. C. 2022

    View details for DOI 10.1097/PRS.0000000000009596

    View details for PubMedID 36075032

  • Say no to cyanokit. Pause at the 10, 10 threshold BURNS Sheckter, C. C., Mandell, S. 2022; 48 (6): 1516-1518
  • Declining commercial market share in facial reconstructive surgery: Implications for academic plastic surgery and training future generations. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Rochlin, D. H., Matros, E., Sheckter, C. C. 2022


    BACKGROUND: As a surgical discipline without anatomic boundaries, plastic surgery overlaps with several other specialties. This study aims to measure longitudinal trends in the proportion of commercially reimbursed procedures performed by plastic surgeons compared to other specialists. We hypothesize that there is encroachment in commercial market share by anatomically defined subspecialists within otolaryngology, ophthalmology, and dermatology.METHODS: The IBM MarketScan Research Databases were queried to extract patients who underwent rhinoplasty, eyelid procedures, and skin cancer reconstruction covered by commercial insurance from 2007 to 2016 in the USA. Surgeon specialty was identified. Poisson regression modeled predictors of provider specialty for each procedure over time, adjusting for patient gender, region, facility setting, and diagnosis.RESULTS: A total of 430,472 rhinoplasty, eyelid, and skin cancer procedures were performed during the study period. For each year, the proportion of cases performed by plastic surgeons decreased by 2.1% for rhinoplasty compared to otolaryngologists, 2.0% for eyelid procedures compared to ophthalmologists, and 3.0% for skin cancer reconstruction compared to dermatologists (p<0.001). Plastic surgeons were less likely to perform the procedure if the underlying diagnosis or preceding procedure drew from referral bases of "anatomic" specialists, such as sinonasal disease for otolaryngologists (incidence rate ratio [IRR] 0.829), disorders of the eyelid or orbit for ophthalmologists (IRR 0.646), and Mohs excision for dermatologists (IRR 0.381) (p<0.001).CONCLUSIONS: Plastic surgeons are losing ground on commercially reimbursed facial reconstructive procedures historically performed by the specialty. Plastic surgeons must develop strategies to preserve the commercial market share of these procedures and avoid compromise to academic centers and resident education.

    View details for DOI 10.1016/j.bjps.2022.08.071

    View details for PubMedID 36241505

  • A National Analysis of Discharge Disposition in Older Adults with Burns-Estimating the Likelihood of Independence at Discharge. Journal of burn care & research : official publication of the American Burn Association Cobert, J., Sheckter, C., Pham, T. N. 2022


    Whereas older age predicts higher burn mortality, the impact of age on discharge disposition is less well defined in older adults with burns. This investigation assesses the relationship between older age and discharge disposition after burns in a nationally representative sample. We queried the 2007 to 2015 National Trauma Data Bank for non-fatal burn hospitalizations in older adults. Pre-defined age categories were 55 to 64 years (working-age comparison group), 65 to 74 years (young-old), 75 to 84 years (middle-old), and 85+ years (old-old). Covariables included inhalation injury, comorbidities, burn total body surface area, injury mechanism, and race/ethnicity. Discharge to non-independent living (nursing home, rehabilitation, and other facilities) was the primary outcome. Logistic regression assessed the association between older age and discharge to non-independent living. There were 25,840 non-fatal burn hospitalizations in older adults during the study period. Working-age encounters comprised 53% of admissions, young-old accounted for 28%, middle-old comprised 15% and old-old comprised 4%. Discharge to non-independent living increased with burn TBSA and older age in survivors. Starting in young-old, the majority (65 %) of patients with burns ≥20% TBSA were discharged to non-independent living. Adjusted odd ratios for discharge to non-independent living were 2.0 for young-old, 3.3 for middle-old, and 5.6 for old-old patients, when compared with working-age patients (all P < .001). Older age strongly predicts non-independent discharge after acute burn hospitalization. Matrix analysis of discharge disposition indicates a stepwise rise in discharge to non-independent living with higher age and TBSA, providing a realistic discharge framework for treatment decisions and expectations about achieving independent living after burn hospitalization.

    View details for DOI 10.1093/jbcr/irac104

    View details for PubMedID 35986487

  • Fire and ice-Demands for thermal and frost injury care from extreme weather. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Radics-Johnson, J., Pham, T. N. 2022

    View details for DOI 10.1016/j.burns.2022.07.009

    View details for PubMedID 35918215

  • Say no to cyanokit. Pause at the 10, 10 threshold. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Mandell, S. 2022

    View details for DOI 10.1016/j.burns.2022.06.019

    View details for PubMedID 35850879

  • Impacts of Financial Assistance on Quality of Life Among People Living with Burn Injury: Matched Cohort Analysis of the National Institute on Disability, Independent Living and Rehabilitation Research Burn Model System Database. Journal of burn care & research : official publication of the American Burn Association Martz, F., McMullen, K. A., Carrougher, G. J., Bunnell, A., Sheckter, C. C., Wolf, S. E., Schneider, J. C., Stewart, B. T. 2022


    Disparities in socioeconomic status and minority status impacts the risk of burn injury and the severity of that injury, thus impacting the subsequent cost of care. We aimed to characterize the demographic details surrounding receipt of financial assistance due to burn injury and its relationship with health-related quality of life scores. Participants ≥18 from Burn Model System National Longitudinal Database (BMS) with complete demographic data were included (n=4,330). Non-responders to financial assistance questions were analyzed separately. The remaining sample (n=1,255) was divided into participants who received financial assistance because of burn injury, those who received no financial assistance, and those who received financial assistance before injury and as a result of injury. A demographic and injury-characteristic comparison was conducted. Health-related quality of life metrics (Satisfaction with Life, Short Form-12/Veterans RAND 12-Item Health Survey, Community Integration Questionnaire Social Component, and the Post-Traumatic Growth Inventory) were analyzed pre-injury, then 6-months, 1-year, and 2-years post-injury. A matched cohort analysis compared these scores. When compared to their no financial assistance counterparts, participants receiving financial assistance due to burns were more likely to be minorities (19% vs. 14%), have more severe injuries (% total body surface area burn 21% vs. 10%), and receive workers' compensation (24% vs. 9%). They also had lower health-related quality of life scores on all metrics except the post traumatic growth inventory. Financial assistance may aid in combating disparities in post-traumatic growth scores for participants at the greatest risk of financial toxicity but does not improve other health-related quality of life metrics.

    View details for DOI 10.1093/jbcr/irac079

    View details for PubMedID 35699664

  • Self-reported health measures in burn survivors undergoing burn surgery following acute hospitalization: A burn model system national database investigation. Burns : journal of the International Society for Burn Injuries Luna Bs, E., Sheckter, C. C., Carrougher, G. J., Stewart, B., Schneider, J. C., Ryan, C., Gibran, N. 2022


    INTRODUCTION: Health Related Quality of Life (HRQoL) surveys such as PROMIS-29 may facilitate shared decision-making regarding surgery after burn injury. We aimed to examine whether scar revision and contracture release surgery after index hospitalization was associated with differences in HRQoL.METHODS: Patient and PROMIS-29 Profile v2.0 data were extracted from the Burn Model System (BMS) at 6-, 12-, and 24-months after burn. PROMIS-29 measures 7 health-related domains. Linear regression was performed to identify associations between independent burn patient variables (e.g. scar-related surgery) and PROMIS-29 scores. Socio-demographic and injury variables were analyzed using logistic regression to determine the likelihood of undergoing burn-related surgery.RESULTS: Of 727 participants, 201 (27.6%) underwent ≥1 scar/contracture operation within 24 months of injury. Number of operations at index hospital admission and range of motion (ROM) deficit at discharge were correlated with an increased likelihood of undergoing subsequent scar/contracture surgery (p<0.05). Participants undergoing scar/contracture surgery and those that were Medicaid insured reported significantly worse HRQoL for PROMIS domains: anxiety, depression, and fatigue (p<0.05).CONCLUSIONS: After adjusting for burn severity and available confounders, participants who underwent scar-related burn reconstructive surgery after index hospitalization reported overall worse Health-Related Quality of Life (HRQoL) in multiple domains.

    View details for DOI 10.1016/j.burns.2022.05.010

    View details for PubMedID 35718573

  • The Impact of Burn Survivor Preinjury Income and Payer Status on Health-Related Quality of Life. Journal of burn care & research : official publication of the American Burn Association Sheckter, C. C., Carrougher, G. J., Wolf, S. E., Schneider, J. C., Gibran, N., Stewart, B. T. 2022; 43 (2): 293-299


    The costs required to provide acute care for patients with serious burn injuries are significant. In the United States, these costs are often shared by patients. However, the impacts of preinjury finances on health-related quality of life (HRQL) have been poorly characterized. We hypothesized that lower income and public payers would be associated with poorer HRQL. Burn survivors with complete data for preinjury personal income and payer status were extracted from the longitudinal Burn Model System National Database. HRQL outcomes were measured with VR-12 scores at 6, 12, and 24 months postinjury. VR-12 scores were evaluated using generalized linear models, adjusting for potential confounders (eg, age, sex, self-identified race, burn injury severity). About 453 participants had complete data for income and payer status. More than one third of BMS participants earned less than $25,000/year (36%), 24% earned $25,000 to 49,000/year, 23% earned $50,000 to 99,000/year, 11% earned $100,000 to 149,000/year, 3% earned $150,000 to 199,000/year, and 4% earned more than $200,000/year. VR-12 mental component summary (MCS) and physical component summary (PCS) scores were highest for those who earned $150,000 to 199,000/year (55.8 and 55.8) and lowest for those who earned less than $25,000/year (49.0 and 46.4). After adjusting for demographics, payer, and burn severity, 12-month MCS and PCS and 24-month PCS scores were negatively associated with Medicare payer (P < .05). Low income was not significantly associated with lower VR-12 scores. There was a peaking relationship between HRQL and middle-class income, but this trend was not significant after adjusting for covariates. Public payers, particularly Medicare, were independently associated with poorer HRQL. The findings might be used to identify those at risk of financial toxicity for targeting assistance during rehabilitation.

    View details for DOI 10.1093/jbcr/irab170

    View details for PubMedID 34519793

  • Foot Burns in Persons With Diabetes: Outcomes From the National Trauma Data Bank. Journal of burn care & research : official publication of the American Burn Association Perrault, D., Cobert, J., Gadiraju, V., Sharma, A., Gurtner, G., Pham, T., Sheckter, C. C. 2022


    Diabetes mellitus (DM) complicates the treatment of burn injuries. Foot burns in diabetic patients are challenging problems with unfavorable outcomes. National-scale evaluations are needed, especially with regard to limb salvage. We aim to characterize lower-extremity burns in persons with DM and evaluate the likelihood of amputation. The National Trauma Data Bank (NTDB) was queried from 2007 to 2015 extracting encounters with primary burn injuries of the feet using International Classification of Diseases (ICD) 9th edition codes. Logistic regression modeled predictors of lower-extremity amputation. Covariables included age, sex, race/ethnicity, comorbidities including DM, % burn TBSA, mechanism, and region of burn center. Poisson regression evaluated temporal incidence rate changes in DM foot burns. Of 116,796 adult burn encounters, 7963 (7%) had foot burns. Of this group, 1308 (16%) had DM. 5.6% of encounters with DM foot burns underwent amputation compared to 1.5% of non-DM encounters (P < .001). Independent predictors of lower-extremity amputation included DM (odds ratio 3.70, 95% confidence interval 2.98-4.59), alcohol use, smoking, chronic kidney disease, and burn size >20%, African-American/black race, male sex, and age >40 years (all P < .01). The incidence of DM foot burns increased over the study period with an incidence rate ratio of 1.07 (95% confidence interval 1.05-1.10, P < .001). In conclusion, DM was associated with nearly a 4-fold increase in amputation after adjusting for covariables. Furthermore, the incidence of DM foot burns is increasing. Strategies for optimizing care in persons with DM foot burns are need to improve limb salvage.

    View details for DOI 10.1093/jbcr/irac021

    View details for PubMedID 35395676

  • Out-of-Pocket Costs and Provider Payments in Cleft Lip and Palate Repair. Annals of plastic surgery Rochlin, D. H., Ma, L. W., Sheckter, C. C., Lorenz, H. P. 2022


    BACKGROUND: As healthcare spending within the United States grows, payers have attempted to curb spending through higher cost sharing for patients. For families attempting to balance financial obligations with their children's surgical needs, high cost sharing could place families in difficult situations, deciding between life-altering surgery and bankruptcy. We aim to investigate trends in patient cost sharing and provider payments for cleft lip and palate repair.METHODS: The IBM MarketScan Commercial Database was queried to extract patients younger than 18 years who underwent primary or secondary cleft lip and/or palate repair from 2007 to 2016. Financial variables included gross payments to the provider (facility and/or physician), net payment as reported by the carrier, coordination of benefits and other savings, and the beneficiary contribution, which consisted of patients' coinsurance, copay, and deductible payments. Linear regression was used to evaluate trends in payments over time. Poisson regression was used to trend the proportion of patients with a nonzero beneficiary contribution. All financial values were adjusted to 2016 dollars per the consumer price index to account for inflation.RESULTS: The sample included 6268 cleft lip and 9118 cleft palate repair episodes. Total provider payments increased significantly from 2007 to 2016 for patients undergoing cleft lip (median, $2527.33 vs $5116.30, P 0.008) and palate ($1766.13 vs $3511.70, P < 0.001) repair. Beneficiary contribution also increased significantly for both cleft lip ($155.75 vs $193.31, P < 0.001) and palate ($124.37 vs $183.22, P < 0.001) repair, driven by an increase in deductibles (P < 0.002). The proportion of cleft palate patients with a nonzero beneficiary contribution increased yearly by 1.6% (P = 0.002). Higher provider payments and beneficiary contributions were found in the Northeast (P < 0.001) and South (P < 0.011), respectively, for both cleft lip and palate repair.CONCLUSIONS: The US national data demonstrate that for commercially insured patients with cleft lip and/or palate, there has been a trend toward higher patient cost sharing, most pronounced in the South. This suggests that patients are bearing an increased cost burden while provider payments are simultaneously accelerating. Additional studies are needed to understand the impact of increased cost sharing on parents' decision to pursue cleft lip and/or palate repair for their children.

    View details for DOI 10.1097/SAP.0000000000003081

    View details for PubMedID 35180754

  • Burn Outcomes at Extremes of Body Mass Index- Underweight is as problematic as Morbid Obesity. Journal of burn care & research : official publication of the American Burn Association Tolley, P. D., McClellan, J. M., Butler, D., Stewart, B. T., Pham, T. N., Sheckter, C. C. 1800


    Limited evidence suggests that obesity adversely affects burn outcomes. However, the impacts of body mass index (BMI) across the continuum has not been fully characterized. Therefore, we aimed to characterize outcomes after burn injury across the BMI continuum. We hypothesized that 'normal' BMI (18.5-24.9) would have the lowest mortality and complication rates. The US National Trauma Data Bank (NTDB) was queried for adult burn-injured patients from 2007-2015. Admission BMI was calculated and grouped according to World Health Organization (WHO) classification. The primary outcome was in-hospital mortality. Secondary outcomes of time to wound closure, length of stay (LOS), and inpatient complications were similarly assessed. Of the 116,008 burn patient encounters that were identified, 7,243 underwent at least one operation for wound closure. Mortality was lowest in the overweight (p=0.039) and obese I cohorts (BMI 25-29.9, 30.0-34.9) at 2.9% and increased in both directions of the BMI continuum to 4.1% in the underweight (p=0.032) and 5.1% in the morbidly obese (class III) group (p=0.042). Time to final wound closure was longest in the two BMI extremes. BMI >40 was associated with increased ICU days, ventilator days, renal and cardiac complications. BMI <18.5 had increased hospital days and rates of sepsis. Aberrations in metabolism associated with both increases and decreases of body weight may cause pathophysiologic changes that lead to worsened outcomes in burn-injured patients. In addition to morbidly obese patients, underweight patients also experience increased burn-related death and complications. In contrast, overweight BMI patients may have greater physiologic reserves without the burden of obesity or sarcopenia.

    View details for DOI 10.1093/jbcr/irac014

    View details for PubMedID 35106572

  • Failed Breast Conservation Therapy Predicts Higher Frequency of Revision Surgery following Mastectomy with Reconstruction. Plastic and reconstructive surgery Rochlin, D. H., Sheckter, C. C., Momeni, A. 1800


    BACKGROUND: Breast conservation therapy remains the gold standard for women with localized breast cancer; however, some women may eventually undergo mastectomy with reconstruction. Little is understood regarding the risks of failed breast conservation therapy as they relate to postmastectomy reconstruction and whether this affects outcomes.METHODS: Patients undergoing breast reconstruction were extracted from a merged version of the MarketScan inpatient and outpatient databases from 2007 to 2016. Frequency of lumpectomy and radiation therapy were determined per reconstructive patient. Outcomes included inpatient complications and frequency of revision procedures. Regression models were adjusted for age, obesity, timing of reconstruction, and Elixhauser Comorbidity Index.RESULTS: Six thousand two hundred eighty-eight of 52,826 (11.9 percent) women underwent more than breast mass excisions before mastectomy with reconstruction. Of those, the mean number of excisions per woman was 1.67 ± 0.90. There were 3334 lumpectomy patients (53.0 percent) who completed radiation therapy. The mean number of revisions with breast conservation therapy was 1.5 versus 1.3 in the general cohort. On multivariable analysis, excision of breast mass alone was not associated with increased odds of inpatient complications (OR, 1.07; p = 0.363), nor was radiation therapy (OR, 0.89; p = 0.153). However, radiation therapy with or without excision of breast mass before mastectomy was a significant predictor of more frequent revision operations (p = 0.032). Excision of breast mass alone was not associated with an increased frequency of revision (p = 0.173).CONCLUSIONS: History of radiation therapy in the setting of failed breast conservation therapy resulting in mastectomy with reconstruction was associated with an increased risk for revision. Patients should be counseled accordingly before breast conservation therapy in the event they may eventually undergo mastectomy with reconstruction.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000008896

    View details for PubMedID 35103635

  • Exploring "Return to Productivity" Among People Living With Burn Injury: A Burn Model System National Database Report. Journal of burn care & research : official publication of the American Burn Association Sheckter, C. C., Brych, S., Carrougher, G. J., Wolf, S. E., Schneider, J. C., Gibran, N., Stewart, B. T. 2021; 42 (6): 1081-1086


    Burn survivors experience barriers to returning to work. For those who do return to work, little is known regarding whether they achieve preinjury productivity (i.e., equivalent or gain in income compared to preinjury income). Identifying patients at risk of not achieving preinjury productivity is important for targeting services that support this population. They extracted occupational and income data through 24 months postinjury from the multicenter, longitudinal Burn Model System National Database. Annual income was reported in six groups: <$25k, $25k-50k, $50k-99k, $100k-149k, $150k-199k, and $>199k. Participants were classified by change in income at each follow-up (i.e., gain, loss, and equivalent). Explanatory variables included demographics, injury characteristics, insurance payer, employment status, and job type. Multilevel, multivariable logistic regression was used to model return to productivity. Four hundred fifty-three participants provided complete income data at discharge and follow-up. Of the 302 participants employed preinjury, 180 (60%) returned to work within 24 months postinjury. Less than half (138) returned to productivity (46% of participants employed preinjury; 77% of those who returned to work). Characteristics associated with return to productivity included older age (median 46.9 vs 45.9 years, OR 1.03, P = .006), Hispanic ethnicity (24% vs 11%, OR 1.80, P = 0.041), burn size >20% TBSA (33.7% vs 33.0%, OR 2.09, P = 0.045), and postinjury employment (54% vs 26%, OR 3.41, P < 0.001). More than half of employed people living with burn injury experienced loss in productivity within 24 months postinjury. Even if they return to work, people living with burn injuries face challenges returning to productivity and may benefit from vocational rehabilitation and/or financial assistance.

    View details for DOI 10.1093/jbcr/irab139

    View details for PubMedID 34302467

  • A systematic review of machine learning and automation in burn wound evaluation: A promising but developing frontier BURNS Huang, S., Dang, J., Sheckter, C. C., Yenikomshian, H. A., Gillenwater, J. 2021; 47 (8): 1691-1704
  • Use of Hand Therapy After Distal Radius Fracture: A National Perspective. The Journal of hand surgery Trinh, P., Rochlin, D., Sheckter, C., Moore, W., Fox, P., Curtin, C. 2021


    PURPOSE: To assess whether certain distal radius fracture (DRF) patients, such as opioid users or complex regional pain syndrome (CRPS) patients, receive more hand therapy.METHODS: Using the IBM MarketScan Research Databases from January 1, 2012, to December 31, 2016, we identified a cohort of DRF patients and created 4 subgroups of interest: frequent follow-up patients, persistent opioid users, prior opioid users, and patients with CRPS. We measured rates and demographic characteristics associated with therapy use in our populations of interest.RESULTS: In this cohort of 87,313 patients, 21% received hand therapy after primary DRF treatment. Patients with CRPS had a higher rate of therapy than non-CRPS patients (44% vs 21%, respectively). Frequent follow-up patients used more therapy than those with less follow-up (30% vs 17%, respectively). Persistent opioid users demonstrated slightly increased therapy use compared to the remaining population (25% vs 22%, respectively). Prior opioid users underwent less therapy than patients without prior opioid use (19% vs 22%, respectively). Female sex, residing in the Northeast, being on a preferred provider organization plan, and having more intense surgical treatments were associated with increased therapy use.CONCLUSIONS: This study showed variations in therapy use after DRF in subpopulations of interest. Patients with CRPS, persistent opioid use, and frequent follow-ups had higher rates of therapy. Patients with prior opioid use had lower rates of therapy.CLINICAL RELEVANCE: Therapy is more common in patients with DRF with CRPS, persistent opioid use, or more follow-up visits.

    View details for DOI 10.1016/j.jhsa.2021.08.018

    View details for PubMedID 34666936

  • Rates of Revision and Obstructive Sleep Apnea after Surgery for Velopharyngeal Insufficiency: A Longitudinal Comparative Analysis of More Than 1000 Operations. Plastic and reconstructive surgery Rochlin, D. H., Sheckter, C. C., Khosla, R. K., Lorenz, H. P. 2021; 148 (2): 387-398


    BACKGROUND: The purpose of this study was to evaluate the comparative incidence of obstructive sleep apnea following velopharyngeal insufficiency surgery in the United States.METHODS: A retrospective analysis of cleft and noncleft pediatric patients who underwent velopharyngeal insufficiency surgery was performed using the IBM MarketScan Commercial Database. Patients were tracked longitudinally from 2007 to 2016 to evaluate the incidence of obstructive sleep apnea. Multivariable regression was used to evaluate predictors of postoperative obstructive sleep apnea and surgical revision.RESULTS: A total of 1098 patients underwent a pharyngeal flap (61.0 percent), sphincter pharyngoplasty (22.2 percent), or palatal lengthening with or without island flaps (16.8 percent). Diagnoses were predominantly cleft lip and/or palate (52.8 percent) and congenital oropharyngeal anomalies (42.6 percent). Eighty patients (7.3 percent) developed obstructive sleep apnea at an average of 10.2 months postoperatively. Predictors of obstructive sleep apnea included older age (p = 0.014) and head and neck neoplasm (p = 0.011). The obstructive sleep apnea rate following sphincter pharyngoplasty was 11.1 percent, compared to 7.2 percent after pharyngeal flap surgery. Compared to sphincter pharyngoplasty, pharyngeal flap surgery was associated with a lower risk of further surgery (OR, 0.43; p = 0.010). Of patients with cleft lip and/or palate, 35 developed obstructive sleep apnea (6.0 percent) without a significant association with procedure type.CONCLUSIONS: In this national claims database analysis of cleft and noncleft pediatric patients, the rate of obstructive sleep apnea following velopharyngeal insufficiency surgery was not significantly different for pharyngeal flap compared to sphincter pharyngoplasty.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000008193

    View details for PubMedID 34398089

  • A systematic review of machine learning and automation in burn wound evaluation: A promising but developing frontier. Burns : journal of the International Society for Burn Injuries Huang, S., Dang, J., Sheckter, C. C., Yenikomshian, H. A., Gillenwater, J. 2021


    BACKGROUND: Visual evaluation is the most common method of evaluating burn wounds. Its subjective nature can lead to inaccurate diagnoses and inappropriate burn center referrals. Machine learning may provide an objective solution. The objective of this study is to summarize the literature on ML in burn wound evaluation.METHODS: A systematic review of articles published between January 2000 and January 2021 was performed using PubMed and MEDLINE (OVID). Articles reporting on ML or automation to evaluate burn wounds were included. Keywords included burns, machine/deep learning, artificial intelligence, burn classification technology, and mobile applications. Data were extracted on study design, method of data acquisition, machine learning techniques, and machine learning accuracy.RESULTS: Thirty articles were included. Nine studies used machine learning and automation to estimate percent total body surface area (%TBSA) burned, 4 calculated fluid estimations, 19 estimated burn depth, 5 estimated need for surgery, and 2 evaluated scarring. Models calculating %TBSA burned demonstrated accuracies comparable to or better than paper methods. Burn depth classification models achieved accuracies of >83%.CONCLUSION: Machine learning provides an objective adjunct that may improve diagnostic accuracy in evaluating burn wound severity. Existing models remain in the early stages with future studies needed to assess their clinical feasibility.

    View details for DOI 10.1016/j.burns.2021.07.007

    View details for PubMedID 34419331

  • Discussion: Self-Reported Risk Factors for Financial Distress and Attitudes Regarding Cost Discussions in Cancer Care: A Single-Institution Cross-Sectional Pilot Study of Breast Reconstruction Recipients. Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2021; 147 (4): 598e–599e

    View details for DOI 10.1097/PRS.0000000000007798

    View details for PubMedID 33776029

  • Variation in Payment per Work Relative Value Unit for Breast Reconstruction and Non-breast Microsurgical Reconstruction - An All-Payer Claims Database Analysis. Plastic and reconstructive surgery Shamsunder, M. G., Sheckter, C. C., Sheinin, A., Rubin, D., Berlin, N. L., Mehrara, B., Matros, E. 2021


    INTRODUCTION: Commercial payments for implant-based breast reconstruction have increased within the past decade while reimbursements have stagnated for microsurgical techniques. The physician payment to Work Relative Value Unit(wRVU) ratio allows for standardization when comparing procedures of differing complexity. This study aims to characterize payment-per-RVU for common breast and non-breast microsurgical procedures.METHODS: The Massachusetts All-Payer Claims Database was queried from 2010-2014 for microsurgical and breast reconstruction related Current Procedural Terminology (CPT) codes. International Classification of Diseases (ICD) codes were further used to categorize procedures by anatomic region including head and neck, breast, trunk, and extremities. Physician payments, for both commercial and governmental, were aggregated by anatomic region and CPT code. Payment distributions were described with means and medians and compared using statistical tests.RESULTS: Among 3,435 commercial claims, distributions of physician payments-per-wRVU for microsurgical and common breast procedures differed only for breast free flaps billed through S-Codes(p<0.001). Microsurgical breast procedures(19364) had significantly greater median payments-per-wRVU compared to microsurgery of the head & neck, trunk, upper extremities(p=0.004). Payment-per-wRVU for common breast and non-breast microsurgical procedures did not differ significantly amongst governmental claims(p=0.103).CONCLUSION: Adjustment of physician payments by RVU did not show significant variability across common breast procedures, except for S-Codes, suggesting payments are mostly driven by differences in wRVUs and individual contractual negotiations. Lower payments-per-wRVU for other regions compared to breast suggests an opportunity for negotiation with commercial payers.

    View details for DOI 10.1097/PRS.0000000000007679

    View details for PubMedID 33587555

  • Bilaminate Synthetic Dermal Matrix versus Free Fascial Flaps: A Cost-Effectiveness Analysis for Full-Thickness Hand Reconstruction. Journal of reconstructive microsurgery Miller, T. J., Lin, W. C., Watt, A. J., Sheckter, C. C. 2021


    BACKGROUND: Full-thickness injuries to the hand require durable soft tissue coverage to preserve tendon gliding and hand motion. We aim to investigate the cost effectiveness of hand resurfacing comparing free fascial flap reconstruction versus bilaminate synthetic dermal matrices.METHODS: Cost effectiveness was modeled using decision tree analysis with the rollback method. Total active range of motion was modeled as the common outcome variable based on systematic literature review. Costing was performed from a payer perspective using national Medicare reimbursements. The willingness to pay threshold was determined by average worker's compensation for hand disability. Probabilistic sensitivity analysis was conducted for range of motion outcomes and the costs using 10,000 Monte Carlo simulations.RESULTS: The average cost of free fascial flap reconstruction was $14,201.24 compared with $13,674.20 for Integra, yielding an incremental cost difference of $527.04. Incremental range of motion improvement was 18.0 degrees with free fascial flaps, yielding an incremental cost effectiveness ratio of $29.30/degree of motion. Assuming willingness to pay thresholds of $557.00/degree of motion, free-fascial flaps were highly cost effective. On probabilistic sensitivity analysis, free fascial flaps were dominant in 25.5% of simulations and cost effective in 32.1% of simulations. Thus, microsurgical reconstruction was the economically sound technique in 57.5% of scenarios.CONCLUSION: Free fascial flap reconstruction of complex hand wounds was marginally more expensive than synthetic dermal matrix and yielded incrementally better outcomes. Both dermal matrix and microsurgical techniques were cost effective in the base case and in sensitivity analysis. In choosing between dermal matrix and microsurgical reconstruction of complex hand wounds, neither technique has a clear economic advantage.

    View details for DOI 10.1055/s-0040-1722761

    View details for PubMedID 33486748

  • Exploring provider- and practice-level drivers of cost-consciousness in breast cancer reconstruction-secondary analysis of a survey of the American Society of Plastic Surgeons. Breast cancer research and treatment Sheckter, C. C., Aliu, O., Bailey, C., Liu, J., Selber, J. C., Butler, C. E., Offodile Ii, A. C. 2021


    BACKGROUND: The role of physicians in dampening health care costs is a renewed focus of policy-makers. We examined provider- and practice-level factors affecting four domains of cost-consciousness among plastic surgeons performing breast reconstruction.METHODS: Secondary analysis was performed on the survey responses of 329 surgeons who routinely performed breast reconstruction. Using a 5-point Likert scale, we queried four domains of cost-consciousness: out-of-pocket cost awareness, cost discussions, cognizance of patients' financial burden, and attitudes regarding cost discussions. Multivariable linear regression was performed to identify provider- and practice-level factors affecting these domains according to composite scores.RESULTS: Overall cost-consciousness scores (CS) were moderate and ranged from 2.14 to 4.30. There were no significant differences across practice settings. Male gender (p=0.048), Hispanic ethnicity (p=0.021), and increasing clinical experience (p=0.015) were associated with higher out-of-pocket cost awareness. Increasing surgeon experience was also associated with having cost discussions (p=0.039). No provider- or practice-level factors were associated with cognizance of patients' financial burden. Salaried physicians displayed a more positive attitude toward out-of-pocket cost discussions (p=0.049). On pairwise testing, the out-of-pocket cost awareness was significantly different between Hispanic surgeons and white surgeons (4.30 vs. 3.55), and between surgeons with more than 20 years' experience and with less than 5 years' experience (3.87 vs. 3.37).CONCLUSIONS: Surgeon gender, ethnicity, and experience and practice compensation type inform various domains of cost-consciousness in breast reconstruction. Structural and behavioral interventions could possibly increase physicians' cost-consciousness.

    View details for DOI 10.1007/s10549-020-06085-4

    View details for PubMedID 33464457

  • System-Level Determinants of Access to Flap Reconstruction after Abdominoperineal Resection. Plastic and reconstructive surgery Dayani, F., Sheckter, C. C., Rochlin, D. H., Nazerali, R. S. 2021


    Reconstruction following abdominoperineal resection improves outcomes by reducing wound-related complications, particularly in irradiated patients. Little is known regarding system-level factors that impact patients' access to reconstructive surgery following abdominoperineal resection. This study aimed to identify barriers to undergoing reconstruction following abdominoperineal resection.Using the National Inpatient Sample database from 2012 to 2014, all encounters with colorectal or anorectal carcinoma patients who underwent abdominoperineal resection were extracted based on International Classification of Disease, Ninth Revision, diagnosis and procedure codes. Multivariable logistic regression analyzed the outcome of undergoing reconstruction.The weighted sample included encounters with 19,205 abdominoperineal resection patients, of whom 1243 (6.5 percent) received a flap. Notable patient-level predictors of receiving a flap included age younger than 55 years (OR, 1.82; 95 percent CI,1.23 to 2.74; p = 0.003) and neoadjuvant chemoradiation therapy (OR, 1.37; 95 percent CI, 1.01 to 1.88; p = 0.041). Race, sex, income level, insurance type, and Elixhauser Comorbidity Index were not associated with increased odds of receiving a flap. For facility-level factors, urban teaching hospitals (OR, 23.6; 95 percent CI, 3.29 to 169.4; p = 0.002) and larger hospital bedsize (OR, 2.64; 95 percent CI, 1.53 to 4.56; p = 0.000) were associated with higher odds of reconstruction. Plastic surgery facility volume was not found to be a significant predictor of undergoing flap reconstruction (p > 0.05).Patients undergoing abdominoperineal resection at academic centers were over 23 times more likely to undergo reconstruction, after adjusting for available confounders. Patients undergoing abdominoperineal resection at smaller, nonacademic centers may not have equitable access to reconstruction despite being appropriate candidates. Given the morbidity of abdominoperineal resection, patients should be referred to large, academic centers to have access to flap reconstruction.Risk, III.

    View details for DOI 10.1097/PRS.0000000000008661

    View details for PubMedID 34813526

  • Homeless Tent Fires: A Descriptive Analysis of Tent Fires in the Homeless Population. Journal of burn care & research : official publication of the American Burn Association Huang, S., Choi, K. J., Pham, C. H., Collier, Z. J., Dang, J. M., Kiwanuka, H., Sheckter, C. C., Yenikomshian, H. A., Gillenwater, T. J. 2021


    Tent fires are a growing issue in regions with large homeless populations given the rise in homelessness within the US and existing data that suggest worse outcomes in this population. The aim of this study is to describe the characteristics and outcomes of tent fire burn injuries in the homeless population. A retrospective review was conducted involving two verified regional burn centers with patients admitted for tent fire burns between January 2015 and December 2020. Variables recorded include demographics, injury characteristics, hospital course, and patient outcomes. Sixty-nine patients met the study inclusion criteria. The most common mechanisms of injury were by portable stove accident, assault, and tobacco or methamphetamine-related. Median percent total body surface area (%TBSA) burned was 6% (IQR 9%). Maximum depth of injury was partial thickness in 65% (n=45) and full thickness in 35% (n=24) of patients. Burns to the upper and lower extremities were present in 87% and 54% of patients, respectively. Median hospital Length-of-Stay (LOS) was 10 days (IQR=10.5) and median ICU LOS was 1 day (IQR=5). Inhalation injury was present in 14% (n=10) of patients. Surgical intervention was required in 43% (n=30) of patients, which included excision, debridement, skin grafting, and escharotomy. In-hospital mortality occurred in 4% (n=3) of patients. Tent fire burns are severe enough to require inpatient and ICU level of care. A high proportion of injuries involved the extremities and pose significant barriers to functional recovery in this vulnerable population. Strategies to prevent these injuries are paramount.

    View details for DOI 10.1093/jbcr/irab095

    View details for PubMedID 34058010

  • The Impact of Plastic Surgery Volume on Inpatient Burn Outcomes. Plastic and reconstructive surgery Perrault, D. P., Rochlin, D. H., Gillenwater, T. J., Karanas, Y. L., Sheckter, C. C. 2021; 148 (6): 1001e-1006e


    Acute burn care involves multiple types of physicians. Plastic surgery offers the full spectrum of acute burn care and reconstructive surgery. The authors hypothesize that access to plastic surgery will be associated with improved inpatient outcomes in the treatment of acute burns.Acute burn encounters with known percentage total body surface area were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Edition, codes. Plastic surgery volume per facility was determined based on procedure codes for flaps, breast reconstruction, and complex hand reconstruction. Outcomes included odds of receiving a flap, patient safety indicators, and mortality. Regression models included the following variables: age, percentage total body surface area, gender, inhalation injury, comorbidities, hospital size, and urban/teaching status of hospital.The weighted sample included 99,510 burn admissions with a mean percentage total body surface area of 15.5 percent. The weighted median plastic surgery volume by facility was 245 cases per year. Compared with the lowest quartile, the upper three quartiles of plastic surgery volume were associated with increased likelihood of undergoing flap procedures (p < 0.03). The top quartile of plastic surgery volume was also associated with decreased odds of patient safety indicator events (p < 0.001). Plastic surgery facility volume was not significantly associated with a difference in the likelihood of inpatient death.Burn encounters treated at high-volume plastic surgery facilities were more likely to undergo flap operations. High-volume plastic surgery centers were also associated with a lower likelihood of inpatient complications. Therefore, where feasible, acute burn patients should be triaged to high-volume centers.Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000008573

    View details for PubMedID 34847127

  • Separating Fact From Fiction: A Nationwide Longitudinal Examination of Complex Regional Pain Syndrome Following Treatment of Dupuytren Contracture. Hand (New York, N.Y.) Rochlin, D. H., Sheckter, C. C., Satteson, E. S., Swan, C. C., Fox, P. M., Curtin, C. 2020: 1558944720963915


    BACKGROUND: One of the most feared complications following treatment of Dupuytren contracture is complex regional pain syndrome (CRPS). This study aims to provide a national perspective on the incidence of CRPS following treatment of Dupuytren contracture and identify patient factors to target for risk reduction.METHODS: Using the Truven MarketScan databases from 2007 to 2016, individuals aged ≥18 years who developed CRPS within 1 year of treatment of Dupuytren contracture were identified using the International Classification of Disease diagnosis code for CRPS. Predictor variables included: age, sex, employment status, region, type of procedure, and concurrent carpal tunnel surgery. Multivariable logistic regression was used to analyze outcomes.RESULTS: In all, 48327 patients received treatment for Dupuytren contracture, including collagenase injection (13.6%); percutaneous palmar fasciotomy (10.3%); open palmar fasciotomy (3.9%); palmar fasciectomy with 0 (10.8%), 1 (29.2%), or multiple (19.6%) digit releases; or a combination of these procedures (12.8%). One hundred forty-five patients (0.31%) were diagnosed with CRPS at a mean of 3.4 months (standard deviation, 2.3) following treatment. Significant predictors of CRPS included female sex (odds ratio [OR], 2.02; P < .001), Southern region (OR, 1.80; P = .022), long-term disability status (OR, 4.73; P = .035), palmar fasciectomy with release of 1 (OR, 5.91; P = .003) or >1 digit (OR, 13.32; P < .001), or multiple concurrent procedures for Dupuytren contracture (OR, 8.23; P = .001).CONCLUSIONS: Based on national commercial claims data, there is a lower incidence of CRPS following treatment of Dupuytren contracture than previously reported. Risk factors identified should help with preoperative counseling and assist clinicians in targeting risk reduction measures.

    View details for DOI 10.1177/1558944720963915

    View details for PubMedID 33081519

  • Nationwide Perioperative Analysis of Endoscopic Versus Open Surgery for Craniosynostosis: Equal Access, Unequal Outcomes. The Journal of craniofacial surgery Rochlin, D. H., Sheckter, C. C., Lorenz, H. P., Khosla, R. K. 2020


    The purpose of this study is to evaluate national differences in inpatient outcomes and predictors of treatment type for endoscopic versus open surgery for craniosynostosis, with particular consideration of racial, socioeconomic, and geographic factors. The 2016 Kids' Inpatient Database was queried to identify patients aged 3 years or younger who underwent craniectomy for craniosynostosis. Multivariable regression modeled treatment type based on patient-level (gender, race, income, comorbidities, payer) and facility-level (bed size, region, teaching status) variables, and was used to assess outcomes. The weighted sample included 474 patients, of whom 81.9% (N = 388) of patients underwent open repair and 18.1% (N = 86) underwent endoscopic repair. A total of 81.1% of patients were under 1 year of age and 12.0% were syndromic. Patients were more likely to be treated open if they were older (odds ratio [OR] 3.07, P = 0.005) or syndromic (OR 8.56, P = 0.029). Patients who underwent open repair were more likely to receive transfusions (OR 2.86, P = 0.021), and have longer lengths of stay (OR 1.02, P < 0.001) and more costly hospitalizations (OR 5228.78, P = 0.018). Complications did not significantly vary between procedure type. The authors conclude that United States national data confirm benefits of endoscopic surgery, including a lower risk of transfusion, shorter hospital stay, and lower hospital costs, without a significant change in the rate of inpatient complications. Racial, socioeconomic, and geographic factors were not significantly associated with treatment type or perioperative surgical outcomes. Future studies are needed to further investigate the influence of such variables on access to craniofacial care.

    View details for DOI 10.1097/SCS.0000000000007178

    View details for PubMedID 33055558

  • Adult Cranioplasty and Perioperative Patient Safety: Does Plastic Surgery Facility Volume Matter? The Journal of craniofacial surgery Rochlin, D. H., Sheckter, C. C., Khosla, R. K., Lorenz, H. P. 2020


    Cranioplasty lies at the intersection of neurosurgery and plastic surgery, though little is known about the impact of plastic surgery involvement. The authors hypothesized that adult cranioplasty patients at higher volume plastic surgery facilities would have improved inpatient outcomes. Adult cranioplasty encounters were extracted from the National Inpatient Sample from 2012 to 2014 based on International Classification of Diseases, Ninth Revision (ICD-9) codes. Regression models included the following variables: age, gender, race/ethnicity, Elixhauser Comorbidity Index, payer, hospital size, region, and urban/teaching status. Outcomes included odds of receiving a flap, perioperative patient safety indicators, and mortality. The weighted sample included 49,305 encounters with diagnoses of neoplasm (31.2%), trauma (56.4%), infection (5.2%), a combination of these diagnoses (3.9%), or other diagnoses (3.2%). There were 1375 inpatient mortalities, of which 10 (0.7%) underwent a flap procedure. On multivariable regression, higher volume plastic surgery facilities and all diagnoses except uncertain neoplasm were associated with an increased likelihood of a flap procedure during the admission for cranioplasty, using benign neoplasm as a reference (P < 0.001). Plastic surgery facility volume was not significantly associated with likelihood of a patient safety indicator event. The highest volume plastic surgery quartile was associated with lower likelihood of inpatient mortality (P = 0.008). These findings support plastic surgery involvement in adult cranioplasty and suggest that these patients are best served at high volume plastic surgery facilities.

    View details for DOI 10.1097/SCS.0000000000007177

    View details for PubMedID 33055559

  • Hospital Volume and Type Is Associated with Flap Reconstruction after Abdominoperineal Resection Dayani, F., Sheckter, C., Nazerali, R. ELSEVIER SCIENCE INC. 2020: S226
  • Evaluation of Patient-Reported Outcomes in Burn Survivors Undergoing Reconstructive Surgery in the Rehabilitative Period. Plastic and reconstructive surgery Sheckter, C. C., Carrougher, G. J., McMullen, K., Bamer, A., Friedstat, J., Pham, T. N., Gibran, N. S. 2020; 146 (1): 171–82


    BACKGROUND: Health-related quality of life is decreased in burn survivors, with scars implicated as a cause. The authors aim to characterize the use of reconstructive surgery following hospitalization and determine whether patient-reported outcomes change over time. The authors hypothesized improvement in health-related quality of life following reconstructive surgery.METHODS: Adult burn survivors undergoing reconstructive surgery within 24 months after injury were extracted from a prospective, longitudinal database from 5 U.S. burn centers (Burn Model System). Surgery was classified by problem as follows: scar, contracture, and open wound. The authors evaluated predictors of surgery using logistic regression. Short Form-12/Veterans RAND 12 health survey outcomes at 6, 12, and 24 months were compared at follow-up intervals and matched with nonoperated participants using propensity score matching.RESULTS: Three hundred seventy-two of 1359 participants (27.4 percent) underwent one or more reconstructive operation within 24 months of injury. Factors that increased the likelihood of surgery included number of operations during index hospitalization (p < 0.001), hand (p = 0.001) and perineal involvement (p = 0.042), and range-of-motion limitation at discharge (p < 0.001). Compared to the physical component scores of peers who were not operated on, physical component scores increased for participants undergoing scar operations; however, these gains were only significant for those undergoing surgery more than 6 months after injury (p < 0.05). Matched physical component scores showed nonsignificant differences following contracture operations. Mental component scores were unchanged or lower following scar and contracture surgery.CONCLUSIONS: Participants requiring more operations during index admission were more likely to undergo reconstructive surgery. There were improvements in Short Form-12/Veterans RAND 12 scores for those undergoing scar operations more than 6 months after injury, although contracture operations were not associated with significant differences in Short Form-12/Veterans RAND 12 scores.

    View details for DOI 10.1097/PRS.0000000000006909

    View details for PubMedID 32590661

  • Surprise Billing in Surgical Care Episodes - Overview, Ethical Concerns, and Policy Solutions in Light of COVID-19. Annals of surgery Sheckter, C. C., Singh, P., Angelos, P., Ii, A. C. 2020

    View details for DOI 10.1097/SLA.0000000000004152

    View details for PubMedID 32520741

  • The Impact of Comorbid Conditions on Long-Term Patient-Reported Outcomes From Burn Survivors. Journal of burn care & research : official publication of the American Burn Association Sheckter, C. C., Li, K., Carrougher, G. J., Pham, T. N., Gibran, N. S., Stewart, B. T. 2020


    Preburn comorbidities increase the risk of death in the acute phase, and negatively impact quality of life among survivors. Investigations to date have only evaluated comorbidities as indices, limiting the ability to target conditions and develop strategies for risk reduction. Therefore, we aimed to evaluate the differential effects of specific conditions on long-term, patient-reported outcomes after burn injury. A prospectively maintained trauma registry was merged with a longitudinal database of patient-reported outcomes from a regional burn center from 2007 to 2018. Demographic data, injury-specific information, and the prevalence of 20 comorbidities were systematically documented. The impact of comorbidities on responses to Short Form-12/Veterans RAND 12 (SF/VR-12) health surveys at 6, 12, and 24 months postinjury was evaluated with generalized linear models. The merged dataset included 493 adult participants. Median age was 46 years (interquartile range, IQR 32-57 years), and 72% were male. Median burn size was 14% TBSA (IQR 5-28%). Seventy percent of participants had ≥1 comorbidity (median 1 comorbidity/participant; IQR 0-2 comorbidities). SF/VR-12 mental component summary scores at 6 and 12 months postinjury were negatively associated with mental illness (P < .001, P = .013). SF/VR-12 physical component summary (PCS) scores were negatively associated with smoking (P = .019), diabetes (P = .001), and alcohol use disorder (P = .001) at 6-month follow-up. Twelve-month SF/VR-12 PCS scores were negatively associated with prior trauma admission (P = .001) and diabetes (P = .042). Twenty-four-month SF/VR-12 PCS scores were negatively associated with mental illness (P = .003). Smoking, alcohol use disorder, and diabetes were associated with lower PCS scores 6 months after injury; diabetes persisted as a negatively associated covariate at 12 months. Mental component summary scores were negatively associated with mental illness 6 and 12 months postinjury. Integrated models of postdischarge comorbidity management need to be tested in burn patients.

    View details for DOI 10.1093/jbcr/iraa090

    View details for PubMedID 32582952

  • "Venous Thromboembolism Following Microsurgical Breast Reconstruction: A Longitudinal Analysis of 12,778 Patients". Plastic and reconstructive surgery Rochlin, D. H., Sheckter, C. C., Pannucci, C., Momeni, A. 2020


    BACKGROUND: Venous thromboembolism (VTE) is a dreaded complication following microsurgical breast reconstruction. While the high-risk nature of the procedure is well-known, a thorough analysis of modifiable risk factors has not been performed. The purpose of this study is to analyze the association of such factors with the postoperative occurrence of VTE longitudinally.METHODS: Using the Truven MarketScan Database, a retrospective cohort study of women who underwent microsurgical breast reconstruction from 2007-2015 and who developed postoperative VTE within 90 days of reconstruction was performed. Predictor variables included: age, timing of reconstruction, body mass index, history of radiation, history of VTE, Elixhauser comorbidity score, and length of stay (LOS). Univariate analyses were performed, in addition to logistic and zero-inflated Poisson regressions to evaluate predictors of VTE and changes in VTE over the study period, respectively.RESULTS: 12,778 women were identified, of which 167 (1.3%) developed VTE. The majority of VTEs (67.1%) occurred post-discharge with no significant change from 2007-2015. Significant predictors of VTE included Elixhauser score (p<0.01), history of VTE (p<0.03), and LOS (p<0.001). Compared to patients who developed a VTE during the inpatient stay, patients who developed a post-discharge VTE had a lower mean Elixhauser score (p<0.001).CONCLUSIONS: Postoperative VTE continues to be an inadequately addressed problem as evidenced by a stable incidence over the study period. Identification of modifiable risk factors, such as LOS, provide potential avenues for intervention. As the majority of VTEs occur post-discharge, future studies are warranted to investigate the role for an intervention in this period.

    View details for DOI 10.1097/PRS.0000000000007051

    View details for PubMedID 32453267

  • European Attitudes and Outcomes Regarding Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Multinational Survey. Aesthetic plastic surgery Villarroya-Marquina, I., Moshrefi, S., Sheckter, C., Lee, G. K. 2020


    BACKGROUND: Breast implants have been related to breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). While some research has been conducted to study BIA-ALCL incidence, little is known regarding surgeon concern about the disease.OBJECTIVES: This study aims to determine surgeon concern about BIA-ALCL within the European plastic surgeon community as related to their practice of breast plastic surgery.METHODS: A 27-question online survey was sent to 2353 members of the European Plastic Surgery Society and EURAPS. 240 surgeons responded (10.2%) from 18 different societies. Questions were related to demographics, exposure to BIA-ALCL cases, clinical practices, awareness, and concern. Univariate and multivariable analyses were used.RESULTS: Of surveyed surgeons, 8% had encountered a case of BIA-ALCL, while 73% were concerned about the disease. The rate of concern seemed to be influenced by seven of the variables studied. However, multivariate analysis demonstrated that none of the combined variables analyzed predicted concern or disclosure of the risks of BIA-ALCL to patients. Textured silicone-filled implants were implicated in the disease (56.5% of cases, P=0.005). Mentor and Polytech were the two brands involved in most of the reported cases (20% each).CONCLUSIONS: Consistent with epidemiological reports worldwide, this study confirms that BIA-ALCL is more prevalent in patients undergoing placement of textured silicone implants, the use of which was greater among surgeons not concerned about the risks of BIA-ALCL. Surgeons appear to approach their patients with similar risk disclosures regardless of practice pattern and type of breast implant used, but not regardless of their concern about the disease.LEVEL OF EVIDENCE V: 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

    View details for DOI 10.1007/s00266-020-01736-9

    View details for PubMedID 32367324

  • Discussion: Postmastectomy Breast Reconstruction: Exploring Plastic Surgeon Practice Patterns and Perspectives. Plastic and reconstructive surgery Sheckter, C. C., Disa, J. J., Matros, E. 2020; 145 (4): 877–78

    View details for DOI 10.1097/PRS.0000000000006628

    View details for PubMedID 32221192

  • Burns: modified metabolism and the nuances of nutrition therapy. Journal of wound care Houschyar, M., Borrelli, M. R., Tapking, C., Maan, Z. N., Rein, S., Chelliah, M. P., Sheckter, C. C., Duscher, D., Branski, L. K., Wallner, C., Behr, B., Lehnhardt, M., Siemers, F., Houschyar, K. S. 2020; 29 (3): 184–91


    OBJECTIVE: To review the effects of burn injury on nutritional requirements and how this can best be supported in a healthcare setting.METHOD: A literature search for articles discussing nutrition and/or metabolism following burn injury was carried out. PubMed, Embase and Web of Science databases were searched using the key search terms 'nutrition' OR 'metabolism' AND 'burn injury' OR 'burns'. There was no limitation on the year of publication.RESULTS: A total of nine articles met the inclusion criteria, the contents of which are discussed in this manuscript.CONCLUSION: Thermal injury elicits the greatest metabolic response, among all traumatic events, in critically ill patients. In order to ensure burn patients can meet the demands of their increased metabolic rate and energy expenditure, adequate nutritional support is essential. Burn injury results in a unique pathophysiology, involving alterations in endocrine, inflammatory, metabolic and immune pathways and nutritional support needed during the inpatient stay varies depending on burn severity and idiosyncratic patient physiologic parameters.

    View details for DOI 10.12968/jowc.2020.29.3.184

    View details for PubMedID 32160092

  • Intraoperative Laser-Assisted Indocyanine Green Imaging Can Reduce the Rate of Fat Necrosis in Microsurgical Breast Reconstruction. Plastic and reconstructive surgery Momeni, A., Sheckter, C. 2020; 145 (3): 507e–513e


    BACKGROUND: Fat necrosis following microsurgical breast reconstruction is common and problematic for patients and surgeons alike. Indocyanine green angiography provides a means of evaluating flap perfusion at the time of surgery to inform judicious excision of hypoperfused tissue. The authors hypothesized that incorporation of protocolized indocyanine green-informed flap debridement at the time of surgery would decrease the incidence of fat necrosis.METHODS: A retrospective study of two cohorts was performed evaluating patients before and after implementation of protocolized indocyanine green-guided flap excision. Variables included demographics, procedural details, and complications. Multivariable analysis was used to determine significant differences between the cohorts and evaluate for meaningful changes in fat necrosis.RESULTS: Eighty patients were included, accounting for 137 flaps. Flap type was the only significant difference between the two groups, with the indocyanine green group more likely to be deep inferior epigastric perforator flaps (43.1 percent versus 25.3 percent; p = 0.038). The overall postoperative incidence of fat necrosis was 14.6 percent (20 of 137 flaps). Comparing by cohort, the standard debridement group showed 18 of 79 flaps with fat necrosis (22.8 percent), whereas the indocyanine green-informed debridement group showed only two of 58 flaps with fat necrosis (3.4 percent; odds ratio, 0.11; 95 percent CI, 0.02 to 0.60; p = 0.011). There were no other significant differences in complication profile.CONCLUSIONS: Intraoperative use of indocyanine green angiography was associated with significantly lower odds of fat necrosis. This technology may reduce additional revision operations and improve patient satisfaction. Additional studies are needed to determine whether this innovation is cost-effective and generalizable to the entire autologous breast reconstruction population.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000006547

    View details for PubMedID 32097299

  • The rise of non-traumatic extremity compartment syndrome in light of the opioid epidemic. The American journal of emergency medicine Sheckter, C. C., Cebron, U., Suarez, P., Rochlin, D., Tedesco, D., Hernandez-Boussard, T., Curtin, C. 2020

    View details for DOI 10.1016/j.ajem.2020.01.020

    View details for PubMedID 32005410

  • The Optimal Treatment for Partial Thickness Burns: A Cost-Utility Analysis of Skin Allograft vs. Topical Silver Dressings. Journal of burn care & research : official publication of the American Burn Association Sheckter, C. C., Meyerkord, N. L., Sinskey, Y. L., Clark, P., Anderson, K., Van Vliet, M. 2020


    INTRODUCTION: Partial thickness burns not undergoing surgical excision are treated with topical silver products including silver sulfadiazine (SSD) and Mepilex Ag. Skin allograft is a more costly alternative that acts as definitive wound coverage until autogenous epithelialization. Economic constraints and the movement toward value-based care demand cost and outcome justification prior to adopting more costly products.METHODS: A cost-utility analysis was performed comparing skin allograft to SSD and Mepilex Ag using decision tree analysis. The base case modeled a superficial partial thickness 20% total body surface area burn. Utilities were derived from expert opinion on the basis of personal experience. Costs were derived from 2019 Medicare payments. Quality adjusted life years were calculated using rollback method assuming standard life expectancies in the United States. Probabilistic sensitivity analysis was performed to asses model robustness.RESULTS: The incremental costs of skin allograft to Mepilex Ag and SSD were $907.71 and $1257.86, respectively. The incremental quality adjusted life year (QALY) gains from allograft over Mepilex Ag and SSD were 0.011 and 0.016. This yielded an incremental cost-utility ratio for allograft vs. Mepilex Ag of $84,189.29/QALY compared with an incremental cost-utility ratio of $79,684.63/QALY for allograft vs. SSD. Assuming willingness-to-pay thresholds of $100,000/QALY, probabilistic sensitivity analysis demonstrated that allograft was cost effective to Mepilex Ag in 62.1% of scenarios, and cost effective to SSD in 64.9% of simulations.CONCLUSION: Skin allograft showed greater QALYs compared with topical silver dressings at a higher cost. Depending on willingness-to-pay thresholds, skin allograft may be a considered a cost-effective treatment of partial-thickness burns.

    View details for DOI 10.1093/jbcr/iraa003

    View details for PubMedID 32043154

  • Timing of Flap Surgery in Acute Burn Patients Does Not Affect Complications. Journal of burn care & research : official publication of the American Burn Association Perrault, D. n., Rochlin, D. n., Pham, C. n., Momeni, A. n., Karanas, Y. n., Sheckter, C. C. 2020


    Pedicled and free flaps are occasionally necessary to reconstruct complex wounds in acute burn patients. Flap coverage has classically been delayed for concern of progressive tissue necrosis and flap failure. We aim to investigate flap complications in primary burn care leveraging national US data.Acute burn patients with known % total body surface area(TBSA) were extracted from the Nationwide/National Inpatient Sample from 2002-2014 based on International Classification of Disease (ICD) Codes 9th edition. Variables included age, gender, race, Elixhauser index, %TBSA, mechanism, inhalation injury, and location of burn. Flap complication was defined by ICD-9 procedure code 86.75, return to OR for flap revision. Multivariable analysis evaluated predictors of flap compromise using stepwise logistic regression with backwards elimination.The weighted sample included 306,924 encounters of which 526 received a flap (0.17%). 7.8% of flap encounters sustained electric injury compared to 2.7% of non-flap encounters (OR 3.76, 95% CI 1.95-7.24, p<0.001). The mean hospital day of flap procedure was 10.1 (SD 10.7) days. Flap complications occurred in 6.4% of cases. The timing of flap coverage was not associated with complications. The only independent predictor of flap complication was electrical injury (OR 40.49, 95% OR 2.98-550.64, p=0.005).Electrical injury was an independent predictor of flap complications compared to other mechanisms. Flap timing was not associated with return to surgery for complications. This suggests that the use of flaps is safe in acute burn care to achieve burn wound closure with an understanding that electrical injuries may warrant particular consideration to avoid failure.

    View details for DOI 10.1093/jbcr/iraa096

    View details for PubMedID 32582915

  • Current and Emerging Topical Scar Mitigation Therapies for Craniofacial Burn Wound Healing. Frontiers in physiology Kwon, S. H., Barrera, J. A., Noishiki, C. n., Chen, K. n., Henn, D. n., Sheckter, C. C., Gurtner, G. C. 2020; 11: 916


    Burn injury in the craniofacial region causes significant health and psychosocial consequences and presents unique reconstructive challenges. Healing of severely burned skin and underlying soft tissue is a dynamic process involving many pathophysiological factors, often leading to devastating outcomes such as the formation of hypertrophic scars and debilitating contractures. There are limited treatment options currently used for post-burn scar mitigation but recent advances in our knowledge of the cellular and molecular wound and scar pathophysiology have allowed for development of new treatment concepts. Clinical effectiveness of these experimental therapies is currently being evaluated. In this review, we discuss current topical therapies for craniofacial burn injuries and emerging new therapeutic concepts that are highly translational.

    View details for DOI 10.3389/fphys.2020.00916

    View details for PubMedID 32848859

    View details for PubMedCentralID PMC7403506

  • Prevalence of Ganglion Cyst Formation After Wrist Arthroscopy: A Retrospective Longitudinal Analysis of 2420 Patients. Hand (New York, N.Y.) Rochlin, D. H., Perrault, D. n., Sheckter, C. C., Fox, P. n., Yao, J. n. 2020: 1558944720939203


    Dorsal wrist ganglion cysts arise from the leakage of synovial fluid through tears in the scapholunate ligament and/or dorsal wrist capsule. An analogous disruption of the dorsal capsule is created with routine portal placement during wrist arthroscopy. We hypothesized that wrist arthroscopy would predispose to wrist ganglions.Using the Truven MarketScan Outpatient Services Database from 2015 to 2016, patients who underwent wrist arthroscopy and developed an ipsilateral wrist ganglion were identified. Exclusion criteria included ganglion diagnosis preceding arthroscopy and bilateral pathology. Postoperative ganglion diagnosis was modeled with logistic regression. Predictor variables included age, gender, comorbidities, and arthroscopic procedure.In all, 2420 patients underwent wrist arthroscopy. Thirty (1.24%) were diagnosed with an ipsilateral wrist ganglion at a mean time of 4.0 months (standard deviation: 2.4, range: 0.2-9.0). Significant predictors of ganglion diagnosis included female gender (odds ratio [OR]: 4.0, P < .01) and triangular fibrocartilage complex and/or joint debridement (OR: 0.13, P < .01). By comparison, among all 24,718,751 outpatients who had not undergone wrist arthroscopy, 39,832 patients had a diagnosis of a wrist ganglion cyst (0.16%).Wrist arthroscopy is associated with a postoperative rate of ganglion cyst formation that is nearly 8 times the rate in the general population. Additional studies are needed to investigate techniques that minimize the risk of this complication.

    View details for DOI 10.1177/1558944720939203

    View details for PubMedID 32935572

  • Hand Burns HANDBOOK OF BURNS VOL 1: ACUTE BURN CARE, 2ND EDITION Sheckter, C. C., Klein, M. B., Jeschke, M. G., Kamolz, L. P., Sjoberg, F., Wolf, S. E. 2020: 465–73
  • Surgical Treatment of Osteonecrosis of the Jaw: An Emerging Problem in the Era of Bisphosphonates. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons Hung, K. S., Sheckter, C. C., Gaudilliere, D. n., Suarez, P. n., Curtin, C. n. 2020

    View details for DOI 10.1016/j.joms.2019.12.018

    View details for PubMedID 32004467

  • Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis. Plastic and reconstructive surgery Panchal, H. n., Shamsunder, M. G., Sheinin, A. n., Sheckter, C. C., Berlin, N. L., Nelson, J. A., Allen, R. n., Rubin, D. n., Kozlow, J. H., Matros, E. n. 2020; 145 (2): 333–39


    Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction.The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality.Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001).Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques.Risk, II.

    View details for DOI 10.1097/PRS.0000000000006453

    View details for PubMedID 31985616

  • The association of burn patient volume with patient safety indicators and mortalityin the US. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Pham, C., Rochlin, D., Maan, Z. N., Karanas, Y., Curtin, C. 2019


    INTRODUCTION: Clinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes.METHODS: All burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002-2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models.RESULTS: Of the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99-0.99, p<0.001) and PSIs (OR 0.99, 95% CI 0.99-0.99, p=0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p<0.05).CONCLUSION: There was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

    View details for DOI 10.1016/j.burns.2019.11.009

    View details for PubMedID 31843281

  • Homelessness and Inpatient Burn Outcomes in the United States JOURNAL OF BURN CARE & RESEARCH Kiwanuka, H., Maan, Z. N., Rochlin, D., Curtin, C., Karanas, Y., Sheckter, C. C. 2019; 40 (5): 633–38
  • Variations in access to specialty care for children with severe burns. The American journal of emergency medicine Ewbank, C., Sheckter, C. C., Warstadt, N. M., Pirrotta, E. A., Curtin, C., Newton, C., Wang, N. E. 2019: 158401


    BACKGROUND: Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access.METHODS: Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not.RESULTS: Of 54,529 patients meeting criteria, 82.0% (n = 44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7 years old; p < 0.0001) and more likely to have burn injuries on multiple body regions (88% versus 12%; p < 0.0001). In urban areas, 84% of care was provided at burn centers versus 0% in rural areas (p < 0.0001), a difference attributable to the lack of burn centers in rural areas. Both length of stay and number of procedures were significantly higher for patients treated at burn centers (7.3 versus 4.4 days, p < 0.0001 and 2.3 versus 1.1 procedures, p < 0.0001; respectively). There were no significant differences in mortality (0.7% versus 0.8%, p = 0.692).CONCLUSION: The majority of children who met criteria were treated at burn centers. There was no significant difference between geographical regions. Of those who were treated at burn centers, more severe injury patterns were noted, but there was no significant mortality difference. Further study of optimal referral of pediatric burn patients is needed.

    View details for DOI 10.1016/j.ajem.2019.158401

    View details for PubMedID 31474377

  • Is Bigger Better?: The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction. Annals of surgery Cerullo, M., Sheckter, C. C., Canner, J. K., Rogers, S. O., Offodile, A. C. 2019


    OBJECTIVES: To examine the relationship between hospital market competition and inpatient costs, procedural markup, inpatient complications, and length of stay among privately insured patients undergoing immediate reconstruction after mastectomy.METHODS: A retrospective cross-sectional analysis of privately insured female patients undergoing immediate breast reconstruction in the 2009 to 2011 Nationwide Inpatient Sample was performed. The Herfindahl-Hirschman index was used to describe hospital market competition; associations with outcomes were explored via hierarchical models adjusting for patient, hospital, and market characteristics.RESULTS: A weighted total of 42,411 patients were identified; 5920 (14.0%) underwent free flap reconstruction. In uncompetitive markets, 6.8% (n=857) underwent free flap reconstruction, compared with 13.6% (n=2773) in highly competitive markets and 24.6% (n=2290) in moderately competitive markets. For every 5 additional hospitals in a market, adjusted costs were 6.6% higher (95% CI: 2.8%-10.5%), for free flap reconstruction, and 5.1% higher (95% CI: 2.0%-8.4%) for nonfree flap reconstruction. Similarly, higher procedural markup was associated with increased hospital market competition both for nonfree flap reconstruction (5.5% increase, 95% CI: 1.1%-10.1%) and for free flap reconstruction (8.2% increase, 95% CI: 1.8%-15.0%). Notably, there was no association between incidence of inpatient complications or extended length of stay and hospital market competition among either free flap or nonfree flap reconstruction patients.CONCLUSIONS: Decreasing market competition was associated with lower inpatient costs and equivocal clinical outcomes. This suggests that some of the economies of scale, access to capital and care delivery efficiencies gained from increased market power following hospital mergers are passed onto payers and consumers as lower costs.

    View details for DOI 10.1097/SLA.0000000000003481

    View details for PubMedID 31356269

  • Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction. Plastic and reconstructive surgery. Global open Miller, T. J., Sheckter, C. C., Barnes, L. A., Li, A. Y., Momeni, A. 2019; 7 (7): e2343


    Abdominoperineal resection (APR) carries a high risk of morbidity. Preoperative risk assessment can help with patient counseling, minimize adverse outcomes, and guide surgeons in their choice of reconstruction. This study examined the impact of sarcopenia (low lean muscle mass) on postoperative complications after APR.One hundred seventy-eight patients who underwent APR between May 2000 and July 2017 were retrospectively analyzed. Sarcopenia was identified on preoperative computed tomography scans using the Hounsfield Unit Average Calculation. Two cohorts were compared (group 1: primary perineal closure; group 2: flap-based perineal reconstruction). Multivariable analysis evaluated predictors of complications.Sarcopenia was an independent risk factor for postoperative surgical site infection in patients undergoing APR (odds ratio [OR] = 2.9, P = 0.04). The risk for sarcopenic patients who underwent flap-based perineal reconstruction was even higher (OR = 8.9, P < 0.01). Male sex was also found to be a risk factor for infection (OR = 3.5, P < 0.01). Perineal flap-based reconstruction was a risk factor for delayed wound healing (OR = 3.2, P < 0.01).Sarcopenia was an independent risk factor for infection in patients undergoing APR. This risk was even greater in patients undergoing flap-based perineal reconstruction. Sarcopenia can be identified on preoperative imaging and inform surgeons on risk stratification and surgical plan.

    View details for DOI 10.1097/GOX.0000000000002343

    View details for PubMedID 31942365

    View details for PubMedCentralID PMC6952152

  • Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Miller, T. J., Sheckter, C. C., Barnes, L. A., Li, A. Y., Momeni, A. 2019; 7 (7)
  • Reply: The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Goverman, J. 2019

    View details for DOI 10.1016/j.burns.2019.03.024

    View details for PubMedID 31176510

  • Optimising management of self-inflicted burns: a retrospective review. Journal of wound care Houschyar, K. S., Tapking, C., Duscher, D., Maan, Z. N., Sheckter, C. C., Rein, S., Chelliah, M. P., Nietzschmann, I., Weissenberg, K., Reumuth, G., Schulz, T., Branski, L. K., Siemers, F. 2019; 28 (6): 317–22


    OBJECTIVE: Self-inflicted burns typically result in extensive injuries requiring intensive care and attention in a specialised burn unit. Burn units should be familiar with the optimal management of self-inflicted burns, including the psychological and psychiatric treatment. This paper describes the experiences of managing these challenging injuries in a German burn centre.METHODS: A retrospective review of patients with self-inflicted burns admitted to the burn centre between 2000 and 2017. Demographics, details of injury, presence of psychiatric disorder, clinical course, operative management and patient outcomes were recorded and compared with a control group without self-inflicted burns. Outcome measures included graft take rate, complications and need for further surgery.RESULTS: There were a total of 2055 burn patient admissions, with 17 cases (0.8%) of self-inflicted burns. The mean age was 36±11 years with an mean percentage total body surface area (%TBSA) burned of 43.5±22.5% which was not significantly different from the control group (p=0.184). Schizophrenia and personality disorder were the most common diagnoses in the self-inflicted burns patients (n=11; 65%). Of these, four had sustained previous self-inflicted burns. Length of hospital stay was significantly longer in the self-inflicted burn group than in the control group (49.0±16.7 days, respectively, p=0.002).CONCLUSION: Attempted suicide by self-inflicted burns represents <1% of burn admissions. This population demonstrates a high incidence of prior psychiatric disorders. Successful treatment includes multidisciplinary management of acute medical, surgical, and psychiatric care.

    View details for DOI 10.12968/jowc.2019.28.6.317

    View details for PubMedID 31166860

  • The Pushback Pharyngeal Flap: An 18-Year Experience. Plastic and reconstructive surgery Rochlin, D. H., Mittermiller, P. A., Sheckter, C. C., Menard, R. M. 2019; 143 (6): 1246e–1254e


    BACKGROUND: The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism.METHODS: A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa.RESULTS: There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001).CONCLUSIONS: The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

    View details for DOI 10.1097/PRS.0000000000005645

    View details for PubMedID 31136490

  • Reply: The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Matros, E. 2019; 143 (6): 1312E–1313E
  • Applying a value-based care framework to post-mastectomy reconstruction BREAST CANCER RESEARCH AND TREATMENT Sheckter, C. C., Matros, E., Lee, G. K., Selber, J. C., Offodile, A. C. 2019; 175 (3): 547–51
  • Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury. Journal of burn care & research : official publication of the American Burn Association Moshrefi, S., Sheckter, C. C., Shepard, K., Pereira, C., Davis, D. J., Karanas, Y., Rochlin, D. H. 2019; 40 (3): 341–46


    The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

    View details for DOI 10.1093/jbcr/irz016

    View details for PubMedID 31222272

  • Homelessness and Inpatient Burn Outcomes in the United States. Journal of burn care & research : official publication of the American Burn Association Kiwanuka, H., Maan, Z., Rochlin, D., Curtin, C., Karanas, Y., Sheckter, C. C. 2019


    INTRODUCTION: Burn injuries are common in the homeless population. Little is known regarding whether homeless patients experience different outcomes when admitted for burns. We aim to 1) characterize the admitted homeless burn population, and 2) investigate differences in inpatient outcomes between the homeless and non-homeless populations.METHODS: A retrospective cohort study was performed utilizing the Nationwide Inpatient Sample. Adult patients with complete data for burn characteristics were extracted. Variables included demographic, burn, and facility characteristics. Homelessness was identified with International Classification of Disease 9th edition codes. Outcomes were modeled with regression analysis and included length of stay, total operations, charges, disposition, and patient safety indicators.RESULTS: 43,872 encounters were included of which 0.76% were homeless. Homeless encounters were more likely to be male (p<0.001) and Medicaid-insured (p<0.001). Flame and frostbite injuries were more likely (p<0.001), and the mean %TBSA was smaller (15.0 versus 16.8, p<0.001). After adjustment, homeless patients had greater lengths of stay (11.5 vs. 9.6, p=0.046), greater charges ($73,597 vs. $66,909, p=0.030), fewer operations (p=0.016), and three times higher likelihood leaving against medical advice (p=0.002). There was no difference in patient safety indicators or mortality.CONCLUSION: Homeless burn admissions represent a unique cohort that carries a higher comorbidity burden and experiences longer lengths of stay with greater difficulty in disposition. Ironically, these patients accumulate more charges with limited means to pay. Even though no differences were observed in patient safety indicators or mortality, further research is needed to understand how the challenges within this population affect their recovery.

    View details for PubMedID 30938433

  • Which Stitch? Replacing Anecdote with Evidence in Minor Hand Surgery. Plastic and reconstructive surgery. Global open Rochlin, D. H., Sheckter, C. C., Curtin, C. M. 2019; 7 (4): e2189


    There is currently no consensus on the optimal suture type for palmar skin closure following open carpal tunnel release and trigger finger release. We performed a retrospective analysis of patients in the Palo Alto Veterans Affairs (PAVA) Health Care System who underwent these procedures over a 2-year period to compare 30-day wound outcomes following closure with poliglecaprone 25 (Monocryl), nylon, and chromic gut suture. Out of 312 PAVA cases (133 carpal tunnel release, 179 trigger finger release), incisions closed with Monocryl were significantly less likely to develop dehiscence (Monocryl 2.1%, nylon 10.5%, chromic 10.3%; P = 0.006) and infection (Monocryl 1.6%, nylon 7.4%, chromic 13.8%; P = 0.003), or lead to additional wound-related encounters (Monocryl 8.0%, nylon 16.8%, chromic 24.1%; P = 0.012). On multivariable logistic regression, suture type and diabetes were independent predictors of 30-day wound complications and extra encounters. At PAVA, compared with Monocryl, closures with nylon and chromic were significantly more likely to dehisce and/or become infected [nylon: odds ratio (OR), 5.0; 95% CI, 1.9-13.3 and chromic: OR, 9.3; 95% CI, 2.7-32.4; P = 0.002], and to be associated with an additional encounter (nylon: OR, 2.4; 95% CI, 1.1-5.3 and chromic: OR, 4.5; 95% CI, 1.6-12.9; P = 0.007). This has led to using Monocryl as the standard closure for these cases at PAVA.

    View details for DOI 10.1097/GOX.0000000000002189

    View details for PubMedID 31321185

    View details for PubMedCentralID PMC6554153

  • Applying a value-based care framework to post-mastectomy reconstruction. Breast cancer research and treatment Sheckter, C. C., Matros, E., Lee, G. K., Selber, J. C., Offodile, A. C. 2019


    PURPOSE: Reconstructive breast surgeons, like all procedural care providers, face a transition from volume reimbursement (i.e., per unit of service) to value-based care. Value can be defined as the relationship between outcomes and costs, or more specifically healthcare outcomes per unit cost. Although the definition of a meaningful outcome for a particular treatment can vary, some weighted average of survival, function, complications, process measures, and patient-reported outcomes (PROs) comprise the numerator, while the total cost of a complete care cycle is the denominator. We aim to construct a value-based care framework for reconstructive surgery using post-mastectomy reconstruction as an organizing element.METHODS: A preexisting value framework was applied to breast reconstruction using expert opinion and literature review. Domains and associated realization strategies were constructed based on established health economic principles.RESULTS: Seven domains were identified including: implementing an inclusive and transparent process for stakeholder engagement, practicing clear and explicit treatment goals, anchoring care delivery to the patient perspective, maximizing value across the entire continuum of care, optimizing operation efficiency, and scaling best practices with implementation science.CONCLUSIONS: In the near future, reconstructive plastic surgeons may be asked to solve clinical problems for fixed reimbursement (i.e. bundled payments). Considering breast reconstruction through a value lens provides surgeons with an opportunity to adapt and thrive in an evolving healthcare landscape. Lastly, we hope this document helps promote value assessment within the specialty.

    View details for PubMedID 30937659

  • Which Stitch? Replacing Anecdote with Evidence in Minor Hand Surgery PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Rochlin, D. H., Sheckter, C. C., Curtin, C. M. 2019; 7 (4)
  • Reply; Reply: "The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis". Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2019

    View details for PubMedID 30907795

  • Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. ELSEVIER SCI LTD. 2019: 165–72
  • Systems Delivery Innovation for Alzheimer Disease AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY Bott, N. T., Sheckter, C. C., Yang, D., Peters, S., Brady, B., Plowman, S., Borson, S., Leff, B., Kaplan, R. M., Platchek, T., Milstein, A. 2019; 27 (2): 149–61
  • The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample BURNS Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2019; 45 (1): 146–56
  • Five Years Experience With Meek Grafting in the Management of Extensive Burns in an Adult Burn Center PLASTIC SURGERY Houschyar, K., Tapking, C., Nietzschmann, I., Rein, S., Weissenberg, K., Chelliah, M., Duscher, D., Maan, Z., Philipps, H., Sheckter, C., Reichelt, B., Branski, L., Siemers, F. 2019; 27 (1): 44–48


    In extensive burn injuries with lack of donor sites for skin grafting, the Meek technique of skin expansion can be an efficient and effective method in covering extensive wounds. The aim of this retrospective study was to present our experience with the Meek technique of grafting.We performed a retrospective analysis of patients from our burn center who underwent Meek grafting between 2012 and 2016. Demographics, burn details, clinical course, operative management, and outcomes were collected and analyzed from patient records and operative notes. Outcome measures, including graft take rate, complications and need for further surgery, were recorded.Twelve patients had Meek grafting. The average age was 38 years (range: 15-66). The average percent total body surface area burned was 54.3% (range: 31%-77%). Eighty-three percent of grafted areas healed well, and no regrafting was necessary. In the remaining 17%, infection and hematoma were the leading cause of graft failure.Meek grafting constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries with limited autograft donor sites.

    View details for PubMedID 30854361

  • Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing. Journal of the American College of Surgeons Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A., Hawn, M. 2019


    INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.

    View details for PubMedID 30660819

  • The impact of hospital volume on patient safety indicators following post-mastectomy breast reconstruction in the US. Breast cancer research and treatment Sheckter, C. C., Rochlin, D. n., Kiwanuka, H. n., Curtin, C. n., Momeni, A. n. 2019


    Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors.Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality's designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes.The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced ≥ 1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p < 0.01) and Elixhauser score ≥ 4 (p < 0.01) for the free flap group, and delayed reconstruction (p < 0.01) for the prosthetic group. Annual reconstructive facility volume was not associated with increased odds of PSIs in either prosthetic or free flap reconstruction (p > 0.05).PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.

    View details for DOI 10.1007/s10549-019-05361-2

    View details for PubMedID 31338643

  • National trends in contralateral prophylactic mastectomy in women with locally advanced breast cancer JOURNAL OF SURGICAL ONCOLOGY Panchal, H., Pilewskie, M. L., Sheckter, C. C., Albornoz, C. R., Razdan, S. N., Disa, J. J., Cordeiro, P. G., Mehrara, B. J., Matros, E. 2019; 119 (1): 79-87

    View details for DOI 10.1002/jso.25315

    View details for Web of Science ID 000452848900010

  • Discussion: A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay. Plastic and reconstructive surgery Sheckter, C. C., Matros, E. n. 2019; 144 (4): 550e–551e

    View details for DOI 10.1097/PRS.0000000000006014

    View details for PubMedID 31568279

  • Cognitive Independence In Plastic Surgery Training: the Value of Professional Development. Plastic and reconstructive surgery Sheckter, C. C., Maan, Z. N., Chang, J. n. 2019

    View details for PubMedID 31021905

  • Cognitive Independence in Plastic Surgery Training: The Value of Professional Development. Plastic and reconstructive surgery Sheckter, C. C., Maan, Z. N., Chang, J. n. 2019; 144 (1): 153e–154e

    View details for DOI 10.1097/PRS.0000000000005762

    View details for PubMedID 31246858

  • The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2018


    BACKGROUND: Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes.METHODS: Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges.RESULTS: After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001).CONCLUSIONS: Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.

    View details for PubMedID 30527451

  • Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample BURNS Sheckter, C. C., Hung, K. S., Rochlin, D., Maan, Z., Karanas, Y., Curtin, C. 2018; 44 (8): 1903–9
  • National trends in contralateral prophylactic mastectomy in women with locally advanced breast cancer. Journal of surgical oncology Panchal, H., Pilewskie, M. L., Sheckter, C. C., Albornoz, C. R., Razdan, S. N., Disa, J. J., Cordeiro, P. G., Mehrara, B. J., Matros, E. 2018


    BACKGROUND AND OBJECTIVES: Women with unilateral early-stage breast cancer are increasingly choosing contralateral prophylactic mastectomy (CPM) despite the absence of survival benefits and increased risk of surgical complications. Data are lacking on whether this trend extends to women with clinically locally advanced nonmetastatic (cT4M0) cancer. This study aims to estimate national CPM trends in women with unilateral cT4M0 breast cancer.METHODS: Women aged≥18 years, who underwent mastectomy during 2004 to 2014 for unilateral cT4M0 breast cancer were identified using the National Cancer Database and grouped as all locally advanced (T4), chest wall invasion, skin nodule/ulceration, or both (T4abc), and inflammatory (T4d) cancer. Poisson regression for trends and logistic modeling for predictors of CPM were performed.RESULTS: Of 23 943 women, 41% had T4abc disease and 35% T4d. Cumulative CPM rates were 15%, 23%, and 18%, for the T4abc, T4d, and all T4 groups, respectively. Trend analysis revealed a significant upsurge in CPM demonstrating 12% annual growth for T4abc tumors, 8% for T4d and 9% for all T4 (all P<0.001).CONCLUSIONS: Increasing numbers of women with unilateral cT4M0 breast cancer are undergoing CPM. This rising trend warrants further research to understand stakeholders' preferences in surgical decision-making for women with locally advanced breast cancer.

    View details for PubMedID 30480805

  • Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample. Plastic and reconstructive surgery Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337-1347


    The ideal timing of soft-tissue coverage for open lower extremity fractures remains controversial. Using U.S. national data, this study aims to characterize secular trends and regional variation in the timing of soft-tissue coverage.Using discharge data from the Nationwide Inpatient Sample (2002 to 2011), the authors identified 888 encounters admitted from the emergency department with isolated open lower extremity fractures treated with pedicled or free tissue transfer. Soft-tissue coverage timing was assessed by patient factors, hospital characteristics, and fracture patterns. Statistical significance and secular trends were analyzed with generalized linear models.The mean day of soft-tissue reconstruction was at 6.64 days. Over the 10-year period, the day of reconstruction increased significantly (from 6.12 days in 2002 to 12.50 days in 2011; coefficient, 0.09; 95 percent CI, 0.05 to 0.12; p < 0.001). Demographic and facility factors did not significantly impact timing. Elixhauser comorbidity scores greater than 2 were associated with later coverage (10.13 days versus 6.29 days; p = 0.001) along with multisite fractures (8.35 days; p = 0.022) and external fixators (8.78 days; p < 0.001). The U.S. Census division showed significant variation in timing ranging from 0.94 days (East North Central) to 9.84 days (Pacific).A progressive delay in the timing of soft-tissue reconstruction was noted and may be attributed to negative-pressure wound therapy. The timing of soft-tissue coverage varied by region after adjusting for patient and hospital factors. Additional studies are needed to understand the impact of delayed soft-tissue coverage on patient outcomes and health services utilization.

    View details for DOI 10.1097/PRS.0000000000004885

    View details for PubMedID 30511989

  • Single Stage Repair of #30 Facial Cleft with Bone Morphogenic Protein PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Sheckter, C. C., Mittermiller, P., Hung, K., Maan, Z., Rochlin, D., Menard, R. M. 2018; 6 (11)
  • Single Stage Repair of #30 Facial Cleft with Bone Morphogenic Protein. Plastic and reconstructive surgery. Global open Sheckter, C. C., Mittermiller, P., Hung, K., Maan, Z., Rochlin, D., Menard, R. M. 2018; 6 (11): e1937


    Tessier #30 clefts (median mandibular clefts) represent a spectrum of deformities ranging from a minor cleft in the lower lip to complete clefts of the mandible involving the tongue, lower lip, hyoid bone, thyroid cartilages, and manubrium. Various techniques have been used to address these problems; the most common procedure involving 2 stages: an initial correction of the soft tissue followed by closure of the mandibular cleft at a later date using bone grafting. This approach was subsequently reduced to a single operation, but still required harvesting of autologous bone graft. Here, we describe a modified single-stage operation using human recombinant bone morphogenic protein, avoiding bone graft harvest and allowing for simultaneous treatment of bone and soft tissue.

    View details for DOI 10.1097/GOX.0000000000001937

    View details for PubMedID 30881779

    View details for PubMedCentralID PMC6414095

  • Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337–47
  • Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2018: S228–S229
  • The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Panchal, H. J., Razdan, S. N., Rubin, D., Yi, D., Disa, J. J., Mehrara, B., Matros, E. 2018; 142 (4): 434E-442E
  • Systems Delivery Innovation for Alzheimer Disease. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry Bott, N. T., Sheckter, C. C., Yang, D., Peters, S., Brady, B., Plowman, S., Borson, S., Leff, B., Kaplan, R. M., Platchek, T., Milstein, A. 2018


    OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

    View details for PubMedID 30477913

  • Breast Reconstruction Following Breast Cancer Treatment-2018 JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Lee, G. K., Sheckter, C. C. 2018; 320 (12): 1277-1278
  • Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. 2018


    INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(<0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032).CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

    View details for PubMedID 30236815

  • Trends in Physician Payments for Breast Reconstruction (vol 141, pg 493e, 2018) PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Yi, D., Panchal, H. J., Rubin, D., Razdan, S. N., Pusic, A. L., McCarthy, C. M., Cordeiro, P. G., Disa, J. J., Mehrara, B., Matros, E. 2018; 142 (3): 833
  • Breast Reconstruction Following Breast Cancer Treatment-2018. JAMA Lee, G. K., Sheckter, C. C. 2018

    View details for PubMedID 30178060

  • Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Hung, K., Rochlin, D., Maan, Z., Karanas, Y., Curtin, C. 2018


    INTRODUCTION: Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population.METHODS: All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores.RESULTS: 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.

    View details for PubMedID 30115531

  • Overuse of Air Ambulance Services at a Regional Burn Center JOURNAL OF BURN CARE & RESEARCH Chattopadhyay, A., Sheckter, C. C., Long, C., Karanas, Y. 2018; 39 (4): 598–603
  • The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis. Plastic and reconstructive surgery Sheckter, C. C., Panchal, H. J., Razdan, S. N., Rubin, D., Yi, D., Disa, J. J., Mehrara, B., Matros, E. 2018


    INTRODUCTION: Flap-based breast reconstruction demands greater operative labor and offers superior patient reported outcomes compared to implants. However, implants continue to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments.METHODS: Using the Blue Health Intelligence database from 2009-2013, patients were identified who received tissue expander (i.e. implant) or free-flap breast reconstruction. The ratio of implants/flaps and physician payments was assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method.RESULTS: 21,259 episodes of breast reconstruction occurred within 122 U.S. markets. The distribution of implant/flap ratio varied by market, ranging from 5 percentile at 1.63 to 95 percentile at 43.7 (median 6.19). Modeling the implant/flap ratio vs. implant payment showed a more elastic quadratic equation (f(x)=0.955x + 2.766x) compared to the function for flap/implant ratio vs. flap payment (f(x)=-0.061x + 0.734x). Probability modeling demonstrated that switching the reconstructive method from implants to flaps with 0.75 probability required a $1,610 payment increase, while switching from flaps to implants at the same certainty occurred at a loss of $960.CONCLUSION: There was a correlation between the ratio of flaps/implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a revenue value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

    View details for PubMedID 29979366

  • Overuse of Air Ambulance Services at a Regional Burn Center. Journal of burn care & research : official publication of the American Burn Association Chattopadhyay, A., Sheckter, C. C., Long, C., Karanas, Y. 2018; 39 (4): 598–603


    Air ambulances rapidly transport burn patients to regional centers, expediting treatment. However, limited guidelines on transport introduce the risk for inappropriate triage and overuse. Given the additional costs of air vs ground transport, evaluation of transportation use is prudent. A retrospective review of all burn patients transported by helicopter to a single burn center from May 2013 to January 2016 was performed. Data gathered included patient demographics, transfer origin, burn characteristics, and inpatient hospital stay. The primary outcome was appropriate triage based on literature-derived severity criteria. Secondary outcomes included independent predictors of emergent treatments and the cost of overuse. Sixty-eight patients were examined, of which 66% met air ambulance criteria. Inappropriately triaged patients sustained smaller burns (% TBSA 4.8 vs 25.3, P < .001), had fewer flame burns (48 vs 82%, P = .007), had decreased lengths of stay (mean days 8.2 vs 21.2, P = .002), underwent fewer inpatient surgeries (mean 0.69 vs 2.57, P = .006), received no emergent procedures (0 vs 56%, P < .001), and suffered no deaths (0 vs 9%, P < .001). Independent predictors of emergent procedures included transport for airway concern (odds ratio = 45.29, confidence interval = 2.49-825.21, P = .010) and % TBSA (odds ratio = 1.13, confidence interval = 1.02-1.27, P = .019). If the 23 inappropriately triaged patients had been transported by ground, a cost savings of $106,370 could have been realized using 2016 California Medicare reimbursements (per-patient savings of $4624). While appropriate in most circumstances, the cost of air ambulances should be weighed in light of their utility, as a significant proportion of patients did not benefit from air transport.

    View details for PubMedID 29901800

  • To Cut is to Cure The Surgeon's Role in Improving Value ANNALS OF SURGERY Jopling, J. K., Sheckter, C. C., James, B. C. 2018; 267 (5): 817–19

    View details for PubMedID 29189380

  • Trends in Physician Payments for Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Yi, D., Panchal, H. J., Razdan, S. N., Pusic, A. L., McCarthy, C. M., Cordeiro, P. G., Disa, J. J., Mehrara, B., Matros, E. 2018; 141 (4): 493E–499E


    Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction.The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models.There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders).The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

    View details for PubMedID 29595721

    View details for PubMedCentralID PMC5880309

  • Assessing value in breast reconstruction: A systematic review of cost-effectiveness studies JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Matros, E., Momeni, A. 2018; 71 (3): 353–65


    Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models.A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017.After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer.Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

    View details for PubMedID 29196176

  • Conceptual Considerations for Payment Bundling in Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Razdan, S. N., Disa, J. J., Mehrara, B. J., Matros, E. 2018; 141 (2): 294–300


    Rising health care costs and quality demands have driven both the Centers for Medicare and Medicaid Services and the private sector to seek innovations in health system design by placing institutions at financial risk. Novel care models, such as bundled reimbursement, aim to boost value though quality improvement and cost reduction. The Center for Medicare and Medicaid Innovation is leading the charge in this area with multiple pilots and mandates, including Comprehensive Care for Joint Replacement. Other high-cost and high-volume procedures could be considered for bundling in the future, including breast reconstruction. In this article, conceptual considerations surrounding bundling of breast reconstruction are discussed.

    View details for PubMedID 29369980

  • Efficacy and Safety of Titanium Miniplates for Patients Undergoing Septorhinoplasty JAMA FACIAL PLASTIC SURGERY Mittermiller, P. A., Sheckter, C. C., Most, S. P. 2018; 20 (1): 82–84

    View details for PubMedID 29167868

  • Dementia Care, Women's Health, and Gender Equity: The Value of Well-Timed Caregiver Support. JAMA neurology Bott, N. T., Sheckter, C. C., Milstein, A. S. 2017

    View details for DOI 10.1001/jamaneurol.2017.0403

    View details for PubMedID 28492832

  • Recovery of a Missile Embolus From the Right Ventricle. Annals of thoracic surgery Marshall, C. D., Ma, M. R., Park, J., Sheckter, C. C., Massoudi, R. A., Ligman, C. M., Jou, R. M., Ogden, W. D. 2017; 103 (1): e69-e71


    Missile embolism is a clinical entity in which a projectile object enters a blood vessel and is carried to a distant part of the body. We present a case of the discovery of an iliac vein to right ventricle missile embolus in a young man, with successful extraction through a right atriotomy. We provide a historical overview of the literature concerning missile embolism, and we argue that whereas acute embolized projectiles should be removed in almost all cases, it may be reasonable to simply observe an asymptomatic chronic missile embolus.

    View details for DOI 10.1016/j.athoracsur.2016.06.107

    View details for PubMedID 28007279

  • Individualized Acute Medical Care for Cognitively Impaired Individuals: A Call Always to Pause Before Hospitalization. Journal of the American Geriatrics Society Sheckter, C. C., Bott, N. T., Milstein, A. n., Leff, B. n. 2017

    View details for PubMedID 28960237

  • Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis. Breast cancer research and treatment Offodile, A. C., Sheckter, C. C., Tucker, A. n., Watzker, A. n., Ottino, K. n., Zammert, M. n., Padula, W. V. 2017


    Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds.A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control.The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40-$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71-$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds.Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.

    View details for PubMedID 28677010

  • Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Shakir, A., Vo, H., Tsai, J., Nazerali, R., Lee, G. K. 2016; 69 (11): 1506-1512


    Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p = 0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.

    View details for DOI 10.1016/j.bjps.2016.06.024

    View details for Web of Science ID 000388293400012

    View details for PubMedID 27538340

  • Vermilion Only Cross-lip Flap for Treating Whistle Deformity in Secondary Bilateral Cleft Lip Repair. Plastic and reconstructive surgery. Global open Sheckter, C. C., Menard, R. M. 2016; 4 (10)


    Bilateral cleft lip repairs can result in various secondary deformities. One more commonly seen deformity, the whistle deformity, is characterized by a reduced or absent tubercle, orbicularis muscle diastasis, and abnormalities of the philtrum with notched appearance of cupid's bow. Various techniques have been described to address these problems. One common procedure is the lip-switch flap originally described by Abbe in 1898, which has been modified by various surgeons. In these procedures, lower lip vermilion, mucosa, orbicularis, and lip skin are transposed to the upper lip on a pedicle that is later divided. In all these variations of the lip-switch procedure, the transposed tissue involves the entire lower lip skin-leaving large, unsightly, and unnecessary scars. It also brings abnormal tissue into the philtrum further distorting the upper lip. A modified cross-lip flap that is limited to the taking only mucosa, vermilion, and orbicularis is feasible and provides an optimal reconstruction without compromising additional tissue.

    View details for PubMedID 27826484

  • Burns resulting from spontaneous combustion of electronic cigarettes: a case series. Burns & trauma Sheckter, C., Chattopadhyay, A., Paro, J., Karanas, Y. 2016; 4: 35-?


    Electronic cigarette (e-cigarette) sales have grown rapidly in recent years, coinciding with a public perception that they are a safer alternative to traditional cigarettes. However, there have been numerous media reports of fires associated with e-cigarette spontaneous combustion.Three severe burns caused by spontaneous combustion of e-cigarettes within a 6-month period were treated at the Santa Clara Valley Medical Center Burn Unit. Patients sustained partial and full-thickness burns. Two required hospitalization and surgical treatment.E-cigarettes are dangerous devices and have the potential to cause significant burns. Consumers and the general public should be made aware of these life-threatening devices.

    View details for PubMedID 27995151

  • Cost-Effectiveness Comparison Between Topical Silver Sulfadiazine and Enclosed Silver Dressing for Partial-Thickness Burn Treatment JOURNAL OF BURN CARE & RESEARCH Sheckter, C. C., Van Vliet, M. M., Krishnan, N. M., Garner, W. L. 2014; 35 (4): 284-290


    The standard treatment of partial-thickness burns includes topical silver products such as silver sulfadiazine (SSD) cream and enclosed dressings including silver-impregnated foam (Mepilex Ag; Molnlycke Health Care, Gothenburg, Sweden) and silver-laden sheets (Aquacel Ag; ConvaTec, Skillman, NJ). The current state of health care is limited by resources, with an emphasis on evidence-based outcomes and cost-effective treatments. This study includes a decision analysis with an incremental cost-utility ratio comparing enclosed silver dressings with SSD in partial-thickness burn patients with TBSA less than 20%. A comprehensive literature review was conducted to identify clinically relevant health states in partial-thickness burn patients. These health states include successful healing, infection, and noninfected delayed healing requiring either surgery or conservative management. The probabilities of these health states were combined with Medicare CPT reimbursement codes (cost) and patient-derived utilities to fit into the decision model. Utilities were obtained using a visual analog scale during patient interviews. Expected cost and quality-adjusted life years (QALYs) were calculated using the roll-back method. The incremental cost-utility ratio for enclosed silver dressing relative to SSD was $40,167.99/QALY. One-way sensitivity analysis of complication rates confirmed robustness of the model. Assuming a maximum willingness to pay $50,000/QALY, the complication rate for SSD must be 22% or higher for enclosed silver dressing to be cost effective. By varying complication rates for SSD and enclosed silver dressings, the two-way sensitivity analysis demonstrated the cost effectiveness of using enclosed silver dressing at the majority of complication rates for both treatment modalities. Enclosed silver dressings are a cost-effective means of treating partial thickness burns.

    View details for DOI 10.1097/BCR.0b013e3182a36916

    View details for Web of Science ID 000338847800020

    View details for PubMedID 24121806

  • Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Rommer, E., Sheckter, C., Minneti, M., Talving, P., Wong, A. K., Garner, W., Urata, M. M. 2014; 67 (2): E42-E48


    Surgical simulation models are often limited by their lack of fidelity, which hinders their essential purpose, making a better surgeon. Fresh cadaveric tissue is a superior model of simulation owing to its approximation of live tissue. One major unresolved difference between dead and live tissue is perfusion. Here, we propose a means of enhancing the fidelity of cadaveric simulation through the development of a perfused cadaveric model whereby simulation is further able to approach life-like surgery and teach one of the more technically demanding skills of plastic surgery: microsurgery.Fresh tissue human cadavers were procured according to university protocol. Perfusion was performed via cannulation of large vessels, and arterial and venous pressure was maintained by centrifugal circulation. Skin perfusion was evaluated with incisions in the perfused regions and was evaluated using indocyanine green angiography. Surgical simulations were selected to broadly evaluate applicability to plastic surgical education.Surgical simulation of 38 procedures ranging in complexity from skin excisions to microsurgical cases was performed with high priority given to the accurate simulation of clinical procedures. Flap dissections included perforator flaps, muscle flaps, and fasciocutaneous flaps. Effective perfusion was noted with ICG angiography and notable bleeding vessels. Microsurgical flap transfer was successfully performed.We report the establishment of a high fidelity surgical simulation using a perfused fresh tissue model in a realistic environment akin to the operating room. We anticipate utilization of this model prior to entering the operating room will enhance surgical ability and offer a valuable resource in plastic surgical education.

    View details for DOI 10.1016/j.bjps.2013.09.026

    View details for Web of Science ID 000330121900002

    View details for PubMedID 24094541

  • Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Sheckter, C. C., Watt, A. J., Lee, G. K. 2013; 66 (8): 1145-1148


    Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

    View details for DOI 10.1016/j.bjps.2012.12.008

    View details for Web of Science ID 000321441300026

    View details for PubMedID 23317765

  • Incorporation of Fresh Tissue Surgical Simulation into Plastic Surgery Education: Maximizing Extraclinical Surgical Experience JOURNAL OF SURGICAL EDUCATION Sheckter, C. C., Kane, J. T., Minneti, M., Garner, W., Sullivan, M., Talving, P., Sherman, R., Urata, M., Carey, J. N. 2013; 70 (4): 466-474


    As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum.Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure.A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.90±1.02 and postdissection confidence was 4.20±0.94 (p<0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps.A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD.

    View details for DOI 10.1016/j.jsurg.2013.02.008

    View details for Web of Science ID 000320211000006

    View details for PubMedID 23725934

  • Scalp Erosion in Ankyloblepharon-Ectodermal Defect-Cleft Lip and/or Palate (AEC Syndrome): Treatment With Acellular Dermal Matrix JOURNAL OF CRANIOFACIAL SURGERY Sheckter, C., Rommer, E., Francis, C., Block, V., Chen, J., Rizvi, M., Urata, M. M., Hammoudeh, J. 2013; 24 (1): E28-E30


    Ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome, also known as Hay-Wells syndrome) is an autosomal dominant disease caused by mutation in the p63 gene that is primarily characterized by facial clefting, presence of ankyloblepharon, ectodermal dysplasia, and scalp erosion. Scalp erosion is perhaps the most debilitating manifestation of AEC due to its problematic treatment that is fraught with failure given the underlying pathology of the p63 mutation causing dysfunctional wound healing. Management is often targeted in a stepwise fashion, beginning with daily baths, light debridement, and emollients and progressing to extensive skin excision. Skin grafting has limited success and, inevitably, infections requiring aggressive debridement and antibiotic therapy result from dysfunctional healing. The use of acellular dermal matrix for treatment of scalp erosion is a novel approach attempted in a patient with severe scalp disease. Here we report her case and the failure of treatment, along with possible explanations and suggestions for future therapy.

    View details for DOI 10.1097/SCS.0b013e3182688c32

    View details for Web of Science ID 000314853300014

    View details for PubMedID 23348327

  • Multifocal Lipoblastoma of the Face JOURNAL OF CRANIOFACIAL SURGERY Sheckter, C. C., Francis, C. S., Block, V., Lypka, M., Rizvi, M., Urata, M. M. 2012; 23 (6): E585-E587


    Lipoblastoma is a rare benign neoplasm found exclusively in the pediatric population that can occur anywhere in the body, most commonly seen in the extremities but also found in the face. We report an 8-month-old female subject who presented with multifocal soft tissue masses of the face. The diagnosis of lipoblastoma was made in 2 separate locations after surgical resection. Subsequent surgery was performed at the cheek site in an attempt to remove further mass, resulting in discovery of 2 other discrete tumors found to be lipoblastomas. Although the literature reports recurrence rates ranging from 14% to 27%, to our knowledge, aside from a case of Proteus syndrome, there are no known reports of multiple lipoblastomas in the literature. Presentation of the case, review of pertinent literature, and consideration of congenital infiltrative lipomatosis of the face follow.

    View details for DOI 10.1097/SCS.0b013e31826bf012

    View details for Web of Science ID 000311889300023

    View details for PubMedID 23172486