Dr. Travis Miller is a fellowship-trained plastic and reconstructive surgeon at Stanford Health Care. He is a Clinical Assistant Professor in the Department of Surgery, Division of Plastic & Reconstructive Surgery at Stanford University School of Medicine.
Dr. Miller specializes in plastic surgery from head to toe with additional training in hand and microsurgery. He treats a multitude of conditions of the hand and upper extremity, including carpal tunnel syndrome, trigger finger, hand and wrist fractures, wrist pain and instability, arthritis, cubital tunnel syndrome, Dupuytren’s, and brachial plexus injury. He specializes in complex reconstruction all over the body using both local tissues and free tissue transfer. He has a special interest in peripheral nerve surgery, including treating nerve compression syndromes, tumors, traumatic injuries, amputation pain, neuromas, and migraines. He also performs aesthetic surgery, and for all his patients he strives to achieve their functional and cosmetic goals.
Dr. Miller received his medical degree from the University of Texas Southwestern Medical School where he graduated first in his class. He completed his residency in plastic and reconstructive surgery through Stanford University School of Medicine. Before pursuing a fellowship in Hand and Microsurgery at the University of Washington, he also completed an in-residency fellowship at the Buncke Clinic in San Francisco, widely considered the birthplace of microsurgery.
Dr. Miller has an extensive research background. He collaborated with a team that invented and patented a medical device used for coiled surgical tools and catheters. In addition to book chapters and monographs, he has written numerous peer-reviewed journal manuscripts that have been published in journals such as The Journal of Hand Surgery, The Journal of Surgical Oncology, Microsurgery, and Plastic and Reconstructive Surgery. Dr. Miller has presented his research at regional, national, and international meetings.
- Hand and Microsurgery
- Plastic Surgery
Clinical Assistant Professor, Surgery - Plastic & Reconstructive Surgery
Fellowship: University of Washington Hand and Microvascular Fellowship (2023) WA
Residency: Stanford University Dept of Plastic Surgery (2022) CA
Fellowship: California Pacific Medical Center (2019) CA
Medical Education: University of Texas Southwestern Medical School Registrar (2015) TX
Acetylsalicylic Acid is Not Associated With Improved Clinical Outcomes After Microsurgical Breast Reconstruction.
The Journal of surgical research
2023; 288: 172-177
Microvascular thrombosis with resultant flap loss remains a devastating complication in autologous breast reconstruction. While acetylsalicylic acid (ASA) for prevention of microvascular thrombosis is commonly administered postoperatively, clinical evidence supporting this practice remains insufficient. Here, we investigate the association of postoperative ASA administration with differences in clinical outcomes following microsurgical breast reconstruction.A prospectively maintained database was queried to identify patients who had undergone microsurgical breast reconstruction. Patients were categorized based on whether they had received postoperative ASA for 30 d (Group 1) or had not received ASA (Group 2). Patient demographics, reconstructive outcomes, complications, and transfusion requirements were retrieved.One hundred thirty six patients with a mean age of 49.5 y and a mean body mass index of 28.5 kg/m2 who had undergone a total of 216 microsurgical breast reconstructions were included. No significant differences were noted with regard to patient demographics with the exceptions of increased rates of neoadjuvant chemotherapy and delayed reconstruction in Group 1. There were no significant differences in the rates of postoperative complications including breast hematoma, mastectomy skin flap necrosis, partial flap necrosis, seroma, and deep venous thrombosis between patients who did or did not receive ASA postoperatively. Similarly, no difference was noted regarding postoperative blood transfusion rates (Group 1: 9.9% versus Group 2: 9.1%; P = 0.78). Finally, patients in Group 1 had significantly longer hospital stays (Q1 = 4, median = 4.5, Q3 = 5).Postoperative ASA administration is not associated with improved postoperative clinical outcomes. The use of ASA routinely after autologous breast reconstruction does not appear to be a necessity in practice.
View details for DOI 10.1016/j.jss.2023.02.027
View details for PubMedID 36989833
Preoperative beta-Lactam Antibiotic Prophylaxis Is Superior to Bacteriostatic Agents in Immediate Breast Reconstruction with Acellular Dermal Matrix
ELSEVIER SCIENCE INC. 2021: S210
View details for Web of Science ID 000718303100396
Prevention and Management of Complications of Tissue Flaps.
The Surgical clinics of North America
2021; 101 (5): 813-829
In this article, we discuss 4 common free flaps performed in reconstructive surgery: the anterolateral thigh flap, the radial forearm flap, the fibula flap, and the transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap. Donor and recipient complications for each flap type and strategies on how to prevent and manage such complications are discussed.
View details for DOI 10.1016/j.suc.2021.06.009
View details for PubMedID 34537145
Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps Technique and Outcomes From 147 Consecutive Cases
ANNALS OF PLASTIC SURGERY
2021; 87 (3): 324-330
Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps.We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin.The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention.Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.
View details for DOI 10.1097/SAP.0000000000002602
View details for Web of Science ID 000686756800018
View details for PubMedID 34397521
Preoperative beta-lactam antibiotic prophylaxis is superior to bacteriostatic alternatives in immediate expander-based breast reconstruction.
Journal of surgical oncology
BACKGROUND: Staged implant-based breast reconstruction is the most common reconstructive modality following mastectomy. Postoperative implant infections can have a significant impact on adjuvant oncologic care and reconstructive outcome. Here, we investigate the impact of beta-lactam antibiotics (i.e., bactericidal) compared to alternative antibiotic agents on postoperative outcomes for implant-based breast reconstruction.METHODS: A retrospective analysis of patients who underwent immediate sub-pectoral tissue expander placement with an inferior acellular dermal matrix (ADM) sling at a single institution between May 2008 and July 2018 was performed. Patient demographics, comorbidities, and complication rates were retrieved. The impact of antibiotic regimen on postoperative outcomes, including infection rate and reconstructive failure, was investigated.RESULTS: A total of 320 patients with a mean age and BMI of 48.2 years and 25.0kg/m2 , respectively, who underwent 542 immediate breast reconstructions were included in the study. The use of a beta-lactam antibiotic was protective against postoperative infection (odds ratio [OR]=0.467, p=.046), infection requiring operative management (OR=0.313, p=.022), and reconstructive failure (OR=0.365, p=.028). Extended, that is, post-discharge, prophylaxis was not associated with any clinical benefit.CONCLUSION: The use of beta-lactam antibiotics for pre-/peri-operative prophylaxis is superior to alternative antibiotics with a bacteriostatic mechanism of action regarding rates of postoperative infection and reconstructive failure following immediate tissue expander-based breast reconstruction. Extended, that is, post-discharge, prophylaxis does not appear to be indicated, regardless of the antibiotic chosen.
View details for DOI 10.1002/jso.26599
View details for PubMedID 34235740
The Impact of Coagulopathy on Clinical Outcomes following Microsurgical Breast Reconstruction.
Plastic and reconstructive surgery
SUMMARY: Autologous breast reconstruction has evolved considerably from pedicled muscle-based approaches to microsurgical perforator-based techniques. Patients with documented coagulopathy, however, remain a particularly challenging population. The authors present their experience in microsurgical breast reconstruction in patients with coagulopathy and discuss their treatment protocol. A prospectively maintained database was queried for patients with coagulopathy who underwent microsurgical breast reconstruction between 2016 and 2019. Information regarding patient demographics, type of coagulopathy, and anticoagulation regimen were retrieved, and clinical outcomes were investigated. Nineteen patients who underwent 34 microsurgical breast reconstructions with free abdominal flaps were included in the study. The most common coagulopathy was factor V Leiden [n = 7 (38.6 percent)]. Nine patients (47.4 percent) developed thrombotic complications (the majority occurring intraoperatively); notably, arterial and venous thrombosis in four (21.1 percent) and two patients (10.5 percent), respectively. Postoperative thrombotic complications included pulmonary embolism [n = 2 (10.5 percent)] and flap congestion secondary to venous thrombosis [two flaps (5.9 percent)]. Only one flap loss was observed secondary to delayed venous thrombosis on postoperative day 6 (2.9 percent). The anticoagulation regimen in the majority of patients consisted of intraoperative intravenous administration of heparin (2000 U [bolus]) followed by a 5-day heparin infusion at 500 U/hour [n = 10 (52.6 percent)]. The high rate of thrombotic complications in patients with coagulopathy who underwent microsurgical breast reconstruction is contrasted by a low flap loss rate. Although coagulopathy is a risk factor for thrombotic complications, successful microsurgical breast reconstruction is still possible in the majority of patients.
View details for DOI 10.1097/PRS.0000000000008099
View details for PubMedID 34003808
A Magnetized Brace Designed to Elevate the Extremity after Hand Trauma and Surgery.
Plastic and reconstructive surgery. Global open
2021; 9 (3): e3460
Hand elevation is a common recommendation for the treatment of hand injuries to combat development of painful swelling. However, noncompliance with elevation after hand procedures is common, and this is due in part to the lack of acceptable orthotics to assist in this elevation. Conventional slings are often not recommended due to potential shoulder morbidity. Additionally, the standard sling design allows for the hand to fall in a dependent position below the level of the heart. Herein described is a brace that uses magnetic technology designed to provide support for hand elevation that is intuitive to use. The simple design promotes elevation and also allows patients to easily exit the elevated position for shoulder ranging and activities of daily living with the hand as needed. Patient satisfaction data are presented. This brace may increase compliance for elevation after hand injuries and surgical procedures.
View details for DOI 10.1097/GOX.0000000000003460
View details for PubMedID 33747691
Bilaminate Synthetic Dermal Matrix versus Free Fascial Flaps: A Cost-Effectiveness Analysis for Full-Thickness Hand Reconstruction.
Journal of reconstructive microsurgery
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
Three-Dimensionally-Printed Hand Surgical Simulator for Resident Training.
Plastic and reconstructive surgery
2020; 146 (5): 1100–1102
Reduced work hours and funding have fueled an increase in simulation-based training for plastic and orthopedic surgery residency programs. Unfortunately, certain simulation training can fail to enhance surgical skills because of availability, cost, or low fidelity. There is a growing interest among training programs for a cost-effective surgical simulator to improve basic skills and muscle memory of residents. The authors developed a three-dimensionally-printed, malleable, and anatomically accurate hand surgery simulator from a computed tomographic scan of an adult male subject. The bone matrix was specifically designed to provide proprioceptive feedback to hone drilling skills used in fracture repair and arthrodesis. The silicone soft-tissue covering provides excellent malleability to dissect and perform fracture-reducing maneuvers. Three-dimensional printing of "fracture bridges" allows the design of on-demand polyfracture models so the trainee can practice multiple types and locations of repairs as skills progress. To summarize, the authors' hand simulator is an anatomical, low-cost, multiprocedure tool that can be used to improve the muscle memory and basic surgery skills of residents in training.
View details for DOI 10.1097/PRS.0000000000007025
View details for PubMedID 33136955
- An abnormal clinical Allen's Test is not a contraindication for free radial forearm flap CLINICAL CASE REPORTS 2020
Radial Artery Occlusion in a Patient With Lupus, Antiphospholipid Syndrome, andRaynaud Phenomenon: AMultimodalApproach.
The Journal of hand surgery
Radial artery occlusion (RAO) is a known complication of transradial catheterization for cardiac procedures. The transradial approach has decreased bleeding complications compared with the transfemoral approach, but risks provoking hand ischemia. We present a case of a 29-year-old peripartum woman with a history of lupus, antiphospholipid syndrome, and Raynaud phenomenon who developed RAO with hand-threatening ischemia despite therapeutic anticoagulation. Given the patient's medical history, a multimodal approach was applied including thrombectomy, arterial bypass, venous arterialization, and onobotulinum toxin A sympathectomy. The patient's ischemia improved after the procedure, and she regained normal use of the hand.
View details for DOI 10.1016/j.jhsa.2019.08.009
View details for PubMedID 31585746
Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes.
2019; 21: 63–74
Introduction: Gender-affirmation surgery is essential in the management of gender dysphoria. For male-to-female transgender women (transwomen), feminization of the chest is a component in this process. There is minimal literature describing effective and safe techniques for breast augmentation in transwomen. Here we describe our operative techniques and considerations.Methods: A retrospective review of a single surgeon experience was performed for transwomen who underwent primary breast augmentation between October 1, 2014, and February 1, 2017. Surgical outcomes and complications were analyzed.Results: Thirty-four patients with an average age of 34.4 years were included in this series (range 19-59 years). Surgical approach was through an inframammary incision with a submuscular pocket and either silicone smooth round (24%) or textured anatomic implants (76%). Six patients experienced postoperative complications (17.6%). Two patients underwent reoperation for implant extrusion (5.9%). Higher BMI and longer preoperative hormonal therapy duration were significantly associated with complications (p = 0.008; p = 0.039, respectively). Feedback from the respondents was overall positive. Most of patients (92.7%) reported being happier and feeling more satisfied with their chest than before their operation. All respondents (100%) reported improvement in their gender dysphoria and would undergo the operation again. Patient dissatisfaction was significantly associated with longer time on preoperative hormones (p = 0.008) and had a trend toward association with higher implant volume (p = 0.083).Conclusions: Breast augmentation in transwomen is safe and typically leads to high patient satisfaction with improvement of gender dysphoria. Larger, longer term studies are needed to appropriately delineate complication risks and contributing factors.
View details for DOI 10.1016/j.jpra.2019.03.003
View details for PubMedID 32158888
Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction.
Plastic and reconstructive surgery. Global open
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 2019; 7 (7)
How Much Time are Physicians and Nurses Spending Together at the Patient Bedside?
Journal of hospital medicine
2019; 14: E1–E6
BACKGROUND: Bedside rounding involving both nurses and physicians has numerous benefits for patients and staff. However, precise quantitative data on the current extent of physician-nurse (MD-RN) overlap at the patient bedside are lacking.OBJECTIVE: This study aimed to examine the frequency of nurse and physician overlap at the patient beside and what factors affect this frequency.DESIGN: This is a prospective, observational study of time-motion data generated from wearable radio frequency identification (RFID)-based locator technology.SETTING: Single-institution academic hospital.MEASUREMENTS: The length of physician rounds, frequency of rounds that include nurses simultaneously at the bedside, and length of MD-RN overlap were measured and analyzed by ward, day of week, and distance between patient room and nursing station.RESULTS: A total of 739 MD rounding events were captured over 90 consecutive days. Of these events, 267 took place in single-bed patient rooms. The frequency of MD-RN overlap was 30.0%, and there was no statistical difference between the three wards studied. Overall, the average length of all MD rounds was 7.31 ± 0.58 minutes, but rounding involving a bedside nurse lasted longer than rounds with MDs alone (9.56 vs 5.68 minutes, P < .05). There was no difference in either the length of rounds or the frequency of MD-RN overlap between weekdays and weekends. Finally, patient rooms located farther away from the nursing station had a lower likelihood of MD-RN overlap (Pearson's r = -0.67, P < .05).CONCLUSION: RFID-based technology provides precise, automated, and high-throughput time-motion data to capture nurse and physician activity. At our institution, 30.0% of rounds involve a bedside nurse, highlighting a potential barrier to bedside interdisciplinary rounding.
View details for DOI 10.12788/jhm.3204
View details for PubMedID 31112496
- Correction of complete thoracic duct obstruction with lymphovenous bypass: A case report MICROSURGERY 2019; 39 (3): 255–58
- Digit Tip Injuries: Current Treatment and Future Regenerative Paradigms STEM CELLS INTERNATIONAL 2019; 2019
Digit Tip Injuries: Current Treatment and Future Regenerative Paradigms.
Stem cells international
2019; 2019: 9619080
Over the past several decades there has been a profound increase in the understanding of tissue regeneration, driven largely by the observance of the tremendous regenerative capacity in lower order life forms, such as hydra and urodeles. However, it is known that humans and other mammals retain the ability to regenerate the distal phalanges of the digits after amputation. Despite the increased knowledge base on model organisms regarding regenerative paradigms, there is a lack of application of regenerative medicine techniques in clinical practice in regard to digit tip injury. Here, we review the current understanding of digit tip regeneration and discuss gaps that remain in translating regenerative medicine into clinical treatment of digit amputation.
View details for PubMedID 30805012
- Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction Plastic and Reconstructive Surgery Global Open 2019; 7 (7)
- Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes JPRAS Open 2019; 21: 53-71
- Tendon Injuries of the Hand: Current Treatment Strategies and Future Options. Stem Cell Research International 2019; 3 (1)
Correction of complete thoracic duct obstruction with lymphovenous bypass: A case report.
Thoracic duct injury can be a devastating injury with disruption of lymphatic flow leading to potentially chylothorax and/or severe lymphedema. Standard treatment modalities include thoracic duct ligation or embolization for chylothorax, but treatment options to date are few for resultant lymphedema. In this case report, we describe lymphaticovenous bypass of the thoracic duct to the jugular venous system in a 21-year-old male with secondary lymphedema after iatrogenic thoracic duct injury. The patient experienced improvement of lymphedema symptoms including decreased weight and limb girth as well as normalization of serum markers indicating improved lymphatic delivery to the venous system. Lymphangiogram at 3 months post op demonstrated patency of the lymphaticovenous anastomoses. At 6-month follow-up, the patient had returned to his preoperative level of activity and showed continued improvement of his lymphedema symptoms. Lymphovenous bypass of the thoracic duct may be an effective technique to treat secondary lymphedema from thoracic duct obstruction, though further studies are required to determine long-term efficacy.
View details for PubMedID 29974499
The Anterolateral Thigh Flap: Clinical Applications and Review of the Literature
Biomedical Journal of Scientific and Technical Research
2018; 7 (2)
View details for DOI 10.26717/BJSTR.2018.07.001473
- Nipple Reconstruction: Risk Factors and Complications. Nipple-Areolar Complex Reconstruction 2018
- Mastectomy Skin Necrosis: Risk Factors, Prevention, and Management Mastectomy 2016: 2–29
Barbed Sutures and Wound Complications in Plastic Surgery: An Analysis of Outcomes
AESTHETIC SURGERY JOURNAL
2015; 35 (2): 178–88
Barbed sutures may expedite dermal approximation and improve tissue support while requiring less time and material than conventional sutures. Several types of barbed sutures are available, each with unique advantages.The authors sought to determine whether the incidence of complications differed after wound approximation in plastic surgery when various brands of barbed vs nonbarbed traditional sutures were employed.The authors conducted a retrospective review of outcomes in body contouring, free flap, and breast reconstruction. Suture type and closure method were noted for each case. The number of complications after traditional 2-layer closure with nonbarbed sutures was compared with the number of complications after closure via 1- and 2-layer techniques with several brands of barbed sutures, and the brands of barbed sutures were compared with each other.A total of 1011 unique surgical procedures, including 298 procedures with barbed sutures and 713 procedures with nonbarbed sutures, were performed by 5 members of the plastic surgery faculty. The 2-layer technique with barbed sutures was associated with significantly higher rates of wound separation than traditional methods. Excessive erythema along the incision site was significantly more frequent with Quill barbed sutures than with V-Loc barbed sutures.Barbed sutures were associated with significantly higher rates of minor wound complications, specifically when the 2-layer closure technique was performed. Significantly higher rates of erythema were associated with Quill barbed sutures than with V-Loc barbed sutures. LEVEL OF EVIDENCE 4: Risk.
View details for DOI 10.1093/asj/sju012
View details for Web of Science ID 000351914800018
View details for PubMedID 25717118
An Alternative Outpatient Care Model: Postoperative Guest Suite-Based Care
AESTHETIC SURGERY JOURNAL
2014; 34 (8): 1225–31
Patients recovering from outpatient surgery are responsible for managing their pain, managing ambulation, and even implementing thromboembolism prophylaxis after discharge. Because of the importance of postoperative care to prevent complications, a model of care that helps a patient transition to independent self-care could provide optimal results.The authors investigated the safety and morbidity rate for patients who underwent body contouring procedures and overnight care at an attached, nurse-staffed guest suite facility.A retrospective review was conducted of 246 patients who underwent major body contouring and who stayed at least 1 night in the guest suite facility. Major complications included a return to the operating room within 48 hours, major wound infection, and unplanned hospitalization within 48 hours. Minor complications included any postsurgical effect necessitating unplanned physician intervention within the first 30 days. Univariate analyses correlating patient characteristics and complication rates were conducted, as well as comparison of complication rates among same procedures reported in the literature.The complication rate (major and minor complications) was 25.20%. Surgical site infection occurred in 8.13% of patients. The most common wound complication was erythema around the incision site (12.20%). Death, deep vein thrombosis, or pulmonary embolism did not occur. Comparison with relevant results reported in the literature indicated a significant reduction in the occurrence of postoperative venous thromboembolism.Patient education after surgery is essential to healing and adequate care. The guest suite model provides improved care and education for the patient and family postsurgery by addressing some of the known risk factors of plastic surgery.4.
View details for DOI 10.1177/1090820X14546161
View details for Web of Science ID 000344130200010
View details for PubMedID 25270544
Effectiveness of Prophylactic Antibiotics in Outpatient Plastic Surgery
AESTHETIC SURGERY JOURNAL
2014; 34 (8): 1252–58
The effectiveness of prophylactic antibiotics has not been established for patients who undergo plastic surgery as outpatients, and consensus guidelines for antibiotic administration in clean-contaminated plastic surgery are not available.In a retrospective study of outpatients, the authors examined preoperative timing of prophylactic antibiotics, whether postoperative antibiotics were administered, and whether any correlations existed between these practices and surgical complications.The medical records of 468 plastic surgery outpatients were reviewed. Collected data included preoperative antibiotic timing, postoperative antibiotic use, comorbidities, and complications. Rates of complications were calculated and compared with other data.All 468 patients received antibiotics preoperatively, but only 93 (19.9%) received them ≥1 hour before the initial incision. Antibiotics were administered 15 to 44 minutes before surgery in 217 patients (46.4%). There was no significant difference in complication rates between the 315 patients who received postoperative prophylactic antibiotics (16.2%) and the 153 who did not (20.9%). Comorbidities had no bearing on postoperative complications.Postoperative antibiotic prophylaxis may be unnecessary for outpatient plastic surgery patients.3.
View details for DOI 10.1177/1090820X14545984
View details for Web of Science ID 000344130200015
View details for PubMedID 25121784
Internal Jugular Vein Stenosis is Common in Patients Presenting with Neurogenic Thoracic Outlet Syndrome
ANNALS OF VASCULAR SURGERY
2014; 28 (4): 946–50
Previous magnetic resonance imaging studies have shown abnormalities of the internal jugular veins in patients with thoracic outlet syndrome (TOS), but this finding has largely been ignored. We, thus, prospectively performed diagnostic brachiocephalic venograms in all patients with diagnosed neurogenic TOS from April 2008 to December 2011 (mean age, 42.6; r, 16-68; 77.8% women and 22.2% men). Stenosis of the left internal jugular vein, left subclavian vein, right internal jugular vein, and right subclavian vein were assessed, and significant stenoses of these vessels were seen in 63.49%, 65.08%, 60.32%, and 68.25% of patients, respectively. Internal jugular vein stenosis was not present in 23.81%, present unilaterally in 28.57%, and present bilaterally in 47.62% of patients. Subclavian vein stenosis was not present in 17.46%, present unilaterally in 28.57%, and present bilaterally in 53.97% of patients. Phi coefficients of correlation were 0.067 between left internal jugular vein and left subclavian vein stenoses, 0.061 between right internal jugular vein and right subclavian vein stenoses, and 0 between any internal jugular vein and any subclavian vein stenoses, indicating there is no correlation between jugular vein stenosis and subclavian vein stenosis in these patients. We conclude that right and left internal jugular vein stenosis is common in patients with neurogenic TOS symptoms. Treatment of internal jugular vein stenosis could potentially benefit these patients, and the implications of these findings warrant further study.
View details for DOI 10.1016/j.avsg.2013.12.009
View details for Web of Science ID 000335655700022
View details for PubMedID 24462538
Evaluation of the American Society of Anesthesiologists Physical Status Classification System in Risk Assessment for Plastic and Reconstructive Surgery Patients
AESTHETIC SURGERY JOURNAL
2014; 34 (3): 448–56
The American Society of Anesthesiologists Physical Status (ASA-PS) classification is a ranking system that quantifies patient health before anesthesia and surgery. Some surgical disciplines apply the ASA-PS to gauge a patient's likelihood of developing postoperative complications.In this study, the authors analyze whether ASA-PS scores can successfully predict risk for postoperative complications in plastic and reconstructive operations.The authors retrospectively reviewed the charts of 1801 patient procedures and selected for inclusion 1794 complex plastic and reconstructive operations that took place at 1 of several academic medical institutions between January 2008 and January 2012. ASA-PS scores, patient comorbidities, and postoperative complications were analyzed. Percentile data were treated with tests for proportions. Nonpercentile data were analyzed through comparison of means (t test). Low-risk (ASA 1-2) and high-risk (ASA 3+) groups were compared with simple odds ratios.For the 1430 women and 364 men in the patient cohort (average age, 49.5 years), the overall complication rate was 27.7%. When patients with complications were compared to those without, body mass index, operation time, recent major surgery, diabetes, hypertension, renal disease, cancer, and oral contraceptive use were statistically significant. After high-risk (n = 398) and low-risk (n = 1396) groups were identified, infection, delayed wound healing, deep vein thrombosis, and overall complications had significantly increased incidence in the high risk group. Notably, deep vein thrombosis displayed the highest odds ratio (4.17) and a complication rate increase from 0.93% to 3.77%.ASA-PS scores can be used either as substitutes for or as adjuncts to questionnaire-based risk assessment methods in plastic surgery. In addition to deducing significant findings for deep vein thrombosis incidence, ASA-PS scores hold important predictive associations for multiple non-venous thromboembolism complications, providing a broader measurement for postoperative complication risks.4.
View details for DOI 10.1177/1090820X14525394
View details for Web of Science ID 000333655500011
View details for PubMedID 24676415
What Is the True Incidence of Anomalous Bovine Left Common Carotid Artery Configuration?
ANNALS OF VASCULAR SURGERY
2014; 28 (2): 381–85
Earlier studies have indicated that bovine left common carotid artery configuration occurs in 10.2-22% of patients and increases the complexity of navigating endovascular devices in the aortic arch. However, we anecdotally noted a higher incidence of bovine arch among angiosuite outpatients in Los Angeles, California. Thus, we retrospectively reviewed aortic arch angiograms performed in 93 unique outpatients to determine the true incidence of this anomalous configuration.We were able to obtain complete angiographies from clinical data on 90 patients (mean age 50 years, SD 15.23 years, range 17-88 years) from May 2006 to January 2012. Angiograms were categorized as: normal arch; bovine arch with brachiocephalic trunk; bovine arch with common trunk; or indeterminate.The findings indicated an overall 35.16% bovine arch incidence, of which 78.13% is bovine arch with common trunk and 21.88% is bovine arch with brachiocephalic trunk. There was a higher prevalence in the women (40%, n = 60) than men (26.67%, n = 30). Caucasians had a lower incidence of bovine arch (27.78%, n = 47) compared with other ethnicities. The prevalence of bovine arch in different ethnicity and gender groups was assessed and the differences were not statistically significant.The incidence of bovine left common carotid artery is higher than previously reported and varies by gender and race. Advanced knowledge of the high prevalence of this anomaly could reduce the risks and increase the efficiency of navigating catheters through the tortuous vessels during endovascular procedures. The clinical implications of this report warrant further investigation.
View details for DOI 10.1016/j.avsg.2013.06.010
View details for Web of Science ID 000330583100016
View details for PubMedID 24275427
Application of the Caprini Risk Assessment Model in Evaluation of Non-Venous Thromboembolism Complications in Plastic and Reconstructive Surgery Patients
AESTHETIC SURGERY JOURNAL
2014; 34 (1): 87–95
The Caprini Risk Assessment Model is used to categorize patient risk for venous thromboembolism (VTE) events; its predictive associations have been repeatedly corroborated. Calculating scores involves consideration of systemic factors that may predict other postoperative complications.This study investigates whether Caprini scores can be applied to non-VTE complications.The authors undertook a retrospective chart review of 1598 encounters for a series of complex reconstructive and body contouring operations at an academic medical institution. Input variables included Caprini score components, patient comorbidities, and prophylactic use of antithrombotic drugs. Output variables were postoperative complications. Tests for proportions were performed on percentile data. Nonpercentile data were treated with comparison of means (t test). Odds ratios for complications were calculated for stratified risk groups and compared.The overall complication rate was 28.03%. Deep vein thrombosis (DVT) incidence was 1.50%. Differences in age, body mass index (BMI), operation time, hypertension, diabetes, renal disease, and cancer were statistically significant between patients who experienced complications and those who did not. For DVT versus DVT-free patients, differences in sex, BMI, operation time, smoking status, diabetes, hypertension, and prior DVT were significant. Caprini scores identified 628 encounters as low risk (0-4) and 970 as high risk (>5). Dehiscence, infection, necrosis, seroma, hematoma, and overall complication rate significantly increased the incidence for the high-risk group.Caprini scores can be used as valuable predictors for some non-VTE postoperative complications (dehiscence, infection, seroma, hematoma, and necrosis). In addition to VTE events, clinicians should pay special attention to clinical signs indicative of the complications listed above when dealing with high-risk, high-Caprini score patients.
View details for DOI 10.1177/1090820X13514077
View details for Web of Science ID 000335881500011
View details for PubMedID 24327763