15.18 Effects of Dry Calyx of Hibiscus Sabdariffa Linn. on Serum Lipid Profile in Hyperlipidemic Subjects

Posted on January 31, 2019

M. Thway1, M. J. Hsann1, L. M. May1, N. H. Win1  1University of Medicine 1,Pharmacology,Yangon, LANMADAW, Myanmar

Introduction: Hyperlipidemia is a group of disorders characterized by an excess of serum total cholesterol, excess LDL-C or excess triglycerides. Hyperlipidemia is a major modifiable risk factor for coronary heart disease and it is important to correct all causes of disease condition.Hibiscus sabdariffa Linn. known as Chin-baung-ni is a plant which belongs to the Malvaceae family and is widely cultivated in tropical and subtropical areas. Taking together these evidences of hypolipidemic efficacies of Hibiscus sabdariffa Linn., it was also worth to know lipid lowering and the sustained lipid lowering action of Hibiscus sabdariffa Linn. Moreover, it was so interesting to focus the effects of Hibiscus which grow in Myanmar climatic and ecological changes. Therefore this study was conducted to evaluate the effects of Hibiscus sabdariffa Linn. on serum lipid profile  in hyperlipidemic subjects.

Methods: In this study, fourty-four hyperlipidemic human volunteers of both genders, who were between 20 – 60 years age group were chosen as subjects and they were randomly allocated into 3 g intake group and 10 g intake group. All subjects were requested to take one package of Hibiscus powder per day for 30 days. The package of Hibiscus powder was prepared in 250 mL of boiled water with sugar (5 g), steeped for 15 minute and it was drunk daily before lunch. Initial baseline levels were recorded and at 30 day of the study, 10 hour fasting blood samples were taken and analyzed for serum total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and then these biochemical parameters were analyzed again after two week washout period to know the sustainable lipid lowering effect.  Enzymatic colorimetric test with Lipid Clearing Factor CHOD-PAP-method and Lipid Clearing Factor GPO-PAP method were used for determination of serum TC and TG levels respectively. HDL-C was determined by HUMAN Cholesterol liquicolour test Kit. Estimation of LDL cholesterol level was calculated by using method of Fridewald et al. (1972). 

Results:

After 30 days consumption, it was found that no significant serum lipid level changes in 3 g daily intake group (P = > 0.05).  However, 10 g daily intake group showed significant reduction in mean serum TC, TG, LDL-C levels by 16.13%, 19.33% and 22.33% respectively. Then, 12.3% elevation of mean serum HDL-C from baseline levels (P = 0.00) was seen. Concerned about sustainable effect in 10 g daily intake group, serum lipid profile levels returned nearly to the initial baseline levels after two week washout period. Therefore, 30 days consumption of Hibiscus is not sustainable after 2 week cessation of the intake.

 

Conclusion:Therefore, according to the obtained data, the higher dose of Hibiscus, daily 10 g intake gave significant lipid lowering effect, however the lower dose, daily 3 g intake have no significant lipid lowering effect

 

15.17 A Comparison of Postoperative Aesthetic and Functional Outcomes in Meshed vs Unmeshed Hand Burns

Posted on January 31, 2019

A. Idicula1, M. Effendi1, A. Nair1, J. Griswold1  1Texas Tech University,Surgery,Lubbock, TX, USA

Introduction:   Split Thickness Skin Grafting (STSG) is considered one of the principal techniques in the treatment of hand burns in the setting of larger, more complex burn injuries.  While traditional STSG does have a few advantages over 1:1 meshed STSG, such as better cosmesis, less surface scaring, and better long term appearance and function they do have many disadvantages. These disadvantages include a longer operating time, increased time demands for deblebbing , limited donor site availability, and longer post-operative healing times.

The use of meshed STSGs allows blood and edematous fluid to drain, leading to reduced healing time as well as reduced incidence of seroma and hematoma formation5,6. Additionally, meshed grafts may also be stretched to provide added area of coverage, which is essential in full body burns where donor site availability is limited. However, excessive tension on the meshed graft may result in additional skin contracturing, leading to a decreased range of motion along with a scale-like appearance11.  Long-term postoperative reviews have shown that tension free meshed grafts have a superior aesthetic result when compared to stretched meshed grafts6. This study plans to retrospectively compare the functional and cosmetic outcomes of hand burn patients who were treated with 1:1 Meshed STSG to those who were treated with traditional STSG grafts.

Methods:

Total of 46 Patient screened for inclusion criteria de-indentified. The chart review and data collection of  occupation therapy and physical therapy review of range of motion collected in regards to postoperative hand function. IRB approved Aesthetic survey performed show photographs of hand burns ranging from 3 months postoperative to 1 year postoperative.  

Results:
Comparison of  aesthetic and functional post-surgical outcomes for hand burn patients receiving 1:1 Meshed STSG to those who were treated with STSG.have similar functional outcomes to those receiving STSG, and if the 1:1 Meshed modification of the STSG reduces the formation of recognizable scar patterns. The 1:1 Meshed STSG modification will provide a functional advantage over traditional STSG by avoiding scarring and contracture and improve range of motion.

Conclusion:

This study will faciitate additional breadth of knowledge in treating hand burns utlizling 1:1 meshed STSG. Our study can serve as a pilot towards establishing standard of care for hand-burn patients receiving skin grafts.  

15.15 The Predictive Value of Baseline Creatinine in Abdominal Wall Reconstruction

Posted on January 31, 2019

C. Davis1, C. Boyd1, J. Wilson1, J. I. De La Torre1  1University Of Alabama at Birmingham,Plastic Surgery,Birmingham, Alabama, USA

Introduction:  Abdominal wall reconstruction (AWR) is an invasive surgical procedure that can result in lengthy hospital stay for patients with certain comorbidities. Postoperative kidney injury is a well described complication in other surgeries.  This study investigates baseline preoperative creatinine and its correlation to hospital length of stay (LOS) as well as acute kidney injury (AKI) after AWR.

Methods:  A retrospective analysis of patients who underwent AWR from a single surgeon at University of Alabama at Birmingham over January 2017-July 2018. Statistical analysis of patients’ charts was compared for baseline creatinine, AKI, LOS, and postoperative complications.  All patient who underwent component separation with acellular dermal reinforcement for ventral hernias during the study period were included.  Patients who did not require the use of biologic acellular dermal matrix were excluded.  Statistical analysis included t-tests and regression analysis.

Results: 52 patients underwent AWR during the respective time frame. Average age of patients was 56, and the majority of patients were female (73.1%).  Of these patients, 11 had a baseline creatinine of ≥1.  Individuals with baseline creatinine ≥1 had a longer length of stay (6.55 days) compared to patients with a baseline Cr < 1 (5.1 days) (p=0.25).   Including all 52 patients into the analysis, baseline creatinine was not significantly correlated to LOS.  Postoperative AKI was associated with a significantly longer LOS compared to patients who did not have a postoperative AKI (9.08 vs 4.14 days, p=0.03012).

Conclusion: Although baseline creatinine alone was not predictive of length of stay, baseline creatinine levels ≥1 correlated to longer length of stay in this patient group. Furthermore, AKI was also predictive of longer hospital courses. These factors can help forecast hospital courses in patients at risk based on their comorbidities and allow physicians to prevent and treat possible complications to reduce LOS and optimize patient health.

15.14 Abdominal Wall Reconstruction in Orthotopic Liver Transplant Patients

Posted on January 31, 2019

S. Kurapati1,2, B. D. Denney1, J. I. De La Torre1,2  1University of Alabama at Birmingham,Plastic Surgery,Birmingham, AL, USA 2Birmingham V.A. Medical Center,Plastic Surgery,Birmingham, AL, USA

Introduction:   Component separation has been established as an effective technique for complex abdominal wall reconstruction. However, incisional hernias following orthotopic liver transplantation (OLT) presents a particular challenge.  This patient population which is immune suppressed often has pre-existing incisions that present a challenge for reconstruction.

Methods:  The records of 183 patients who underwent complex abdominal wall reconstruction since 2010 were reviewed and used as our control.  Within this group, patients were identified by CPT codes for a history of both component separation and  liver transplantation. Data reviewed included patient demographics and comorbidities, concomitant procedures, and characteristics of the reconstruction such as surgical incision. Primary data endpoints were complications following surgery, including recurrence. 

Results: The study group consisted of 9 patients, 8 who were OLT recipients and a single patient who was a partial liver donor. In the study group, there were no hernia recurrences. Primary myofacial continuiuty was achieved in 100% of the patients. A chevron incision was used in 66% of cases and biologic material was used in 78%. Overall morbidity was 11%, with one patient identified with deep venous thrombosis.  There were no significant wound healing problems.  For comparison, in the control group, the recurrence rate was 7% and primary approximation of the fascial defect was achieved in 92% of the patients. Significant complications occurred in 17%.

Conclusion: Modified abdominal wall reconstruction with component separation with or without onlay biologic mesh is a reliable approach to address hernia defects in patients who have had incisions associated with liver transplants, including those on ongoing immunosuppression.  With appropriate care, this patient group has no increase in adverse outcomes compared to those patients who do not have the pre-existing surgical scars and immunosuppression.
 

15.13 Meta-Analysis of Superficial Temporal Artery Anatomy

Posted on January 31, 2019

C. D. Liao1, S. Svoboda1, M. Applebaum1,2, J. Thompson1,2  1Virginia Tech Carilion School of Medicine,Roanoke, VA, USA 2Carilion Clinic,Department Of Plastic And Reconstructive Surgery,Roanoke, VA, USA

Introduction:  

In head and neck reconstruction, the superficial temporal artery (STA) and vein are often the first-choice recipient vessels for tissue flaps. Thorough understanding of STA anatomy and variability is crucial for avoiding surgical complications.

To date, no study has determined the influence of patient characteristics such as ethnicity, age, and sex on anatomical variations in the STA, underscoring a need to record these data in future studies. Additionally, study designs of reports documenting STA anatomy vary considerably. Therefore, more robust and comprehensive studies are necessary to accurately capture STA anatomy, enable more skillful dissections, and minimize complications.

A comprehensive review of the current literature offers an appropriate starting point. This study aims to provide surgeons with accurate and reliable measurements of STA architecture to promote safe dissection.

Methods:

We screened 1,105 studies by title/abstract. We consolidated data from 16 primary reports, all of which were examined for study design, patient characteristics, and relevant anatomical data.

Results:

The 16 studies represent patient populations in 11 different countries and yielded a total of 961 STAs for analysis. About half of the studies were cadaveric; the other half were angiographic. The male-to-female ratio is 57:43 among the studies that specified these details (N = 343 subjects). On average, only about 6 out of 16 of the studies documented important patient descriptors such as health status, sex, ethnicity, and age.

About 98% of STAs were reported to have two branches. About 74% of STAs bifurcated above the zygomatic arch; furthermore, we discovered considerable variation in the level of bifurcation among the 16 studies. Forest plots demonstrated that the average diameters of the STA, frontal branch, and parietal branch differ significantly from the pooled average in all categories, indicating cross-study inconsistencies. The pooled average diameters of the STA, frontal branch, and parietal branch were 2.03 ± 0.09 mm, 1.53 ± 0.06 mm, and 1.48 ± 0.06 mm, respectively. Distance of the STA anterior to the pinna was also inconsistent among the 3 studies that reported this information; the pooled average was 1.46 ± 0.12 cm. Comparing radiologic and cadaveric studies demonstrated significant differences in reported parietal and frontal artery diameters, but no differences in STA diameter, level of bifurcation, and number of branches.

Conclusion:

This meta-analysis provides a necessary first step in revisiting anatomical architecture and variability of the STA, which can promote positive outcomes for patients requiring flaps for head and neck reconstruction. Future work will entail collection of anatomical data with consistent documentation of patient characteristics.
 

15.12 Breast Lidocaine Priming for Improved Mastectomy Survival: The Lazarus Effect

Posted on January 31, 2019

A. M. Botty Van Den Bruele1, M. Crandall1, D. Chesire1, J. Murray1  1University of Florida- Jacksonville,Department Of Surgery,Jacksonville, FL, USA

Introduction:  Insufficient perfusion in breast skin is a leading cause of early complications following mastectomy reconstructive procedures. Accurate and reliable intraoperative methods for assessment of tissue perfusion are needed to help surgeons identify tissue at risk for ischemia and necrosis. Image guided mastectomy with indocyanine green (ICG) fluorescent angiography has emerged as form of intraoperative imaging that helps provide assessment of tissue perfusion. Perfusion indices have been developed for ICG imaging to indicate when the operative surgeon should remove ischemic tissue. Less than 20% perfusion has been shown to correlate with necrosis. While tumescent priming of the breast with lidocaine-epinephrine solution facilitates dissection and decreases blood loss, associated dermal vasoconstriction may affect ICG perfusion indices. Our goal was to study the effect of pre-mastectomy breast lidocaine priming on intraoperative perfusion indices and aesthetic outcomes. 

Methods:  We performed a retrospective review of perfusion indices and aesthetic outcomes for 49 mastectomies performed on 31 consecutive patients (some unilateral vs bilateral). Patient data recorded included age, race, BMI, smoking status, HTN, DM, and history of radiation therapy. All mastectomies were performed with lidocaine-epinephrine tumescence and received paravertebral block; ICG measurements <20% and mastectomy weight were recorded. Outcomes of interest were dermal necrosis/epidermolysis and hematoma or seroma formation. 

Results: Of the 49 mastectomies performed, 44 were reviewed and included in our analysis due to incomplete data in 5 of the mastectomies. Thirty-four breasts exhibited areas of <20% perfusion by ICG fluorescent analysis. Of these, only 5 demonstrated minor necrosis in postoperative follow-up, none of which warranted operative intervention. Multivariate analysis was performed and independent t-test employed. Increased BMI was noted to be a risk factor for minor necrosis, although not statistically significant (p=0.051). Only smoking history was noted to have a positive correlation with minor necrosis (p£ 0.001), whereas ICG perfusion was not significantly associated with necrosis in our sample (p=0.146).

Conclusion: Several previous studies have found ICG angiography to be highly accurate at predicting mastectomy skin flap viability after breast reconstruction. Therefore, the 34 patients who were noted to have decreased perfusion with ICG imaging in our study should have gone on to have extensive necrosis. Fortunately, however, all of those breasts went on to uneventful healing without additional intervention. Given our results, future research should focus on whether it is a difference in demographic factors or operative technique that may explain the discordance.

 

15.11 Comparing Plastic Surgery and ENT Outcomes and Cartilage Graft Preferences in Pediatric Rhinoplasty

Posted on January 31, 2019

A. F. Doval1, A. Ourian1, V. Chegireddy1, M. Lypka2, J. Friedman1, A. Echo1  1Houston Methodist Hospital,Plastic And Reconstructive Surgery,Houston, TEXAS, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Plastic And Reconstructive Surgery,Kansas City, MO, USA

Introduction:  Rhinoplasty in children has raised concerns about its impact in nasoseptal growth as well as its safeness in the pediatric population. There is scarcity of evidence describing outcomes and surgical techniques performed in pediatric rhinoplasty. Here, we analyze post-operative complications and cartilage preferences between plastic surgeons and otolaryngologists on a national level.

Methods:  Data was collected through the Pediatric National Surgical Improvement Program (NSQIP) from 2012 to 2016. Current Procedure Terminology (CPT) and International Classification of Disease 9th Revision (ICD-9) codes were used for data extraction. A comparison between plastic surgeons and otolaryngologists was made in terms of 30-day post-operative complications followed by a sub-group analysis based on cartilage preferences for rhinoplasty in each specialty.

Results: The data demonstrated that plastic surgeons performed 944 (71.3%) and otolaryngologists performed 380 (28.7%) of rhinoplasty cases. There were significant differences in terms of demographic characteristics between the two specialties including ages, race, ethnicity, and history of congenital malformations (all p < 0.0001). The most common post-operative complications were superficial wound infections (0.3% and 0.8%) and related reoperations for infection drainage and surgical control of hemorrhage (0.6% and 0.3%). No outcome differences between plastic surgeons and otolaryngologists were noted. Subgroup analysis revealed that plastic surgeons prefer to use rib and ear cartilage, while otolaryngologists prefer septal cartilage.

Conclusion: This national level study confirms that rhinoplasty in the pediatric population is a safe procedure. Plastic surgeons and otolaryngologists have comparable 30-day complication rates but the preferences of cartilage usage varies between specialties.

 

15.10 Implications of incidental abdominal CT angiography findings on free flap breast reconstruction

Posted on January 31, 2019

L. M. Ngaage1,2, D. Ghorra3, G. Oni3, B. C. Koo4, J. Ang2, S. L. Benyon3, M. S. Irwin3, C. M. Malata3,5,6  1Imperial College Trust,Foundation School,London, ENGLAND, United Kingdom 2University of Cambridge,School Of Clinical Medicine,Cambridge, ENGLAND, United Kingdom 3Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 4Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Radiology,Cambridge, ENGLAND, United Kingdom 5Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Cambridge Breast Unit,Cambridge, ENGLAND, United Kingdom 6Anglia Ruskin University,School Of Medicine,Chelmsford & Cambridge, ENGLAND, United Kingdom

Introduction:
Preoperative CT angiography (CTA) of the abdominal wall vessels is routinely used when planning free flap breast reconstruction (FFBR) because it provides a surgical roadmap, which facilitates flap harvest. However, there are few reports on the effect of incidental findings on the operative plan.

Methods:
A retrospective study of all FFBRs performed at a tertiary referral centre for breast reconstruction over a six-year period (November 2011 to June 2017) was conducted. One consultant radiologist (BCK) reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.

Results:
200 patients received preoperative CTAs. 14% of patients (n=28) had incidental findings. Of the incidental findings, 18% were vascular anomalies; 36% tumour-related and 46% were “other”. In four patients, findings were severe enough to prevent surgery. They comprised of mesenteric artery aneurysm, absent DIEVs due to previous surgery, bilateral occluded DIEAs, and significant bone metastasis. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled TRAM flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of a free flap breast reconstruction. Nearly a quarter of those with incidental findings went on to have further imaging before their operation. 

Conclusion:
CTA in breast reconstruction can have a wider impact than facilitating surgical planning and reducing operative times.  Incidental findings can influence the surgical plan, and in some instances, avoid doomed to fail and unsafe surgery. It is important that these scans are reported by an experienced interventional radiologist. 
 

15.09 Prepectoral Breast Reconstruction with BraxonR Acellular Dermal Matrix (ADM): Indications & Pitfalls

Posted on January 31, 2019

E. Theodorakopoulou1, D. T. Ghorra1,2, S. Samaras1, P. Forouhi3, C. M. Malata1,3,4  1Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 2University of Alexandria Medical School,Department Of Plastic & Reconstructive Surgery,Alexandria, ALEXANDRIA, Egypt 3Cambridge Breast Unit,Department Of Surgery,Cambridge, ENGLAND, United Kingdom 4Anglia Ruskin Univerisity School of Medicine,Surgery,Cambridge & Chelmsford, ENGLAND, United Kingdom

Introduction:
Epipectoral implant placement is a new technic designed to simplify and minimize the drawbacks of immediate implant-based breast reconstruction. As with most new procedures the indications have yet to be clearly defined. A single plastic surgeon's initial experience with prosthetic reconstruction using BraxonR total acellular dermal matrix coverage of the implant/expander in the prepectoral plane at the time of mastectomy is presented.

Methods:
Patients undergoing Braxon (porcine ADM) immediate breast reconstruction by a single surgeon (2017-2018) were reviewed with respect to demographics, specific indication, implant type & volume, mastectomy type and early outcomes. They were identified from a prospective Implant Register and data collected from Epic.

Results:
Eleven consecutive patients (mean age 38 years) underwent Braxon-ADM reconstruction of 17 breasts with fixed volume implants i.e., direct-to-implant (7) and permanent expanders (4). The surgical indications (number of breasts) were risk-reduction (9), therapeutic (6) and noncancer (2). The reconstructions were bilateral in six patients. Based on the breast size and shape, mastectomies were performed via a variety of incisions: Wise pattern skin-reducing technics (6 with half of them including dermal slings), inframammary incisions (4), hemi-Y periareolar incisions (4) and traditional elliptical periareolar incisions (3). Twelve breasts had nipple-sparing mastectomies. Uneventful healing was achieved in 9 breasts, implant loss 4 breasts, large seromas (5 breasts – 2 of the implant losses), infection (4 breasts, included in the implant losses), unplanned readmissions (3 patients), severe capsular contracture following unplanned radiotherapy (1 breast), transient localised tenderness at the superior fixation points (3 breasts), exercise-induced "partial dislodging" (1 breast) and visible rippling (4 breasts). Unlike subpectoral breast recosntructions there were no cases of breast animation deformity caused by hyperactive pectoralis major muscle contraction with resulting distortion of the breasts.

The putative prredisposing factors (by patients) to implant loss and significant seromas/ wound dehiscence were smoking (1), skin-reducing mastectomy (2), early (<5 days) removal of drains (1), tight wound closure (1), postoperative radiotherapy (1) and axillary clearance (1).

Conclusion:
Prepectoral implant placement constitutes a practical novel addition to the repertoire of postmastectomy breast reconstruction technics. It is particularly useful in bilateral reconstructions such as for risk-reducing mastectomies. Patient selection is, however, very important to avoid complications and optimise outcomes. It is also more exacting in terms of implant selection for unilateral breast reconstruction. Further large-scale studies are needed to determine the place of prepectoral reconstruction and whether it is an improvement on current implant-based reconstructive methods.
 

15.08 Geometric analysis and retrospective study of fascial tensile reduction in severe keloid surgery.

Posted on January 31, 2019

T. Tsuge1, M. Aoki1, S. Akaishi1, T. Dohi1, H. Yamamoto1, R. Ogawa1  1Nippon Medical School,Plastic, Reconstructive And Aesthetic Surgery,Tokyo, TOKYO, Japan

Introduction: The current treatment for severe keloids is surgery followed by postoperative radiation. The possibility of recurrence after surgery is high without strict follow-up treatment. Some specific suture methods are thought to be effective for preventing recurrence. Stretching tension is an important factor associated with keloid generation and progression. We believe that suture methods that prevent tension occurring in the dermis are effective. We have attempted a fascial tensile reduction (FTR) method in severe keloid surgery over the long term. Tension after the resection of keloids is strong in the anterior chest, and we have tried the combination of deep fascia tensile reduction (DFTR) and superficial fascia tensile reduction (SFTR). We analyzed the effects of SFTR and the combination of DFTR and SFTR (DFTR+SFTR).

Methods: Geometric analysis was performed by Obtaining Anatomic Shapes in 3D using DISCUS drawing software and ADINA analytical software. All keloids were treated by surgery and postoperative radiation therapy. The data set consisted of 386 patients who were treated surgically from 2011 through 2016 in the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School in Tokyo. Among the patients, 77 with anterior chest severe keloids who underwent fascial tensile reduction and were followed for over 18 months after surgery were used as the subjects of this study. The patient characteristics, surgical outcomes, and recurrence rates at the point of 18 months after surgery were analyzed.

Results:The maximum mechanical force to the dermis was 4700 Pa when only a dermal suture was used, whereas that to the dermis was decreased to the maximum of 573 Pa with additional SFTR.  DFTR+SFTR decreased the force to the superficial fascia compared with SFTR. The percentage of total keloid excision was significantly higher in the group of DFTR+SFTR (60.0%) than in the group of SFTR (34.6%). The length of hospital stay in the DFTR+SFTR group was significantly longer than in the SFTR group. At the point of 18 months after surgery, no recurrence was recognized in 44.0% and 51.9% of the patients in the DFTR+SFTR group and the SFTR group, respectively. Signs of recurrence or residual keloids were observed in 54.0% and 44.4% of the patients in the DFTR+SFTR group and the SFTR group, respectively. Only 1 case in the DFTR+SFTR group (2.0%) and 1 case in SFTR group (3.7%) were judged to be obvious recurrence. Statistical analysis detected no significant difference between the 2 groups (p=0.670).

Conclusion:DFTR + SFTR should be selected in cases of total resection with relatively large keloids. DFTR appears to facilitate SFTR, and is considered to be useful when reduction by SFTR is technically difficult. It was found that the additional DFTR did not lower the recurrence rate.

 

15.07 Enhanced Recovery after Surgery in Breast Reconstruction: A Meta-Analysis of the Literature

Posted on January 31, 2019

A. C. Offodile1, C. Gu2, S. Boukovalas1, C. J. Coroneos3, A. Chatterjee4, R. D. Largo1, C. Butler1  1University Of Texas MD Anderson Cancer Center,Department Of Plastic Surgery,Houston, TX, USA 2McGovern Medical School at UTHealth,McGovern Medical School,Houston, TX, USA 3McMaster University,Division Of Plastic Surgery,Hamilton, ONTARIO, Canada 4Tufts Medical Center,Division Of Plastic Surgery,Boston, MA, USA

Introduction:  Enhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in
breast reconstruction.

 

Methods:  Electronic database search identified reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis.

Results: A total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use (Mean difference (MD) = – 183.96, 95%CI -340.27 – -27.64, p=0.02) and LOS (MD = -1.58, 95%CI -1.99 – -1.18], p<0.00001) versus traditional care. There is no difference in complications (major complications, readmission, hematoma, and infection).

Conclusion: ERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.

 

15.06 Bipedicled DIEP & SIEA Lower Abdominal Perforator Free Flaps For Unilateral Breast Reconstruction

Posted on January 31, 2019

I. See1,3, D. T. Ghorra2,3, L. MacLennan3, N. G. Rabey3, C. M. Malata3,4,5  1University Of Auckland,Auckland, AUCKLAND, New Zealand 2University of Alexandria,Alexandria, ALEXANDRIA, Egypt 3Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic And Reconstructive Surgery,Cambridge, CAMBRIDGE, United Kingdom 4Addenbrooke’s University Hospital,Cambridge Breast Unit,Cambridge, CAMBRIDGE, United Kingdom 5Anglia Ruskin University School of Medicine,Cambridge & Chelmsford, CAMBRIDGE & CHELMSFORD, United Kingdom

Introduction: Double-pedicled lower abdominal free flaps are an effective technique for postmastectomy autologous reconstruction of patients who are slim, nulliparous, large-breasted relative to their abdominal pannus or have midline abdominal scars. These are particularly useful when adjuvant radiotherapy is planned or implant-based reconstruction is declined. Studies suggest they carry no increased morbidity over unipedicled flaps. Both extraflap (independent) and intraflap (dependent) microvascular anastomoses have been employed but utilizing rib-sacrifice technique of internal mammary recipient vessel exposure. We report a consecutive series of 40 patients (80 flaps) undertaken with both configurations without recourse to rib sacrifice. An algorithm incorporating CT angiography of the lower abdominal wall is presented.

Methods: Patients undergoing bipedicled flap unilateral breast reconstruction by a single surgeon (2010-2018) were reviewed with respect to flap type, anastomotic configuration, intercostal space(s) used for the microsurgery and the flap outcomes.

Results: 40 consecutive double-pedicled free flaps (20% of the all breast free flaps) utilizing both intra-flap (n=11) and extra-flap (n=29) techniques with no partial or total flap losses and only one postoperative re-exploration for flap salvage were undertaken in 40 patients with a median age of 46 years (range 27-66). 32 reconstructions were immediate, 3 delayed, and 5 salvage (tertiary). The series comprised 67 deep inferior epigastric artery perforator (DIEP) and 13 superficial inferior epigastric artery (SIEA) flaps. All 80 anastomoses but three (which used the thoracodorsal system) were performed to the internal mammary vessels using the total rib-preserving method. The combinations used were DIEA/DIEA (29), DIEA/SIEA (9) and SIEA-SIEA (2). The median surgery duration was 697 (range 468-790) with a first flap ischemia time of 104 minutes. The 2nd space was used in 22 patients and both 2nd and 3rd in 18 patients. The vein of the 2nd flap was anastomosed anterogradely to the bifurcated IMV vein in 10 cases, retrograde limb in 25, intraflap continuity in 10 and to the thoracodorsal vein in two. The arterial anastomosis of the 2nd pedicle was performed to the retrograde IM artery in 24 cases. Five breasts were liposuctioned for reshaping and three showed minor fat necrosis, which did not require excision.

Conclusion: Bipedicled free abdominal perforator flaps are a reliable option for unilateral breast reconstruction. In view of their technical complexity and prolonged surgical duration, our algorithm facilitates microsurgical flap design in terms of flap pedicle, recipient vessels, and anastomotic permutations to enable successful execution of these operations. CT angiography helps to predict those patients who will benefit from intraflap anastomoses (Moon & Taylor type II vascular anatomy) and thus do not need apriori exposure of the 3rd intercostal space.

15.05 Circumferential and Complete Wound VAC Application to the Grafted Hand Does Not Compromise Dermal Perfusion

Posted on January 31, 2019

C. N. Thompson2,3, R. Smith4, B. Carney4,5,7, K. Monger4, L. Moffatt2,4,5,8, J. W. Shupp2,4,5,6, L. S. Johnson2,4,6  4Firefighters’ Burn and Surgical Research Laboratory,MedStar Health Research Institute,Washington, DC, USA 5Georgetown University School of Medicine,Department Of Biochemisty,Washington, DC, USA 6Georgetown University School of Medicine,Department Of Surgery,Washington, DC, USA 7Georgetown University School of Medicine,Biochemistry, Graduate Student,Washington, DC, USA 8Georgetown University School of Medicine,Biochemistry, Faculty Appointment,Washington, DC, USA 2MedStar Washington Hospital Center,The Burn Center,Washington, DC, USA 3Georgetown University Medical Center,General Surgery,Washington, DC, USA

Introduction: Negative pressure wound therapy (NPWT) is used to accelerate healing of various wounds.  Studies have demonstrated that NPWT optimizes blood flow, decreases local tissue edema, and removes excess fluid from the wound bed. Use of circumferential NPWT on distal extremities is controversial; while isolated case reports suggest positive outcomes, macrodeformation of the tissue in the wound bed has been shown to increase extracellular pressure.  This data has been extrapolated to suggest a risk for decreased blood flow in the setting of circumferential placement. In the present experiment, the impact of circumferential NPWT on perfusion was examined in hands. 

Methods: Part 1: Healthy volunteers (n=16)  had NPWT sponge placed circumferentially around a hand and secured into position in the standard fashion. Windows for imaging the tissue during the therapy application were created over the thenar eminence (palmar area) and over the central dorsal hand (dorsal area) and 125mmHg suction was applied for 15min.  Laser doppler imaging (LDI) was utilized to measure the perfusion of the hands before (baseline), during, and after NPWT. Regions of interest were selected for analysis in each area and averaged to obtain mean perfusion units.  Data were analyzed using a one-way ANOVA to determine the significance of the differences in perfusion between pre-and post-application of NPWT and between regions of the hand imaged. Part 2: A retrospective case review was performed on patients who underwent split thickness skin grafting and NPWT to identify graft loss, need for repeat operation, and pain associated with therapy. 

Results: 

Part 1:There was no difference in perfusion during and after NPWT placement compared to baseline in the palmar position (Figure 1, p=.86). A statistically significant increase in perfusion at the end of NPWT compared to baseline was identified in the dorsal position (p=0.01). 

Part 2:Over a twelve-month time period, 63 patients underwent burn eschar excision, split thickness skin grafting and the placement of circumferential NPWT. Only 1 patient required a repeat operation for graft loss; two additional patients had documented graft loss requiring local wound therapy. No patients deviated from protocolized unit pain algorithms for reasons related to their NPWT. 

Conclusion: The use of circumferential NPWT on the hand does not decrease cutaneous blood flow during the therapy period. Split thickness skin grafts stabilized with NPWD rarely need second operations for graft failure and are tolerated by patients for the 72-hour period of treatment. Maintenance of blood flow coupled with other therapeutic properties of NPWT may explain upper extremity skin grafting results after use of NPWT for stabilization.  

15.04 Prepectoral Breast Reconstruction Lowers Capsular Contracture Rates after Post-mastectomy Radiation

Posted on January 31, 2019

R. E. Weitzman1, N. Sobti1, K. P. Nealon1, A. S. Colwell1, W. G. Austen1, E. C. Liao1  1Massachusetts General Hospital,Division Of Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Breast cancer is one of the most common cancers to affect women, and implant-based breast reconstruction accounts for more than 80% of reconstruction cases, with over 100,000 procedures performed in the US per year. One of the most common problems after implant-based breast reconstruction occurs after post-mastectomy radiation therapy (PMRT).  Breast implants are usually placed in the subpectoral plane, but we and others have innovated muscle-sparing prepectoral implant placement. This study tests the hypothesize that prepectoral breast reconstruction is associated with lower incidence of capsular contracture when compared to subpectoral placement in an irradiated patient population.

Methods:  Retrospective chart review was conducted to identify consecutive procedures performed at a tertiary academic medical institution over 4 years. Patients who had either pre-operative or post-operative radiation therapy were included. Univariate and penalized logistic regression analyses were conducted to compare clinical endpoints across the implant positioning groups.

Results: Rate of capsular contracture was significantly greater in the subpectoral group compared to the prepectoral group [n = 14 (9.5%) v. n = 0 (0.0%), respectively, p = 0.04]. Penalized logistic regression revealed that subpectoral implant placement was nearly 3 times as likely to result in capsular contracture when compared to prepectoral breast reconstruction within an irradiated population, although the result did not achieve statistical significance. Rates of revision, explantation, infection, tissue necrosis, and hematoma were comparable between groups.

Conclusion: This study compares capsular contracture rates between prepectoral and subpectoral breast reconstruction groups in an irradiated patient population. The results suggest that prepectoral implant breast reconstruction is associated with lower rate of capsular contracture after breast irradiation when compared to subpectoral reconstruction. This data supports the hypothesis that implant coverage by skeletal muscle tissue in subpectoral breast reconstruction could predispose the breast to prosthesis deformity and contracture after radiation as the muscle undergoes fibrosis. Prepectoral breast reconstruction technique excludes the pectoralis muscle from the reconstruction soft tissue, mitigating post-radiation deformity and reducing capsular contracture.

 

15.03 Ankylosis of the Temporomandibular Joint in Pediatric Patients: A Meta-Analysis of 227 Joints

Posted on January 31, 2019

C. Rozanski1, K. Wood1, P. Sanati1, H. Xu1, P. J. Taub2  1Icahn School of Medicine at Mount Sinai,New York, NY, USA 2Kravis Children’s Hospital at Mount Sinai,Division Of Pediatric Plastic Surgery,New York, NY, USA

Introduction:
Temporomandibular joint (TMJ) ankylosis involves the fusion of the mandibular condyle to the skull base. Surgical interventions include: gap arthroplasty, interpositional arthroplasty, and joint reconstruction. Managing TMJ ankylosis in the pediatric population presents particular challenges due to the need to anticipate unpredictable mandibular growth and high rate of recurrence. While surgical management of TMJ ankylosis is well documented in the literature, there is a lack of consensus regarding which approach is best, especially in pediatrics. 

Methods:
A systematic review of PubMed (Jan 1, 1990-Jan 1, 2017) and Scopus (Jan 1, 1990-Jan 1, 2017) was performed by searching an appropriate combination of key words and MeSH terms including “temporomandibular joint ankylosis” and “TMJ ankylosis” with “pediatric” or “pediatrics”. Case reports and case series in the English language including at least one patient under the age of 18 that had a diagnosis of TMJ ankylosis who underwent surgical correction were included for review. Only pediatric cases were included. Main outcomes included preoperative maximum interincisal opening (MIO), postoperative MIO, change in MIO, and complications.

Results:
24 case series and case reports were identified that met inclusion criteria. From these studies, 176 patients and 227 joints were included. There was a significant difference in ΔMIO between intervention groups as determined by one-way ANOVA (p<0.001). Independent sample t-tests comparing MIO variables for each of the intervention groups were performed. MIOpostop (mm) was greater for gap arthroplasty (30.18) compared to reconstruction (27.47) (t=4.9, p=0.043), interpositional arthroplasty (32.87) compared to reconstruction (t=3.25, p=0.002), but not for gap arthroplasty compared to interpositional arthroplasty (t=-1.9, p=0.054). ΔMIO (mm) was not significantly different for gap arthroplasty (28.67) compared to reconstruction (22.24) (t=4.2, p=0.001) or interpositional arthroplasty (28.33) compared to gap arthroplasty (t=0.29, p=0.33). There was no significant difference in incidence of re-ankylosis between treatment modalities.

Conclusion:
Previous studies in adult patients with TMJ ankylosis have suggested interpositional arthroplasty to be superior to gap arthroplasty; however, this distinction has not been explored in pediatrics. The present study found no significant difference in ΔMIO, postoperative MIO, or recurrence of ankylosis between gap arthroplasty and interpositional arthroplasty. Given these nonsignificant differences and the relative technical ease and shorter operation time of gap arthroplasty compared to interpositional arthroplasty, the authors suggest serious consideration of gap arthroplasty for primary ankylosis repair in pediatric patients. 

15.02 Virtual Reality Improves Patient Experience during Wide Awake Local Anesthesia No Tourniquet Surgery

Posted on January 31, 2019

I. J. Behr1, E. Hoxhallari1, J. Clarkson1  1Michigan State University,Surgery,Lansing, MI, USA

Introduction: While technology has the power to change medical practice, it can sometimes take decades for advances to become adopted. At Michigan State University (MSU) we offer Wide Awake Local Anesthetic Surgery No Tourniquet (WALANT) to our hand surgery patients using virtual reality (VR) technology during procedures. We hypothesized the patient experience might be improved by the introduction of VR.

Methods: All patients undergoing routine WALANT hand surgeries in an office procedure room at MSU Department of Surgery were invited to participate. Data collection took place over a 6-month period.

Unlabelled Envelopes containing either VR or Non-VR were given to patients so that single blinded randomization was achieved; Those who received VR during injection and surgery (VR) and those who did not (Non-VR).  A Galaxy S7 phone and a Samsung Gear VR headset with headphones was used.

Phase 1: Tumescent local anesthesia
All patients received an injection of local anesthetic. For the VR patients, this was performed while watching a specifically selected video in which the injection was timed to coincide with a moment of catharsis in the VR experience. 

Phase 2: Surgical procedure
During the procedure, VR patients were provided with freely available 360 YouTube materials.

Prospective data collection:
Data was collected prospectively at multiple time points during the injection and procedure phases.  In addition, there was a postoperative questionnaire completed by all patients.

Prospective physical observations, including pulse and blood pressure, were recorded. Anxiety, fun, and pain were assessed with a Likert type scale rating each 0-10 points. Follow up questions were administered after the procedure to the VR group. All patients were asked to rate how much they enjoyed their surgical experience on a 10-point Likert type scale.

Results:

There were no significant differences between the VR and Non-VR group for either heart rate or blood pressure (p= 0.0072).

Analysis revealed a highly significant difference between the anxiety scores of VR versus Non-VR patients, with anxiety reduced for the VR group (p=0.0003).

Using a 10-point Likert type scale all patients were asked how much they enjoyed their experience with the VR group reporting significantly higher enjoyment (P= 0.0001).

Conclusion:This study demonstrates readily available VR hardware and software can be utilized to provide a passive and immersive experience that reduces patient anxiety during both the injection phase of tumescent local anesthetic and during the surgical procedure. Patients that utilized VR also reported higher levels of joy during the injection and procedure than those who did not. A post procedural questionnaire also revealed the VR group reported a significantly more enjoyable surgical experience than the Non-VR group. 

15.01 Surgical Approach as a Risk Factor for Trigger Digit Development Following Carpal Tunnel Release

Posted on January 31, 2019

J. Nosewicz1, C. Cavallin1, C. Cheng2, A. Zacharek3  1Central Michigan University College Of Medicine,Mount Pleasant, MI, USA 2Central Michigan University,Department Of Mathematics,Mt. Pleasant, MI, USA 3Covenant Healthcare,Saginaw, MI, USA

Introduction: Carpal tunnel release (CTR) is associated with trigger digit development. Surgical approach to CTR has been inconsistently reported as an independent risk factor for postoperative trigger digit. This study aims to identify whether endoscopic (ECTR) or open carpal tunnel release (OCTR) will increase the risk of postoperative trigger digit. Furthermore, shared comorbidities of trigger digit and CTS will be evaluated as potential risk factors for trigger digit development following CTR.

Methods:  967 CTR procedures were evaluated for the development of trigger digit. Multivariate regression analysis was conducted to evaluate independent patient risk factors for trigger digit development. Patients were then stratified into an ECTR group and an OCTR group. Two logit models were conducted to test the association between patient risk factors and postoperative trigger digit within each surgical group.

Results: A total of 47 hands developed trigger digit following 967 carpal tunnel release procedures (4.9%). Regression analysis revealed no independent risk factors for postoperative trigger digit development, including surgical approach. Both the OCTR and ECTR groups were similar in baseline characteristics. There was no significant difference between ECTR and OCTR groups to develop trigger digit following CTR. Furthermore, the majority of risk factors were found to not be associated with postoperative trigger digit when evaluated within the ECTR or OCTR groups. Females were significantly more likely than males to develop trigger digit following OCTR, but were significantly less likely to develop trigger digit following ECTR.

Conclusion: OCTR may predispose females to develop trigger digit following surgery while ECTR may predispose males. Further studies evaluating gender differences in structural changes of the postoperative carpal tunnel are needed to support our findings.

 

100.20 The Impact of Enhanced Recovery After Surgery (ERAS) on the Costs of Elective Colorectal Surgery

Posted on January 31, 2019

A. N. Khanijow1, L. E. Goss1, M. S. Morris1, J. A. Cannon1, G. D. Kennedy1, J. S. Richman1, D. I. Chu1  1University Of Alabama at Birmingham,Department Of Surgery, Division Of Gastrointestinal Surgery,Birmingham, Alabama, USA

Introduction:  ERAS pathways are standardized perioperative care programs that improve postoperative surgical outcomes, including reduced length of stay and readmissions. As more US hospitals adopt ERAS programs, evaluating its impact on healthcare costs is increasingly important in order to determine the value of implementing ERAS protocols. The purpose of this study was to assess the cost of an ERAS program for colorectal surgery through a retrospective analysis comparing surgeries done before ERAS and with ERAS.

Methods:  ERAS was implemented at a tertiary-care single-institution in January 2015. Variable cost data, the costs that vary with care decisions, were collected from the institution's financial department for the surgical inpatient stay for patients undergoing elective colorectal surgery from 2012-2014 (pre-ERAS) and 2015-2017 (ERAS). Costs were adjusted for inflation to 2017 US dollars using the Producer Price Index. Variable costs (overall and by categories) were compared using Wilcoxon tests between the two cohorts and with stratification by severity of illness (SOI) into minor, moderate, major, and extreme.

Results: Of 1,692 elective colorectal surgeries, pre-ERAS procedures (n=389) and ERAS procedures (n=1,303) had median total variable costs per surgery of $7,495.32 and $6,386.71, respectively; a difference of $1,108.61 (p<0.001). Additionally, comparing the average total variable costs between the two groups showed procedures with ERAS saved $128.51 (p<0.001). When comparing costs by categories, significantly (p<0.001) decreased median costs for ERAS surgeries were seen in the following: nursing ($670.29), surgery ($353.88), anesthesiology ($246.59), pharmacy ($75.31), and lab costs ($45.96). Mean variable costs by these categories followed a similar trend with significant cost savings per procedure in ERAS surgeries for the following: surgery ($487.49), anesthesiology ($238.59), nursing ($16.05), and lab costs ($7.19). Of note, mean variable pharmacy costs per surgery were significantly more expensive with the ERAS protocol ($342.17, p<0.001). Median variable costs stratified by SOI were consistent with the overall analysis, revealing significant savings in median total variable costs and in the same cost categories for the ERAS cohorts with mild and moderate SOIs, compared to the pre-ERAS cohort.

Conclusion: ERAS implementation at a large institution resulted in reduced median and mean variable costs associated with hospital stay, showing that ERAS implementation can have both clinical and financial benefits.

 

100.19 Racial Disparities After Self-Inflicted Injury: A Single Center Retrospective Review

Posted on January 31, 2019

M. J. Chaudhary1, E. Miraflor1  1UCSF East Bay,Surgery,Oakland, CA, USA

Introduction:
Self-inflicted injury was the second leading cause of death for the 15-34 year age group in the United States for 2015, only superseded by unintentional injury. Little is understood about racial disparities following self-inflicted injury.

Methods:
This study is a single trauma center twenty-year (1998-2017) retrospective review of all patients suffering self-inflicted injury (SII). Baseline patient demographics (age, gender), injury severity scale (ISS) and mechanism of injury were evaluated by race. The primary outcomes of mortality, psychiatric hold, and discharge to legal custody were analyzed using a multiple logistic regression that included race, age, ISS, and sex.

Results:
The study sample included 440 patients (172 White, 157 Black, 56 Asian, 55 Latino). Each racial group of SII patients had similar ISS scores and a greater proportion of male subjects. Logistic regression revealed that Black and Latino patients were less likely than White and Asian patients to be placed on a psychiatric hold following SII. Asian patients were less likely to die following SII compared to other racial groups. There were no significant differences in discharge to custody following SII between racial groups.

Conclusion:
This retrospective review reveals a potential mortality disparity after SII favoring Asian patients. Furthermore, White and Asian patients suffering SII injury were maintained on a psychiatric hold more frequently than Black or Latino patients. Whether such differences in rates of psychiatric hold by racial group represent disparity in psychiatric resource allocation or simply the nature of SII by racial group merits further study.
 

100.18 Hospital Readmission Following Discharge from the NICU–A Pediatric Health Information System Study

Posted on January 31, 2019

M. Joseph1, M. A. Bartz-Kurycki1, J. K. Chica1, K. Tsao1, M. T. Austin1  1McGovern Medical School at UTHealth,Pediatric Surgery,Houston, TX, USA

Introduction: Approximately 8% of all live births in the US require admission to the neonatal intensive care unit (NICU) after birth.  Prior studies have shown that these infants are at significantly increased risk of readmission after discharge with readmission rates ranging from 15-50%.  Our prior work identified minority race/ethnicity as the strongest predictor of readmission following NICU discharge in our hospital system.  In this study, we aimed to determine the incidence of 90 day hospital readmission for infants discharged from the NICU and determine patient characteristics that increase likelihood of readmission using a large national database.

Methods: The Pediatric Health Information System (PHIS) nationwide was queried from 2016-2018 for patients discharged from the NICU. Deceased patients and those discharged within three days of admission were excluded. Descriptive statistics and univariate and multivariate logistic regression were tabulated utilizing SPSS (v24) to determine factors associated with readmission to the hospital within 90 days of discharge from the NICU.

Results: 86,114 patients were included in the final sample. The majority were non-Hispanic white (NHW) (49.6%) followed by non-Hispanic black (NHB) (15.5%), and Hispanic (14.5%). Most were publically insured (n=51,800, 56%).  The median gestational age was 35 weeks (IQ range 26-38) and median birthweight was 2780gm (IQ range 1910-3374gm).  53,914 (63%) were readmitted to the hospital within 90 days of discharge from the NICU.  NHB race/ethnicity and the diagnosis of a complex chronic medical condition were associated with increased odds of readmission (OR 1.04, 95% CI 1.01-1.08 and OR 1.04, 95% CI 1.01-1.07, respectively).  After controlling for other demographic and clinical factors, only complex chronic medical condition was associated with 90-day readmission (OR 1.05, 95% CI 1.02-1.08).

Conclusions: Infants are readmitted at an alarmingly high rate following discharge to home from the NICU; however, few factors were identified to be associated with readmissions using this dataset.  Race/ethnicity may play a role but the causes of readmission are likely multifactorial.  These will only be addressed through future study that uses both quantitative and qualitative methods to identify potential modifiable risk factors for readmission in this high risk population.

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