INTRODUCTION: As medical cost continues to rise, so has the use of medical tourism by patients as a more cost-effective alternative. While the upfront cost savings lure many unsuspecting patients from their country of origin, there are significant patient safety issues surrounding short and long-term follow-up and the management and cost of complications. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-analyses PRISMA. Additionally, three cases from our institution are presented demonstrating complications from cosmetic procedures performed abroad. RESULTS: 589 patients were identified in the literature who presented with complications after having a cosmetic procedure abroad. Infection was the most prevalent complication in this study followed by wound dehiscence, seroma/ hematoma, and tissue necrosis. 98% of the infectious organisms were bacterial, and 81% of them were from the Mycobacterium genus. Two of the patients we encountered underwent their initial surgery in the Dominican Republic and the third, in Colombia. The three patients presented with nontuberculous mycobacteria (NTM) infections. CONCLUSIONS: Medical tourism is a rapidly growing industry, and it is important to report on risks associated with seeking aesthetic surgery abroad. This systematic review highlights the nature of complications following cosmetic tourism, the surgeries that resulted in complications, the countries that primary procedures took place in, and the countries of origin of the patients. While cost savings is a large motivator for patients to travel for surgeries, the financial burden and psychological impact of potential complications can be devastating. More awareness and resources are necessary to protect patients and empower them in making educated medical decisions when seeking care.
Abstract Pediatric cervical spine injuries (CSI) are uncommon events, but can be devastating injuries. Facial fractures have been associated with injuries to the cervical spine in children, but may be deemed isolated facial fractures and bypass the standard trauma pathway. The objective of this study is to describe the mechanisms, associated injuries and outcomes of pediatric cervical spine injuries in patients with known maxillofacial trauma at a level 1 trauma center. An analysis was performed of all patients under the age of 18 with maxillofacial trauma admissions to a single level 1 trauma center, from 2006 to 2015. Patients were stratified based on the presence or absence of a cervical spine injury. Data was abstracted to include demographic, mechanism and clinical outcomes data. There were 1274 patients who were admitted with maxillofacial trauma during the study period. Of these, 72 (5.7%) experienced a cervical spine injury. Factors associated with cervical spine injuries include older age and penetrating mechanism. Cervical spine injuries were associated with concomitant traumatic brain injuries and skull fractures. Patients with spine injuries were more like to experience a longer length of stay and death. On multivariate analysis, only increased age predicted CSI. Our database demonstrated a 5.7% incidence of pediatric cervical spine injuries in patients with maxillofacial trauma. This incidence is higher than previously published reports of smaller cohorts. Clinicians must take care to stabilize the cervical spine in any patient with facial fractures, especially during work up and diagnostic maneuvers performed before spinal injuries are ruled out.
Pediatric facial fractures due to intentionally violent mechanisms represent a unique subset of facial fractures. The objective of our research is to identify how violence affects patterns of facial fractures and their management in pediatric patients.An IRB approved, retrospective study of our institution's pediatric patients ≤18 years of age who presented with ≥1 facial fracture due to violence from January 2006 to December 2015 was performed. Violence was defined as trauma intended to hurt another or self. Demographics, fractures, mechanism, concomitant injuries, and management were analyzed.The 1274 patients were diagnosed with facial fractures, with 235 of these due to violence (18%). These patients of violence (POV) had 332 fractures, with an average fracture per patient of 1.4 ± .0.8. The majority (86%) were male, Non-Hispanic African American (35%), and the average age was 15.9 ± 2.8 years. The most common fracture was the mandible (50% of patients) and most common mechanism was assault (76%). The POV were older, male, and of minority race/ethnic groups when compared to patients of non-violence (PONV) (P <0.01). The POV presented with fewer concomitant injuries, were less likely to be admitted to the intensive care unit, and more often surgically managed when compared to the PONV (P <0.01).This study represents the largest US, single institution, Level 1 trauma center study of pediatric facial fractures. Pediatric patients with facial fractures due to a violent mechanism represent a distinct category of trauma patients with a unique profile of injuries.
Congenital cardiac malformations have been reported in 8% of patients with craniosynostosis undergoing cranial vault remodeling (CVR), but associations with surgical outcomes are unknown. This study evaluated postoperative complications in patients who underwent CVR for craniosynostosis with or without cardiac risk factors (CRF) using the National Safety Quality Improvement Program-Pediatric (NSQIP-P) database. NSQIP-P database was queried for patients <2 years with craniosynostosis who underwent CVR from 2012 to 2016 based on diagnosis and procedure codes. The primary outcome was a composite of available NSQIP-P complications. Analysis compared patients with craniosynostosis based on the presence or absence of CRF. Univariate and multiple logistic regression identified risk factors associated with postoperative complications. A total of 3293 patients met inclusion criteria (8% with CRF). Two-thirds of patients experienced at least 1 complication, though patients with CRF experienced a greater proportion (74% vs 66%, P = 0.001). Univariate analysis identified associations between post-operative complications and age, ASA class, supplemental oxygen, neuromuscular disorders, preoperative nutritional supplementation, interventricular hemorrhage, and CRF. On multivariate regression, only older age (OR 1.17, 95% CI 1.01-1.36) and longer operative duration (OR 1.01, 95% CI 1.01-1.01) were associated with greater odds of postoperative complications. The most common complication in patients with craniosynostosis who undergo CVR is bleeding requiring transfusion. Older age and longer operative duration were associated with postoperative complications. Although patients with CRF have more postoperative complications, CRF was not a risk factor on adjusted analysis.
Medical tourism in plastic surgery has grown exponentially over the last decade. The rise in the number of cases is multifactorial but is mostly driven by reduced cost. While this may seem attractive to patients, it is not without risk. Even under the best circumstances, complications can arise, and patients may be put at increased risk of atypical infections due to different sterilization standards. Lack of customary follow-up and accessibility can lead to delays in diagnosing infections and cause patients to seek care locally. We present our experience in managing atypical infections resulting from cosmetic surgery tourism in a tertiary care system.
BACKGROUND: Patients undergoing primary palatoplasty generally rely on narcotic medication for pain control. However, there are concerns with over-medication, sedation, respiratory depression, sensitization to pain, and physical dependency with the use of narcotics. Enhanced Recovery after Surgery (ERAS) protocols using multi-modal therapy for pain control have seen adoption in numerous surgical sub-specialties since their inception in the 1990s. Recent publications have demonstrated decreased narcotic usage and hospital length of stay after palatoplasty with the use of ERAS protocols. This study aims to assess clinical outcomes before and after ERAS implementation to evaluate for a differential effect among Veau Classifications and identify significant predictors of narcotic medication prescription at discharge. METHODS: A single center study of patients undergoing primary palatoplasty examined two cohorts: a retrospective review (2014–2016) of patients treated prior to ERAS implementation and a prospective trial (2016–2018) in which palatoplasty patients were managed with an ERAS protocol. Data regarding postoperative pain scores, oral intake, morphine milligram equivalents (MMEs) administered, narcotic medication prescription at discharge, and length of stay for retrospective and prospective cohorts were compiled (Excel, Microsoft Corporation). Pain scores were measured using the Faces, Legs, Activity, Cry, and Consolability scale. All data were analyzed using R Software (R Foundation for Statistical Computing, Vienna, Austria). RESULTS: A total of 113 patients (56 Pre-ERAS, 57 ERAS) were included in this study. ERAS patients were found to have significantly longer operative times when compared with Pre-ERAS [167min (121–191) versus 131min (114.75–157)] as well as a significantly higher rate of Furlow repair (63.2% versus 33.9%, P = 0.002). The ERAS group was found to have a significant decrease in total MMEs administered when compared with Pre-ERAS (5.29 ± 4.61 versus 11.83 ± 7.13, P < 0.001). Comparison of clinical outcomes within Veau classifications by their respective cohorts yielded no significant differences. Comparison of clinical outcomes among Veau classification between cohorts revealed significant decreases in the ERAS group for total MMEs administered in Veau class II (8.87 ± 5.97 versus 4.38 ± 3.43, p =0.015), III (12.42 ± 7.05 versus 6.25 ± 5.39, P = 0.001), and IV (16.54 ± 6.39 versus 4.54 ± 4.45, P = 0.003). A multivariate generalized linear model using significant univariate variables as well as Cohort and Veau Classification data demonstrated that total MMEs administered was a significant predictor with a P value of 0.041 and an odds ratio of 1.10 (CI 1.01–1.21). CONCLUSIONS: Our ERAS protocol for primary palatoplasty led to decreased pain scores and improved oral intake. Significant reductions in total MMEs administered to patients with Veau II–IV cleft palates were observed, which was associated with 10% increased odds for discharge narcotics per MME administered. There was variability in outcomes based on Veau classification, though larger studies may demonstrate a more reproducible effect. Our results illustrate the potential benefit that standardized ERAS protocols may have in this patient population, and merit further study.
Pediatric facial fractures present and are managed differently than the adult population. This study describes the pattern and mechanism of facial fractures in children and identifies factors associated with need for surgical management. An IRB-approved retrospective chart analysis of all pediatric patients age ≤ 18 years diagnosed with facial fractures at our level 1 trauma center over a 10-year period (January 2006-December 2015) was performed. Demographics, fracture location, mechanism of injury, concomitant head and neck injuries, and surgical management were reviewed. Statistical analysis was then performed comparing surgical and nonsurgical cohorts using univariate and multivariate analyses. One thousand two hundred seventy-four patients were diagnosed with facial fractures. Five hundred seventeen (40.6%) underwent surgical management. Two thousand one hundred seventy-two total facial fractures were recorded. Orbit fractures (29%) were the most commonly recorded, observed in 49% of patients presenting. Increased age was associated with increased odds of surgical management (OR 1.13; 95% CI 1.09-1.16). Mandible (OR 9.28; 95% CI 6.88-12.51) and Le Fort fractures (OR 19.73; 95% CI 9.78-39.77) had increased odds of surgical management. Patients with traumatic brain injury had reduced odds (OR 0.54; 95% CI 0.35-0.83) of surgical management for their facial fractures. Older pediatric patients may be more likely to require surgical management of their facial fractures, especially those with mandible or Le Fort fractures. Patients with traumatic brain injury are likely to sustain life threatening injuries, deferring repair of their facial fractures. Patient education and counseling, as well as predictive models, can be improved to reflect these data.
Autologous fat grafting is a technique that can be used for cosmetic and reconstructive indications such as oncologic defects, aging, trauma, and congenital malformations. However, there is no standardized technique, and one of the main challenges is the unpredictable rate of fat resorption. When using fat grafting, it is crucial to understand the different factors that contribute to adipocyte viability. A literature search, using PubMed, was conducted in 2022 with variations of the terms "autologous fat grafting," "fat harvesting," "fat processing," and "fat injection." Articles in the English language that presented original data about different factors that may affect adipocyte viability for fat grafting were included in this review. Syringe suction harvests (lower pressures), compared with other methods with higher pressures, were found to have increased adipocyte counts and viability, but this did not translate clinically during in vivo studies. The studies have shown that, despite our efforts in optimizing fat harvest, processing, and injection, no statistical or clinical differences have been found. Additional studies are still needed to determine a universal protocol for optimal fat graft survival.
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