Firriolo, Joseph M.

Ganor, Oren

Greene, Arin K.

Labow, Brian I.

Meara, John G.

Ontiveros, Nicole C.

Pike, Carolyn M.

Taghinia, Amir H.

Harvard University - DASH 

Abstract P11: Pediatric OrbitalFloor Fractures: Clinical andRadiological Predictors of TissueEntrapment and the Effect ofOperative Timing on Ocular OutcomesThe Harvard community has made thisarticle openly available.  Please share  howthis access benefits you. Your story mattersCitation Firriolo, Joseph M., Nicole C. Ontiveros, Carolyn M. Pike, JohnG. Meara, Arin K. Greene, Oren Ganor, Amir H. Taghinia, andBrian I. Labow. 2017. “Abstract P11: Pediatric Orbital FloorFractures: Clinical and Radiological Predictors of TissueEntrapment and the Effect of Operative Timing on OcularOutcomes.” Plastic and Reconstructive Surgery Global Open 5(4 Suppl): 109. doi:10.1097/01.GOX.0000516668.39481.76. http://dx.doi.org/10.1097/01.GOX.0000516668.39481.76.Published Version doi:10.1097/01.GOX.0000516668.39481.76Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:33030016Terms of Use This article was downloaded from Harvard University’s DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth at http://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAA109PSRC Abstract SupplementPoster ProofsRESULTS: 358 breasts underwent reconstruction before protocol implementation and 135 afterwards. Patients were similar in terms of demographics and surgical char-acteristics. There was a significantly reduced incidence of clinically relevant infection after protocol implementation (10.1% to 2.9%, p= 0.009). Logistic regression analysis confirmed that the protocol was independently associated with a decrease in infection risk (OR 0.244, p=0.017). Post-protocol, no gram positive bacteria were isolated among cultures obtained from infected periprosthetic fluid. Radia-tion and drain duration greater than 21 days were indepen-dently associated with greater risk for infection.CONCLUSIONS: Our evidence-based protocol was associ-ated with a significant decline in infection rates among implant based breast reconstruction patients, and was particularly effective for gram-positive infections. We will continue to employ this protocol in our practice, and will consider future directions for addressing gram negative infections as well.P11Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular OutcomesJoseph M. Firriolo, MD, Nicole C. Ontiveros, BA, Carolyn M. Pike, MPH, John G. Meara, MD, DMD, MBA, Arin K. Greene, MD, MMSc, Oren Ganor, MD, Amir H. Taghinia, MD, MPH, Brian I. Labow, MD.Boston Children’s Hospital, Harvard Medical School, Boston, MAPURPOSE: Although rare, orbital floor fractures in the pediatric population are cause for concern. Specifically, chil-dren’s bones exhibit considerable elasticity, increasing their risk of tissue entrapment. These injuries have the potential to produce acute constitutional symptoms and poor long-term ocular outcomes. This study aims to determine the clinical and radiological predictors of tissue entrapment and to estab-lish how operative timing influences ocular outcomes.METHODS: We retrospectively reviewed the medical records of pediatric patients who acutely presented with orbital floor fractures at our institution from October 2007 to October 2015. 152 patients, aged less than 18 years, were consulted, managed, and followed-up by pediatric plastic surgery and ophthalmology services. Patients were considered to have experienced poorer ocular outcomes at follow-up if they had persistent enopththalmos, extraocular movement restriction, or diplopia. Independent t-tests and Fisher’s exact tests were used to analyze the association between variables at both presentation and outcome.RESULTS: 152 patients with 159 orbital floor fractures (seven bilateral) were included in the study. 122 (80.3%) patients were male, and the mean age was 12.2 ± 4.2 years. Twelve patients (7.9%) sustained orbital floor fractures with tissue entrapment. At presentation, extraocular movement restric-tion, diplopia, nausea, and vomiting were all associated with tissue entrapment (P<0.001). Facial computed tomography scans detected all cases of tissue entrapment, with a sensitivity of 100% and specificity of 97.9%.Amongst patients with trap-door fractures, the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, and negative predictive value 100%.For all patients, regard-less of fracture configuration, vomiting alone had a negative predictive value of 94.1% for tissue entrapment. For patients with tissue entrapment, poorer ocular outcomes were signifi-cantly associated with the length of operation (P=0.007), but not with the time interval to operation (P=0.146).CONCLUSION: Whilst EOM restriction and diplopia have a well-established relationship with tissue entrapment, they are often difficult to accurately assess in children in the emergency room setting. Pain and edema frequently compli-cate the interpretation of these signs, and a lack of coopera-tion during physical examination may also obscure deficits. Nausea and vomiting are valuable predictors of tissues entrapment, particularly when EOM restriction and diplo-pia are equivocal. In our study, radiological findings were predictive of entrapment, but a lack of consistent language in this area limits the external validity of these results. Our study also draws attention to the relationship between oper-ation length and poorer ocular outcomes. Operation length may be a surrogate marker of case severity/complexity, sur-gical technique and/or surgeon experience; where possible, optimizing these factors may improve ocular outcomes.P12Functional Outcomes Following Soft Tissue Reconstruction and Attempted Limb Salvage After Lower Extremity Trauma

Abstract P11: Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

Taghinia, Amir

Abstract 37. Pediatric OrbitalFloor Fractures: Clinical andRadiological Predictors of TissueEntrapment and the Effect ofOperative Timing on Ocular OutcomesThe Harvard community has made thisarticle openly available.  Please share  howthis access benefits you. Your story mattersCitation Firriolo, Joseph M., Nicole C. Ontiveros, Carolyn M. Pike, JohnG. Meara, Arin K. Greene, Oren Ganor, Amir Taghinia, andBrian I. Labow. 2017. “Abstract 37. Pediatric Orbital FloorFractures: Clinical and Radiological Predictors of TissueEntrapment and the Effect of Operative Timing on OcularOutcomes.” Plastic and Reconstructive Surgery Global Open 5 (2Suppl): 40-41. doi:10.1097/01.GOX.0000513452.31374.f3. http://dx.doi.org/10.1097/01.GOX.0000513452.31374.f3.Published Version doi:10.1097/01.GOX.0000513452.31374.f3Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:32072205Terms of Use This article was downloaded from Harvard University’s DASHrepository, and is made available under the terms and conditionsapplicable to Other Posted Material, as set forth at http://nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of-use#LAA40PRS Global Open • 2017over free flaps for fear of impairing flap perfusion and/or assessment. In 2011 we described the use of NPDs over skin grafted free muscle flaps in 13 cases, showing favorable results.METHODS: We performed a retrospective review of these cases performed at 2 institutions over a 6 year period.RESULTS: The majority of flaps were for lower extremity trauma wounds (74), followed by upper extremity trauma wounds (8), scalp tumor defects (4), and one torso wound. There were 7 flap losses, but of these, 4 were due to non-compliance with postoperative immobilization/elevation orders; excluding these 4 failures for which the NPD was clearly not a factor, the flap success rate was 96.4%. Skin graft healing was uniformly excellent, with the exception of the above 7 cases, as well as 2 graft losses due to disruption during flap takeback, 2 partial graft losses due to infection, and 1 partial graft loss due to hematoma. In only one case (a scalp flap), the NPD was discontinued early, on postopera-tive day 1, due to inability to maintain a seal.CONCLUSION: This series strongly suggests that NPDs do not contribute to free flap failure. While we do believe there are important technical caveats to NPD placement over free flaps, we feel that NPDs are safe, effective, and in many ways advantageous in this setting.36. COST ANALYSIS OF TWO STAGED IMPLANTS WITH ALLODERM AND DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP AUTOLOGOUS RECONSTRUCTIONBao Ngoc Tran, M.D., Ayotunde Fadayomi, MBBS, MPH, Dhruv Singhal, M.D., Bernard Lee, M.D., MPH, MBA, FACSBeth Israel Deaconess Medical Center, Boston, MA, USA.PURPOSE: Two staged tissue expander-implant recon-struction with acellular matrix (TE/I+ADM) and deep infe-rior epigastric perforator flaps (DIEP) are the most common implant and autologous methods of reconstruction in the U.S. respectively. Implant based techniques are dispropor-tionally more popular, partially due to their presumed cost effectiveness.METHODS: We performed a comprehensive cost-utility analysis to compare (TE/I+ADM) and (DIEP). Medicare reimbursement costs for each procedure and their associ-ated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using studies from 2010–2016.RESULTS: The average cost for a successful TE/I+ADM and DIEP were $13,680.75 and $10,237.13 respectively. Incorporating pooled complication data from the published literature, an excess cost of $14,348.2 for TE/I+ADM and $11,395 for DIEP reconstruction was calculated. The expected costs for a successful TE/I+ADM and DIEP reconstruction were $9,974.63 and $7,395.30, significantly lower than the actual costs.CONCLUSION: When comparing TE/I+ADM to DIEP flap reconstruction, DIEP flaps are more cost effective both at baseline and when factoring pooled complications and secondary procedures. These findings can be used to develop a decision analysis model when providing care to patients.37. PEDIATRIC ORBITAL FLOOR FRACTURES: CLINICAL AND RADIOLOGICAL PREDICTORS OF TISSUE ENTRAPMENT AND THE EFFECT OF OPERATIVE TIMING ON OCULAR OUTCOMESJoseph M. Firriolo, M.D., Nicole C. Ontiveros, BA, Carolyn M. Pike, MPH, John G. Meara, M.D., DM.D., MBA, Arin K. Greene, M.D., MMSc, Oren Ganor, M.D., Amir Taghinia, M.D., MPH, Brian I. Labow, M.D.Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA.PURPOSE: To determine the clinical and radiological pre-dictors of tissue entrapment in pediatric orbital floor frac-tures and to explore the effect of operative timing on ocular outcomes.METHODS: We retrospectively reviewed the medical records of pediatric patients (aged <18 years) who acutely 41AAPS 2017 Abstract SupplementMonday,  March 27, 2017presented with orbital floor fractures from October 2007 to October 2015.RESULTS: 152 patients with 159 orbital floor fractures were included. 122 (80.3%) patients were male, and the mean age was 12.2 years. Twelve patients (7.9%) sustained orbital floor fractures with tissue entrapment. At presenta-tion extraocular movement (EOM) restriction, diplopia, nausea, and vomiting were all associated with tissue entrap-ment (P<0.001). Amongst patients with trapdoor fractures, the presence of nausea and/or vomiting was predictive of tissue entrapment: positive predictive value 80%, negative predictive value 100%. For patients with tissue entrapment, poorer ocular outcomes (persistent EOM restriction and diplopia) were significantly associated with the length of operation (P=0.007), but not with the time interval to opera-tion (P=0.146).CONCLUSION: Nausea and vomiting are valuable predic-tors of tissues entrapment, particularly when EOM restric-tion and diplopia are equivocal. In our study, radiological findings were predictive of entrapment, but a lack of con-sistent language in this area limits the external validity of these results. Our study draws attention to the relationship between operation length and poorer ocular outcomes, sug-gesting that case severity/complexity and surgeon tech-nique/experience may influence ocular outcomes.38. ATYPICAL PROLIFERATIVE LESIONS AFTER REDUCTION MAMMAPLASTY: INCIDENCE AND IMPLICATIONS IN 993 REDUCTIONSAmy S. Colwell, M.D., Melissa Mastroianni, M.D., Alex Lin, M.S., William G. Austen, Jr., M.D.Massachusetts General Hospital, Boston, MA, USA.PURPOSE: Reduction mammoplasty occasionally reveals unsuspected proliferative lesions or carcinoma. Few stud-ies examine incidence, risk factors, and outcomes in this population.METHODS: Retrospective review was performed between 2000 and 2012. Pathology was categorized as benign, pro-liferative, or cancer (DCIS or invasive).RESULTS: Five hundred seventy-three patients had 993 reduction mammaplasties (85% bilateral, 15% unilateral). Cancer was detected in 23 (2.3%) specimens and prolif-erative lesions in 148 (14.9%). Compared to patients with benign pathology, patients with proliferative lesions or cancer were older (p<0.001), with larger BMI (p=0.001), increased unilateral procedures (p<0.001) and more had a history of cancer (p<0.001). On multivariate regression analysis, age and prior breast cancer were independent risk factors for proliferative lesions (OR 1.057, CI 1.039–1.075, p<0.001 and OR 2.201, CI 1.291–3.752, p=0.004) and age significantly predicted cancer (OR 1.050, CI 1.009–1.093, p=0.015). There was no association with resection weight (p>0.5). Fifty-four percent of patients with proliferative lesions and no history of cancer had a change in manage-ment with increased surveillance, hormones, radiation, che-motherapy, or surgery. If there was a history of cancer, 31% had a change in management. Of patients with DCIS or can-cer, all required treatment.CONCLUSION: Proliferative lesions of the breast may be more common that previously reported. Age and a history of breast cancer increase risk for proliferative lesions. All should be referred to oncology.39. A COMPARISON OF OPEN VERSUS ENDOSCOPIC CARPAL TUNNEL RELEASE WITHIN THE SAME PATIENTKavita T. Vakharia, M.D., Brett F. Michelotti, M.D., Diane Romanowsky, PA-C, Randy M. Hauck, M.D.Penn State Hershey Medical Center/College of Medicine, Hershey, PA, USA.PURPOSE: Several studies have shown less postopera-tive pain and faster improvement in grip and pinch strength with the endoscopic technique. The goal of this study was to prospectively examine subjective and functional outcomes, satisfaction, and complications after both ECTR and OCTR in the opposite hands of the same patient.METHODS: This was a prospective, randomized study in which patients with bilateral carpal tunnel syndrome under-went surgical release with both endoscopic and open tech-niques. The initial operative approach utilized was randomly assigned to the more symptomatic hand. Demographic data 

Abstract 37. Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

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Abstract P11: Pediatric Orbital Floor Fractures: Clinical and Radiological Predictors of Tissue Entrapment and the Effect of Operative Timing on Ocular Outcomes

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