This document summarizes the results of a retrospective audit assessing the financial implications of breast reconstruction procedures. It analyzed 274 patients who underwent 278 primary breast reconstructions and 366 secondary procedures between 2000-2007. DIEP flap reconstruction had the longest average length of stay but also the highest costs. Implant reconstruction had fewer secondary procedures on average but costs were still substantial due to additional procedures needed. The document concludes that while autologous reconstruction provides better long-term symmetry, the current tariff system financially discourages immediate and bilateral breast reconstruction procedures.
The document discusses various local flap options for reconstructing fingertip injuries. It describes the anatomy of the fingertip and goals of reconstruction which are to close wounds, maximize sensation, preserve length and function. Local flap options mentioned include volar V-Y flaps, bilateral V-Y flaps, cross-finger flaps, thenar flaps and lateral island flaps. Choice of flap depends on wound orientation and configuration.
Z-plasty is a surgical technique used to close wounds where two triangular flaps based on a shared limb are transposed to close each other's defects, increasing the length of scars. The degree of elongation depends on the angle of the flaps, with greater angles providing more lengthening up to 125% for 90 degree flaps. Multiple opposing or adjacent Z-plasties can be combined for even greater lengthening effect.
The document discusses common hand tumours such as ganglion, giant cell tumour of tendon sheath, and epidermoid inclusion cysts. It provides details on clinical presentation, investigations, classification systems, and treatment approaches for various bone and soft tissue tumours that can occur in the hand. Common malignant tumours of the hand discussed include synovial sarcoma, clear cell sarcoma, chondrosarcoma, and osteosarcoma.
This document discusses principles of tendon transfers. Tendon transfers involve reattaching a functioning tendon to replace a paralyzed or injured tendon. Key points include indications such as nerve injuries or ruptured tendons. Donor tendons should match the amplitude, power, and function needed. Timing depends on factors like prognosis. Post-operative rehabilitation is important to regain motion and train new muscle functions. The goal is to restore useful hand function rather than just motion.
Flaps and grafts are used in reconstructive surgery to restore form and function. A flap maintains its blood supply, and can be skin, muscle, bone or composite tissue. Key differences between flaps and grafts are discussed. Various flap types are described based on their components, relationship to the defect, blood supply nature, and movement. Reconstructive goals include separating cavities, protecting structures, obtaining wound healing, restoring function and aesthetics. Specific flap choices are outlined for pharyngeal and mandibular defects, facial reanimation, and tongue reconstruction.
This document discusses Cubital Tunnel Syndrome and Ulnar Tunnel Syndrome. Cubital Tunnel Syndrome involves compression of the ulnar nerve at the elbow, and can cause sensory changes and weakness in the hand. It is often treated initially with splinting and anti-inflammatories, and may require surgical decompression or transposition of the nerve. Ulnar Tunnel Syndrome (Guyon's canal) involves compression in the wrist and can cause numbness and weakness, sometimes from conditions like ganglions or fractures; its treatment may involve surgical release of the canal.
The radial nerve originates from the posterior cord of the brachial plexus and innervates the triceps brachii, anconeus, brachioradialis, extensor carpi radialis longus and brevis muscles. It provides sensory innervation to the posterior aspect of the forearm and back of the hand. Damage to the radial nerve can result in weakness of wrist and finger extension.
This document discusses the anatomy and injuries of the proximal interphalangeal joint (PIPJ). The PIPJ is stabilized by articular contours, ligaments including the collateral and volar plate ligaments, and adjacent tendons. Dorsal dislocations of the PIPJ can be classified as Type I-III depending on the degree of ligament disruption and presence of fractures. Treatment depends on whether the injury is open or closed, stable or unstable, and may involve splinting, traction, pinning, open reduction and internal fixation, or tenodesis. Complications can include redisplacement, angular deformity, contractures, and stiffness.
The document discusses various local flap options for reconstructing fingertip injuries. It describes the anatomy of the fingertip and goals of reconstruction which are to close wounds, maximize sensation, preserve length and function. Local flap options mentioned include volar V-Y flaps, bilateral V-Y flaps, cross-finger flaps, thenar flaps and lateral island flaps. Choice of flap depends on wound orientation and configuration.
Z-plasty is a surgical technique used to close wounds where two triangular flaps based on a shared limb are transposed to close each other's defects, increasing the length of scars. The degree of elongation depends on the angle of the flaps, with greater angles providing more lengthening up to 125% for 90 degree flaps. Multiple opposing or adjacent Z-plasties can be combined for even greater lengthening effect.
The document discusses common hand tumours such as ganglion, giant cell tumour of tendon sheath, and epidermoid inclusion cysts. It provides details on clinical presentation, investigations, classification systems, and treatment approaches for various bone and soft tissue tumours that can occur in the hand. Common malignant tumours of the hand discussed include synovial sarcoma, clear cell sarcoma, chondrosarcoma, and osteosarcoma.
This document discusses principles of tendon transfers. Tendon transfers involve reattaching a functioning tendon to replace a paralyzed or injured tendon. Key points include indications such as nerve injuries or ruptured tendons. Donor tendons should match the amplitude, power, and function needed. Timing depends on factors like prognosis. Post-operative rehabilitation is important to regain motion and train new muscle functions. The goal is to restore useful hand function rather than just motion.
Flaps and grafts are used in reconstructive surgery to restore form and function. A flap maintains its blood supply, and can be skin, muscle, bone or composite tissue. Key differences between flaps and grafts are discussed. Various flap types are described based on their components, relationship to the defect, blood supply nature, and movement. Reconstructive goals include separating cavities, protecting structures, obtaining wound healing, restoring function and aesthetics. Specific flap choices are outlined for pharyngeal and mandibular defects, facial reanimation, and tongue reconstruction.
This document discusses Cubital Tunnel Syndrome and Ulnar Tunnel Syndrome. Cubital Tunnel Syndrome involves compression of the ulnar nerve at the elbow, and can cause sensory changes and weakness in the hand. It is often treated initially with splinting and anti-inflammatories, and may require surgical decompression or transposition of the nerve. Ulnar Tunnel Syndrome (Guyon's canal) involves compression in the wrist and can cause numbness and weakness, sometimes from conditions like ganglions or fractures; its treatment may involve surgical release of the canal.
The radial nerve originates from the posterior cord of the brachial plexus and innervates the triceps brachii, anconeus, brachioradialis, extensor carpi radialis longus and brevis muscles. It provides sensory innervation to the posterior aspect of the forearm and back of the hand. Damage to the radial nerve can result in weakness of wrist and finger extension.
This document discusses the anatomy and injuries of the proximal interphalangeal joint (PIPJ). The PIPJ is stabilized by articular contours, ligaments including the collateral and volar plate ligaments, and adjacent tendons. Dorsal dislocations of the PIPJ can be classified as Type I-III depending on the degree of ligament disruption and presence of fractures. Treatment depends on whether the injury is open or closed, stable or unstable, and may involve splinting, traction, pinning, open reduction and internal fixation, or tenodesis. Complications can include redisplacement, angular deformity, contractures, and stiffness.
The document summarizes the anatomy of the hand, including:
1) The skin, fascia, muscles, blood vessels, and nerves of the palm and dorsum. Key structures include the thenar and hypothenar muscles innervated by the median and ulnar nerves respectively.
2) The flexor tendons in the hand pass through zones in the flexor sheath and connect to the phalanges via pulleys.
3) Extensor tendons are separated into compartments by the extensor retinaculum and pass dorsally to extend the fingers.
4) Interossei muscles abduct and adduct the fingers at the MCP and PIP joints.
The document discusses emergency management of burns. It provides information on common causes of burns, pathophysiology involving initial and secondary tissue damage, burn wound classification models, and initial management steps of EMSB (airway, breathing, circulation, disability, exposure, fluids). It also covers assessment of burn severity and extent, wound care, fluid resuscitation guidelines, signs necessitating escharotomy or burn unit transfer, and the evolving nature of burn wounds over time.
Annual scientific congress perth couplerdrmoradisyd
This document discusses the venous coupler as an alternative to sutures for microvascular anastomoses. It provides a brief history of vascular couplers and summarizes previous animal and clinical studies showing couplers can create anastomoses faster than sutures with similar or better patency rates. A study at Imperial College London directly compared the time and costs of using couplers versus sutures for venous anastomoses, finding couplers were significantly faster, saved over 12 minutes of ischemia time per case, and were cost effective after accounting for equipment and material costs.
The document provides guidance on suturing techniques. It recommends everting the skin edges when suturing to achieve better dermal apposition, improved healing, and a finer scar. A triangular suture passage with the base located deeply is suggested to evert the wound edges, while an inverted triangular shape tends to invert them. Dermal sutures are recommended first to reduce tension before cutaneous sutures. Adjusting where the knot lies can help flatten steps between uneven wound edges. The document also reviews appropriate suture materials for different areas, recommending absorbable sutures that elicit minimal tissue reaction for the face and longer-absorbing sutures for prone areas like the back.
Flaps and grafts are used in reconstructive surgery to restore form and function. A flap maintains its blood supply, while a graft does not. There are several types of flaps characterized by their tissue components and blood supply. Free flaps use tissue transferred without a pedicle, while pedicled flaps maintain an attachment. Reconstructive procedures aim to separate cavities, restore function, and provide aesthetically pleasing results with minimal complications. Specific flap choices are tailored to the goals and defects in pharyngeal, mandibular, facial, and tongue reconstruction.
This document discusses flexor tendon zones, tenosynovitis (infection of the flexor tendon sheath), and its diagnosis and treatment. Tenosynovitis most often results from penetrating trauma near joint creases. It causes purulence and adhesions within the sheath, destroying gliding and blood supply. Key signs are tenderness over the sheath, swelling of the digit, and pain with passive extension. Early cases may be treated with antibiotics but established infections require prompt surgical drainage to prevent tendon and skin necrosis.
This document describes the anatomy and reconstruction of the eyelids. It discusses:
1. The layers and structures of the eyelid including the skin, orbicularis oculi muscle, tarsal plates, levator palpebrae superioris muscle, and conjunctiva.
2. Embryology, blood supply, innervation, and cross section of the eyelid.
3. Specific structures like the orbital septum, tarsal plates, pre-aponeurotic fat, and lacrimal system.
4. Goals and requirements of eyelid reconstruction including reestablishing function, protection, cosmesis as well as anterior and posterior lamellae reconstruction techniques.
Evidence based medicine and cosmetic surgerydrmoradisyd
This document discusses the relationship between evidence-based medicine and aesthetic plastic surgery. It provides definitions of evidence-based medicine and outlines its five primary components. The document then examines several examples of how evidence-based medicine has been applied to topics in aesthetic plastic surgery, including bariatric surgery outcomes, breast augmentation practices like antibiotic use and drain usage, and outcomes of facelifts with or without drain usage. It acknowledges that while plastic surgery literature often contains lower levels of evidence, the field should aim to both appreciate existing evidence and continue raising the overall level of evidence to best serve patients.
Scaphoid fractures are the most common carpal bone fractures, often occurring in young adults from falls on an outstretched hand. The scaphoid has a tenuous blood supply and is prone to non-union, especially for proximal pole fractures. Treatment depends on fracture type and stability, ranging from casting to operative fixation with screws. Complications include malunion, delayed union, non-union and avascular necrosis, requiring further procedures like bone grafting or carpal fusion.
Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel. While open carpal tunnel release was previously the standard treatment, endoscopic carpal tunnel release has gained popularity as an alternative. Multiple reviews have found no difference in symptom relief between the two techniques. Evidence is conflicting on whether endoscopic surgery results in earlier return to work. Endoscopic surgery is associated with a higher risk of reversible median nerve injury but results in superior grip strength and less scar tenderness in the short term. Further research is still needed to make definitive conclusions about the relative effectiveness of open versus endoscopic carpal tunnel release.
Squamous cell carcinoma (SCC) is the second most common skin cancer. It has a propensity to metastasize, making it responsible for most skin cancer deaths. Risk factors include UV exposure, age, immunosuppression, and primary dermatoses. Histological subtypes include pleomorphic, adenoid, small cell, verrucous, and keratoacanthoma. Tumor size greater than 2 cm and depth greater than 6 mm increase metastatic risk. Treatment involves surgical excision with adequate margins or other modalities like radiation for high risk cases.
Mucous cysts of the DIPJ usually occur in older adults and are associated with osteoarthritis. They contain mucin and form from degeneration of joint structures. Clinically, they appear as nodules near the DIPJ that can cause nail deformities. Treatment involves surgical excision, sometimes with additional procedures like osteophyte removal. Complications include residual deformities, stiffness, skin issues, and recurrence due to incomplete excision or persistent arthritis.
A 48-year-old man who lost 200 kg through diet and exercise underwent a lower body lift. During the 4-hour, 2-surgeon procedure, he required repositioning 3 times and 6 drains. Post-operatively he developed hemorrhages requiring exploration. He was discharged after 8 days requiring weekly drainage of seromas. The document discusses nutritional deficiencies common after bariatric surgery that can impact wound healing for body contouring procedures. It notes diet and exercise patients have higher complication rates than those who had bariatric surgery. Careful patient evaluation and counseling is important due to the risks and limitations of massive weight loss body contouring.
Basal cell carcinoma is a malignant skin tumor caused by chronic sun exposure. It is most common in areas with high sun exposure like the head and neck. While typically slow-growing and non-metastatic, it can cause local tissue destruction if left untreated. Treatment options include surgical excision, Mohs micrographic surgery, cryotherapy, and topical chemotherapy. The goal of treatment is complete removal of the tumor while preserving skin and function.
This document describes the arterial blood supply and potential flaps in the lower limb. It discusses various fasciocutaneous and musculocutaneous flaps that can be raised based on named arteries in the lower limb, including the femoral, lateral circumflex femoral, profunda femoris, popliteal, and posterior tibial arteries. Specific flaps are described such as the anteromedial thigh flap, gracilis flap, and gastrocnemius flap. The angiosome concept and variations in vascular anatomy are also covered.
This document discusses the physiology and process of skin grafts. It describes the layers of skin - epidermis and dermis - and their functions. It explains the classification of different types of skin grafts including full thickness and split thickness grafts. The document then outlines the four phases of "take" that a skin graft undergoes as it revascularizes and attaches to the recipient bed. It provides details on the histological and structural changes that occur in the epidermis and dermis during the healing process over subsequent days and weeks. Factors that influence graft survival and potential causes of graft failure are also summarized.
Akademikliniken (AK) is a plastic surgery clinic in Stockholm with two centers and over 100 employees. They offer a 1-year unpaid fellowship that provides housing and meals. Starting this year, the fellowship will be formalized into a paid 1-year program. The fellow would assist with over 4,500 operations per year, primarily aesthetic procedures. In Moradi's 4.5 month fellowship, he assisted with over 300 cases across facial aesthetics, breast procedures, body contouring surgeries, and free flaps. The clinic also hosts monthly masterclasses and social events for fellows and surgeons.
Annual scientific congress perth siea vs diepdrmoradisyd
The document discusses a study comparing abdominal drain volumes and seroma rates between SIEA (superficial inferior epigastric artery) flaps and DIEP (deep inferior epigastric perforator) flaps for breast reconstruction. The study found that SIEA flaps had significantly higher abdominal drain volumes than DIEP flaps, though length of hospital stay was only increased by about 1 day. SIEA flaps also showed a non-significant trend toward higher rates of outpatient seroma aspiration. While SIEA flaps are less invasive than DIEP flaps, this study suggests they may be associated with increased abdominal seroma rates post-operatively.
This case report describes a rare case of an acquired anterior thoracic lung herniation in a 63-year-old female that developed four years after video-assisted thoracic surgery (VATS) for lung cancer resection and adjuvant radiation for breast cancer. The 8 cm x 10 cm chest wall defect was reconstructed with mesh and reinforced with a latissimus dorsi flap. The authors believe the herniation was caused by intercostal muscle denervation from the distant VATS and soft tissue damage from radiation. The patient had complete resolution of symptoms after surgical repair. The case demonstrates that lung herniation can occur remotely from VATS incision sites due to potential nerve or muscle injury during the procedure.
The radial nerve originates from cervical and thoracic nerve roots and is the largest branch of the brachial plexus. It provides cutaneous innervation to the posterior arm and forearm and motor innervation to triceps, brachioradialis, and extensor muscles of the forearm and hand. The radial nerve is vulnerable to compression at the radial tunnel as it travels through the forearm. Compression can cause radial tunnel syndrome. The superficial branch of the radial nerve can be affected by Wartenberg syndrome. Radial nerve palsy can result from fractures, injuries, tumors, or iatrogenic causes.
These documents summarize several studies that evaluated the costs of various interventional radiology (IR) procedures compared to alternative treatments. The studies used a variety of methods to calculate costs, including activity-based costing, cost center reporting, Medicare claims data, and hospital cost databases. The results generally found that IR procedures had lower total costs, shorter hospital stays, and fewer complications compared to alternative treatments, making many IR procedures more cost-effective options. Presenting research also suggested that complications from central venous access can lead to significantly higher costs and longer hospitalizations.
With help of two suitable example, Explain following concept under operating costing in case of a transporter (Hotel / Hospital)
Solution:-
1. Fixed Cost / Standing Cost, Variable Cost. Absolute tonne km, Commercial Tonne Km.Effective passenger km.
2. Decision making
3. Integral accounting system
4. Non - Integral Accounting System
The document summarizes the anatomy of the hand, including:
1) The skin, fascia, muscles, blood vessels, and nerves of the palm and dorsum. Key structures include the thenar and hypothenar muscles innervated by the median and ulnar nerves respectively.
2) The flexor tendons in the hand pass through zones in the flexor sheath and connect to the phalanges via pulleys.
3) Extensor tendons are separated into compartments by the extensor retinaculum and pass dorsally to extend the fingers.
4) Interossei muscles abduct and adduct the fingers at the MCP and PIP joints.
The document discusses emergency management of burns. It provides information on common causes of burns, pathophysiology involving initial and secondary tissue damage, burn wound classification models, and initial management steps of EMSB (airway, breathing, circulation, disability, exposure, fluids). It also covers assessment of burn severity and extent, wound care, fluid resuscitation guidelines, signs necessitating escharotomy or burn unit transfer, and the evolving nature of burn wounds over time.
Annual scientific congress perth couplerdrmoradisyd
This document discusses the venous coupler as an alternative to sutures for microvascular anastomoses. It provides a brief history of vascular couplers and summarizes previous animal and clinical studies showing couplers can create anastomoses faster than sutures with similar or better patency rates. A study at Imperial College London directly compared the time and costs of using couplers versus sutures for venous anastomoses, finding couplers were significantly faster, saved over 12 minutes of ischemia time per case, and were cost effective after accounting for equipment and material costs.
The document provides guidance on suturing techniques. It recommends everting the skin edges when suturing to achieve better dermal apposition, improved healing, and a finer scar. A triangular suture passage with the base located deeply is suggested to evert the wound edges, while an inverted triangular shape tends to invert them. Dermal sutures are recommended first to reduce tension before cutaneous sutures. Adjusting where the knot lies can help flatten steps between uneven wound edges. The document also reviews appropriate suture materials for different areas, recommending absorbable sutures that elicit minimal tissue reaction for the face and longer-absorbing sutures for prone areas like the back.
Flaps and grafts are used in reconstructive surgery to restore form and function. A flap maintains its blood supply, while a graft does not. There are several types of flaps characterized by their tissue components and blood supply. Free flaps use tissue transferred without a pedicle, while pedicled flaps maintain an attachment. Reconstructive procedures aim to separate cavities, restore function, and provide aesthetically pleasing results with minimal complications. Specific flap choices are tailored to the goals and defects in pharyngeal, mandibular, facial, and tongue reconstruction.
This document discusses flexor tendon zones, tenosynovitis (infection of the flexor tendon sheath), and its diagnosis and treatment. Tenosynovitis most often results from penetrating trauma near joint creases. It causes purulence and adhesions within the sheath, destroying gliding and blood supply. Key signs are tenderness over the sheath, swelling of the digit, and pain with passive extension. Early cases may be treated with antibiotics but established infections require prompt surgical drainage to prevent tendon and skin necrosis.
This document describes the anatomy and reconstruction of the eyelids. It discusses:
1. The layers and structures of the eyelid including the skin, orbicularis oculi muscle, tarsal plates, levator palpebrae superioris muscle, and conjunctiva.
2. Embryology, blood supply, innervation, and cross section of the eyelid.
3. Specific structures like the orbital septum, tarsal plates, pre-aponeurotic fat, and lacrimal system.
4. Goals and requirements of eyelid reconstruction including reestablishing function, protection, cosmesis as well as anterior and posterior lamellae reconstruction techniques.
Evidence based medicine and cosmetic surgerydrmoradisyd
This document discusses the relationship between evidence-based medicine and aesthetic plastic surgery. It provides definitions of evidence-based medicine and outlines its five primary components. The document then examines several examples of how evidence-based medicine has been applied to topics in aesthetic plastic surgery, including bariatric surgery outcomes, breast augmentation practices like antibiotic use and drain usage, and outcomes of facelifts with or without drain usage. It acknowledges that while plastic surgery literature often contains lower levels of evidence, the field should aim to both appreciate existing evidence and continue raising the overall level of evidence to best serve patients.
Scaphoid fractures are the most common carpal bone fractures, often occurring in young adults from falls on an outstretched hand. The scaphoid has a tenuous blood supply and is prone to non-union, especially for proximal pole fractures. Treatment depends on fracture type and stability, ranging from casting to operative fixation with screws. Complications include malunion, delayed union, non-union and avascular necrosis, requiring further procedures like bone grafting or carpal fusion.
Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel. While open carpal tunnel release was previously the standard treatment, endoscopic carpal tunnel release has gained popularity as an alternative. Multiple reviews have found no difference in symptom relief between the two techniques. Evidence is conflicting on whether endoscopic surgery results in earlier return to work. Endoscopic surgery is associated with a higher risk of reversible median nerve injury but results in superior grip strength and less scar tenderness in the short term. Further research is still needed to make definitive conclusions about the relative effectiveness of open versus endoscopic carpal tunnel release.
Squamous cell carcinoma (SCC) is the second most common skin cancer. It has a propensity to metastasize, making it responsible for most skin cancer deaths. Risk factors include UV exposure, age, immunosuppression, and primary dermatoses. Histological subtypes include pleomorphic, adenoid, small cell, verrucous, and keratoacanthoma. Tumor size greater than 2 cm and depth greater than 6 mm increase metastatic risk. Treatment involves surgical excision with adequate margins or other modalities like radiation for high risk cases.
Mucous cysts of the DIPJ usually occur in older adults and are associated with osteoarthritis. They contain mucin and form from degeneration of joint structures. Clinically, they appear as nodules near the DIPJ that can cause nail deformities. Treatment involves surgical excision, sometimes with additional procedures like osteophyte removal. Complications include residual deformities, stiffness, skin issues, and recurrence due to incomplete excision or persistent arthritis.
A 48-year-old man who lost 200 kg through diet and exercise underwent a lower body lift. During the 4-hour, 2-surgeon procedure, he required repositioning 3 times and 6 drains. Post-operatively he developed hemorrhages requiring exploration. He was discharged after 8 days requiring weekly drainage of seromas. The document discusses nutritional deficiencies common after bariatric surgery that can impact wound healing for body contouring procedures. It notes diet and exercise patients have higher complication rates than those who had bariatric surgery. Careful patient evaluation and counseling is important due to the risks and limitations of massive weight loss body contouring.
Basal cell carcinoma is a malignant skin tumor caused by chronic sun exposure. It is most common in areas with high sun exposure like the head and neck. While typically slow-growing and non-metastatic, it can cause local tissue destruction if left untreated. Treatment options include surgical excision, Mohs micrographic surgery, cryotherapy, and topical chemotherapy. The goal of treatment is complete removal of the tumor while preserving skin and function.
This document describes the arterial blood supply and potential flaps in the lower limb. It discusses various fasciocutaneous and musculocutaneous flaps that can be raised based on named arteries in the lower limb, including the femoral, lateral circumflex femoral, profunda femoris, popliteal, and posterior tibial arteries. Specific flaps are described such as the anteromedial thigh flap, gracilis flap, and gastrocnemius flap. The angiosome concept and variations in vascular anatomy are also covered.
This document discusses the physiology and process of skin grafts. It describes the layers of skin - epidermis and dermis - and their functions. It explains the classification of different types of skin grafts including full thickness and split thickness grafts. The document then outlines the four phases of "take" that a skin graft undergoes as it revascularizes and attaches to the recipient bed. It provides details on the histological and structural changes that occur in the epidermis and dermis during the healing process over subsequent days and weeks. Factors that influence graft survival and potential causes of graft failure are also summarized.
Akademikliniken (AK) is a plastic surgery clinic in Stockholm with two centers and over 100 employees. They offer a 1-year unpaid fellowship that provides housing and meals. Starting this year, the fellowship will be formalized into a paid 1-year program. The fellow would assist with over 4,500 operations per year, primarily aesthetic procedures. In Moradi's 4.5 month fellowship, he assisted with over 300 cases across facial aesthetics, breast procedures, body contouring surgeries, and free flaps. The clinic also hosts monthly masterclasses and social events for fellows and surgeons.
Annual scientific congress perth siea vs diepdrmoradisyd
The document discusses a study comparing abdominal drain volumes and seroma rates between SIEA (superficial inferior epigastric artery) flaps and DIEP (deep inferior epigastric perforator) flaps for breast reconstruction. The study found that SIEA flaps had significantly higher abdominal drain volumes than DIEP flaps, though length of hospital stay was only increased by about 1 day. SIEA flaps also showed a non-significant trend toward higher rates of outpatient seroma aspiration. While SIEA flaps are less invasive than DIEP flaps, this study suggests they may be associated with increased abdominal seroma rates post-operatively.
This case report describes a rare case of an acquired anterior thoracic lung herniation in a 63-year-old female that developed four years after video-assisted thoracic surgery (VATS) for lung cancer resection and adjuvant radiation for breast cancer. The 8 cm x 10 cm chest wall defect was reconstructed with mesh and reinforced with a latissimus dorsi flap. The authors believe the herniation was caused by intercostal muscle denervation from the distant VATS and soft tissue damage from radiation. The patient had complete resolution of symptoms after surgical repair. The case demonstrates that lung herniation can occur remotely from VATS incision sites due to potential nerve or muscle injury during the procedure.
The radial nerve originates from cervical and thoracic nerve roots and is the largest branch of the brachial plexus. It provides cutaneous innervation to the posterior arm and forearm and motor innervation to triceps, brachioradialis, and extensor muscles of the forearm and hand. The radial nerve is vulnerable to compression at the radial tunnel as it travels through the forearm. Compression can cause radial tunnel syndrome. The superficial branch of the radial nerve can be affected by Wartenberg syndrome. Radial nerve palsy can result from fractures, injuries, tumors, or iatrogenic causes.
These documents summarize several studies that evaluated the costs of various interventional radiology (IR) procedures compared to alternative treatments. The studies used a variety of methods to calculate costs, including activity-based costing, cost center reporting, Medicare claims data, and hospital cost databases. The results generally found that IR procedures had lower total costs, shorter hospital stays, and fewer complications compared to alternative treatments, making many IR procedures more cost-effective options. Presenting research also suggested that complications from central venous access can lead to significantly higher costs and longer hospitalizations.
With help of two suitable example, Explain following concept under operating costing in case of a transporter (Hotel / Hospital)
Solution:-
1. Fixed Cost / Standing Cost, Variable Cost. Absolute tonne km, Commercial Tonne Km.Effective passenger km.
2. Decision making
3. Integral accounting system
4. Non - Integral Accounting System
Endovascular revascularization is generally a cost-effective treatment for critical limb ischemia. Studies show that angioplasty has a lower cost than bypass surgery but provides similar effectiveness in terms of amputation prevention and quality-adjusted life years gained over a 3 year period. For patients with intermittent claudication, adding endovascular or surgical revascularization to a background of optimal medical treatment including exercise can improve walking ability and quality of life compared to exercise alone. Overall, endovascular techniques tend to be more cost-effective than open surgery for peripheral artery disease, but further reductions in reintervention rates could help increase cost-effectiveness. Disease prevention provides the most cost-effective approach.
11.56 vermassen site cost effectiveness endovascular def2Salutaria
Endovascular revascularization is generally a cost-effective treatment for critical limb ischemia. Studies show that angioplasty has a lower cost than bypass surgery per quality-adjusted life year gained, though bypass surgery provides better outcomes for patients likely to survive more than two years. For patients with intermittent claudication, adding endovascular or surgical revascularization to a regimen of exercise and medical management can improve walking ability and quality of life in a cost-effective manner compared to no intervention or exercise alone. Further reducing reintervention rates could help increase the cost-effectiveness of endovascular techniques relative to surgery.
This document summarizes a presentation given at the Primary Care Conference on livinghealth on November 17th, 2011 by Dr. David Molony. The presentation discussed innovation, research, and standards in primary care as well as barriers to development. Specific examples were given of an innovative warfarin clinic, a research study on ear health in the elderly, and developing standards for primary healthcare centers. Barriers to primary care development mentioned included a lack of flexibility and proper commitment of resources from hospitals. The presentation argued that primary care can provide many services more efficiently than hospitals and help address issues of cost and wait times if given more support and flexibility.
Breakout 2.4 Making the system work for you:Using levers and drivers to deliv...NHS Improvement
Breakout 2.4 Making the system work for you:Using levers and drivers to deliver change
Lesley Kitchen Advancing Quality, Programme Director
Part of a set of presentations from NHS Improvement event: Better value, better outcomes held on Thursday 21 February 2013,
Guoman Tower Hotel, London
How to deliver quality and value in chronic care:sharing the learning from the respiratory programme
Making the most of your PROM data, pop up uni, 10am, 2 september 2015NHS England
1) The document provides background on the national PROMs (patient-reported outcome measures) programme in the UK, which collects data on patient outcomes and experiences before and after various surgical procedures.
2) It discusses how PROMs data can be used to identify variations in outcomes across different provider trusts nationally and help trusts investigate areas for improvement.
3) It presents a case study from Northumbria Healthcare NHS Trust where they used their PROMs data to identify better outcomes associated with a particular knee replacement implant. They were able to significantly improve outcomes by changing to this implant.
4) It also discusses a study they did which found that preserving the infrapatella fat pad during knee replacements led to
This document provides an executive summary of a national review of adult elective orthopaedic services in England led by Professor Tim Briggs. The review found significant undesirable variation in orthopaedic practice and outcomes across the country. Emerging themes included low surgeon volume, failure to follow evidence on implants, and variation in pathways, management models, and commissioning relationships. The review aims to improve quality and reduce costs by reducing unwarranted variation and encouraging best practice. Over 200 hospitals were visited and individual reports provided. The methodology was effective and could be applied to other specialties.
Matthew Taylor and Alexandra Filby present on:
- What drives the outcomes in oncology models?
- Relationship between clinical effectiveness and cost-effectiveness
- Development of a tool to visualise the impact of survival on cost-effectiveness
- Evaluation of various scenarios
Objectives: Economic evaluations typically include all costs relevant to a disease. This is particularly relevant to oncology modelling, as costs are assigned to each health state in the model, and, therefore, extending survival also increases costs. Because patients often incur higher healthcare costs in the post-progressed state of disease where costs of disease management are high, extending survival and increasing a patient’s time in the post-progressed stage can be particularly costly. The objective of this research was to investigate the methodology used in oncology modelling, and to determine the effect that this has on predicted cost-effectiveness.
Methods: A simple three-state economic model was produced with with ten key parameters to calculate the ICERs associated with various combinations of inputs. Extensive scenario and multiway sensitivity analyses were carried out to document informative patterns and relationships between parameters that affected the results. Specifically, the model tested the impact of: (i) the relative duration of progression-free survival and post-progression survival, (ii) the shape and scale of parametric coefficients for survival, (iii) the impact of treatment duration and (iv) the time-dependency of post-progression costs.
Results: The paper presents the concept of a ‘natural ICER’, the value towards which the results tend as survival is indefinitely increased. Results showed that the ‘natural ICER’ is independent of the model design and the choice of survival inputs, and is driven purely by the cost and utility of the post-progressed state. In some cases with higher post-progression costs, the likelihood of a treatment being cost-effective decreased as the effectiveness of the treatment improved. The results demonstrate circumstances in which no matter how effective a treatment is and how low the price is, it will not be cost-effective.
Conclusions: The results demonstrate that when a treatment is not cost-effective, it is not always due to the pricing or effectiveness of the treatment. These results are due to the disease area (high post-progression background costs and low post-progression utility). For many oncology treatments whose primary aim is to extend survival, this impact can be prohibitive to an intervention’s probability of being cost-effective.
The document discusses improving clinical quality in orthopaedic care within the NHS in England. It notes significant increases in joint replacement procedures and revisions in recent years. There is huge variation between trusts in outcomes like infection rates, readmission rates, and litigation costs. The GIRFT program aims to address this variation by collecting comprehensive data on trusts, identifying best practices, and supporting implementation of quality improvements to achieve better outcomes and cost savings. The document advocates for more centralized specialty services and clinical networks to improve quality and training.
Economic analysis on art task shifting ppp (for athens conference)Naod Mekonnen
This study analyzed the economic impact of task shifting for antiretroviral treatment (ART) in Ethiopia using an econometric model. The study found that nurses and health officers spent 16% less time per patient visit and had 16% lower labor costs compared to physicians. However, there were no significant differences found between health center and hospital visit costs or between initial and follow-up visits. The results support task shifting as a cost-effective strategy for expanding ART access in Ethiopia. Future research could analyze additional factors like quality of care and incorporate more variables into the economic model.
Presentation by David Wonderling, Head of Health Economics at National Guideline Centre, Royal College of Physicians and Lauren Ramjee, Senior Health Economist, Royal College of Physicians.
This workshop outlines the principles of health economic evaluation for the NHS.
This document discusses cost-effectiveness analysis (CEA) and calculating the incremental cost-effectiveness ratio (ICER). There are 4 main types of CEA: cost-minimization analysis, CEA using natural units, cost-utility analysis using quality-adjusted life years (QALYs), and cost-benefit analysis using monetary units. The ICER is calculated as the incremental cost divided by the incremental effectiveness (e.g. cost per QALY gained) of a new intervention compared to the existing one. Key information needed includes outcomes and costs of both the existing and new interventions. An example ICER calculation for a new treatment for thingyitis is provided. Thresholds of willingness to pay per QAL
This document discusses how the Healthcare Quality Improvement Partnership (HQIP) supports quality improvement through various programs and tools. HQIP manages the National Clinical Audit Programme which includes 34 national audits across different clinical areas. It also oversees other national programmes focused on specific topics like learning disabilities. HQIP helps align quality improvement programs with NICE guidance and standards. Tools like clinical audits and the Quality Standard Service Improvement Template help providers assess current practice against standards and plan improvements. NICE guidance and quality standards can support quality improvement when implemented using these resources.
This document discusses the implementation of oesophageal Doppler monitoring (ODM) to guide fluid administration for major surgery patients at three NHS hospitals between 2008-2009. It finds that using ODM:
1) Reduced length of hospital stay by 4 days on average and critical care use by 17-42% compared to pre-implementation patients.
2) Decreased complication rates like re-admission by 25% and re-operation by 43%.
3) Was successfully adopted through engaging management and clinicians, training staff, and demonstrating improved outcomes from a controlled initial rollout.
Shouldice - A great success in service delivery10021980
The document provides details about Shouldice Hospital, which specializes in hernia repair surgery. It discusses the hospital's history and founding, operating procedures, success factors, costs, capacity, and options to increase capacity. Shouldice achieves high quality outcomes at a low cost through focus, efficiency, patient participation, and an emphasis on quality. It facilitates over 7,000 surgeries annually and has high patient satisfaction.
Costing for Hospitals - How to arrive at service level cost ?Manivannan S
Costing hospital Services poses serious challenges in identifying the basis of allocation of costs and the allocation itself. This PPT gives you the entire methodology
Slides from launch event on 16 July 2013 for CDE themed call for research proposals. For full details of this call see: http://www.science.mod.uk/events/event_detail.aspx?eventid=260
This is all the information that is available.Chapter 5 – Activity.pdfprajeetjain
This is all the information that is available.
Chapter 5 – Activity-Based Costing
St. Francis Healthcare and Dialysis Clinic
St. Francis Healthcare and Dialysis Clinic (SFHDC) is an independent, nonprofit full-service
renal dialysis clinic. The clinic provides two types of treatments. Hemodialysis (HD) requires
patients to visit a dialysis clinic three times a week, where they are connected to special,
expensive equipment to perform the dialysis. Peritoneal dialysis (PD) allows patients to
administer their own treatment daily at home. The clinic monitors PD patients and assists them in
ordering supplied consumed during the home treatment. The total and product-line income
statement for the clinic is shown below:
CLINIC INCOME STATEMENT
TOTAL
HD
PD
Revenues
Number of patients
164
102
62
Number of treatments
34,067
14,343
20,624
Total revenue
$3,006,775
$1,860,287
$1,146,488
Supply costs
Standard supplies (drugs, syringes)
664,900
512,619
152,281
Episodic supplies (for special conditions)
310,695
98,680
212,015
Total supply costs
975,595
611,299
364,296
Service costs
General overhead (occupancy, administration)
785,825
Durable equipment (maintenance, depreciation)
137,046
Nursing services (RNs, LPNs, nursing administrators
equipment technicians)
883,280
Total service costs
1,806,151
1,117,463
688,688
Total operating expenses
2,781,746
1,728,762
1,052,984
Net income
$225,029
$131,525
$93,504
Treatment Level Profit
Average charge per treatment
$129.70
$55.59
Average cost per treatment
120.53
51.06
Profit per treatment
$9.17
$4.53
The existing cost system assigned the traceable supply costs directly to the two types of
treatments. The service costs, however, were not analyzed by type of treatment. The total service
costs of $1,806,151 were allocated to the treatments using the ration-of-cost-to-charges (RCC)
method developed for government cost-based reimbursement programs. With this procedure,
since HD t4reatments represented about 61% of total revenues, HD received an allocation of
61% of the $1.8 million service expenses.
For many years, the clinics such as SFHDC received much of their reimbursement on the basis
of reported costs. Starting in 2015, however, payment mechanisms shifted, and now SFHDC
received most of its reimbursement on the basis of a fixed fee not the cost of the service
provided. In particular, because HD and PD procedures were categorized by the government as a
single category – dialysis treatment-the weekly reimbursement for each patient was the same
$389.10. As a consequence, the three HD treatments per week led to a reported revenue per HD
treatment of $129.70, and the seven PD treatments per week led to a reported revenue per PD
treatment of $55.59.
Both procedures appeared to be profitable, according to the clinic’s existing cost and revenue
recognition system. Francis Bernadone, the controller of SFHDC was concerned, however, that
the procedures currently being used to assign common expenses may not be representative of.
Workshop 3. Energy efficient improvement schemes/ reducing energy costs (incl. support with switching energy suppliers)
• Dr. Heather Brown, Newcastle University ‘What does research tell us? Findings from the evaluation of the Stockton ECO Scheme’
Similar to Economic viability of_autologous_breast_reconstruction_final (20)
Plastic and reconstructive surgery aims to restore form and function through surgical techniques. The key areas covered are anatomy of skin circulation via perforators, angiosomes, and vascular territories; skin physiology and function; and the reconstructive ladder of closure techniques from primary closure to grafts and flaps. Flaps maintain an intrinsic blood supply unlike skin grafts.
Carpal tunnel syndrome is caused by compression of the median nerve as it passes through the carpal tunnel. While open carpal tunnel release has traditionally been used to treat carpal tunnel syndrome, endoscopic carpal tunnel release is an alternative technique. Reviews of randomized controlled trials have found no clear difference in relief of symptoms between the two techniques. The evidence is conflicting on whether endoscopic carpal tunnel release results in earlier return to work compared to open release. Endoscopic release may provide superior short-term grip strength and less scar tenderness but risks more reversible median nerve injuries. Further research is still needed to make definitive conclusions.
Swan neck deformity is characterized by hyperextension of the proximal interphalangeal (PIP) joint and flexion of the distal interphalangeal (DIP) joint. It results from intrinsic tightness and extensor tendon imbalance caused by rheumatoid arthritis (RA). Management involves preventing further PIP hyperextension, restoring DIP extension, and addressing any underlying joint problems or soft tissue tightness based on the classification and pathophysiology. Surgical options range from splinting to tendon procedures to joint replacement depending on the severity of deformity and functional impairment.
This document discusses tendon transfers, which involve detaching the tendon of a functioning muscle and reattaching it to replace the function of a paralyzed muscle. The key points are:
1. Tendon transfers work to correct issues like instability, imbalance, lack of coordination, and restore function.
2. They are indicated for paralyzed muscles due to nerve injury, neurological disease, or nerve repair with early transfer. They are also used for injured tendons or muscles.
3. General principles include only restoring functional hand motion, considering patient factors, ensuring the recipient site is suitable, matching the donor muscle properties, and immobilizing initially to reduce tension.
Perineal reconstruction after pelvic surgery aims to restore form and function through flap reconstruction. The VRAM flap provides reliable vascularity, bulk, and a large skin paddle, making it the first choice for reconstruction. A study found VRAM flaps had significantly fewer complications than thigh flaps for perineal defects. Other flap options include the gracilis, posterior thigh, and perforator flaps from the gluteal arteries. Proper postoperative care is needed to ensure flap survival.
The document discusses the anatomy and tumours of the parotid gland. It describes the location and lobes of the parotid gland, its blood supply and innervation. It then discusses the various types of tumours that can occur in the parotid gland and other salivary glands, including pleomorphic adenoma, Warthin's tumour, mucoepidermoid carcinoma, adenoid cystic carcinoma, and metastatic carcinomas. It provides details on the histology, presentation and characteristics of these tumour types.
Orbital fractures involve breaks in the bones surrounding the eye socket. The orbital anatomy consists of 7 bones that form the pyramid-shaped orbit. Common types of orbital fractures include fractures of the orbital floor, medial wall, and lateral wall. Signs and symptoms vary depending on the structures involved but may include diplopia, limited eye movement, numbness, and vision changes. Evaluation involves history, exam of cranial nerves and eye movement, and CT scan. Treatment depends on findings but may involve initial management with ice and antibiotics followed by surgery to repair the fracture if indicated to address issues like diplopia or enophthalmos. Surgical approaches and potential complications are discussed.
This document describes the arterial blood supply to the lower limbs and various flap options based on these arteries. It outlines the vascular anatomy of arteries like the femoral artery and its branches, including the lateral circumflex femoral artery. It then provides details on specific musculocutaneous and fasciocutaneous flap options based on these arteries, such as the anteromedial thigh flap, anterolateral thigh flap, gracilis flap, and hamstring flaps.
Hand infections were a major cause of disability before antibiotics. Kanavel defined hand anatomy and drainage techniques. Penicillin reduced severe infections. Antibiotics alone rarely cure infections beyond 48 hours due to vessel thrombosis and pressure in closed spaces. Felons and paronychia each account for 1/3 of hand infections and usually result from minor trauma introducing Staph aureus. Flexor tenosynovitis is a surgical emergency to prevent tendon damage. Deep space infections involve the palmar, dorsal, thenar and midpalmar spaces and spread if not drained properly.
1. The authors present their 10-year experience with 43 jejunal free flaps for reconstruction following pharyngolaryngectomy.
2. They report a 100% acute flap survival rate and an overall benign fistula rate of 4.7%. No fistulas occurred in patients who received a prophylactic pectoralis major muscle flap after radiotherapy.
3. Using a gastrointestinal stapler for the proximal and distal anastomoses was associated with a lower fistula rate compared to hand-sewn anastomoses.
This document discusses different methods of classifying flaps used in reconstructive surgery. It describes classification based on composition, proximity to the defect, method of movement, and vascular anatomy. Specific types of flaps are also outlined including local, regional, distant, and free flaps as well as fascio/cutaneous and musculocutaneous flaps. Arterial supply, types of movement including advancement, transposition, and rotation are summarized.
This document discusses reconstructive options for fingertip injuries. The goals of reconstruction are to close wounds, maximize sensory return, preserve length and joint function, and obtain a cosmetic appearance. Options include healing by secondary intention, skin grafting, and local flap reconstruction using flaps such as volar V-Y flaps, bilateral V-Y flaps, cross-finger flaps, and thenar flaps. Major complications are hypersensitivity and cold intolerance, which usually resolve after 1-2 years.
2. Pouria Moradi
Alexander Hills
Duncan Atherton
Simon Wood
Charing Cross Hospital, London
ASC, Perth 2010
3. Aims
• Assess the financial implications of breast
reconstruction
• Establish whether the current gold standard of
DIEP is economically viable
4. Materials and methods
• Retrospective audit of:
– Procedure
– Length of stay
– Reconstructive amendments/corrections
– Cost
• For 1 surgeon, at 1 unit, between 2000-07
5. • Review of surgical diaries cross referenced
against electronic patient records
6. Results
• 274 patients
• Average age 48 years
• 278 primary breast reconstructions
• 366 secondary procedures
• Minimum of 1 year follow up
• Mean 3 year follow up
15. What are the financial implications
of the additional procedures?
16. What is the actual cost?
THEATRE TIME
• Half day list £3200
» Anaesthetic consultant
» ODP Nurse (Band 6)
» Theatre nurses (Band 6)
» Theatre nurse HCA (Band 2)
» Recovery Nurse (Band 6)
» A&C Support
» Limited non pay consumables
• So a DIEP/TRAM on a full list - £6400
• LD and implant - £3200
• Implant reconstruction - £1700
17. What other costs?
• In patient stay (£275 per night)
• DIEP/TRAM - 19 hours of one to one nursing -
£253 (vs £600 for ITU)
• OPD attendances (New £152, FU £78)
• (Mastectomy)
• LD/Implants - Prosthesis – (£250 – £700)
19. Tariff Disparity
• Paid solely for the principle procedure
• Separately the mastectomy tariff is £2623 and
axillary surgery £2549 (Total £5172)
– In 2009-10 with HRG4 coding it will vary from £5132-7015
– As not coded - no research grant for masectomy (£480)
• Immediate reconstruction financially discouraged
21. Conclusions
• Our belief that autologous reconstruction offers
better symmetry at 4-5 years
• Weight change impact on symmetry greater
with implants
• Minimal number of procedures
– Autologous less secondary procedures than
Implants
– Socio-economic costs related to repeat operations
Good morning, I’m Alexander Hills and today I am going to talk on ‘the economic viability of autologous breast reconstruction’
Our aim was to look at breast reconstruction as a whole and assess the financial implications of choosing one technique over another through this we aimed to establish whether DIEP, as the current AESTHETIC gold standard, was economically viable
To do this we conducted a retrospective audit looking at the primary procedures, length of stay, subsequent reconstructive amendments and cost It was based on one surgeons data, at one unit between 2000 and 2007
The data was extracted from surgical diaries and cross referenced against electronic patient records
We had 274 patients, with an average age of 48 years between them. These patients underwent a total of 278 primary reconstructions and a total of 366 secondary procedures They had a minimum follow up of 1 year, and a mean follow up of 3 years
This key graph outlines how our practice changed over the 7 years Looking at the grey bars, you can see how the practice of TRAMS has gradually faded following the introduction of the DIEP in 2004, shown here in blue, which quickly become the technique of choice. Likewise, if you now look at purple bars, representing Latissimus Dorsi’s, you can see how they were by far the most commonly performed breast reconstruction up until the introduction of the DIEP. Finally, if I can draw your attention to the implants, in pink at the bottom, you can see their numbers have stayed relatively stable. 73 implants, 98 LD’s, 39 TRAM’s and 68 DIEP’s were performed
This is another key slide. It summarises the Length of stay between the various procedures, with the coloured boxes on the graph representing the mean, and the blue lines the median length of stay. The bar along the bottom shows the subsequent median cost, based on the cost of a standard bed at our unit per night . As you can see implants have a much shorter length of stay and as such a much lower median cost.
I appreciate this is a busy of this key slide, It shows how the secondary procedures break down. We have divided up into implant, symmetrisation and wound care procedures I would like to draw your attention to how LD and implants dominate every group
I appreciate this is a busy of this key slide, It shows how the secondary procedures break down. We have divided up into implant, symmetrisation and wound care procedures I would like to draw your attention to how LD and implants dominate every group
These ‘top up’ fees come from four main areas; ‘ Market forces factor’ – which is effectively a subsidy for performing the procedure in London Research grants, Teaching and… Co-morbidities. Which for the purposes of this study we have assumed these to be equal. and it is worth noting at this point that market force make up a substantial part of the income- accounting for approximately 20- 30% of these procedures final tariff, a fee that you would be substantially lower in areas out side of likes of London
These ‘top up’ fees come from four main areas; ‘ Market forces factor’ – which is effectively a subsidy for performing the procedure in London Research grants, Teaching and… Co-morbidities. Which for the purposes of this study we have assumed these to be equal. and it is worth noting at this point that market force make up a substantial part of the income- accounting for approximately 20- 30% of these procedures final tariff, a fee that you would be substantially lower in areas out side of likes of London
Moving on, this is how the secondary procedures tariffs breakdown
Based on this, we worked out average tariff for the additional procedures If we take the implant as an example we can see that for every primary procedure you perform, you have to do a further 1.6 COMPLEX operations, such as implant exchange, equating to an additional £3,652, on top of the original tariff. DIEP’s only require 1 further SIMPLER operation, such as scar revision equating to a much lower additional tariff at £1,851.
So those were the tariffs being paid to the hospital, what about the actual costs to the hospital? Taking the theatre costs as those outlined here, it works out at £3,200 for a half day list. Therefore a DIEP or TRAM equates to £6,400, LD’s £3,200 and implants £1,700
Then we add on our additional costs of hospital stay, one to one nursing, the standard outpatient attendances and, in the case of procedures with implants, the cost of implants.
The first column shows how much we get paid, the second, how much it costs us As you can see on the primary procedure alone, the trust is making a loss on all the procedures except the LD
At this point I just want to take stock that these costs are only conservative estimates This is because these are largely cancer operations which have other procedures performed at the same time And…as we only get paid for the principle procedure we miss out out on income we would otherwise receive if done separately. Such as a further £2,600 for a masectomy, …and…we also miss out on income from other areas, like research. Which, using masectomy as an example again, is around £480. Significantly the tariff system also neglects the cost of any contralateral procedures done at the same time. As a result the current tariff system is financially discouraging the ideal of immediate reconstruction as well as bilateral procedures
This slide is a summary of our data By a relatively short follow up of 3 years, once you account for the cost of secondary procedures there is only £3,000 diffeence between implant and DIEP, that is the cost of one further implant exchange And.. The LD is only £600 shy of of the a DIEP, the equivalent of a few additional out patient appointments
Many would agree that we should aim for the best aesthetic outcome through the minimal number of procedures… to these ends at our data at 3 years has shown autologous procedures such as DIEP are the have the least number of revisions and for them to be relatively stable We also know that in the longer term weight change impacts on the symmetry in those with implants to a greater degree than tissue reconstructions Our belief is that autologous reconstruction offers better symmetry at 4-5 years, something we are looking to formally validate. Most would agree that we should aim to achieve the best symmetry and long term results possible using the minimal number of procedures To these ends there are numerous papers supportive of autologous reconstruction being the gold standard Currently our data set has a mean of 3 years follow up, however, when we look at longer term studies like kroll and beahm they project that implants are likely to require even more future surgeries, and, consensus alongside current data suggests that DIEP’s will remain relatively stable. Extrapolating this forward it is likely that with follow up there will be a breakeven point where DIEP will be more cost effective than implants.
Financially…we have found that the LD’s has effectively reached cross over with the DIEP- with the DIEP being more cost effective at 3 years However the with regards to the absolute costs of implants, they remain cheaper than autologous breast reconstruction at a mean FU of 3 years , albeit minimally so, But when looking at projected costs, as implants have been shown to continue to require further operations into the future, and as DIEPs remain relatively stable, there is going to be a cross over regarding financial viability, Kroll in 1996 placed this cross over at around 4 years for a TRAM against an implant, however we project on the basis of our data it to be slightly more than this for a DIEP. As such our data is supportive of autologous reconstuctions being both better and more cost effective in the longer term
Finally… we also found that the current tariff system is not supportive of either immediate, or bilateral, breast reconstruction