Dr. Sheckter is a chief resident in plastic and reconstructive surgery with clinical interests in acute and reconstructive burn care along with surgical scar management. His research interests include understanding the role of reconstructive surgery in improving the quality of life of those with disfiguring scars. He's also interested in health systems design as it relates to the delivery of high value wound and burn care. Likewise, he studies the influence of economic forces on surgical decision making in reconstructive surgery.

Current Role at Stanford

Resident physician in the Division of Plastic & Reconstructive Surgery.
Health services and health policy researcher in the Department of Surgery.

Clinical Focus

  • Residency
  • Burn
  • Scar


All Publications

  • Discussion: Postmastectomy Breast Reconstruction: Exploring Plastic Surgeon Practice Patterns and Perspectives. Plastic and reconstructive surgery Sheckter, C. C., Disa, J. J., Matros, E. 2020; 145 (4): 877?78

    View details for DOI 10.1097/PRS.0000000000006628

    View details for PubMedID 32221192

  • Burns: modified metabolism and the nuances of nutrition therapy. Journal of wound care Houschyar, M., Borrelli, M. R., Tapking, C., Maan, Z. N., Rein, S., Chelliah, M. P., Sheckter, C. C., Duscher, D., Branski, L. K., Wallner, C., Behr, B., Lehnhardt, M., Siemers, F., Houschyar, K. S. 2020; 29 (3): 184?91


    OBJECTIVE: To review the effects of burn injury on nutritional requirements and how this can best be supported in a healthcare setting.METHOD: A literature search for articles discussing nutrition and/or metabolism following burn injury was carried out. PubMed, Embase and Web of Science databases were searched using the key search terms 'nutrition' OR 'metabolism' AND 'burn injury' OR 'burns'. There was no limitation on the year of publication.RESULTS: A total of nine articles met the inclusion criteria, the contents of which are discussed in this manuscript.CONCLUSION: Thermal injury elicits the greatest metabolic response, among all traumatic events, in critically ill patients. In order to ensure burn patients can meet the demands of their increased metabolic rate and energy expenditure, adequate nutritional support is essential. Burn injury results in a unique pathophysiology, involving alterations in endocrine, inflammatory, metabolic and immune pathways and nutritional support needed during the inpatient stay varies depending on burn severity and idiosyncratic patient physiologic parameters.

    View details for DOI 10.12968/jowc.2020.29.3.184

    View details for PubMedID 32160092

  • Intraoperative Laser-Assisted Indocyanine Green Imaging Can Reduce the Rate of Fat Necrosis in Microsurgical Breast Reconstruction. Plastic and reconstructive surgery Momeni, A., Sheckter, C. 2020; 145 (3): 507e?513e


    BACKGROUND: Fat necrosis following microsurgical breast reconstruction is common and problematic for patients and surgeons alike. Indocyanine green angiography provides a means of evaluating flap perfusion at the time of surgery to inform judicious excision of hypoperfused tissue. The authors hypothesized that incorporation of protocolized indocyanine green-informed flap debridement at the time of surgery would decrease the incidence of fat necrosis.METHODS: A retrospective study of two cohorts was performed evaluating patients before and after implementation of protocolized indocyanine green-guided flap excision. Variables included demographics, procedural details, and complications. Multivariable analysis was used to determine significant differences between the cohorts and evaluate for meaningful changes in fat necrosis.RESULTS: Eighty patients were included, accounting for 137 flaps. Flap type was the only significant difference between the two groups, with the indocyanine green group more likely to be deep inferior epigastric perforator flaps (43.1 percent versus 25.3 percent; p = 0.038). The overall postoperative incidence of fat necrosis was 14.6 percent (20 of 137 flaps). Comparing by cohort, the standard debridement group showed 18 of 79 flaps with fat necrosis (22.8 percent), whereas the indocyanine green-informed debridement group showed only two of 58 flaps with fat necrosis (3.4 percent; odds ratio, 0.11; 95 percent CI, 0.02 to 0.60; p = 0.011). There were no other significant differences in complication profile.CONCLUSIONS: Intraoperative use of indocyanine green angiography was associated with significantly lower odds of fat necrosis. This technology may reduce additional revision operations and improve patient satisfaction. Additional studies are needed to determine whether this innovation is cost-effective and generalizable to the entire autologous breast reconstruction population.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

    View details for DOI 10.1097/PRS.0000000000006547

    View details for PubMedID 32097299

  • The rise of non-traumatic extremity compartment syndrome in light of the opioid epidemic. The American journal of emergency medicine Sheckter, C. C., Cebron, U., Suarez, P., Rochlin, D., Tedesco, D., Hernandez-Boussard, T., Curtin, C. 2020

    View details for DOI 10.1016/j.ajem.2020.01.020

    View details for PubMedID 32005410

  • The Optimal Treatment for Partial Thickness Burns: A Cost-Utility Analysis of Skin Allograft vs. Topical Silver Dressings. Journal of burn care & research : official publication of the American Burn Association Sheckter, C. C., Meyerkord, N. L., Sinskey, Y. L., Clark, P., Anderson, K., Van Vliet, M. 2020


    INTRODUCTION: Partial thickness burns not undergoing surgical excision are treated with topical silver products including silver sulfadiazine (SSD) and Mepilex Ag. Skin allograft is a more costly alternative that acts as definitive wound coverage until autogenous epithelialization. Economic constraints and the movement toward value-based care demand cost and outcome justification prior to adopting more costly products.METHODS: A cost-utility analysis was performed comparing skin allograft to SSD and Mepilex Ag using decision tree analysis. The base case modeled a superficial partial thickness 20% total body surface area burn. Utilities were derived from expert opinion on the basis of personal experience. Costs were derived from 2019 Medicare payments. Quality adjusted life years were calculated using rollback method assuming standard life expectancies in the United States. Probabilistic sensitivity analysis was performed to asses model robustness.RESULTS: The incremental costs of skin allograft to Mepilex Ag and SSD were $907.71 and $1257.86, respectively. The incremental quality adjusted life year (QALY) gains from allograft over Mepilex Ag and SSD were 0.011 and 0.016. This yielded an incremental cost-utility ratio for allograft vs. Mepilex Ag of $84,189.29/QALY compared with an incremental cost-utility ratio of $79,684.63/QALY for allograft vs. SSD. Assuming willingness-to-pay thresholds of $100,000/QALY, probabilistic sensitivity analysis demonstrated that allograft was cost effective to Mepilex Ag in 62.1% of scenarios, and cost effective to SSD in 64.9% of simulations.CONCLUSION: Skin allograft showed greater QALYs compared with topical silver dressings at a higher cost. Depending on willingness-to-pay thresholds, skin allograft may be a considered a cost-effective treatment of partial-thickness burns.

    View details for DOI 10.1093/jbcr/iraa003

    View details for PubMedID 32043154

  • Impact of Physician Payments on Microvascular Breast Reconstruction: An All-Payer Claim Database Analysis. Plastic and reconstructive surgery Panchal, H., Shamsunder, M. G., Sheinin, A., Sheckter, C. C., Berlin, N. L., Nelson, J. A., Allen, R., Rubin, D., Kozlow, J. H., Matros, E. 2020; 145 (2): 333?39


    Rates of autologous breast reconstruction are stagnant compared with prosthetic techniques. Insufficient physician payment for microsurgical autologous breast reconstruction is one possible explanation. The payment difference between governmental and commercial payers creates a natural experiment to evaluate its impact on method of reconstruction. This study assessed the influence of physician payment differences for microsurgical autologous breast reconstruction and implants by insurance type on the likelihood of undergoing microsurgical reconstruction.The Massachusetts All-Payer Claims Database was queried for women undergoing immediate autologous or implant breast reconstruction from 2010 to 2014. Univariate analyses compared demographic and clinical characteristics between different reconstructive approaches. Logistic regression explored the relative impact of insurance type and physician payments on breast reconstruction modality.Of the women in this study, 82.7 percent had commercial and 17.3 percent had governmental insurance. Implants were performed in 80 percent of women, whereas 20 percent underwent microsurgical autologous reconstruction. Women with Medicaid versus commercial insurance were less likely to undergo microsurgical reconstruction (16.4 percent versus 20.3 percent; p = 0.063). Commercial insurance, older age, and obesity independently increased the odds of microsurgical reconstruction (p < 0.01). When comparing median physician payments, governmental payers reimbursed 78 percent and 63 percent less than commercial payers for microsurgical reconstruction ($1831 versus $8435) and implants ($1249 versus $3359, respectively). Stratified analysis demonstrated that as physician payment increased, the likelihood of undergoing microsurgical reconstruction increased, independent of insurance type (p < 0.001).Women with governmental insurance had lower odds of undergoing microsurgical autologous breast reconstruction compared with commercial payers. Regardless of payer, greater reimbursement for microsurgical reconstruction increased the likelihood of microsurgical reconstruction. Current microsurgical autologous breast reconstruction reimbursements may not be commensurate with physician effort when compared to prosthetic techniques.Risk, II.

    View details for DOI 10.1097/PRS.0000000000006453

    View details for PubMedID 31985616

  • Surgical Treatment of Osteonecrosis of the Jaw: An Emerging Problem in the Era of Bisphosphonates. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons Hung, K. S., Sheckter, C. C., Gaudilliere, D., Suarez, P., Curtin, C. 2020

    View details for DOI 10.1016/j.joms.2019.12.018

    View details for PubMedID 32004467

  • The association of burn patient volume with patient safety indicators and mortalityin the US. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Pham, C., Rochlin, D., Maan, Z. N., Karanas, Y., Curtin, C. 2019


    INTRODUCTION: Clinical volume has been associated with rate of complications and mortality for various conditions and procedures. We aim to analyze the relationship between annual hospital burn admission, patient safety indicators (PSI), line infections, and inpatient mortality. We hypothesize that high facility volume will correlate with better outcomes.METHODS: All burn admissions with complete data for total body surface area (TBSA) and depth were extracted from the Nationwide Inpatient Sample from 2002-2011. Predictor variables included age, gender, comorbidities, %TBSA, burn depth, and inhalation injury. Surgically relevant PSIs were drawn from the Healthcare Cost & Utilization Project and included: sepsis, venous thromboembolic disease, hemorrhage, pneumonia, and wound complications. Outcomes were analyzed with regression models.RESULTS: Of the 57,468 encounters included, 3.1% died, 6.3% experienced >1 PSI event, and 0.3% experienced a catheter-associated urinary tract infections or central line associated blood stream infections. The most frequent PSI was pneumonia followed by sepsis and VTE. Annual hospital burn admission volume was independently associated with decreased odds of mortality (OR 0.99, 95% CI 0.99-0.99, p<0.001) and PSIs (OR 0.99, 95% CI 0.99-0.99, p=0.031). There was no significant correlation with line infections. In both mortality and PSI models, age, %TBSA, inhalation injuries, and Elixhauser comorbidity score were significantly associated with adverse outcomes (p<0.05).CONCLUSION: There was a significant association between higher hospital volume and decreased likelihood of patient safety indicators and mortality. There was no observed relationship with line infections. These findings could inform future verification policies of US burn centers.

    View details for DOI 10.1016/j.burns.2019.11.009

    View details for PubMedID 31843281

  • Homelessness and Inpatient Burn Outcomes in the United States JOURNAL OF BURN CARE & RESEARCH Kiwanuka, H., Maan, Z. N., Rochlin, D., Curtin, C., Karanas, Y., Sheckter, C. C. 2019; 40 (5): 633?38
  • Variations in access to specialty care for children with severe burns. The American journal of emergency medicine Ewbank, C., Sheckter, C. C., Warstadt, N. M., Pirrotta, E. A., Curtin, C., Newton, C., Wang, N. E. 2019: 158401


    BACKGROUND: Pediatric burns account for 120,000 emergency department visits and 10,000 hospitalizations annually. The American Burn Association has guidelines regarding referrals to burn centers; however there is variation in burn center distribution. We hypothesized that disparity in access would be related to burn center access.METHODS: Using weighted discharge data from the Nationwide Inpatient Sample 2001-2011, we identified pediatric patients with International Classification of Diseases-9th Revision codes for burns that also met American Burn Association criteria. Key characteristics were compared between pediatric patients treated at burn centers and those that were not.RESULTS: Of 54,529 patients meeting criteria, 82.0% (n?=?44,632) were treated at burn centers. Patients treated at burn centers were younger (5.6 versus 6.7?years old; p?

    View details for DOI 10.1016/j.ajem.2019.158401

    View details for PubMedID 31474377

  • Is Bigger Better?: The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction. Annals of surgery Cerullo, M., Sheckter, C. C., Canner, J. K., Rogers, S. O., Offodile, A. C. 2019


    OBJECTIVES: To examine the relationship between hospital market competition and inpatient costs, procedural markup, inpatient complications, and length of stay among privately insured patients undergoing immediate reconstruction after mastectomy.METHODS: A retrospective cross-sectional analysis of privately insured female patients undergoing immediate breast reconstruction in the 2009 to 2011 Nationwide Inpatient Sample was performed. The Herfindahl-Hirschman index was used to describe hospital market competition; associations with outcomes were explored via hierarchical models adjusting for patient, hospital, and market characteristics.RESULTS: A weighted total of 42,411 patients were identified; 5920 (14.0%) underwent free flap reconstruction. In uncompetitive markets, 6.8% (n=857) underwent free flap reconstruction, compared with 13.6% (n=2773) in highly competitive markets and 24.6% (n=2290) in moderately competitive markets. For every 5 additional hospitals in a market, adjusted costs were 6.6% higher (95% CI: 2.8%-10.5%), for free flap reconstruction, and 5.1% higher (95% CI: 2.0%-8.4%) for nonfree flap reconstruction. Similarly, higher procedural markup was associated with increased hospital market competition both for nonfree flap reconstruction (5.5% increase, 95% CI: 1.1%-10.1%) and for free flap reconstruction (8.2% increase, 95% CI: 1.8%-15.0%). Notably, there was no association between incidence of inpatient complications or extended length of stay and hospital market competition among either free flap or nonfree flap reconstruction patients.CONCLUSIONS: Decreasing market competition was associated with lower inpatient costs and equivocal clinical outcomes. This suggests that some of the economies of scale, access to capital and care delivery efficiencies gained from increased market power following hospital mergers are passed onto payers and consumers as lower costs.

    View details for DOI 10.1097/SLA.0000000000003481

    View details for PubMedID 31356269

  • Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Miller, T. J., Sheckter, C. C., Barnes, L. A., Li, A. Y., Momeni, A. 2019; 7 (7)
  • Reply: The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Goverman, J. 2019

    View details for DOI 10.1016/j.burns.2019.03.024

    View details for PubMedID 31176510

  • Optimising management of self-inflicted burns: a retrospective review. Journal of wound care Houschyar, K. S., Tapking, C., Duscher, D., Maan, Z. N., Sheckter, C. C., Rein, S., Chelliah, M. P., Nietzschmann, I., Weissenberg, K., Reumuth, G., Schulz, T., Branski, L. K., Siemers, F. 2019; 28 (6): 317?22


    OBJECTIVE: Self-inflicted burns typically result in extensive injuries requiring intensive care and attention in a specialised burn unit. Burn units should be familiar with the optimal management of self-inflicted burns, including the psychological and psychiatric treatment. This paper describes the experiences of managing these challenging injuries in a German burn centre.METHODS: A retrospective review of patients with self-inflicted burns admitted to the burn centre between 2000 and 2017. Demographics, details of injury, presence of psychiatric disorder, clinical course, operative management and patient outcomes were recorded and compared with a control group without self-inflicted burns. Outcome measures included graft take rate, complications and need for further surgery.RESULTS: There were a total of 2055 burn patient admissions, with 17 cases (0.8%) of self-inflicted burns. The mean age was 3611 years with an mean percentage total body surface area (%TBSA) burned of 43.522.5% which was not significantly different from the control group (p=0.184). Schizophrenia and personality disorder were the most common diagnoses in the self-inflicted burns patients (n=11; 65%). Of these, four had sustained previous self-inflicted burns. Length of hospital stay was significantly longer in the self-inflicted burn group than in the control group (49.016.7 days, respectively, p=0.002).CONCLUSION: Attempted suicide by self-inflicted burns represents <1% of burn admissions. This population demonstrates a high incidence of prior psychiatric disorders. Successful treatment includes multidisciplinary management of acute medical, surgical, and psychiatric care.

    View details for DOI 10.12968/jowc.2019.28.6.317

    View details for PubMedID 31166860

  • The Pushback Pharyngeal Flap: An 18-Year Experience. Plastic and reconstructive surgery Rochlin, D. H., Mittermiller, P. A., Sheckter, C. C., Menard, R. M. 2019; 143 (6): 1246e?1254e


    BACKGROUND: The pharyngeal flap is one of the oldest and most popular techniques for correction of velopharyngeal insufficiency. The authors describe a large series using a technique that combines a pharyngeal flap with a palate pushback to avoid common causes of operative failure while restoring the velopharyngeal mechanism.METHODS: A retrospective cohort study was performed of patients who underwent a pushback pharyngeal flap by a single surgeon from 2000 to 2017. All patients had a preoperative nasoendoscopy diagnostic of velopharyngeal insufficiency. Operative technique involved elevation of the hard palate mucosa through a retroalveolar incision, passage of the flap through the nasopharyngeal mucosa opening, and inset with sutures through the hard palate mucosa.RESULTS: There were 40 patients with a median age of 9.7 years. Preoperative closure patterns were predominately coronal (85.7 percent), with poor posterior wall motion and an average gap size of 27.5 mm. Postoperative complications included flap dehiscence (n = 1), transient dysphagia (n = 2), obstructive sleep apnea (n = 4), and a palatal fistula and/or persistent velopharyngeal insufficiency that required further surgery (n = 6). At an average of 2.5 years postoperatively, 91.7 percent of patients achieved adequate velopharyngeal function, with significant improvements in the majority of speech metrics (p < 0.001).CONCLUSIONS: The pushback pharyngeal flap is a safe and effective technique for treatment of velopharyngeal insufficiency. Advantages include high, secure inset with prevention of palatal scar contracture and shortening.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

    View details for DOI 10.1097/PRS.0000000000005645

    View details for PubMedID 31136490

  • Reply: The Influence of Physician Payments on the Method of Breast Reconstruction: A National Claims Analysis PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Matros, E. 2019; 143 (6): 1312E?1313E
  • Applying a value-based care framework to post-mastectomy reconstruction BREAST CANCER RESEARCH AND TREATMENT Sheckter, C. C., Matros, E., Lee, G. K., Selber, J. C., Offodile, A. C. 2019; 175 (3): 547?51
  • Preventing Unnecessary Intubations: A 5-Year Regional Burn Center Experience Using Flexible Fiberoptic Laryngoscopy for Airway Evaluation in Patients With Suspected Inhalation or Airway Injury. Journal of burn care & research : official publication of the American Burn Association Moshrefi, S., Sheckter, C. C., Shepard, K., Pereira, C., Davis, D. J., Karanas, Y., Rochlin, D. H. 2019; 40 (3): 341?46


    The decision to intubate acute burn patients is often based on the presence of classic clinical exam findings. However, these findings may have poor correlation with airway injury and result in unnecessary intubation. We investigated flexible fiberoptic laryngoscopy (FFL) as a means to diagnose upper airway thermal and inhalation injury and guide airway management. A retrospective chart review of all burn patients who underwent FFL from 2013 to 2017 was performed. Their charts were reviewed to determine the indications for FFL including the historical data and physical exam findings that indicated airway injury as well as patient age, TBSA, type and depth of burn injury, carboxyhemoglobin level, and clinical course. Fifty-one patients underwent FFL, with an average TBSA of 6.5% (range 0.5-38.0%) and carboxyhemoglobin level of 3.5%. Burn mechanism was flame (35.3%) or flash (51.0%), with 50% occurring in enclosed spaces. In all cases, the decision to perform FFL was based on physical exam findings meeting criteria for intubation, including facial burns, singed nasal hairs, nasal soot, voice change, throat pain or abnormal sensation, shortness of breath, carbonaceous sputum, wheezing, or stridor. Based on FFL, 9 patients (17.7%) were treated with steroids, 28 patients (54.9%) received supportive care, and 6 patients (11.8%) had repeat FFL for monitoring. One patient was intubated after repeat FFL examination. All patients who underwent FFL met traditional criteria for intubation based on exam, however 98% were monitored without issues based on FFL findings. FFL is a valuable tool that can lead to fewer intubations in acute burn patients with a stable respiratory status for whom history and physical exam suggest upper airway injury.

    View details for DOI 10.1093/jbcr/irz016

    View details for PubMedID 31222272

  • Homelessness and Inpatient Burn Outcomes in the United States. Journal of burn care & research : official publication of the American Burn Association Kiwanuka, H., Maan, Z., Rochlin, D., Curtin, C., Karanas, Y., Sheckter, C. C. 2019


    INTRODUCTION: Burn injuries are common in the homeless population. Little is known regarding whether homeless patients experience different outcomes when admitted for burns. We aim to 1) characterize the admitted homeless burn population, and 2) investigate differences in inpatient outcomes between the homeless and non-homeless populations.METHODS: A retrospective cohort study was performed utilizing the Nationwide Inpatient Sample. Adult patients with complete data for burn characteristics were extracted. Variables included demographic, burn, and facility characteristics. Homelessness was identified with International Classification of Disease 9th edition codes. Outcomes were modeled with regression analysis and included length of stay, total operations, charges, disposition, and patient safety indicators.RESULTS: 43,872 encounters were included of which 0.76% were homeless. Homeless encounters were more likely to be male (p<0.001) and Medicaid-insured (p<0.001). Flame and frostbite injuries were more likely (p<0.001), and the mean %TBSA was smaller (15.0 versus 16.8, p<0.001). After adjustment, homeless patients had greater lengths of stay (11.5 vs. 9.6, p=0.046), greater charges ($73,597 vs. $66,909, p=0.030), fewer operations (p=0.016), and three times higher likelihood leaving against medical advice (p=0.002). There was no difference in patient safety indicators or mortality.CONCLUSION: Homeless burn admissions represent a unique cohort that carries a higher comorbidity burden and experiences longer lengths of stay with greater difficulty in disposition. Ironically, these patients accumulate more charges with limited means to pay. Even though no differences were observed in patient safety indicators or mortality, further research is needed to understand how the challenges within this population affect their recovery.

    View details for PubMedID 30938433

  • Which Stitch? Replacing Anecdote with Evidence in Minor Hand Surgery PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Rochlin, D. H., Sheckter, C. C., Curtin, C. M. 2019; 7 (4)
  • Applying a value-based care framework to post-mastectomy reconstruction. Breast cancer research and treatment Sheckter, C. C., Matros, E., Lee, G. K., Selber, J. C., Offodile, A. C. 2019


    PURPOSE: Reconstructive breast surgeons, like all procedural care providers, face a transition from volume reimbursement (i.e., per unit of service) to value-based care. Value can be defined as the relationship between outcomes and costs, or more specifically healthcare outcomes per unit cost. Although the definition of a meaningful outcome for a particular treatment can vary, some weighted average of survival, function, complications, process measures, and patient-reported outcomes (PROs) comprise the numerator, while the total cost of a complete care cycle is the denominator. We aim to construct a value-based care framework for reconstructive surgery using post-mastectomy reconstruction as an organizing element.METHODS: A preexisting value framework was applied to breast reconstruction using expert opinion and literature review. Domains and associated realization strategies were constructed based on established health economic principles.RESULTS: Seven domains were identified including: implementing an inclusive and transparent process for stakeholder engagement, practicing clear and explicit treatment goals, anchoring care delivery to the patient perspective, maximizing value across the entire continuum of care, optimizing operation efficiency, and scaling best practices with implementation science.CONCLUSIONS: In the near future, reconstructive plastic surgeons may be asked to solve clinical problems for fixed reimbursement (i.e. bundled payments). Considering breast reconstruction through a value lens provides surgeons with an opportunity to adapt and thrive in an evolving healthcare landscape. Lastly, we hope this document helps promote value assessment within the specialty.

    View details for PubMedID 30937659

  • Reply; Reply: "The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis". Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2019

    View details for PubMedID 30907795

  • Five Years Experience With Meek Grafting in the Management of Extensive Burns in an Adult Burn Center PLASTIC SURGERY Houschyar, K., Tapking, C., Nietzschmann, I., Rein, S., Weissenberg, K., Chelliah, M., Duscher, D., Maan, Z., Philipps, H., Sheckter, C., Reichelt, B., Branski, L., Siemers, F. 2019; 27 (1): 44?48


    In extensive burn injuries with lack of donor sites for skin grafting, the Meek technique of skin expansion can be an efficient and effective method in covering extensive wounds. The aim of this retrospective study was to present our experience with the Meek technique of grafting.We performed a retrospective analysis of patients from our burn center who underwent Meek grafting between 2012 and 2016. Demographics, burn details, clinical course, operative management, and outcomes were collected and analyzed from patient records and operative notes. Outcome measures, including graft take rate, complications and need for further surgery, were recorded.Twelve patients had Meek grafting. The average age was 38 years (range: 15-66). The average percent total body surface area burned was 54.3% (range: 31%-77%). Eighty-three percent of grafted areas healed well, and no regrafting was necessary. In the remaining 17%, infection and hematoma were the leading cause of graft failure.Meek grafting constitutes a rapid and efficient surgical approach for the skin coverage of extensive full-thickness burn injuries with limited autograft donor sites.

    View details for PubMedID 30854361

  • Resident Sensitive Processes of Care: the Impact of Surgical Residents on Inpatient Testing. Journal of the American College of Surgeons Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A., Hawn, M. 2019


    INTRODUCTION: Healthcare value is a national priority, and there are substantial efforts to reduce overuse of low-value testing. Residency training programs and teaching hospitals have been implicated in excessive testing. We evaluated the impact of surgery residents on the frequency of inpatient testing and investigated potential inter-resident variation.METHODS: Inpatient laboratory and imaging orders placed on general surgery services were extracted from an academic institution from 2014-2016 and linked to National Surgical Quality Improvement Program data. Using negative binomial mixed effects regression with unstructured covariance, we evaluated the frequency of testing orders compared to median utilization, accounting for case, patient, and attending-level variables.RESULTS: 111,055 laboratory and 7,360 imaging orders were linked with 2,357 patients. Multivariable analysis demonstrated multiple significant predictors of increased testing including: postoperative complications, medical comorbidities, length of stay, relative value units, attending surgeon, and resident surgeon (95% confidence intervals >1, p<0.05). Compared to the median resident physician, 47 residents (37.9%) placed significantly more laboratory orders, and 2 residents (1.6%) placed significantly more imaging orders (95% confidence interval >1, p<0.05). Resident identification explained 3.5% of the total variation in laboratory ordering and 4.9% in imaging orders.CONCLUSIONS: Individual surgical residents had a significant association with the frequency of inpatient testing after adjusting for attending, case, and patient-level variables. There was greater resident variation in laboratory testing compared to imaging, yet surgical residents had small contributions to the total variation in both laboratory and imaging testing. Our models provide a means of identifying high utilizers and could be used to educate residents on their ordering patterns.

    View details for PubMedID 30660819

  • Sarcopenia Is a Risk Factor for Infection for Patients Undergoing Abdominoperineal Resection and Flap-based Reconstruction. Plastic and reconstructive surgery. Global open Miller, T. J., Sheckter, C. C., Barnes, L. A., Li, A. Y., Momeni, A. 2019; 7 (7): e2343


    Abdominoperineal resection (APR) carries a high risk of morbidity. Preoperative risk assessment can help with patient counseling, minimize adverse outcomes, and guide surgeons in their choice of reconstruction. This study examined the impact of sarcopenia (low lean muscle mass) on postoperative complications after APR.One hundred seventy-eight patients who underwent APR between May 2000 and July 2017 were retrospectively analyzed. Sarcopenia was identified on preoperative computed tomography scans using the Hounsfield Unit Average Calculation. Two cohorts were compared (group 1: primary perineal closure; group 2: flap-based perineal reconstruction). Multivariable analysis evaluated predictors of complications.Sarcopenia was an independent risk factor for postoperative surgical site infection in patients undergoing APR (odds ratio [OR] = 2.9, P = 0.04). The risk for sarcopenic patients who underwent flap-based perineal reconstruction was even higher (OR = 8.9, P < 0.01). Male sex was also found to be a risk factor for infection (OR = 3.5, P < 0.01). Perineal flap-based reconstruction was a risk factor for delayed wound healing (OR = 3.2, P < 0.01).Sarcopenia was an independent risk factor for infection in patients undergoing APR. This risk was even greater in patients undergoing flap-based perineal reconstruction. Sarcopenia can be identified on preoperative imaging and inform surgeons on risk stratification and surgical plan.

    View details for DOI 10.1097/GOX.0000000000002343

    View details for PubMedID 31942365

    View details for PubMedCentralID PMC6952152

  • Discussion: A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay. Plastic and reconstructive surgery Sheckter, C. C., Matros, E. 2019; 144 (4): 550e?551e

    View details for DOI 10.1097/PRS.0000000000006014

    View details for PubMedID 31568279

  • Cognitive Independence In Plastic Surgery Training: the Value of Professional Development. Plastic and reconstructive surgery Sheckter, C. C., Maan, Z. N., Chang, J. 2019

    View details for PubMedID 31021905

  • The impact of hospital volume on patient safety indicators following post-mastectomy breast reconstruction in the US. Breast cancer research and treatment Sheckter, C. C., Rochlin, D., Kiwanuka, H., Curtin, C., Momeni, A. 2019


    Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors.Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality's designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes.The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced???1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p??0.05).PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.

    View details for DOI 10.1007/s10549-019-05361-2

    View details for PubMedID 31338643

  • Which Stitch? Replacing Anecdote with Evidence in Minor Hand Surgery. Plastic and reconstructive surgery. Global open Rochlin, D. H., Sheckter, C. C., Curtin, C. M. 2019; 7 (4): e2189


    There is currently no consensus on the optimal suture type for palmar skin closure following open carpal tunnel release and trigger finger release. We performed a retrospective analysis of patients in the Palo Alto Veterans Affairs (PAVA) Health Care System who underwent these procedures over a 2-year period to compare 30-day wound outcomes following closure with poliglecaprone 25 (Monocryl), nylon, and chromic gut suture. Out of 312 PAVA cases (133 carpal tunnel release, 179 trigger finger release), incisions closed with Monocryl were significantly less likely to develop dehiscence (Monocryl 2.1%, nylon 10.5%, chromic 10.3%; P = 0.006) and infection (Monocryl 1.6%, nylon 7.4%, chromic 13.8%; P = 0.003), or lead to additional wound-related encounters (Monocryl 8.0%, nylon 16.8%, chromic 24.1%; P = 0.012). On multivariable logistic regression, suture type and diabetes were independent predictors of 30-day wound complications and extra encounters. At PAVA, compared with Monocryl, closures with nylon and chromic were significantly more likely to dehisce and/or become infected [nylon: odds ratio (OR), 5.0; 95% CI, 1.9-13.3 and chromic: OR, 9.3; 95% CI, 2.7-32.4; P = 0.002], and to be associated with an additional encounter (nylon: OR, 2.4; 95% CI, 1.1-5.3 and chromic: OR, 4.5; 95% CI, 1.6-12.9; P = 0.007). This has led to using Monocryl as the standard closure for these cases at PAVA.

    View details for DOI 10.1097/GOX.0000000000002189

    View details for PubMedID 31321185

    View details for PubMedCentralID PMC6554153

  • Cognitive Independence in Plastic Surgery Training: The Value of Professional Development. Plastic and reconstructive surgery Sheckter, C. C., Maan, Z. N., Chang, J. 2019; 144 (1): 153e?154e

    View details for DOI 10.1097/PRS.0000000000005762

    View details for PubMedID 31246858

  • The impact of skin allograft on inpatient outcomes in the treatment of major burns 20-50% total body surface area - A propensity score matched analysis using the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Li, A., Pridgen, B., Trickey, A. W., Karanas, Y., Curtin, C. 2018


    BACKGROUND: Human cadaveric skin (allograft) is used in treating major burns both as temporizing wound coverage and a means of testing wound bed viability following burn excision. There is limited information on outcomes, and clinicians disagree on indications for application in intermediate-sized burns. This study aims to improve understanding of allograft use in 20-50% total body surface burns by assessing current utilization and evaluating inpatient outcomes.METHODS: Discharge data from the Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality assessed 3557 major burn patients (>second degree depth and 20-50% TBSA) undergoing operative treatment. Outcomes were evaluated with propensity score matching. The primary outcome was mortality with secondary outcomes including complications, length of stay, total burn operations, and charges.RESULTS: After matching, 771 allografted patients were paired with 1774 controls. Covariate mean standard differences were all <11% after matching. The average treatment effect (ATE) of allograft on inpatient mortality was an increase of 2.8% (95% CI 0.2-5.3%, p=0.041). Allograft ATEs were all significantly higher for secondary outcomes: composite complication index increased 0.13 (95% CI 0.07-0.20, p<0.001), length of stay 8.4days (95% CI 6.1-1.9 days, p<0.001), total burn operations 1.6 (95% CI 1.4-1.9, p<0.001), and total charges $139,476 [$100,716-178,236, p<0.001).CONCLUSIONS: Allograft use in major burns 20-50% TBSA was associated with a significant increase in inpatient mortality. There was a notable correlation with increased inpatient complications, longer length of stay, more burn operations, and greater total charges. Better studies are needed to justify the use of this costly and limited resource in the intermediate sized major burn population.

    View details for PubMedID 30527451

  • National trends in contralateral prophylactic mastectomy in women with locally advanced breast cancer. Journal of surgical oncology Panchal, H., Pilewskie, M. L., Sheckter, C. C., Albornoz, C. R., Razdan, S. N., Disa, J. J., Cordeiro, P. G., Mehrara, B. J., Matros, E. 2018


    BACKGROUND AND OBJECTIVES: Women with unilateral early-stage breast cancer are increasingly choosing contralateral prophylactic mastectomy (CPM) despite the absence of survival benefits and increased risk of surgical complications. Data are lacking on whether this trend extends to women with clinically locally advanced nonmetastatic (cT4M0) cancer. This study aims to estimate national CPM trends in women with unilateral cT4M0 breast cancer.METHODS: Women aged?18 years, who underwent mastectomy during 2004 to 2014 for unilateral cT4M0 breast cancer were identified using the National Cancer Database and grouped as all locally advanced (T4), chest wall invasion, skin nodule/ulceration, or both (T4abc), and inflammatory (T4d) cancer. Poisson regression for trends and logistic modeling for predictors of CPM were performed.RESULTS: Of 23 943 women, 41% had T4abc disease and 35% T4d. Cumulative CPM rates were 15%, 23%, and 18%, for the T4abc, T4d, and all T4 groups, respectively. Trend analysis revealed a significant upsurge in CPM demonstrating 12% annual growth for T4abc tumors, 8% for T4d and 9% for all T4 (all P<0.001).CONCLUSIONS: Increasing numbers of women with unilateral cT4M0 breast cancer are undergoing CPM. This rising trend warrants further research to understand stakeholders' preferences in surgical decision-making for women with locally advanced breast cancer.

    View details for PubMedID 30480805

  • Single Stage Repair of #30 Facial Cleft with Bone Morphogenic Protein PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Sheckter, C. C., Mittermiller, P., Hung, K., Maan, Z., Rochlin, D., Menard, R. M. 2018; 6 (11)
  • Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337?47
  • Resident Sensitive Processes of Care: The Impact of Individual Surgical Residents on Laboratory Testing Sheckter, C. C., Jopling, J., Ding, Q., Trickey, A. W., Wagner, T., Morris, A. M., Hawn, M. T. ELSEVIER SCIENCE INC. 2018: S228?S229
  • Systems Delivery Innovation for Alzheimer Disease. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry Bott, N. T., Sheckter, C. C., Yang, D., Peters, S., Brady, B., Plowman, S., Borson, S., Leff, B., Kaplan, R. M., Platchek, T., Milstein, A. 2018


    OBJECTIVE: The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.METHODS: Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.RESULTS: After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).CONCLUSION: A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

    View details for PubMedID 30477913

  • Increasing ambulatory treatment of pediatric minor burns-The emerging paradigm for burn care in children. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Kiwanuka, H., Maan, Z., Pirrotta, E., Curtin, C., Wang, N. E. 2018


    INTRODUCTION: Innovations in topical burn treatment along with a drive toward value-based care are steering burn care to the outpatient setting. Little is known regarding what characteristics predict outpatient treatment of pediatric minor burns and whether there is a temporal trend toward this treatment paradigm.METHODS: A retrospective cohort study was performed using California's Office of Statewide Health Planning and Development linked emergency department and inpatient database (2005-2013). All patients under 18years of age with a primary burn diagnosis were extracted. Using patient and facility level variables, we used regression modeling to evaluate predictors of outpatient burn treatment and temporal trends.RESULTS: There were 16,480 pediatric minor burn encounters during the period. 56.4% were male, 85.3% had <10% total body surface area (TBSA), 76.3% were scald or contact, and 77.3% were at deepest depth 2nd degree. Multiple variables predicted an increased likelihood of discharge home including older age(p<0.001), smaller TBSA(p<0.001), and superficial/partial thickness burns(<0.001). Children of Hispanic and Black race were less likely to be discharged home compared to White and Asian peers(p=<0.001). On Poisson modeling, the incidence rate ratio over the 9-year period for home discharge was 1.004 (95% CI 1.001-1.008, p=0.032).CONCLUSION: Older patients and those with more superficial burns were more likely to be treated as outpatients. Black and non-white Hispanic race was associated with inpatient admission. There is a growing trend toward ambulatory treatment of minor burns in the pediatric population. Further research is needed to assess whether outpatient treatment of pediatric minor burns results in greater readmissions.

    View details for PubMedID 30236815

  • Trends in Physician Payments for Breast Reconstruction (vol 141, pg 493e, 2018) PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Yi, D., Panchal, H. J., Rubin, D., Razdan, S. N., Pusic, A. L., McCarthy, C. M., Cordeiro, P. G., Disa, J. J., Mehrara, B., Matros, E. 2018; 142 (3): 833
  • Breast Reconstruction Following Breast Cancer Treatment-2018. JAMA Lee, G. K., Sheckter, C. C. 2018

    View details for PubMedID 30178060

  • Trends and inpatient outcomes for palliative care services in major burn patients: A 10-year analysis of the nationwide inpatient sample. Burns : journal of the International Society for Burn Injuries Sheckter, C. C., Hung, K., Rochlin, D., Maan, Z., Karanas, Y., Curtin, C. 2018


    INTRODUCTION: Despite advances in critical care and the surgical management of major burns, highly moribund patients are unlikely to survive. Little is known regarding the utilization and effects of palliative care services in this population.METHODS: All major burn hospitalizations were identified within the Nationwide Inpatient Sample. Patients were characterized by burn, demographic, facility, and diseases factors. Palliative care services were identified with International Classification Disease 9th edition code V6.67. Temporal trends were assessed with Poisson modeling. Inpatient mortality and death without surgical intervention were assessed with logistic regression. Outcomes were stratified by modified Baux scores.RESULTS: 7424 major burns were included; 1.9% received palliative care services. Patients receiving palliation had a mean age of 63.6 years (SD 19.6), mean total body surface area of 62.2% (SD 24.9%), and mean modified Baux score of 127.1 (SD 26.7). Adjusting for covariates, the incidence rate ratio was 1.42 over the 10-year period (95% CI, 1.31-1.54, p<0.001). Independent predictors of palliative consultations included older age, larger burns, deeper burns, and higher Elixhauser comorbidity score. Among patients with modified Baux scores between 100-153, those receiving palliative care services were significantly more likely to die without surgery, OR 3.24 (95% CI 1.13-10.39, p=0.029), with no significant difference in mortality, OR 11.72 (95% CI 0.87-22.57, p=0.051) CONCLUSION AND RELEVANCE: Palliative care services were increasingly used during the study period. Palliative care services in highly moribund burn patients do not impact survival and may decrease the likelihood of surgical intervention in select patients.

    View details for PubMedID 30115531

  • The Influence of Physician Payments on the Method of Breast Reconstruction: a National Claims Analysis. Plastic and reconstructive surgery Sheckter, C. C., Panchal, H. J., Razdan, S. N., Rubin, D., Yi, D., Disa, J. J., Mehrara, B., Matros, E. 2018


    INTRODUCTION: Flap-based breast reconstruction demands greater operative labor and offers superior patient reported outcomes compared to implants. However, implants continue to outpace flaps, with some suggesting inadequate remuneration as one barrier. This study aims to characterize market variation in the ratio of implants to flaps and assess correlation with physician payments.METHODS: Using the Blue Health Intelligence database from 2009-2013, patients were identified who received tissue expander (i.e. implant) or free-flap breast reconstruction. The ratio of implants/flaps and physician payments was assessed using quadratic modeling. Matched bootstrapped samples from the early and late periods generated probability distributions, approximating the odds of surgeons switching reconstructive method.RESULTS: 21,259 episodes of breast reconstruction occurred within 122 U.S. markets. The distribution of implant/flap ratio varied by market, ranging from 5 percentile at 1.63 to 95 percentile at 43.7 (median 6.19). Modeling the implant/flap ratio vs. implant payment showed a more elastic quadratic equation (f(x)=0.955x + 2.766x) compared to the function for flap/implant ratio vs. flap payment (f(x)=-0.061x + 0.734x). Probability modeling demonstrated that switching the reconstructive method from implants to flaps with 0.75 probability required a $1,610 payment increase, while switching from flaps to implants at the same certainty occurred at a loss of $960.CONCLUSION: There was a correlation between the ratio of flaps/implants and physician reimbursement by market. Switching from implants to flaps required large surgeon payment increases. Despite a revenue value unit schedule over twice as high for flaps, current flap reimbursements do not appear commensurate with physician effort.

    View details for PubMedID 29979366

  • Overuse of Air Ambulance Services at a Regional Burn Center. Journal of burn care & research : official publication of the American Burn Association Chattopadhyay, A., Sheckter, C. C., Long, C., Karanas, Y. 2018; 39 (4): 598?603


    Air ambulances rapidly transport burn patients to regional centers, expediting treatment. However, limited guidelines on transport introduce the risk for inappropriate triage and overuse. Given the additional costs of air vs ground transport, evaluation of transportation use is prudent. A retrospective review of all burn patients transported by helicopter to a single burn center from May 2013 to January 2016 was performed. Data gathered included patient demographics, transfer origin, burn characteristics, and inpatient hospital stay. The primary outcome was appropriate triage based on literature-derived severity criteria. Secondary outcomes included independent predictors of emergent treatments and the cost of overuse. Sixty-eight patients were examined, of which 66% met air ambulance criteria. Inappropriately triaged patients sustained smaller burns (% TBSA 4.8 vs 25.3, P < .001), had fewer flame burns (48 vs 82%, P = .007), had decreased lengths of stay (mean days 8.2 vs 21.2, P = .002), underwent fewer inpatient surgeries (mean 0.69 vs 2.57, P = .006), received no emergent procedures (0 vs 56%, P < .001), and suffered no deaths (0 vs 9%, P < .001). Independent predictors of emergent procedures included transport for airway concern (odds ratio = 45.29, confidence interval = 2.49-825.21, P = .010) and % TBSA (odds ratio = 1.13, confidence interval = 1.02-1.27, P = .019). If the 23 inappropriately triaged patients had been transported by ground, a cost savings of $106,370 could have been realized using 2016 California Medicare reimbursements (per-patient savings of $4624). While appropriate in most circumstances, the cost of air ambulances should be weighed in light of their utility, as a significant proportion of patients did not benefit from air transport.

    View details for PubMedID 29901800

  • To Cut is to Cure The Surgeon's Role in Improving Value ANNALS OF SURGERY Jopling, J. K., Sheckter, C. C., James, B. C. 2018; 267 (5): 817?19

    View details for PubMedID 29189380

  • Trends in Physician Payments for Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Yi, D., Panchal, H. J., Razdan, S. N., Pusic, A. L., McCarthy, C. M., Cordeiro, P. G., Disa, J. J., Mehrara, B., Matros, E. 2018; 141 (4): 493E?499E


    Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction.The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models.There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders).The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

    View details for PubMedID 29595721

    View details for PubMedCentralID PMC5880309

  • Assessing value in breast reconstruction: A systematic review of cost-effectiveness studies JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Matros, E., Momeni, A. 2018; 71 (3): 353?65


    Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models.A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017.After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer.Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

    View details for PubMedID 29196176

  • Conceptual Considerations for Payment Bundling in Breast Reconstruction PLASTIC AND RECONSTRUCTIVE SURGERY Sheckter, C. C., Razdan, S. N., Disa, J. J., Mehrara, B. J., Matros, E. 2018; 141 (2): 294?300


    Rising health care costs and quality demands have driven both the Centers for Medicare and Medicaid Services and the private sector to seek innovations in health system design by placing institutions at financial risk. Novel care models, such as bundled reimbursement, aim to boost value though quality improvement and cost reduction. The Center for Medicare and Medicaid Innovation is leading the charge in this area with multiple pilots and mandates, including Comprehensive Care for Joint Replacement. Other high-cost and high-volume procedures could be considered for bundling in the future, including breast reconstruction. In this article, conceptual considerations surrounding bundling of breast reconstruction are discussed.

    View details for PubMedID 29369980

  • Single Stage Repair of #30 Facial Cleft with Bone Morphogenic Protein. Plastic and reconstructive surgery. Global open Sheckter, C. C., Mittermiller, P., Hung, K., Maan, Z., Rochlin, D., Menard, R. M. 2018; 6 (11): e1937


    Tessier #30 clefts (median mandibular clefts) represent a spectrum of deformities ranging from a minor cleft in the lower lip to complete clefts of the mandible involving the tongue, lower lip, hyoid bone, thyroid cartilages, and manubrium. Various techniques have been used to address these problems; the most common procedure involving 2 stages: an initial correction of the soft tissue followed by closure of the mandibular cleft at a later date using bone grafting. This approach was subsequently reduced to a single operation, but still required harvesting of autologous bone graft. Here, we describe a modified single-stage operation using human recombinant bone morphogenic protein, avoiding bone graft harvest and allowing for simultaneous treatment of bone and soft tissue.

    View details for PubMedID 30881779

    View details for PubMedCentralID PMC6414095

  • Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample. Plastic and reconstructive surgery Sheckter, C. C., Pridgen, B., Li, A., Curtin, C., Momeni, A. 2018; 142 (5): 1337?47


    The ideal timing of soft-tissue coverage for open lower extremity fractures remains controversial. Using U.S. national data, this study aims to characterize secular trends and regional variation in the timing of soft-tissue coverage.Using discharge data from the Nationwide Inpatient Sample (2002 to 2011), the authors identified 888 encounters admitted from the emergency department with isolated open lower extremity fractures treated with pedicled or free tissue transfer. Soft-tissue coverage timing was assessed by patient factors, hospital characteristics, and fracture patterns. Statistical significance and secular trends were analyzed with generalized linear models.The mean day of soft-tissue reconstruction was at 6.64 days. Over the 10-year period, the day of reconstruction increased significantly (from 6.12 days in 2002 to 12.50 days in 2011; coefficient, 0.09; 95 percent CI, 0.05 to 0.12; p < 0.001). Demographic and facility factors did not significantly impact timing. Elixhauser comorbidity scores greater than 2 were associated with later coverage (10.13 days versus 6.29 days; p = 0.001) along with multisite fractures (8.35 days; p = 0.022) and external fixators (8.78 days; p < 0.001). The U.S. Census division showed significant variation in timing ranging from 0.94 days (East North Central) to 9.84 days (Pacific).A progressive delay in the timing of soft-tissue reconstruction was noted and may be attributed to negative-pressure wound therapy. The timing of soft-tissue coverage varied by region after adjusting for patient and hospital factors. Additional studies are needed to understand the impact of delayed soft-tissue coverage on patient outcomes and health services utilization.

    View details for PubMedID 30511989

  • Efficacy and Safety of Titanium Miniplates for Patients Undergoing Septorhinoplasty JAMA FACIAL PLASTIC SURGERY Mittermiller, P. A., Sheckter, C. C., Most, S. P. 2018; 20 (1): 82?84

    View details for PubMedID 29167868

  • Dementia Care, Women's Health, and Gender Equity: The Value of Well-Timed Caregiver Support. JAMA neurology Bott, N. T., Sheckter, C. C., Milstein, A. S. 2017

    View details for DOI 10.1001/jamaneurol.2017.0403

    View details for PubMedID 28492832

  • Recovery of a Missile Embolus From the Right Ventricle. Annals of thoracic surgery Marshall, C. D., Ma, M. R., Park, J., Sheckter, C. C., Massoudi, R. A., Ligman, C. M., Jou, R. M., Ogden, W. D. 2017; 103 (1): e69-e71


    Missile embolism is a clinical entity in which a projectile object enters a blood vessel and is carried to a distant part of the body. We present a case of the discovery of an iliac vein to right ventricle missile embolus in a young man, with successful extraction through a right atriotomy. We provide a historical overview of the literature concerning missile embolism, and we argue that whereas acute embolized projectiles should be removed in almost all cases, it may be reasonable to simply observe an asymptomatic chronic missile embolus.

    View details for DOI 10.1016/j.athoracsur.2016.06.107

    View details for PubMedID 28007279

  • Individualized Acute Medical Care for Cognitively Impaired Individuals: A Call Always to Pause Before Hospitalization. Journal of the American Geriatrics Society Sheckter, C. C., Bott, N. T., Milstein, A., Leff, B. 2017

    View details for PubMedID 28960237

  • Preoperative paravertebral blocks for the management of acute pain following mastectomy: a cost-effectiveness analysis. Breast cancer research and treatment Offodile, A. C., Sheckter, C. C., Tucker, A., Watzker, A., Ottino, K., Zammert, M., Padula, W. V. 2017


    Preoperative paravertebral blocks (PPVBs) are routinely used for treating post-mastectomy pain, yet uncertainties remain about the cost-effectiveness of this modality. We aim to evaluate the cost-effectiveness of PPVBs at common willingness-to-pay (WTP) thresholds.A decision analytic model compared two strategies: general anesthesia (GA) alone versus GA with multilevel PPVB. For the GA plus PPVB limb, patients were subjected to successful block placement versus varying severity of complications based on literature-derived probabilities. The need for rescue pain medication was the terminal node for all postoperative scenarios. Patient-reported pain scores sourced from published meta-analyses measured treatment effectiveness. Costing was derived from wholesale acquisition costs, the Medicare fee schedule, and publicly available hospital charge masters. Charges were converted to costs and adjusted for 2016 US dollars. A commercial payer perspective was adopted. Incremental cost-effectiveness ratios (ICERs) were evaluated against WTP thresholds of $500 and $50,000 for postoperative pain control.The ICER for preoperative paravertebral blocks was $154.49 per point reduction in pain score. 15% variation in inpatient costs resulted in ICER values ranging from $124.40-$180.66 per pain point score reduction. Altering the probability of block success by 5% generated ICER values of $144.71-$163.81 per pain score reduction. Probabilistic sensitivity analysis yielded cost-effective trials 69.43% of the time at $500 WTP thresholds.Over a broad range of probabilities, PPVB in mastectomy reduces postoperative pain at an acceptable incremental cost compared to GA. Commercial payers should be persuaded to reimburse this technique based on convincing evidence of cost-effectiveness.

    View details for PubMedID 28677010

  • Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Sheckter, C. C., Shakir, A., Vo, H., Tsai, J., Nazerali, R., Lee, G. K. 2016; 69 (11): 1506-1512


    Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred.A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications.A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p=0.039).Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.

    View details for DOI 10.1016/j.bjps.2016.06.024

    View details for Web of Science ID 000388293400012

    View details for PubMedID 27538340

  • Vermilion Only Cross-lip Flap for Treating Whistle Deformity in Secondary Bilateral Cleft Lip Repair. Plastic and reconstructive surgery. Global open Sheckter, C. C., Menard, R. M. 2016; 4 (10)


    Bilateral cleft lip repairs can result in various secondary deformities. One more commonly seen deformity, the whistle deformity, is characterized by a reduced or absent tubercle, orbicularis muscle diastasis, and abnormalities of the philtrum with notched appearance of cupid's bow. Various techniques have been described to address these problems. One common procedure is the lip-switch flap originally described by Abbe in 1898, which has been modified by various surgeons. In these procedures, lower lip vermilion, mucosa, orbicularis, and lip skin are transposed to the upper lip on a pedicle that is later divided. In all these variations of the lip-switch procedure, the transposed tissue involves the entire lower lip skin-leaving large, unsightly, and unnecessary scars. It also brings abnormal tissue into the philtrum further distorting the upper lip. A modified cross-lip flap that is limited to the taking only mucosa, vermilion, and orbicularis is feasible and provides an optimal reconstruction without compromising additional tissue.

    View details for PubMedID 27826484

  • Burns resulting from spontaneous combustion of electronic cigarettes: a case series. Burns & trauma Sheckter, C., Chattopadhyay, A., Paro, J., Karanas, Y. 2016; 4: 35-?


    Electronic cigarette (e-cigarette) sales have grown rapidly in recent years, coinciding with a public perception that they are a safer alternative to traditional cigarettes. However, there have been numerous media reports of fires associated with e-cigarette spontaneous combustion.Three severe burns caused by spontaneous combustion of e-cigarettes within a 6-month period were treated at the Santa Clara Valley Medical Center Burn Unit. Patients sustained partial and full-thickness burns. Two required hospitalization and surgical treatment.E-cigarettes are dangerous devices and have the potential to cause significant burns. Consumers and the general public should be made aware of these life-threatening devices.

    View details for PubMedID 27995151

  • Cost-Effectiveness Comparison Between Topical Silver Sulfadiazine and Enclosed Silver Dressing for Partial-Thickness Burn Treatment JOURNAL OF BURN CARE & RESEARCH Sheckter, C. C., Van Vliet, M. M., Krishnan, N. M., Garner, W. L. 2014; 35 (4): 284-290


    The standard treatment of partial-thickness burns includes topical silver products such as silver sulfadiazine (SSD) cream and enclosed dressings including silver-impregnated foam (Mepilex Ag; Molnlycke Health Care, Gothenburg, Sweden) and silver-laden sheets (Aquacel Ag; ConvaTec, Skillman, NJ). The current state of health care is limited by resources, with an emphasis on evidence-based outcomes and cost-effective treatments. This study includes a decision analysis with an incremental cost-utility ratio comparing enclosed silver dressings with SSD in partial-thickness burn patients with TBSA less than 20%. A comprehensive literature review was conducted to identify clinically relevant health states in partial-thickness burn patients. These health states include successful healing, infection, and noninfected delayed healing requiring either surgery or conservative management. The probabilities of these health states were combined with Medicare CPT reimbursement codes (cost) and patient-derived utilities to fit into the decision model. Utilities were obtained using a visual analog scale during patient interviews. Expected cost and quality-adjusted life years (QALYs) were calculated using the roll-back method. The incremental cost-utility ratio for enclosed silver dressing relative to SSD was $40,167.99/QALY. One-way sensitivity analysis of complication rates confirmed robustness of the model. Assuming a maximum willingness to pay $50,000/QALY, the complication rate for SSD must be 22% or higher for enclosed silver dressing to be cost effective. By varying complication rates for SSD and enclosed silver dressings, the two-way sensitivity analysis demonstrated the cost effectiveness of using enclosed silver dressing at the majority of complication rates for both treatment modalities. Enclosed silver dressings are a cost-effective means of treating partial thickness burns.

    View details for DOI 10.1097/BCR.0b013e3182a36916

    View details for Web of Science ID 000338847800020

    View details for PubMedID 24121806

  • Simulation of plastic surgery and microvascular procedures using perfused fresh human cadavers JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Rommer, E., Sheckter, C., Minneti, M., Talving, P., Wong, A. K., Garner, W., Urata, M. M. 2014; 67 (2): E42-E48


    Surgical simulation models are often limited by their lack of fidelity, which hinders their essential purpose, making a better surgeon. Fresh cadaveric tissue is a superior model of simulation owing to its approximation of live tissue. One major unresolved difference between dead and live tissue is perfusion. Here, we propose a means of enhancing the fidelity of cadaveric simulation through the development of a perfused cadaveric model whereby simulation is further able to approach life-like surgery and teach one of the more technically demanding skills of plastic surgery: microsurgery.Fresh tissue human cadavers were procured according to university protocol. Perfusion was performed via cannulation of large vessels, and arterial and venous pressure was maintained by centrifugal circulation. Skin perfusion was evaluated with incisions in the perfused regions and was evaluated using indocyanine green angiography. Surgical simulations were selected to broadly evaluate applicability to plastic surgical education.Surgical simulation of 38 procedures ranging in complexity from skin excisions to microsurgical cases was performed with high priority given to the accurate simulation of clinical procedures. Flap dissections included perforator flaps, muscle flaps, and fasciocutaneous flaps. Effective perfusion was noted with ICG angiography and notable bleeding vessels. Microsurgical flap transfer was successfully performed.We report the establishment of a high fidelity surgical simulation using a perfused fresh tissue model in a realistic environment akin to the operating room. We anticipate utilization of this model prior to entering the operating room will enhance surgical ability and offer a valuable resource in plastic surgical education.

    View details for DOI 10.1016/j.bjps.2013.09.026

    View details for Web of Science ID 000330121900002

    View details for PubMedID 24094541

  • Intra-abdominal pedicled rectus abdominis muscle flap for treatment of high-output enterocutaneous fistulae: Case reports and review of literature JOURNAL OF PLASTIC RECONSTRUCTIVE AND AESTHETIC SURGERY Carey, J. N., Sheckter, C. C., Watt, A. J., Lee, G. K. 2013; 66 (8): 1145-1148


    Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

    View details for DOI 10.1016/j.bjps.2012.12.008

    View details for Web of Science ID 000321441300026

    View details for PubMedID 23317765

  • Incorporation of Fresh Tissue Surgical Simulation into Plastic Surgery Education: Maximizing Extraclinical Surgical Experience JOURNAL OF SURGICAL EDUCATION Sheckter, C. C., Kane, J. T., Minneti, M., Garner, W., Sullivan, M., Talving, P., Sherman, R., Urata, M., Carey, J. N. 2013; 70 (4): 466-474


    As interest in surgical simulation grows, plastic surgical educators are pressed to provide realistic surgical experience outside of the operating suite. Simulation models of plastic surgery procedures have been developed, but they are incomparable to the dissection of fresh tissue. We evolved a fresh tissue dissection (FTD) and simulation program with emphasis on surgical technique and simulation of clinical surgery. We hypothesized that resident confidence could be improved by adding FTD to our resident curriculum.Over a 5-year period, FTD was incorporated into the curriculum. Participants included clinical medical students, postgraduate year 1 to 7 residents, and attending surgeons. Participants performed dissections and procedures with structured emphasis on anatomical detail, surgical technique, and rehearsal of operative sequence. Resident confidence was evaluated using retrospective pretest and posttest analysis with a 5-point scale, ranging from 1 (least confident) to 5 (most confident). Confidence was evaluated according to postgraduate year level, anatomical region, and procedure.A total of 103 dissection days occurred, and a total of 192 dissections were reported, representing 73 different procedures. Overall, resident predissection confidence was 1.901.02 and postdissection confidence was 4.200.94 (p<0.001). The average increase in confidence correlated with training year, such that senior residents had greater gains. When compared by anatomical region, confidence was lowest for the head and neck region. When compared by procedure, confidence was lowest for rhinoplasty and face-lift, and highest for radial forearm and latissimus flaps.A high-volume FTD experience was successfully incorporated into the residency program over 5 years. Training with FTD improves resident confidence, and this effect increases with seniority of training. Although initial data demonstrate that resident confidence is improved with FTD, additional evaluation is needed to establish objective evidence that patient outcomes and surgical quality can be improved with FTD.

    View details for DOI 10.1016/j.jsurg.2013.02.008

    View details for Web of Science ID 000320211000006

    View details for PubMedID 23725934

  • Scalp Erosion in Ankyloblepharon-Ectodermal Defect-Cleft Lip and/or Palate (AEC Syndrome): Treatment With Acellular Dermal Matrix JOURNAL OF CRANIOFACIAL SURGERY Sheckter, C., Rommer, E., Francis, C., Block, V., Chen, J., Rizvi, M., Urata, M. M., Hammoudeh, J. 2013; 24 (1): E28-E30


    Ankyloblepharon-ectodermal defect-cleft lip and/or palate (AEC syndrome, also known as Hay-Wells syndrome) is an autosomal dominant disease caused by mutation in the p63 gene that is primarily characterized by facial clefting, presence of ankyloblepharon, ectodermal dysplasia, and scalp erosion. Scalp erosion is perhaps the most debilitating manifestation of AEC due to its problematic treatment that is fraught with failure given the underlying pathology of the p63 mutation causing dysfunctional wound healing. Management is often targeted in a stepwise fashion, beginning with daily baths, light debridement, and emollients and progressing to extensive skin excision. Skin grafting has limited success and, inevitably, infections requiring aggressive debridement and antibiotic therapy result from dysfunctional healing. The use of acellular dermal matrix for treatment of scalp erosion is a novel approach attempted in a patient with severe scalp disease. Here we report her case and the failure of treatment, along with possible explanations and suggestions for future therapy.

    View details for DOI 10.1097/SCS.0b013e3182688c32

    View details for Web of Science ID 000314853300014

    View details for PubMedID 23348327

  • Multifocal Lipoblastoma of the Face JOURNAL OF CRANIOFACIAL SURGERY Sheckter, C. C., Francis, C. S., Block, V., Lypka, M., Rizvi, M., Urata, M. M. 2012; 23 (6): E585-E587


    Lipoblastoma is a rare benign neoplasm found exclusively in the pediatric population that can occur anywhere in the body, most commonly seen in the extremities but also found in the face. We report an 8-month-old female subject who presented with multifocal soft tissue masses of the face. The diagnosis of lipoblastoma was made in 2 separate locations after surgical resection. Subsequent surgery was performed at the cheek site in an attempt to remove further mass, resulting in discovery of 2 other discrete tumors found to be lipoblastomas. Although the literature reports recurrence rates ranging from 14% to 27%, to our knowledge, aside from a case of Proteus syndrome, there are no known reports of multiple lipoblastomas in the literature. Presentation of the case, review of pertinent literature, and consideration of congenital infiltrative lipomatosis of the face follow.

    View details for DOI 10.1097/SCS.0b013e31826bf012

    View details for Web of Science ID 000311889300023

    View details for PubMedID 23172486

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