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Adjuvant Radiotherapy After Keloid Excision: Preliminary Experience in Taiwan.

We agree that limitations to our study include lack of information with regard to why postoperative CT imaging is ordered, as our study included many different surgeons with differing practice patterns. Although we do not conclude that preoperative CT imaging before revision surgery is unwarranted, we do argue against routine postoperative CT imaging in the absence of concerning symptomatology. There is an important distinction between these completely varying scenarios. For the 6 postoperative patients for whom a CT scan influenced clinical management, we did not have enough information from the clinical charts to knowwhether or not the surgeon had intraoperative concerns. However, we do know that CT scans did not change the management course for the vast majority of patients who received postoperative CT scans. Dr Ellis asserts that postoperative imaging can help guide the surgeon during a patient's recovery when patients have common concerns. However, we feel that clinical acumen in assessing a patient over time is far more useful than ordering a postoperative CT scan every time a patient notes short-term pain or numbness postoperatively. It is critical for a surgeon to think about exactly why he or she is ordering a scan and to have an actual specific provisional diagnosis in mind, rather than to order costly scans without noting any physical examination findings whatsoever. In a recent study on single-level thoracolumbar fractures, it was determined that the 225 postoperative images that were read, which totaled to over 40% of the perioperative image interpretation spending, did not provoke reoperation in a single patient. Given that 82% of reoperations in our cohort were not prompted by CT scans alone, it is certainly plausible that history and physical examination findings alone can guide a surgeon back to the operating room when warranted. Of course, we agree with Dr Ellis that CT scans should still be ordered to help direct surgical treatment after a determination (by physical examination) that surgical revision is necessary. With health care costs skyrocketing in the United States, we feel that plastic surgeons are not exempt from the responsibility to act as stewards of the health care system. The more than 70 million annual CT scans in the United States contribute significant costs given that these scans can range from US $100 to $500 (US $143.84 at our institution). It is certainly warranted to scrutinize the quantity and costs of CT scans in the United States when placed into the context of the rest of the world. Compared with the costs in other high-income countries such as Canada or the Netherlands, the average cost of a CT scan in the United States is significantly higher by hundreds of dollars in some cases. Furthermore, even in countries with lower costs for CTexaminations and extensive publicly available health care