Cosmetic_and_Plastic RSS : Gourt

Fantastic Plastic Surgery Opportunity With Group of Three Surgeons :: Pennsylvania :: CompHealth Inc

Job 658071 Busy Plastic Surgery group is recruiting an experienced Plastic Surgeon to join them Top Salary and benefits for the right candidate Call 1:4 No competition in local region Located in a wonderful

Facial Plastic Surgeon Needed for Excellent Practice Opportunity :: Pennsylvania :: CompHealth Inc

Job 6512599 Require Board Certified / Board Eligible Plastic Surgeon with Fellowship training in craniofacial surgery Employed position Join a surgical team at a 400 bed modern facility Enjoy an established

Metro Area Plastic Surgery With Hand (30%) Opportunity :: Iowa :: CompHealth Inc

Job 6512314 Hospital based surgery group seeks a Plastic Surgeon Unbeatable location - the best that Iowa offers Must be Board Eligible or Board Certified Plastic Surgeon with Hand training or experience

Plastic Surgeon Needed for Breast Reconstruction :: Pennsylvania :: CompHealth Inc

Job 6512851 Breast Surgery program is expanding Requires an additional Fellowship in Breast Reconstruction beyond Plastic Surgery Residency Relocation and CME Medical Education Debt Repayment Assistance

Clinic in Pennsylvania seeks Plastic Surgeon :: Pennsylvania :: Weatherby Locums

Job 9502828-0066 Plastic Surgeon needed to provide locums coverage in October. Group seeks to add additional physician and ideal candidate is eligible for licensure. Office and scheduled surgeries.

Western Maryland Seeks Plastic Surgeon :: Maryland :: Enterprise Medical Service

Single Specialty Group is seeking a Plastic Surgeon to join practice. Hours are Monday - Friday, 9a -5p. 1:4 shared call w/mariller facial, plastic surgeon and hand surgeon. 90% Outpatient; 10% Inpatient.

Call for Information :: Illinois :: Inhouse Physician Recruiters Network

The In-House Physician Recruiter Network, composed of over 500 hospital recruiters, represents over 10,000 hospitals and clinics. Our Network's special feature is to showcase outstanding physicians (who

Call for Information :: North Carolina :: Inhouse Physician Recruiters Network

Call for Information :: North Dakota :: Inhouse Physician Recruiters Network

Excellent Location :: North Carolina :: Spot On Recruiting

Plastic Surgeon needed in the Greenville, NC area: Plastic surgeon needed to join this University town. Enjoy a clinical practice while enjoying teaching responsibilities. Solid clinical training in

Close to the Coast :: South Carolina :: CompHealth Inc

Job 6511321 Hospital employed position Generous salary Large referral base Mix of Cosmetic and Reconstructive (high volume of referrals from in house Cancer Center) Paid Malpractice Close to major metro

Wilkes Barre :: Pennsylvania :: Community Health Systems

Wilkes-Barre General Hospital is seeking a board certified/board eligible breast surgeon with a fellowship in breast reconstruction. Contact: Joyce Y. McCuller Email: joyce_mcculler@chs.net Phone:

About This Journal [About This Journal]

Highlights of Archives of Facial Plastic Surgery [Highlights of Archives of Facial Plastic Surgery]

Alar Rim Grafting in Rhinoplasty: Indications, Technique, and Outcomes [Original Article]

Objective To determine the potential indications for placement of cartilaginous alar rim grafts in primary and revision septorhinoplasty. Methods Retrospective medical chart analysis of all patients undergoing septorhinoplasty from March 2003 through June 2004 in a private facial plastic and reconstructive surgery center and a tertiary teaching hospital. Patients who received alar rim grafts were identified. The indications for placement of the alar rim grafts were deduced from their preoperative evaluation and intraoperative assessment as noted in their comprehensive operative notes. Preoperative and postoperative digital photographs as well as postoperative medical records were analyzed for alar contour, pertinent patient complaints, and complications. Results During the 15-month study period, 150 patients underwent septorhinoplasty performed by the senior author. Of these patients, 31 received alar rim grafts. The most frequent indications for placement of alar rim grafts were cephalic malposition of the lower lateral cartilage with inadequate alar support (9 patients [29%]), correction of alar flare (9 patients [29%]), and correction of dynamic alar margin collapse (8 patients [26%]). At a mean 6-month follow-up, there were no graft displacements or extrusion. Conclusion Alar rim grafting is a simple and versatile approach to providing additional support to the external nasal valve and for improving nasal base contour.

Analysis of Patient-Determined Preoperative Computer Imaging [Original Article]

Objective To compare patients' goals in aesthetic rhinoplasty with aesthetic ideals by analyzing changes requested through computer imaging during the initial consultation. Methods The frontal and lateral views of 20 consecutive female rhinoplasty patients were analyzed retrospectively before and after using image manipulation software. Indexes from the frontal view included the ratio of alar base width to dorsal length and the ratio of alar base width to interpupillary distance. On the lateral view, parameters included the nasolabial angle, nasofacial angle, and tip projection (Goode ratio). Ideal parameters were based on descriptions by Powell and Humphreys. Results The ideal and patient-determined proportions were compared using a paired 2-tailed t test. The mean nasolabial angle falls within the ideal range before and after image manipulation. However, the Goode ratio and the ratio of alar base width to interpupillary distance were statistically similar to ideal values only after image manipulation. The nasofacial angle and the ratio of alar base width to dorsal length showed a trend toward the ideal ratio. Conclusions Patients' preferences were similar to the ideal in 3 of 5 parameters, and the remaining parameters approached the ideal. These parameters are useful in creating satisfying proportions in aesthetic rhinoplasty and reconstructive surgery within our population. Rather than population-based normative data or ideals based on fashion models or Greek statuary, these are proportions requested by patients. Computer imaging software, used by a growing number of aesthetic surgeons, holds a wealth of data regarding common patient preferences.

The Treatment of Nasal Fractures: A Changing Paradigm [Original Article]

Objectives To compare the efficacy of closed vs open treatment of nasal fractures, and to suggest an algorithm for nasal fracture management that includes closed and open techniques. Methods Retrospective study of 86 patients with nasal fractures who received either closed treatment (41 patients) or open treatment (45 patients) between January 1, 1997, and December 30, 2007. Fractures were classified as 1 of 5 types. Revision rates were calculated for each group. Preoperative and postoperative photographs were rated, if available, and patients were interviewed about aesthetic, functional, and quality of life issues related to surgical treatment. Results The revision rate for all fractures was 6%. The revision rate for closed vs open treatment was 2% vs 9%, respectively. Many closed treatment cases were classified as type II fractures, whereas most open treatment cases were classified as type IV fractures. There was no statistical difference in revision rate, patient satisfaction, or surgeon photographic evaluation scores between the closed and open treatment groups when fractures were treated in the recommended fashion. Conclusions Patients who undergo open or closed treatment have similar outcomes if the surgical approach is well matched to the individual fracture. Our treatment algorithm provided consistent aesthetic and functional results while minimizing the need for revision procedures.

Margin Reflex Distance in Different Ethnic Groups [Original Article]

Objective To determine the normal range for eyelid margin reflex distance (MRD) in adults according to their ethnicity, age, and sex. Methods A prospective study of eyelid measurements in 112 consecutive adult African American, Asian, white, and Latino patients was compared using t test analysis. Measurements of MRD were collected by a single examiner across 5 months. Patients with conditions disposing to eyelid height changes were excluded. Results The MRD showed statistically significant variance among select ethnic groups. There was no statistical significance between sexes within each ethnic group. Conclusions Variance in MRD exists among ethnic groups. This information and further data on ethnicity and sex variance of eyelid measurements can be used for both diagnostic purposes and surgical treatment of patients for optimal results.

Improved Skin Paddle Survival in Pectoralis Major Myocutaneous Flap Reconstruction of Head and Neck Defects [Original Article]

Objective To examine our outcomes with skin paddle survival using pectoralis myocutaneous flaps in reconstruction of the head and neck. The pectoralis major myocutaneous flap has been associated with a notable incidence of distal skin necrosis and flap loss. Our experience has been favorable compared with that reported in the literature. Methods Retrospective medical record review of 81 cases of pectoralis major muscle flap reconstruction performed in 78 patients from 1995 to 2008 using a flap harvest technique that is slightly different from the classic descriptions. Data were obtained regarding coexisting health conditions and perioperative complications, which were divided into major and minor categories. Major complications were defined as total flap failure or greater than 25% skin paddle loss. Minor complications and donor site complications included fistulas that were managed conservatively, wound dehiscence not requiring additional surgery, local infections, seromas, and hematomas. Results Of the 81 flaps performed, 22 complications were encountered. Total flap loss was not encountered in any patient. The overall major complication rate in myocutaneous flaps was 3 of 76 (4%), with these cases consisting of significant skin paddle loss. Minor complications occurred in 14 of 81 myofascial and myocutaneous flaps (17%). Donor site complications of the chest wall occurred in 5 of 81 flaps (6%). Conclusions Skin paddle necrosis may be minimized with modifications of the classic technique. We believe that extension of the skin flap over the rectus sheath is the cause of distal skin flap necrosis. The pectoralis major myocutaneous flap remains a valuable reconstructive option in the head and neck.

Correction of Pollybeak and Dimpling Deformities of the Nasal Tip in the Contracted, Short Nose by the Use of a Supratip Transposition Flap [Original Article]

Objective To discuss our experiences with the use of a supratip transposition flap to simultaneously correct pollybeak deformity and nasal tip dimpling. Design From April 1, 2007, through August 31, 2008, 10 Asian women with a contracted, short nose that exhibited nasal tip dimpling were retrospectively included in this study. By use of an open approach, the osteocartilaginous framework was elongated first. If the pollybeak and dimpling deformities of the nasal tip were found after the closure of the transcolumellar incision, a supratip transposition flap was designed to correct the combined deformities over the supratip and nasal tip areas. Finally, bilateral marginal incisions were closed. Results The follow-up period ranged from 2 to 16 months, with an average of 5 months. No immediate complications were noted in this small series. Four of 10 patients required minor flap revisions, with satisfactory results attained thereafter. All patients were satisfied with the aesthetic result after scar maturation. Conclusions The use of the supratip transposition flap not only corrects pollybeak deformity but also resolves dimpled nasal tip depression. The techniques presented herein add to the armamentarium of revision rhinoplasty surgeons, especially those dedicated to the treatment of the Asian patient who undergoes rhinoplasty.

Comparison of Incision Closures With Subcuticular and Percutaneous Staples [Original Article]

Objective Incision closures should yield safe, effective healing with excellent cosmesis. Subcuticular absorbable staples may combine the advantages of subcuticular suturing with the efficiency of percutaneous stapling. This study compares absorbable subcuticular staples with percutaneous metal staples as a means of incision closure in facial rejuvenation surgery. Methods Sixteen patients undergoing endoscopic eyebrow-lift and/or rhytidectomy were studied. Each patient had 50% of their temporal and postauricular skin incisions closed with subcuticular staples oversewn with 5-0 plain gut and the remaining 50% closed with percutaneous metal staples. Incisions were evaluated intraoperatively and at regular intervals for 1 year postoperatively. Intraoperative assessments included device handling, bleeding, tension, and cosmesis. Postoperative assessments included incision integrity, inflammation, and cosmesis. Patients were also interviewed regarding incision appearance and comfort. Results During the early postoperative period, metal staples produced greater incisional erythema and crusting. Subcuticular staples produced better tissue eversion, less erythema, equivalent if not superior comfort, and shorter office visits. These differences faded over time. The need to properly engage the subcuticular stapler in the dermis was the principal impediment to optimal stapler use. Conclusions Subcuticular staples represent a safe, comfortable, and potentially more rapid alternative to percutaneous staples. Modifications of the subcuticular stapler device are required before its full potential can be realized.

Meta-analysis of Surgical Techniques for Preventing Parotidectomy Sequelae [Original Article]

Objective To conduct a meta-analysis of the literature on surgical methods for the prevention of Frey syndrome and concave facial deformity after parotidectomy. Methods A PubMed search through February 2008 identified more than 60 English-language studies involving surgical techniques for prevention of these parameters. Analyzed works included 15 retrospective or prospective controlled studies reporting quantitative data for all included participants for 1 or more of the measured parameters in patients who had undergone parotidectomy. Report quality was assessed by the strength of taxonomy recommendation (SORT) score. Data were directly extracted from reports and dichotomized into positive and negative outcomes. The statistical significance was then calculated. Results The mean SORT score for all studies was 2.34, and the mean SORT score for all the analyzed studies was 1.88. Meta-analysis for multiple techniques to prevent symptomatic Frey syndrome, positive starch-iodine test results, and contour deformity favored intervention with a cumulative odds ratio (OR) of 3.88 (95% confidence interval [CI], 2.81-5.34); OR, 3.66 (95% CI; 2.32-5.77); and OR, 5.25 (95% CI, 3.57-7.72), respectively. Conclusion Meta-analysis of operative techniques to prevent symptomatic Frey syndrome, positive starch-iodine test results, and facial asymmetry suggests that such methods are likely to reduce the incidence of these complications after parotidectomy.

Profilometric and Morphometric Response of Murine Skin to Cosmeceutical Agents [Original Article]

Objective To investigate whether topical antiaging compounds can reduce wrinkle depth as noted at replica profilometry with comparable changes in histologic findings in hairless mice. Methods Commercial retinoic acid cream, a peptide lotion, and a soy cream were applied to the dorsal skin for 4 weeks. Silicone-negative replicas of treated and untreated skin surface were photographed and evaluated for traditional features of surface roughness. Skin samples were processed using histomorphometry and immunohistochemistry of proliferating cell nuclear antigen. Quantitative light microscopic data were acquired for estimating replication of epidermal keratinocytes, epidermal thickness, and depth of dermal collagen bundles. Results Data were analyzed by comparing means with 1-way analysis of variance, and significant changes in all measurements were noted. Augmented keratinocyte proliferation and thickening of viable epidermis were observed with all 3 compounds, although a greater effect was found in the retinoic acid and peptide treatment groups. A similar trend was noted with respect to widening of the collagen layer. Epidermal surface roughness manifested maximum smoothing after treatment with the peptide compound. Conclusion The pronounced effects noted with all 3 compounds indicate that topical agents other than retinoic acid may have comparative stimulating effects on the skin in nonirradiated mice.

Use of the Remnant Ear for Reconstruction in Lobule-Type Microtia [Original Article]

Objective To present in detail a reconstruction technique using the remnant ear in lobule-type microtia. Methods By comparing the location of residual ear and the contralateral normal ear, we classified 3 different types of the remnant ear. Three techniques of transposition were applied to adjust the location of the reconstructed ear. Results The reconstructed earlobes not only looked real but also were symmetrical with the contralateral normal ears. Conclusion The remnant ear is a key factor—in addition to the framework and covering skin—in ear reconstruction in microtia.

The Use of Ultrasonic Shears for the Harvest of Perforator Free Flaps [Surgical Technique]

A retrospective chart review was performed at a university medical center to evaluate the use of ultrasonic shears for the harvest of perforator free flaps over an 18-month period. The anterolateral thigh (ALT) was the perforator free flap site selected for the study. The site of origin and the number of musculocutaneous perforator vessels that were dissected using ultrasonic shears were recorded, and ALT flap viability and wound-healing complications were evaluated to assess safety. Seventeen patients underwent harvest of ALT perforator free flaps. Successful dissection of musculocutaneous perforators was achieved in 96% (27 of 28) of the descending branch perforators and in 100% (9 of 9) of the transverse branch perforators. Flap viability was 100% (17 of 17). We found that ultrasonic shears were effective and safe to use for harvesting perforator free flaps. According to these preliminary findings, the use of ultrasonic shears appears promising, yet further prospective analysis is needed.

Facial Anthropometric Analysis of the Javanese Female [Research Letters]

Absorbable Suture Compared With Nonabsorbable Suture in Upper Eyelid Blepharoplasty Closure [Research Letters]

Abstracts: In Other Archives Journals [Abstracts: In Other Archives Journals]

Edgar Degas's La Savoisienne [Beauty]

Announcements

Announcements Content Type Journal ArticleCategory AnnouncementsDOI 10.1007/s00266-009-9430-0 Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Percutaneous Electrothrombosis: A Minimally Invasive Technique for the Treatment of Deep Hemangiomas

Abstract Background A percutaneous electrocauterization technique for the treatment of deep hemangiomas is introduced as an alternative and minimally invasive treatment mode. Methods Percutaneous electrothrombosis was applied through a needle-catheter that is a small silicone catheter with a needle guide in it. Thus, it is possible to do needle-point monopolar electrocauterization only at the needle tip because of the insulation of the other parts of the needle by the silicone catheter. By retracting the needle with catheter on it during electrocauterization, electrothrombosis was achieved through and around the channel of the needle, leaving vascularized tissue areas between the channels to perfuse the skin or mucosa covering the hemangioma. Results This technique was applied as a single treatment or before surgery for the treatment of cavernous hemangiomas to more than 40 patients. However, adequate documentation was found for only 10 patients. After percutaneous electrocauterization of deep hemangiomas, discrete areas of skin necrosis appeared in some patients during the healing period, but the subsequent debridement and surgical excisions were easier because of the thrombosis effect of the technique due to the diffuse denaturation and fibrosis through and around the electrocauterization channels. The follow-up period was 1–13 years. Conclusion The proposed percutaneous electrocauterization technique for the treatment of deep hemangiomas achieved four effects: (1) volume reduction, (2) bleeding reduction, (3) anesthesia time reduction, and (4) cost reduction. The technique can be defined as a minimally invasive and effective alternative treatment for deep hemangiomas. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9425-xAuthors O. Onur Erol, ONEP Plastic Surgery Science Institute Manolyali Sokak No.15 Levent 34330 Istanbul TurkeyO. Ata Uysal, ONEP Plastic Surgery Science Institute Manolyali Sokak No.15 Levent 34330 Istanbul TurkeyGalip Agaoglu, ONEP Plastic Surgery Science Institute Manolyali Sokak No.15 Levent 34330 Istanbul Turkey Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Experience of 1000 Cases on Subfascial Breast Augmentation

Abstract Background Throughout the years the female breast has been manipulated through aesthetic and reconstructive surgery. Since the 18th century there have been reports of techniques that have tried to increase the volume of the mammary gland. This article demonstrates a technique for increasing the volume of the mammary gland by dissection of the fascia of the pectoralis major muscle. This technique provides long-term results due to the optimized dynamics between the soft tissue and the implant. The subfascial technique is paramount to the subglandular method because primarily it offers better palpable firmness in the periareolar area, a significant decrease in the step effect produced by an excessive projection of the breast, a favorable gravitational pull of the breast, and a considerable reduction in the incidence of capsular contractures. The movement of the implant, postsurgical pain, and bleeding caused by the incision of the pectoralis muscle diminish with this technique. Because of the fascia’s tendency to be preserved, this procedure has the advantage of being able to be applied where previous surgery has been performed; this concedes the subfascial technique a more versatile angle. Methods In the last 10 years 1000 patients were subjected to subfascial breast augmentation with soft-gel cohesive textured implants. An inframammary incision was used in 95% of the patients and the periareolar incision in 5%. Results The patient does not suffer from immediate postsurgical pain. Recovery time and the ability to start daily activities is briefer than after the submuscular procedure. A better projection is obtained without the need to use a bigger implant to get the same result because there is no pressure on top of the implant as in the submuscular technique. Conclusion The subfascial procedure offers a high-grade result for the short and long term and has fewer disadvantages than the submuscular or subglandular technique. Likewise, there are fewer immediate postoperative symptoms and patients have a much better and less painful recovery. The morbidity in these patients is less than with the subglandular and submuscular methods. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9402-4Authors Victor Noe Elizondo Tijerina, Monterrey Nuevo Leon MexicoRodolfo A. Elizondo Saenz, Monterrey Nuevo Leon MexicoJair Garcia-Guerrero, Monterrey Nuevo Leon Mexico Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Silicone Nipple Shields: An Innovative Postoperative Dressing Technique After Nipple Reconstruction

Abstract Background The newly reconstructed nipple is extremely sensitive to mechanical pressure and shearing forces, which can cause flap necrosis and sloughing of the skin, eventually promoting infection. Current available dressing solutions are cumbersome, inefficient, displeasing, or otherwise not readily obtainable. Methods In this study, 10 patients with newly reconstructed nipples were instructed to use breastfeeding nipple shields as the sole means of nipple dressing after the reconstruction procedure. Results No complications were observed overall. Patients reported full adherence to the postoperative dressing regimen as well as ease of use, availability, low costs, and pleasing aesthetic appearance under garments. Discussion Silicone breastfeeding nipple shields offer an efficient, affable, cheap, widely available, and aesthetically pleasing form of postoperative dressing for reconstructed nipples. Their use may enhance patient compliance with the dressing regimen and lower the postoperative complication rate. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9426-9Authors Oren Weissman, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelAriel Tessone, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelAlon Liran, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelDemetris Stavrou, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelNimrod Farber, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelArie Orenstein, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelJosef Haik, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan IsraelEyal Winkler, Sheba Medical Center Department of Plastic and Reconstructive Surgery Tel Hashomer, Ramat Gan Israel Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Erratum to: Abdominal Fascial Flaps for Providing Total Implant Coverage in One-Stage Breast Reconstruction: An Autologous Solution

Erratum to: Abdominal Fascial Flaps for Providing Total Implant Coverage in One-Stage Breast Reconstruction: An Autologous Solution Content Type Journal ArticleCategory ErratumDOI 10.1007/s00266-009-9420-2Authors Tonguc Isken, Kocaeli University Faculty of Medicine Department of Plastic and Reconstructive Surgery Kocaeli TurkeyMurat Onyedi, Kocaeli University Faculty of Medicine Department of Plastic and Reconstructive Surgery Kocaeli TurkeyHakki Izmirli, Kocaeli University Faculty of Medicine Department of Plastic and Reconstructive Surgery Kocaeli TurkeySahin Alagoz, Kocaeli University Faculty of Medicine Department of Plastic and Reconstructive Surgery Kocaeli TurkeyRyan Katz, Johns Hopkins University School of Medicine Department of Plastic and Reconstructive Surgery Baltimore MD USA Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Breast Augmentation, Antibiotic Prophylaxis, and Infection: Comparative Analysis of 1,628 Primary Augmentation Mammoplasties Assessing the Role and Efficacy of Antibiotics Prophylaxis Duration

Abstract Background Infections after augmentation mammoplasty are not uncommon, and prophylactic antibiotics are routinely administered to minimize infection. However, there is paucity of information on the relationship between the length of prophylaxis cover and its benefits in primary augmentation mammoplasty. A retrospective analysis of different antibiotic cover regimens, their effectiveness in preventing infections, and the management of infection in established cases is reviewed. Methods A retrospective chart analysis of periprosthetic infections in primary augmentation mammoplasties performed over the past 10 years was conducted. Periprosthetic infection was determined by the presence of pain, swelling, redness, and discharge. Each breast was taken as an individual unit in 1,628 patients, and data for 3,256 breasts were analyzed. The patients had their augmentation in the partial submuscular plane (214 breasts in 107 patients), the subglandular plane (1,548 breasts in 774 patients), and the muscle-splitting biplane (1,494 breasts in 747 patients). All the patients had soft round cohesive gel silicone implants. Of the 3,256 implants, 3,218 were textured, and 38 were smooth surfaced. The patients received antibiotics as a single intravenous dose of cephalosporin (474 breasts in 237 patients), a single intravenous dose plus an oral dose for 24 h (344 breasts in 172 patients), or a single intravenous dose plus an oral course for 5 days (2,438 breasts in 1,219 patients). Infection was recorded as superficial (e.g., wound breakdown, stitch extrusion, stitch abscess) or deep (periprosthetic). The patients with established periprosthetic infections, determined clinically by the presence of pain, discharge, swelling, and redness of the breasts, were managed either conservatively using antibiotics, passive wound drainage, and healing of the wound with secondary intention or by explantation and replacement after 3 to 4 months. In selected cases of periprosthetic infection, the implants were removed after a course of antibiotics and negative swab cultures. The cavity was washed thoroughly with betadine and saline, and new implants were simultaneously reimplanted. Results The incidence of infection was lowest with a single perioperative dose of intravenous antibiotic compared with a combination of intravenous and oral antibiotics. Superficial infection was seen in 38 breasts (all unilateral), with an incidence of 1.2%, and periprosthetic infection was observed in 17 breasts (13 unilateral and 2 bilateral), giving an infection incidence of 0.52% (p = 0.002). In patients with a single intravenous dose of antibiotic, superficial and periprosthetic infection was seen in four breasts (0.8%) and no breasts, respectively. The difference was not significant (p = 0.13). The patients receiving a single intravenous antibiotic and a 24-h oral antibiotic had superficial and periprosthetic infection rates of 2.3% (8 breasts) and 0.3% (1 breast), respectively, and the difference between the two sub-groups was significantly higher (p = 0.04). The patients receiving an intravenous antibiotic and 5 days of oral antibiotics had superficial and periprosthetic infection rates of 1.1% (26 breasts) and 0.65% (14 breasts), respectively. The difference between the two subgroups was not significant (p = 0.09). Of the 17 periprosthetic infections in 15 patients (13 unilateral and 2 bilateral), 11 breasts (1 bilateral and 9 unilateral) were treated conservatively using antibiotics, passive drainage, and wound healing with secondary intention. Capsular contracture developed in two of the conservatively treated breasts, requiring capsulotomies with change of implants. Of the six periprosthetic infections in six patients, requiring surgical intervention, two implants were treated using explantation with immediate replacement after a course of antibiotics and a negative culture, and two implants were explanted followed by reimplantation later. One patient had both implants removed after unilateral infection, and no reimplantation was performed. One patient had a bilateral infection. In this case, one implant was explanted and the other was treated conservatively. The patient had bilateral reimplantion 6 months later, and bilateral Baker 4 capsular contracture developed in both breasts within 6 months. No other complications were seen in the patients who underwent surgery. Conclusion A single dose of intravenous antibiotic is adequate for prophylaxis in breast augmentation surgery, and the extra duration of antibiotic cover does not result in reduced superficial or periprosthetic infections. Infection can be managed in more than one way depending on the nature, degree, and extent of infection. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9427-8Authors Umar Daraz Khan, Re-shape House 2-4 High Street ME 19 6QR West Malling, Kent UK Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

The New Face of Transplant Surgery: A Survey on Cosmetic Surgery in Transplant Recipients

The New Face of Transplant Surgery: A Survey on Cosmetic Surgery in Transplant Recipients Content Type Journal ArticleCategory DiscussionDOI 10.1007/s00266-009-9416-yAuthors Linda Cendales, Emory University Division of Plastic Surgery and Division of Transplantation, Vascularized Composite Allografts and the Laboratory of Microsurgery, Emory Transplant Center 101 Woodruff Circle, Suite 5105 WMB Atlanta GA 30045 USA Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

A New Postoperative Otoplasty Dressing Technique Using Cyanoacrylate Tissue Adhesives

Abstract There are many techniques for cosmetic surgery of the ears and also many different procedures for postoperative treatment. The postoperative dressing is described as important for a successful outcome. We present our method of postoperative dressing in the form of liquid bonding. Cyanoacrylate tissue adhesives as liquid bonding agents are used for fixation of the pinna at the mastoid area. After 10–14 days the bonding can be easily removed. No huge dressings, tapes, or plasters are necessary. The patients are satisfied with the light dressing; they do not feel ashamed to appear in public. We have found this dressing technique to be simple and economical, especially because of the use of the bonding for skin closure before. It can be used after otoplasty with an anterior or a posterior approach. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9419-8Authors Miriam Vetter, Plastic, Reconstructive and Aesthetic Surgery, Kantonsspital Frauenfeld Frauenfeld SwitzerlandMatthias Foehn, Plastic, Reconstructive and Aesthetic Surgery, Kantonsspital Frauenfeld Frauenfeld SwitzerlandVolker Wedler, Plastic, Reconstructive and Aesthetic Surgery, Kantonsspital Frauenfeld Frauenfeld Switzerland Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Breast Prostheses and Connective Tissue Disease (CTD): Myth or Reality?

Abstract Since their first appearance, breast prostheses have been criticized as being both responsible for and giving rise to systemic disease. The literature contains many reports on the subject, and theories were controversial from the 1980s to the 2000s. The aim of this review was to gather together the most important studies on breast prostheses and systemic disease, with particular attention to connective tissue disease (CTD), in order to verify any relationship between silicone breast implants and the occurrence of pathologies. Content Type Journal ArticleCategory ReviewDOI 10.1007/s00266-009-9422-0Authors F. Bassetto, University of Padova Plastic Surgery Clinic Padova ItalyV. Vindigni, University of Padova Plastic Surgery Clinic Padova ItalyCarlotta Scarpa, University of Padova Plastic Surgery Clinic Padova ItalyA. Doria, University of Padova Institute of Rheumatology Padova Italy Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Effect of Botulinum Toxin Type A on Transforming Growth Factor β1 in Fibroblasts Derived from Hypertrophic Scar: A Preliminary Report

Abstract Background Hypertrophic scar is a common dermal disease. Numerous treatments are currently available but they do not always yield excellent therapeutic results. Hence, alternatives are needed. Recent basic and clinical research has shown that botulinum toxin type A (BTXA) has antihypertrophic scar properties but the molecular mechanism for this action is unknown. The aim of this study was to explore the effect of BTXA on transforming growth factor β1 (TGF-β1) in fibroblasts derived from hypertrophic scar and further elucidate its actual mechanism. Methods Fibroblasts were isolated from tissue specimens of hypertrophic scar. Fibroblasts were treated with BTXA and the difference in proliferation between treated and nontreated cells was analyzed through the MTT method from the first to the fifth day after treatment. Proteins of TGF-β1 were checked using ELISA in fibroblasts with BTXA and without BTXA from the first to the fifth day. Results The growth of the fibroblast treated with BTXA was obviously slower than that of the fibroblast without BTXA treatment (p < 0.01), which showed that BTXA effectively inhibited the growth of fibroblasts. Proteins of TGF-β1 between fibroblasts with BTXA and fibroblasts without BTXA are statistically significant (p < 0.01). Conclusion These results suggest that BTXA effectively inhibited the growth of fibroblasts derived from hypertrophic scar and in turn caused a decrease in TGF-β1 protein, indicating that BTXA-based therapies for hypertrophic scar are promising and worth investigating further. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9423-zAuthors Zhibo Xiao, Second Affiliated Hospital of Harbin Medical University Department of Plastic Surgery Harbin City People’s Republic of ChinaFengmin Zhang, College of Basic Medical Science, Harbin Medical University Department of Microbiology Harbin City People’s Republic of ChinaWeibin Lin, Second Affiliated Hospital of Harbin Medical University Department of Very Important Patient Harbin City People’s Republic of ChinaMiaobo Zhang, Second Affiliated Hospital of Harbin Medical University Department of Plastic Surgery Harbin City People’s Republic of ChinaYing Liu, Second Affiliated Hospital of Harbin Medical University Department of Plastic Surgery Harbin City People’s Republic of China Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

ArteFill® Permanent Injectable for Soft Tissue Augmentation: I. Mechanism of Action and Injection Techniques

Abstract After more than 25 years of research and development, in October 2006 ArteFill® became the first and only permanent injectable wrinkle filler to receive FDA approval. ArteFill is a third-generation polymeric microsphere-based filler, following its predecessor Artecoll®, which was marketed outside the United States between 1994 and 2006. ArteFill is approved for the correction of nasolabial folds and has been used in over 15,000 patients since its U.S. market introduction in February 2007. No serious side effects have been reported to date according to the FDA’s MAUDE reporting database. ArteFill consists of polymethylmethacrylate (PMMA) microspheres (20% by volume), 30–50 μm in diameter, suspended in 3.5% bovine collagen solution (80% by volume) and 0.3% lidocaine. The collagen carrier is absorbed within 1 month after injection and completely replaced by the patient’s own connective tissue within 3 months. Each cc of ArteFill contains approximately six million microspheres and histological studies have shown that long-term wrinkle correction consists of 80% of the patient’s own connective tissue and 20% microspheres. The standard injection technique is subdermal tunneling that delivers a strand of ArteFill at the dermal–subdermal junction. This strand beneath a wrinkle or fold acts like a support structure that protects against further wrinkling and allows the diminished thickness of the dermis to recover to its original thickness. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9413-1Authors Gottfried Lemperle, University of California, San Diego Division of Plastic Surgery 200 West Arbor Drive San Diego CA 92103 USATerry R. Knapp, 7451 North 63rd Street Niwot CO 80503 USANeil S. Sadick, 911 Park Avenue, Suite 1A New York NY 10075 USAStefan M. Lemperle, 5672 Dolphin Place La Jolla CA 92037 USA Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

ArteFill® Permanent Injectable for Soft Tissue Augmentation: II. Indications and Applications

Abstract Patients ask for procedures with long-lasting effects. ArteFill is the first permanent injectable approved in 2006 by the FDA for nasolabial folds. It consists of cleaned microspheres of polymethylmethacrylate (PMMA) suspended in bovine collagen. Over the development period of 20 years most of its side effects have been eliminated to achieve the same safety standard as today’s hyaluronic acid products. A 5-year follow-up study in U.S. clinical trial patients has shown the same wrinkle improvement as seen at 6 months. Long-term follow-up in European Artecoll patients has shown successful wrinkle correction lasting up to 15 years. A wide variety of off-label indications and applications have been developed that help the physician meet the individual needs of his/her patients. Serious complications after ArteFill injections, such as granuloma formation, have not been reported due to the reduction of PMMA microspheres smaller than 20 μm to less than 1% “by the number.” Minor technique-related side effects, however, may occur during the initial learning curve. Patient and physician satisfaction with ArteFill has been shown to be greater than 90%. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9414-0Authors Gottfried Lemperle, University of California, San Diego Division of Plastic Surgery 200 West Arbor Drive San Diego CA 92103 USANeil S. Sadick, 911 Park Avenue New York NY 10075 USATerry R. Knapp, 7451 North 63rd Street Niwot CO 80503 USAStefan M. Lemperle, 5672 Dolphin Place La Jolla CA 92037 USA Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Lateral Brow Fixation in Endoscopic Forehead Lift: Long-Term Results with Braided Nylon Percutaneous Sutures

Abstract Background Since the introduction of endoscopic forehead surgery, several fixation techniques have been described to remediate the fall of the lateral portion of the brow. Unfortunately, few studies demonstrate good long-term results with these methods. Methods This study evaluates long-term results of a lateral brow fixation technique that uses two points in the lateral eyebrow: one in the distal extremity and another corresponding to the midpoint between the pupil and the lateral canthus of the eye. Transcutaneous fixation was performed using the Casagrande needle. Braided white nylon 2-0 suture was passed through the needle and retroceded without exiting the skin, catching the supraorbital adhesions. These sutures were fixed to the deep temporal fascia. Results A total of 44 patients underwent endoscopic forehead lift between March 2000 and March 2006. Pre- and postoperative forehead position was documented using photos and the Mirror® (Canfield, NJ, USA) program. Through a line perpendicular to the interpupillary line, the following measurements were taken between the vertical center of the eyebrow and the (1) lateral canthus (2) midpoint between the lateral canthus and the pupil, and (3) pupillary midpoint. Three groups were studied: Group 1 (n = 32), evaluated at 1–1.5 years after surgery, Group 2 (n = 20), evaluated at 3+ years after surgery, and Group 3 (n = 8), evaluated at both 1–1.5 years and 3+ years after surgery. A student t test for Groups 1 and 2 and a Wilcoxon test for Group 3 indicated statistical significance. Conclusion Through a solid evaluation method, our technique has demonstrated significantly good near- and longer-term results. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9401-5Authors Ana Zulmira Eschholz Diniz Badin, Centro Medico Athena Rua Desembargador Vieira, Cavalcanti, 604 Bairro Mercês Curitiba Paraná 80510090 BrazilLeandra Muniz Bittencourt, Centro Medico Athena Rua Desembargador Vieira, Cavalcanti, 604 Bairro Mercês Curitiba Paraná 80510090 BrazilCynthia Rojas Balderrama, Centro Medico Athena Rua Desembargador Vieira, Cavalcanti, 604 Bairro Mercês Curitiba Paraná 80510090 Brazil Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

The New Face of Transplant Surgery: A Survey on Cosmetic Surgery in Transplant Recipients

Abstract Background Transplant surgery has undergone tremendous advances within the last decade. Improvements in surgical techniques, availability of potent immunosuppressive medications, and utilization of more sophisticated post-transplant immunosuppression protocols have revolutionized the field. These developments have resulted in increased allograft survival, prolonged longevity, and improved quality of life in transplant organ recipients. Elimination of steroids in many postoperative immunosuppressive regimens has tremendously impacted the quality of life and physical appearance of these patients. They are living longer and more normal lives than previously considered possible. As a testament to the success of transplantation surgery, many transplant patients are now seeking aesthetic surgery. Methods A survey was sent to ASPS members asking about their experience with transplant patients undergoing aesthetic procedures. Results Of the 789 (18%) plastic surgeons who responded, 201 (25%) have performed aesthetic surgery on transplant recipients. A total of 278 patients underwent 292 surgical aesthetic procedures and 64 patients underwent 94 nonsurgical aesthetic procedures. The incidence of reported perioperative complications was 3.4%. There were very few additional precautions taken with these patients relative to the general population. With the exception of obtaining medical clearance, these additional precautions were inconsistent among plastic surgeons. Conclusion Cosmetic surgery in transplant recipients is being successfully practiced in the USA. Surgical and nonsurgical aesthetic procedures are being performed safely in organ transplant recipients without a significant increase in the incidence or degree of complications. If certain precautions are undertaken, these patients may expect a degree of success comparable to that of the rest of the population. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9417-xAuthors Iliana Sweis, University of Illinois at Chicago Department of Surgery 840 South Wood Street, Suite 402 Chicago IL 60612 USAIvo Tzvetanov, University of Illinois at Chicago Department of Surgery 840 South Wood Street, Suite 402 Chicago IL 60612 USAEnrico Benedetti, University of Illinois at Chicago Department of Surgery 840 South Wood Street, Suite 402 Chicago IL 60612 USA Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Abdominoplasty: Same Classification and a New Treatment Concept 20 Years Later

Abstract Twenty years after my first paper on abdominoplasty, I find that the classification of abdominoplasty remains the same, but new operative techniques allow for accentuated improvement of the results through more liposuction, less undermining in tunnels, and reduction of skin traction. I use the same classification of diagnoses proposed in 1988, dividing the aesthetic alterations into five groups, and describe my experience during a 6-year period with 502 patients. I used vibroliposuction and performed plicature of the muscular aponeurosis through tunnels (where there are no important muscular perforator vessels), without damaging the vascularization. I propose an appropriate ratio of 1/1.5 between infra- and supraumbilical segments for uses in diagnosis and treatment, and the same ratio between the perimeter of the waist and the hips up to 1/1.618, known as the golden or divine proportion. According to this new treatment concept, vibroliposuction is used in GI. Vibroliposuction and suprapubic fusiform skin resection with an indigenous canoe shape are used in GII. Vibroliposuction, fusiform skin resection, and plicature of the external oblique muscle aponeurosis through two lateral tunnels are used in GIII. Vibroliposuction, fusiform skin resection, plicature of the rectus muscles aponeurosis through a medial tunnel, and detachment of the umbilicus aponeurotic implantation and reattachment in a maximum proportion of 1/1.6 between the infra- and supraumbilical skin segment with a bolster stitch are used in GIV. In GV, all the infraumbilical skin and a subcutaneous segment are removed after vibroliposuction, then a median tunnel from the umbilicus to the xiphoid process and a plicature of the rectus muscle aponeurosis from the pubis to the xiphoid process are made, and then the umbilicus is transposed. When necessary, a plicature of the oblique external muscle aponeurosis through two lateral tunnels is made resulting in three tunnels. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9407-zAuthors Antonio Roberto Bozola, FAMERP - Medicine School of São José do Rio Preto Department of Plastic Surgery Avenida José Munia, 7075 São José do Rio Preto SP 15085-350 Brazil Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Improvement in Quality of Life and Self-Esteem After Breast Reduction Surgery

Abstract Background Breast reduction surgery is sought by patients who have physical and psychological symptoms. This study assessed the quality of life and self-esteem before and after breast reduction surgery. Methods Thirty patients with a diagnosis of mammary hypertrophy who were consecutively selected to undergo breast reduction and aged between 18 and 54 years (mean = 32.65 years, SD = 9.87) participated in the study. Diagnosis was performed by breast measurements associated with symptoms related to excessive breast size. Patients completed the SF-36 Quality of Life Inventory and Rosenberg Self-Esteem Scale before the procedure and 30 and 120 days after surgery. The nonparametric sign test and Fisher’s exact test were used to analyze the data. Results There was significant improvement (p ≤ 0.05) in all domains of quality of life and in self-esteem when scores before and after surgery were compared. Conclusion Both self-esteem and quality of life significantly improved after breast reduction surgery. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9409-xAuthors Arnaldo A. Mello, FAMERP Medical School and FUNFARME Hospital de Base Avenida Brigadeiro Faria Lima, 5416 São José do Rio Preto São Paulo 15090 000 BrazilNeide A. M. Domingos, FAMERP Medical School and FUNFARME Hospital de Base Avenida Brigadeiro Faria Lima, 5416 São José do Rio Preto São Paulo 15090 000 BrazilM. Cristina Miyazaki, FAMERP Medical School and FUNFARME Hospital de Base Avenida Brigadeiro Faria Lima, 5416 São José do Rio Preto São Paulo 15090 000 Brazil Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Soft Tissue Diagnosis in Maxillofacial Surgery: A Preliminary Study on Three-Dimensional Face Geometrical Features-Based Analysis

Abstract To obtain the best surgical results in orthognathic surgery, treatment planning and evaluation of results should be performed. In these operations it is necessary to provide the physician with powerful tools that can underline the behavior of soft tissue. For this reason, considering the improvements provided by the use of 3D scanners in medical diagnosis, we propose a methodology for analyzing facial morphology working with geometrical features. The methodology has been tested on patients with malocclusion in order to analyze the reliability and efficiency of the provided diagnostic results. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9410-4Authors Flaviana Calignano, Politecnico di Torino Dipartimento di Sistemi di Produzione Ed Economia dell’Azienda Corso Duca degli Abruzzi 24 10129 Torino ItalyEnrico Vezzetti, Politecnico di Torino Dipartimento di Sistemi di Produzione Ed Economia dell’Azienda Corso Duca degli Abruzzi 24 10129 Torino Italy Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Late-Onset Pulmonary Edema and Disseminated Intravascular Coagulation Due to Latex Anaphylaxis

Abstract Background Anaphylaxis after the administration of tissue expanders has been reported. Late onset hypotension, thrombocytopenia, disseminated intravascular coagulation (DIC) and pulmonary edema due to the tissue expanders have not been reported. Methods In this case report, late onset hypotension, thrombocytopenia, disseminated intravascular coagulation and pulmonary edema due to the administration of tissue expanders were described. Results The authors report a 16-year-old girl with burn scar deformities scheduled for reconstruction of the scar contractures with insertion of tissue expanders in which the administration of latex tissue expanders was associated with late onset hypotension, thrombocytopenia, disseminated intravascular coagulation and pulmonary edema. Skin tests performed for latex demonstrated strong positive weal and flare reactions. Conclusion Late onset anaphylactic reactions due to latex tissue expanders, an unusual unpredictable adverse reaction, must be kept in mind. Early recognition and proper emergent treatment are essential to reversing this complication. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s00266-009-9412-2Authors Mehmet Turan Inal, Trakya University Department of Anesthesiology, Faculty of Medicine 22030 Edirne TurkeyDilek Memis, Trakya University Department of Anesthesiology, Faculty of Medicine 22030 Edirne TurkeyHusamettin Top, Trakya University Department of Plastic and Reconstructive Surgery, Faculty of Medicine Edirne TurkeyMeral Bahar, Trakya University Department of Anesthesiology, Faculty of Medicine 22030 Edirne TurkeyErkan Celik, Trakya University Department of Anesthesiology, Faculty of Medicine 22030 Edirne TurkeyEmel Yurdakul Sıkar, Trakya University Department of Plastic and Reconstructive Surgery, Faculty of Medicine Edirne TurkeyBulent Kement, Trakya University Department of Plastic and Reconstructive Surgery, Faculty of Medicine Edirne Turkey Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Announcements

Announcements Content Type Journal ArticleCategory AnnouncementsDOI 10.1007/s00266-009-9415-z Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X Journal Volume Volume 33 Journal Issue Volume 33, Number 5 / September, 2009

Review of 1,447 Breast Augmentation Patients Using PERTHESE Silicone Implants

Abstract Introduction A survey of surgeons in Brazil on their experience with PERTHESE silicone breast implants was performed. Materials and methods Surgeons that used PERTHESE implants between 2002 and 2008 were surveyed on the shape and volume of the implants used, surgical incision site, surgical plane of insertion, key postoperative complications, and surgeon and patient satisfaction. Results The survey had a response rate of 20%, with ten surgeons reporting data on 1447 patients. The majority of the implants used were 200–300 cc, round, and high profile. Preference for the traditional inframammary incision site (47% of patients) was favored over transaxillary (33%) and periareolar (19%), and both subglandular (55%) and submuscular (44%) planes of insertion were used. Over 97% of surgeons and patients were satisfied with the results and surgeons indicated that the implants were easy to use. Conclusions This review demonstrates that these implants are safe, maybe easier to introduce than other implants, and result in a high level of surgeon and patient satisfaction. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00266-009-9405-1Authors Jorge Miguel Psillakis, Universidade Estadual de Campinas (FCM-UNICAMP) Plastic Surgery Area, Department of Surgery, School of Medical Sciences São Paulo BrazilPaulo Henrique Facchina, Universidade Estadual de Campinas (FCM-UNICAMP) Plastic Surgery Area, Department of Surgery, School of Medical Sciences São Paulo BrazilPaulo Kharmandayan, Universidade Estadual de Campinas (FCM-UNICAMP) Plastic Surgery Area, Department of Surgery, School of Medical Sciences São Paulo BrazilLuis Trillo, Universidade Estadual de Campinas (FCM-UNICAMP) Plastic Surgery Area, Department of Surgery, School of Medical Sciences São Paulo BrazilWaldecir Chiarelo Canzi, Canzi Plastic Surgery Clinic Passo Fundo, Rio Grande do Sul BrazilHerberti Rosique Aguiar, Universidade Estadual de Campinas (FCM-UNICAMP) Plastic Surgery Area, Department of Surgery, School of Medical Sciences São Paulo Brazil Journal Aesthetic Plastic SurgeryOnline ISSN 1432-5241Print ISSN 0364-216X

Oblique branch of the lateral circumflex femoral artery also found in 32 percent of cadavers in Brazil.

Related Articles Oblique branch of the lateral circumflex femoral artery also found in 32 percent of cadavers in Brazil. Plast Reconstr Surg. 2009 Sep;124(3):1011-2; author reply 1012-3 Authors: da Costa AC, Lancelotti CL PMID: 19730345 [PubMed - indexed for MEDLINE]

Damage control flap reconstruction.

Related Articles Damage control flap reconstruction. Plast Reconstr Surg. 2009 Sep;124(3):1010-1 Authors: Steiert A, Gohritz A, Knobloch K, Krettek C, Vogt PM PMID: 19730344 [PubMed - indexed for MEDLINE]

The free gracilis perforator flap: is a perforator flap really indicated in the case of the gracilis flap?

Related Articles The free gracilis perforator flap: is a perforator flap really indicated in the case of the gracilis flap? Plast Reconstr Surg. 2009 Sep;124(3):1008-9; author reply 1009-10 Authors: Momeni A, Bannasch H, Lee GK PMID: 19730342 [PubMed - indexed for MEDLINE]

Split-thickness skin flap technique for elevating the radial forearm flap.

Related Articles Split-thickness skin flap technique for elevating the radial forearm flap. Plast Reconstr Surg. 2009 Sep;124(3):1007; author reply 1007-8 Authors: Makkar SS, Sharma RK, Parashar A PMID: 19730341 [PubMed - indexed for MEDLINE]

Percutaneous transosseous fixation of zone 1 flexor tendon injuries in primary or two-stage repair.

Related Articles Percutaneous transosseous fixation of zone 1 flexor tendon injuries in primary or two-stage repair. Plast Reconstr Surg. 2009 Sep;124(3):1006 Authors: Norton SE PMID: 19730339 [PubMed - indexed for MEDLINE]

Is Marjolin's ulcer always a squamous cell carcinoma? Shedding some light on the old problem.

Related Articles Is Marjolin's ulcer always a squamous cell carcinoma? Shedding some light on the old problem. Plast Reconstr Surg. 2009 Sep;124(3):1005; author reply 1005-6 Authors: Sharma RK PMID: 19730338 [PubMed - indexed for MEDLINE]

Parenchymal rearrangement may be routinely used in smaller volume breast tissue for optimal cosmesis.

Related Articles Parenchymal rearrangement may be routinely used in smaller volume breast tissue for optimal cosmesis. Plast Reconstr Surg. 2009 Sep;124(3):1002-4; author reply 1004-5 Authors: Tan MP PMID: 19730334 [PubMed - indexed for MEDLINE]

Subfascial perforator dissection for DIEP flap harvest.

Related Articles Subfascial perforator dissection for DIEP flap harvest. Plast Reconstr Surg. 2009 Sep;124(3):1001-2; author reply 1002 Authors: Tan BK, Newman MI, Swartz KA, Samson MC PMID: 19730333 [PubMed - indexed for MEDLINE]

The muscle-sparing latissimus dorsi flap for breast reconstruction.

Related Articles The muscle-sparing latissimus dorsi flap for breast reconstruction. Plast Reconstr Surg. 2009 Sep;124(3):1000-1 Authors: Berry MG, Curnier A, Fitoussi AD, Couturaud B, Salmon RJ PMID: 19730332 [PubMed - indexed for MEDLINE]

Massive hemorrhage in facial fracture patients: definition, incidence, and management.

Related Articles Massive hemorrhage in facial fracture patients: definition, incidence, and management. Plast Reconstr Surg. 2009 Sep;124(3):998; author reply 998 Authors: Ilango N PMID: 19730330 [PubMed - indexed for MEDLINE]

Hyperbaric oxygen therapy in craniofacial osteopathy of jaws.

Related Articles Hyperbaric oxygen therapy in craniofacial osteopathy of jaws. Plast Reconstr Surg. 2009 Sep;124(3):998-9; author reply 999-1000 Authors: Durrani KM PMID: 19730328 [PubMed - indexed for MEDLINE]

Oncoplastic surgery.

Related Articles Oncoplastic surgery. Plast Reconstr Surg. 2009 Sep;124(3):993-4 Authors: Spear SL PMID: 19730325 [PubMed - indexed for MEDLINE]

The use of fibrin glue in plastic surgery.

Related Articles The use of fibrin glue in plastic surgery. Plast Reconstr Surg. 2009 Sep;124(3):989-92 Authors: Mooney E, Loh C, Pu LL, Fibrin glue has been used as an adjunct to hemostasis for many years. This article provides an overview of fibrin glue, including its composition, mechanism of action, availability, safety, efficacy, and potential applications in plastic surgery. PMID: 19730324 [PubMed - indexed for MEDLINE]

Archie Cochrane and his vision for evidence-based medicine.

Related Articles Archie Cochrane and his vision for evidence-based medicine. Plast Reconstr Surg. 2009 Sep;124(3):982-8 Authors: Shah HM, Chung KC Archibald (Archie) Cochrane's most influential mark on health care was his 1971 publication, Effectiveness and Efficiency. This book strongly criticized the lack of reliable evidence behind many of the commonly accepted health care interventions at the time. His criticisms spurred rigorous evaluations of health care interventions and highlighted the need for evidence in medicine. His call for a collection of systematic reviews led to the creation of The Cochrane Collaboration. Archie Cochrane was a visionary person who helped lay down much of the foundation for evidence-based medicine. This article introduces evidence-based medicine to plastic surgery by tracing its history to the seminal efforts by Archie Cochrane. PMID: 19730323 [PubMed - indexed for MEDLINE]

The role of the plastic surgeon in disaster relief.

Related Articles The role of the plastic surgeon in disaster relief. Plast Reconstr Surg. 2009 Sep;124(3):975-81 Authors: Thakar HJ, Pepe PE, Rohrich RJ Awareness of large-scale disasters among members of the medical community and the public at large has been heightened by recent events such as the 1995 Oklahoma City bombing incident, the 2001 World Trade Center attack, and the 2005 London Underground bombings. Experience with these events has highlighted the critical role of surgical specialists, including plastic surgeons. As part of their residency, plastic surgeons are trained in acute trauma management. In addition, they also are required to demonstrate expertise in the assessment and treatment of soft-tissue injuries, upper extremity trauma, facial fractures, and both operative and nonoperative burn management. Accordingly, the plastic surgeon is among the most qualified of physicians to provide specialized injury care, especially in the disaster medicine setting. In turn, training programs should include key elements of incident command and catastrophe relief. PMID: 19730322 [PubMed - indexed for MEDLINE]

Discussion. Oncoplastic breast surgery: past, present, and future directions in the United States.

Related Articles Discussion. Oncoplastic breast surgery: past, present, and future directions in the United States. Plast Reconstr Surg. 2009 Sep;124(3):973-4 Authors: Canady JW, D'Amico RA, McGuire MF PMID: 19730321 [PubMed - indexed for MEDLINE]

Oncoplastic breast surgery: past, present, and future directions in the United States.

Related Articles Oncoplastic breast surgery: past, present, and future directions in the United States. Plast Reconstr Surg. 2009 Sep;124(3):969-72 Authors: Losken A, Nahabedian MY PMID: 19730320 [PubMed - indexed for MEDLINE]

The role of modified Jessner's solution with 35% trichloroacetic acid peel.

Related Articles The role of modified Jessner's solution with 35% trichloroacetic acid peel. Plast Reconstr Surg. 2009 Sep;124(3):965-6 Authors: Rohrich RJ, Herbig KS PMID: 19730319 [PubMed - indexed for MEDLINE]

Combination Jessner's solution and trichloroacetic acid chemical peel: technique and outcomes.

Related Articles Combination Jessner's solution and trichloroacetic acid chemical peel: technique and outcomes. Plast Reconstr Surg. 2009 Sep;124(3):955-64 Authors: Herbig K, Trussler AP, Khosla RK, Rohrich RJ BACKGROUND: Trichloroacetic acid is a commonly utilized agent for chemical resurfacing of the face. Jessner's solution in combination with trichloroacetic acid has been previously described for the treatment of facial rhytids in the dermatology literature. The purpose of this study was to describe the application technique and examine the clinical results of Jessner's solution in combination with trichloroacetic acid in a diverse plastic surgery patient population. METHOD: A retrospective chart evaluation of 105 patients undergoing combination Jessner's and 35% trichloroacetic acid facial peel procedures by the senior author was performed. Patient demographics, anatomic location of peel, concomitant surgical procedures, and postoperative complications were noted. Technique and endpoints are described. RESULTS: Between January of 2000 and April of 2007, 115 chemical peels were performed by the senior author. All patients were female, ranging in age from 32 to 83 years (mean, 54 years). Of the 115 chemical peels performed, 104 were done with concomitant procedures. Eleven peels were performed alone. The most significant complications related to the combination peel were fungal infections (7.8 percent overall rate). In addition, the senior author performed 27 face/neck lifts with superficial musculoaponeurotic system (SMAS)-ectomy or SMAS plication along with full face combination peel, with minimal postoperative complications and no evidence of hypertrophic scarring. CONCLUSIONS: The combination of Jessner's solution and 35% trichloroacetic acid is an effective, safe resurfacing tool that can treat superficial to moderate rhytids. Despite the apparent simplicity of the procedure, there is a significant learning curve to understand the intricacies of chemical penetration in the skin. Consistency in results is achieved with experience and proper preoperative patient evaluation and selection. PMID: 19730318 [PubMed - indexed for MEDLINE]

Rhinoplasty: a hands-on training module.

Related Articles Rhinoplasty: a hands-on training module. Plast Reconstr Surg. 2009 Sep;124(3):952-4 Authors: Zabaneh G, Lederer R, Grosvenor A, Wilkes G BACKGROUND: Rhinoplasty is a complex surgical procedure with a steep learning curve and a small margin for error. The authors present a hands-on, anatomically correct, silicone training model designed specifically for learning the technical aspects of rhinoplasty. METHOD: Computed tomographic data were acquired and used to create a plaster mold. Silicone was cast into this mold to create an operable, realistic, three-dimensional silicone model. RESULTS: The prototype created an anatomically accurate rhinoplasty training model. The silicone materials simulate the properties and behavior of the anatomical structures of the nose. CONCLUSION: A realistic three-dimensional silicone nasal model has the potential to be used as a hands-on training module for learning rhinoplasty and assessing surgical competency. PMID: 19730317 [PubMed - indexed for MEDLINE]

The anatomy of suborbicularis fat: implications for periorbital rejuvenation.

Related Articles The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg. 2009 Sep;124(3):946-51 Authors: Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE BACKGROUND: Periorbital rejuvenation has increasingly relied on augmentation with fillers. Numerous techniques have been described, including augmentation of the sub-orbicularis oculi fat. Cadaver studies initiated 2 years ago yielded presumptive evidence that sub-orbicularis oculi fat consists of two distinct regions. Knowledge of this anatomy is important for precision in facial rejuvenation. METHODS: A pilot study was performed with radiopaque dye injection into the sub-orbicularis oculi fat and computed tomographic evaluation with three-dimensional reconstruction. Eight hemifacial fresh cadaver dissections were then performed with a modified dye injection technique to isolate regions of sub-orbicularis oculi fat and periorbital fat. The relationship of suborbicularis fat to deep cheek fat was observed. RESULTS: This study confirms the presence of two distinct regions of sub-orbicularis oculi fat. A medial component extends along the orbital rim from the medial limbus to the lateral canthus. A lateral component extends from the lateral canthus to the temporal fat pad. The lateral component terminated superiorly at the lateral orbital thickening. Deep cheek fat abutted the medial sub-orbicularis oculi fat, thus creating a deep fat system in continuity across the face of the maxilla and along the orbital rim. CONCLUSIONS: This anatomy helps to define midface adipose tissue as a system of superficial and deep fat, of which medial and lateral sub-orbicularis oculi fat are a part. A working hypothesis of facial aging continues with the concept that loss and/or ptosis of deep fat compartments leads to changes in shape and contour. Folds, in contrast, occur at transition points between thick and thinner superficial fat compartments. These anatomical observations further the goal of site-specific augmentation and facial rejuvenation. PMID: 19730316 [PubMed - indexed for MEDLINE]

Discussion. Lipoabdominoplasty.

Related Articles Discussion. Lipoabdominoplasty. Plast Reconstr Surg. 2009 Sep;124(3):943-5 Authors: Aly A PMID: 19730315 [PubMed - indexed for MEDLINE]

Lipoabdominoplasty.

Lipoabdominoplasty. Plast Reconstr Surg. 2009 Sep;124(3):934-42 Authors: Saldanha OR, Federico R, Daher PF, Malheiros AA, Carneiro PR, Azevedo SF, Saldanha Filho OR, Saldanha CB BACKGROUND: Abdominoplasty is one of the most common aesthetic operations. Wide bibliographic research has revealed that there is a safe method whereby two techniques--liposuction and abdominoplasty--can be associated in the same procedure. The authors present a new abdominoplasty technique combining a selective undermining with complete abdominal liposuction. METHODS: The authors standardized steps with which to perform a safe association of traditional abdominoplasty with liposuction of the entire abdomen and infracostal areas. Using selective undermining, it is possible to preserve at least 80 percent of the blood supply in the abdominal wall, causing little nervous trauma, preserving the great majority of the lymphatic vessels, and resulting in few complications compared with traditional abdominoplasty, including post-bariatric surgery procedures. In this study, lipoabdominoplasty was performed on 445 patients: eight male patients and 437 female patients, from 2000 to 2007. RESULTS: The authors consider the results good and excellent, especially regarding patient evaluation, better body contour, abdominal rejuvenation, shorter scars, the form of the umbilicus, and a decrease in the abdominal measures. CONCLUSION: With a progressive adaptation of this technique, it is possible to achieve a harmonious body contour using a safe liposuction method on the abdominal and costal areas, with fast recovery and good to excellent results. PMID: 19730314 [PubMed - indexed for MEDLINE]

National bariatric surgery and massive weight loss body contouring survey.

Related Articles National bariatric surgery and massive weight loss body contouring survey. Plast Reconstr Surg. 2009 Sep;124(3):926-33 Authors: Warner JP, Stacey DH, Sillah NM, Gould JC, Garren MJ, Gutowski KA BACKGROUND: As bariatric surgery has become more popular, plastic surgeons have seen increases in post-bariatric surgery body contouring procedures. The aim of the authors' survey was to better understand perspectives of bariatric surgeons toward body contouring procedures and referral patterns to plastic surgeons. METHODS: A questionnaire was sent to 500 surgeon members of the American Society for Metabolic and Bariatric Surgery. Questions focused on bariatric surgery practices, perspectives toward massive weight loss body contouring, and referral patterns. One hundred eighty-eight surveys were analyzed. RESULTS: Sixty-four percent of surgeons surveyed reported that patients ask about body contouring procedures before bariatric procedures. Only 54 percent reported routine counseling on the potential functional and aesthetic consequences of bariatric surgery. Ninety-six percent of bariatric surgeons have access to plastic surgeons, but only 7 percent of bariatric surgeons always refer their patients to a plastic surgeon and 33 percent rarely refer to a plastic surgeon. Fifty-one percent of surgeons report that patients who have undergone body contouring procedures are overall more satisfied with their decision to undergo bariatric surgery versus bariatric patients who have not had body contouring. Seventy-five percent of surgeons reported that patients rarely express any concern regarding their decision to undergo plastic surgery. CONCLUSIONS: Bariatric surgery requires multispecialty care from bariatric and plastic surgeons. Results and outcomes can be improved with body contouring procedures, especially with regard to better self-image, self-confidence, and satisfaction. However, there are deficiencies in pre-bariatric surgery counseling regarding outcomes and discussions of body contouring procedures. Therefore, better methods of referrals to plastic surgeons need to be identified. PMID: 19730313 [PubMed - indexed for MEDLINE]

Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the breast.

Related Articles Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the breast. Plast Reconstr Surg. 2009 Sep;124(3):919-25 Authors: Hvilsom GB, Hölmich LR, Henriksen TF, Lipworth L, McLaughlin JK, Friis S BACKGROUND: Prospective long-term data on the occurrence of complications following breast augmentation are sparse and the reported frequencies differ substantially. METHODS: The Danish Registry for Plastic Surgery of the Breast has prospectively registered preoperative, perioperative, and postoperative data for women undergoing breast augmentation in Denmark since 1999. From the Registry, the authors identified 5373 women with a primary cosmetic breast augmentation between 1999 and 2007. The authors calculated incidence proportions of adverse clinical outcomes within three time intervals (0 to 30 days, 0 to 3 years, and 0 to 5 years) after primary implantation. Outcomes of primary interest were capsular contracture, asymmetry/displacement of the implant, hematoma, and infection. RESULTS: During the entire follow-up period (mean, 3.8 years; range, 0.1 to 8.7 years), 16.7 percent of the women were registered with an adverse event and 4.8 percent of the women were registered with a surgery-requiring complication. The most common adverse events within 30 days were hematoma (1.1 percent) and infections (1.2 percent), whereas the most common adverse events within 5 years were change of tactile sense (8.7 percent) and asymmetry/displacement of implant (5.2 percent). Within 5 years, 1.7 percent of the women had a record of severe capsular contracture. Displacement/asymmetry and capsular contracture were the most frequent indications for reoperation with removal or exchange of the implant. CONCLUSIONS: Population-based complication frequencies among women with cosmetic breast augmentation in a Danish nationwide implant registry were generally lower than those reported in other studies, although frequencies of complications increased with length of follow-up. PMID: 19730312 [PubMed - indexed for MEDLINE]

Preliminary review of pediatric nasal reconstruction with detailed report of one case.

Related Articles Preliminary review of pediatric nasal reconstruction with detailed report of one case. Plast Reconstr Surg. 2009 Sep;124(3):907-18 Authors: Burget GC BACKGROUND: A young child with a badly deformed nose is a dilemma to a plastic surgeon. There is an impulse to rebuild the nose; however, confusion exists regarding the optimal technique. METHODS: The forehead flap achieves excellent aesthetic and functional results, has acceptable donor-site morbidity, and grows as the patient grows. The donor site heals well in children because of the nonsebaceous quality of their forehead skin; however, some scars may require revision. Only the forehead flap can eliminate a substantial nasal deformity and create a nearly normal or normal appearance that enables the child to grow and develop normally without the stigma and psychological insult a nasal deformity bestows. RESULTS: The methods above are further illustrated in a case example of a 9.6-year-old female pediatric patient. This young girl is one of a series of 25 pediatric nasal reconstruction cases to appear in a forthcoming comprehensive book on the subject. In this patient, a forehead flap was an appropriate option to eliminate her deformity. Reshaping the nose with small local flaps, cartilage grafts, and/or composite grafts would merely have softened her deformity and never eradicated it. CONCLUSIONS: Use of a forehead flap and cartilage grafts does not automatically create a normal, aesthetic nose, especially for a child. Correct framework, form, and dimension are required, or the result will be merely a new but different deformity. Creation of a nose requires artistic and surgical ability, and can be learned by careful study of the technical aspects and artistry of aesthetic nasal reconstruction in children. PMID: 19730311 [PubMed - indexed for MEDLINE]

Current surgical practices in cleft care: cleft palate repair techniques and postoperative care.

Related Articles Current surgical practices in cleft care: cleft palate repair techniques and postoperative care. Plast Reconstr Surg. 2009 Sep;124(3):899-906 Authors: Katzel EB, Basile P, Koltz PF, Marcus JR, Girotto JA BACKGROUND: The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery. METHODS: All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients. RESULTS: Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons' self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely. CONCLUSIONS: The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article. PMID: 19730310 [PubMed - indexed for MEDLINE]

Rapid intraoperative zygoma fracture imaging.

Related Articles Rapid intraoperative zygoma fracture imaging. Plast Reconstr Surg. 2009 Sep;124(3):888-98 Authors: Czerwinski M, Parker WL, Beckman L, Williams HB BACKGROUND: A fractured zygoma frequently results in an aesthetically displeasing facial asymmetry. Open reduction and internal fixation may accurately realign the facial skeleton but often with undesirable sequelae. The authors' objective was to develop a precise technique of intraoperative zygoma fracture imaging using a C-arm to permit anatomical fracture realignment while reducing the extent of skeletal exposure required. The simplicity and accessibility of this method should allow its widespread clinical application. METHODS: First, using a model skull, the relative positions of the C-arm required to adequately depict zygoma projection, width, arch contour, and zygoma rotation were defined. Second, diverse zygoma fracture types were created in six cadaver heads with a Mini Bionix machine and were repaired using C-arm guidance; accuracy was confirmed with postoperative computed tomography. Third, after defining optimal operating room setup, the accuracy in a clinical case was assessed. RESULTS: Two C-arm views were defined. The zygoma projection view (C-arm at 70 to 90 degrees to the skull's coronal plane) allows visualization of projection, width, and contour. The rotation view (C-arm at 70 to 90 degrees to the skull's sagittal plane) allows visualization of zygoma rotation. Postoperative computed tomographic imaging confirmed anatomical repair in all cases. Average operating room duration was less than 30 minutes, with operating room times decreasing progressively. CONCLUSIONS: The authors have developed an accurate technique of intraoperative zygoma fracture imaging and reduction guidance. This technique may decrease the risks of open access by potentially limiting direct skeletal exposure to buttresses where skeletal stabilization is required. In addition, this method is simple, can be learned and used rapidly, and is readily accessible. PMID: 19730309 [PubMed - indexed for MEDLINE]

Discussion. Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry.

Related Articles Discussion. Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry. Plast Reconstr Surg. 2009 Sep;124(3):887 Authors: Hatef DA, Hollier LH PMID: 19730308 [PubMed - indexed for MEDLINE]

Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry.

Single-splint technique in orthognathic surgery: intraoperative checkpoints to control facial symmetry. Plast Reconstr Surg. 2009 Sep;124(3):879-86 Authors: Yu CC, Bergeron L, Lin CH, Chu YM, Chen YR BACKGROUND: Despite the most meticulous preoperative planning and execution, intraoperative soft-tissue response to dentoskeletal changes is often different from those statistically predicted, especially when midline asymmetry is present. A "single-splint" technique for bimaxillary surgery, with intraoperative adjustments and checkpoints, was developed in an attempt to overcome these limitations. The purpose of this study was therefore to determine whether this technique can improve the midline symmetry of facial soft tissues. METHODS: Forty-five patients who underwent at least a Le Fort I and a bilateral sagittal split osteotomy of the mandible were identified in the authors' patient database. Standardized frontal photographs were used to measure the change in midfacial, intercommissural, chin to midface, and chin to ideal facial midline angles. The facial midline symmetry index, an overall score of facial symmetry, was also calculated. RESULTS: This study demonstrates that there is a statistically significant improvement of the four angles measured and of the facial midline symmetry index. CONCLUSIONS: These findings demonstrate that the single-splint technique with its intraoperative checkpoints can successfully maintain or improve facial midline symmetry. Thus, the single-splint technique is a useful alternative to the classic two-splint technique for bimaxillary surgery. PMID: 19730307 [PubMed - indexed for MEDLINE]

Le Fort III distraction: Part I. Controlling position and vectors of the midface segment.

Related Articles Le Fort III distraction: Part I. Controlling position and vectors of the midface segment. Plast Reconstr Surg. 2009 Sep;124(3):871-8 Authors: Shetye PR, Giannoutsos E, Grayson BH, McCarthy JG BACKGROUND: The purpose of this investigation was to determine the response of the osteotomized Le Fort III midface bony segment to variations in the location and direction, or vector, of force application on using the rigid external distraction device. METHODS: This retrospective study involved 18 consecutive syndromic craniosynostotic patients (average age, 5.7 years) who underwent Le Fort III midface advancement distraction. Various cephalometric and novel landmarks, located on the mobilized Le Fort III segment and on the components of the distraction device, were identified before activation and at mid-activation. The direction and magnitude of change for these points were recorded. RESULTS: Based on the observed change in the position of the midface during distraction, the sample was divided into the following groups. In group 1 (n = 5), the Le Fort III segment translated forward and no rotation was noted. In group 2 (n = 3), the Le Fort III segment rotated clockwise and showed downward displacement. In group 3 (n = 6), the Le Fort III segment showed forward displacement and rotated counterclockwise. In group 4 (n = 4), the Le Fort III segment translated forward and downward. CONCLUSIONS: Direction of movement and resultant change in position of the Le Fort III segment during distraction are directly related to the location and direction of force application. Translation forward, with minimal rotation, was achieved when the force was applied at a location 55 percent above the occlusal plane (between the occlusal plane and the nasion) and in a direction parallel to the maxillary occlusal plane. PMID: 19730306 [PubMed - indexed for MEDLINE]

Targeted reinnervation for transhumeral amputees: current surgical technique and update on results.

Related Articles Targeted reinnervation for transhumeral amputees: current surgical technique and update on results. Plast Reconstr Surg. 2009 Sep;124(3):863-9 Authors: Dumanian GA, Ko JH, O'Shaughnessy KD, Kim PS, Wilson CJ, Kuiken TA BACKGROUND: Targeted reinnervation in upper extremity transhumeral amputees can improve control and dexterity of myoelectric prostheses. The operation as described previously required a long residual limb and the presence of a brachialis muscle. METHODS: Brachial plexus dissections were performed to confirm and better understand the branching pattern of the radial nerve in the upper arm. A simplified surgical approach for targeted reinnervation in transhumeral amputees was devised. This study reports on the first six transhumeral amputees who have undergone this simplified procedure. RESULTS: The long and lateral heads of the triceps receive distinct and separate motor nerves from the proximal radial nerve. This anatomy allows a nerve transfer of the distal radial nerve to the motor nerve of the lateral head of the triceps without injury to the innervation of the long head of the triceps. The median nerve transfer to the motor branch of the medial head of the biceps is performed on the anterior surface of the arm as described previously. All six patients had successful targeted reinnervation procedures using this simplified approach. CONCLUSION: Targeted reinnervation for transhumeral amputees can now be performed in patients with amputations at the level of the middle of the humerus or longer. PMID: 19730305 [PubMed - indexed for MEDLINE]

The impact of topical lidocaine on pain level assessment during and after vacuum-assisted closure dressing changes: a double-blind, prospective, randomized study.

Related Articles The impact of topical lidocaine on pain level assessment during and after vacuum-assisted closure dressing changes: a double-blind, prospective, randomized study. Plast Reconstr Surg. 2009 Sep;124(3):854-61 Authors: Franczyk M, Lohman RF, Agarwal JP, Rupani G, Drum M, Gottlieb LJ BACKGROUND: Vacuum-assisted closure dressing changes are frequently painful. The authors hypothesized that administering topical lidocaine into the vacuum-assisted closure sponge would decrease pain during dressing changes. METHODS: A double-blind, randomized, prospective study was performed on patients (n = 70) undergoing vacuum-assisted closure dressing changes at a single institution between October of 2003 and June of 2005. Patients were randomized to receive either 0.2% lidocaine or 0.9% saline administered through the vacuum-assisted closure tubing into the foam dressing 30 minutes before changing the dressing. All patients received morphine sulfate ad libitum. Pain scores were assessed according to a 0 to 10 numeric pain scale. RESULTS: Wound characteristics and patient demographics were similar for both groups. Patients receiving lidocaine reported less pain than control patients during the dressing change (4.3 versus 6.3; p = 0.005) and immediately after (2.4 versus 4.7; p < 0.001) the dressing change. Thirty minutes after the dressing change, pain scores were similar in both groups. Thirty minutes after the dressing change, more patients in the lidocaine group requested small doses of narcotics (>3 mg morphine equivalent) than in the control group. CONCLUSIONS: During the initial vacuum-assisted closure dressing change, 0.2% lidocaine administered through the suction tubing led to a reduction in pain reported by the patients in the authors' study. The duration of lidocaine administered in this fashion may be fairly short, because more patients in this group began to request small doses of opiates 30 minutes after the dressing change. Thus, lidocaine may improve patient comfort during vacuum-assisted closure therapy. PMID: 19730304 [PubMed - indexed for MEDLINE]

The venous anatomy of the anterior abdominal wall: an anatomical and clinical study.

Related Articles The venous anatomy of the anterior abdominal wall: an anatomical and clinical study. Plast Reconstr Surg. 2009 Sep;124(3):848-53 Authors: Rozen WM, Pan WR, Le Roux CM, Taylor GI, Ashton MW BACKGROUND: Despite improving outcomes, venous problems in the harvest of deep inferior epigastric artery perforator (DIEP) flaps remain the more common vascular complications. However, it is apparent that the venous anatomy of the anterior abdominal wall has not been described to the same extent as the arterial anatomy. Previous anatomical studies have focused on cadaveric anatomy or excisional specimens. The current study uses in vivo computed tomographic angiography to evaluate this anatomy, in combination with a cadaveric radiographic study. METHODS: Both cadaveric and in vivo studies were undertaken using eight whole fresh cadaveric specimens (16 sides) and 100 patients undergoing DIEP flap breast reconstruction (200 sides). The cadaveric component used direct catheter venography and the in vivo studies were undertaken using preoperative computed tomographic angiography, mapping in vivo venous flow. RESULTS:: The location, caliber, course, and distribution of the superficial and deep inferior epigastric veins were recorded. The dominance of each system and their direction of drainage were described. Mechanisms for poor venous drainage were postulated, including perforator size, midline crossover of the superficial inferior epigastric vein, and the superficial and deep inferior epigastric vein communications. The incidence of each of these anatomical factors was evaluated. CONCLUSION: The cause of venous compromise is multifactorial, with the current study showing that preoperative computed tomographic angiography may predict venous problems during flap harvest, by demonstrating perforator diameter, midline crossover, and deep-superficial venous communications. PMID: 19730303 [PubMed - indexed for MEDLINE]

Soft polypropylene mesh, but not cadaveric dermis, significantly improves outcomes in midline hernia repairs using the components separation technique.

Related Articles Soft polypropylene mesh, but not cadaveric dermis, significantly improves outcomes in midline hernia repairs using the components separation technique. Plast Reconstr Surg. 2009 Sep;124(3):836-47 Authors: Ko JH, Salvay DM, Paul BC, Wang EC, Dumanian GA BACKGROUND: The search continues for the "ideal" repair of the midline ventral hernia, and the components separation technique has a low, but still concerning, hernia recurrence rate. The authors hypothesize that adding prosthetic or bioprosthetic meshes to the midline closure during components separation would reduce recurrence rates with minimal added morbidity. METHODS: Over a 3-year period, patients had a components separation procedure where either acellular cadaveric dermis (n = 26) or soft polypropylene mesh (n = 28) was used as an intraperitoneal underlay for reinforcement of the midline repair, but not as a "bridging material." In 36 operations, the mesh or cadaveric dermis was placed at the time of the components separation, and in the remaining cases (n = 18), the underlay was used to treat a recurrence after components separation. RESULTS: Cadaveric dermis was associated with a 46 percent "true" recurrence rate that required reoperation (mean follow-up, 17.3 months), whereas soft polypropylene mesh had a significantly lower recurrence rate of 11 percent (p = 0.0057) during a follow-up period of 16 months. Because of a higher incidence of concomitant bowel surgery and contamination in the cadaveric dermis group, additional subset analysis of uncontaminated cases was performed, demonstrating a 61 percent recurrence rate for cadaveric dermis compared with 12 percent for soft polypropylene (p = 0.0017). No significant differences in major and minor complications were seen between groups. CONCLUSION: Soft polypropylene mesh, but not acellular dermis, demonstrates acceptably low complication and hernia recurrence rates when used as a reinforcement of the midline ventral hernia closure in conjunction with components separation. PMID: 19730302 [PubMed - indexed for MEDLINE]

Lower third nasal reconstruction: when is skin grafting an appropriate option?

Related Articles Lower third nasal reconstruction: when is skin grafting an appropriate option? Plast Reconstr Surg. 2009 Sep;124(3):826-35 Authors: McCluskey PD, Constantine FC, Thornton JF BACKGROUND: A full-thickness skin graft is generally not considered the ideal replacement for the thick, sebaceous skin of the nasal tip, ala, lower sidewalls, or dorsum. Instead, many clinicians prefer to reconstruct these defects with local or axial composite flaps that incorporate skin, subcutaneous tissue, and fat. METHODS: The authors conducted a retrospective analysis of 55 consecutive patients who underwent reconstruction of lower third nasal defects with full-thickness skin grafts between 2002 and 2007 performed by the senior author (J.F.T.). All of the patients in this review underwent skin cancer ablation by means of Mohs' micrographic surgery. RESULTS: Good aesthetic results, based on preoperative and postoperative photographic analysis of contour and pigmentation, have been achieved in both the recipient and donor sites in 52 of 55 patients. Three patients, all of whom were smokers, experienced loss of the skin graft requiring alternative reconstructive techniques. CONCLUSIONS: Under certain conditions, skin grafting of defects of the caudal third of the nose offers a viable reconstructive option that yields good contour and color match. Careful analysis of defect size, location, and depth and consideration of donor-site skin thickness and pigmentation are vital for accurate replacement of the thick, pitted, sebaceous skin of the caudal nose. An evolution in technique has revealed that the forehead donor skin often provides a more consistent color and contour match in such reconstructions. Secondary dermabrasion of the graft provides a critical step for obtaining final aesthetic contour and color. PMID: 19730301 [PubMed - indexed for MEDLINE]

Generating ears from cultured autologous auricular chondrocytes by using two-stage implantation in treatment of microtia.

Related Articles Generating ears from cultured autologous auricular chondrocytes by using two-stage implantation in treatment of microtia. Plast Reconstr Surg. 2009 Sep;124(3):817-25 Authors: Yanaga H, Imai K, Fujimoto T, Yanaga K BACKGROUND: Microtia is a congenital ear hypoplasia associated with auricular defects. Conventional treatment involves implanted costal cartilage. The impact of surgical invasion and donor-site morbidity can be particularly severe in pediatric patients, and the collectable volume of autologous cartilage is limited. The authors therefore developed a new technique for microtia and applied it to treat four patients. METHODS: Through the development of a multilayer chondrocyte culture system and two-stage implantation technique, the authors successfully generated human ears. In culture, the chondrocytes are expanded to a sufficiently large volume, produce rich chondroid matrix, and form immature cartilaginous tissues. In the authors' two-stage implantation, the cultured chondrocytes are injection-implanted into the lower abdomen of the patient, where the cells grow into a large, newly generated cartilage with neoperichondrium in 6 months. This cartilage is harvested surgically, sculptured into an ear framework, and implanted subcutaneously into the position of the new ear. RESULTS: The cultured chondrocytes formed a mature cartilage block with sufficient elasticity for use as an auricular cartilage. The formed block had the same histologic origin as elastic cartilage. The ear framework produced from this block was implanted into the auricular defect area, and an auricle with a smooth curvature and shape was subsequently configured. In the 2 to 5 years of postoperative monitoring, the neocartilage maintained good shape, without absorption. CONCLUSIONS: The authors' four patients are the first successful cases of regenerative surgery for microtia using cultured ear chondrocytes. The benefits of the technique include minimal surgical invasion, lower donor-site morbidity, lessened chance of immunologic rejection, and implantation stability. PMID: 19730300 [PubMed - indexed for MEDLINE]

The effect of adipose-derived stem cells on ischemia-reperfusion injury: immunohistochemical and ultrastructural evaluation.

Related Articles The effect of adipose-derived stem cells on ischemia-reperfusion injury: immunohistochemical and ultrastructural evaluation. Plast Reconstr Surg. 2009 Sep;124(3):804-15 Authors: Uysal AC, Mizuno H, Tobita M, Ogawa R, Hyakusoku H BACKGROUND: Advances in the treatment of reperfusion injury have created an opportunity for plastic surgeons to apply these treatments to flaps and implanted tissues. The authors examined the direct and indirect effects of adipose-derived stem cells on ischemia-reperfusion injury on a skin flap model to determine the in vivo differentiation of adipose-derived stem cells to endothelial cells; the levels of vascular endothelial growth factor (VEGF), transforming growth factor-beta, and fibroblast growth factor; and the ultrastructural changes apparent with scanning electron microscopy to clarify the initial events and the following cascades. METHODS: Two identical cranial based random flaps with a dimension of 1 x 5 cm were elevated on the dorsums of 20 ICR mice. The left flap was designated as the control and the right flap was injected with adipose-derived stem cells. The flaps were then subjected to 6 hours of ischemia by clamping the pedicle, and then reperfusion. RESULTS: The mean viable flap length in the control and experimental groups was 15.2 +/- 3.4 mm and 24.4 +/- 2.9 mm, respectively. The mean viable flap area in the control and experimental groups was 12.9 +/- 4.1 mm and 21.8 +/- 3.7 mm, respectively. The in vivo differentiation of adipose-derived stem cells to endothelial cells was observed. The immunohistochemical stainings, VEGF, transforming growth factor-beta, and fibroblast growth factor revealed increased levels in the experimental groups. Scanning electron microscopy indicated mild injury in the experimental group. CONCLUSIONS: The adipose-derived stem cells could prevent ischemia-reperfusion injury, mainly by regulating the growth factors. Although VEGF was the foremost inhibitor of injury, the overall cascade was enhanced by adipose-derived stem cells, with the help of the other growth factors. PMID: 19730299 [PubMed - indexed for MEDLINE]

Monitoring partial and full venous outflow compromise in a rabbit skin flap model.

Related Articles Monitoring partial and full venous outflow compromise in a rabbit skin flap model. Plast Reconstr Surg. 2009 Sep;124(3):796-803 Authors: Gimbel ML, Rollins MD, Fukaya E, Hopf HW BACKGROUND: Free flap failure often results from venous thrombosis. The authors developed a rabbit flap model of partial venous obstruction and evaluated four monitoring devices in detecting partial and full venous compromise. METHODS: Nine skin flaps were elevated on their arteriovenous pedicles in rabbits. The flap was assessed with quantitative Doppler of arterial inflow, transcutaneous oxygen and carbon dioxide tension, near-infrared spectroscopy tissue oxygen saturation, and scanning laser Doppler imaging. After a stable baseline was achieved, the outflow vein was subjected to partial and full venous obstruction followed by release. RESULTS: Pedicle arterial flow decreased significantly from baseline (5.9 +/- 3.0 ml/minute) during partial (4.1 +/- 2.4 ml/minute; 30.5 percent; p < 0.01) and full obstruction (0.3 +/- 0.4 ml/minute; 94.9 percent; p < 0.01). All other measures changed significantly with full obstruction: transcutaneous oxygen tension decreased by 79.6 percent; transcutaneous carbon dioxide tension increased by 69.0 percent; near-infrared spectroscopy tissue oxygen saturation decreased by 35.7 percent; and scanning laser Doppler imaging decreased by 78.8 percent. Laser Doppler imaging was the only noninvasive device that decreased significantly (p < 0.01) with partial obstruction, from 222.8 +/- 77.3 units to 186.5 +/- 73.2 units (16.3 percent). CONCLUSIONS: The authors established a venous obstruction flap model and evaluated four clinically relevant monitoring devices during partial and full venous occlusion. All devices detected full occlusion, but only scanning laser Doppler imaging and arterial Doppler detected partial occlusion. Scanning laser Doppler imaging monitoring may allow warning of impending venous obstruction. Near-infrared spectroscopy tissue oxygen saturation varied the least between flaps and therefore may be the most easily interpreted device for full venous occlusion. Both characteristics are important for clinical application. PMID: 19730298 [PubMed - indexed for MEDLINE]

Periosteum-guided prefabrication of vascularized bone of clinical shape and volume.

Related Articles Periosteum-guided prefabrication of vascularized bone of clinical shape and volume. Plast Reconstr Surg. 2009 Sep;124(3):787-95 Authors: Cheng MH, Brey EM, Allori AC, Gassman A, Chang DW, Patrick CW, Miller MJ BACKGROUND: Large craniofacial skeletal defects require complex reconstruction. Vascularized tissue transfer is the current standard in treatment, but these operations are technically difficult and associated with donor-site morbidity. Guided flap prefabrication offers a technique for endogenously engineering vascularized composite tissues with complex three-dimensional structure. This study evaluates the relationship between implantation time and tissue structure for generating tissues of clinically relevant volume and structure. METHODS: Twenty skeletally mature domestic sheep were implanted with poly(methyl methacrylate) chambers designed to mimic the size and shape of the mental protuberance of the mandible. Each chamber was filled with morcellized bone graft and implanted with the open face apposed to the cambium layer of the rib periosteum. Chambers were harvested at 3, 6, 9, 12, and 24 weeks, and the tissue inside the chambers was analyzed for shape conformation to chamber geometry, gross tissue volume, and bone histomorphometric parameters. RESULTS: Histologically, active endochondral, direct, and appositional bone formation was observed. Calcified tissue area and new bone formation increased for each time point up to 12 weeks of implantation. The tissues formed maintained volumetric and geometrical structure consistent with the chamber up to 9 weeks after implantation. Significant decreases in total volume and agreement with chamber geometry were observed at 12 and 24 weeks. CONCLUSIONS: Periosteum-guided tissue prefabrication was found to be an effective means of engineering three-dimensional vascularized bone of clinical size and shape. The optimal duration of incubation before significant volume loss occurs is 9 weeks in this large-animal model. PMID: 19730297 [PubMed - indexed for MEDLINE]

Experimental assessment of autologous lymph node transplantation as treatment of postsurgical lymphedema.

Related Articles Experimental assessment of autologous lymph node transplantation as treatment of postsurgical lymphedema. Plast Reconstr Surg. 2009 Sep;124(3):777-86 Authors: Tobbia D, Semple J, Baker A, Dumont D, Johnston M BACKGROUND: The authors' objective was to test whether the transplantation of an autologous lymph node into a nodal excision site in sheep would restore lymphatic transport function and reduce the magnitude of postsurgical lymphedema. METHODS: As a measure of lymph transport, iodine-125 human serum albumin was injected into prenodal vessels at 8 and 12 weeks after surgery, and plasma levels of the protein were used to calculate the transport rate of the tracer to blood (percent injected per hour). Edema was quantified from the circumferential measurement of the hind limbs. RESULTS: The transplantation of avascular lymph nodes at 8 (n = 6) and 12 weeks (n = 6) produced lymphatic function levels of 12.3 +/- 0.5 and 12.6 +/- 0.8, respectively. These values were significantly less (p < 0.001) than those measured at similar times in the animals receiving sham surgical procedures (16.6 +/- 0.7, n = 6; and 16.1 +/- 0.7, n = 6, respectively). When vascularized transplants were performed, lymphatic function was similar to the sham controls and significantly greater (p < 0.001) than that of the avascular group (8 weeks, 15.8 +/- 0.9, n = 8; 12 weeks, 15.7 +/- 1.0, n = 10). Lymph transport correlated significantly with the health of the transplanted nodes (scaled with histologic analysis) (p < 0.0001). The vascularized node transplants (n = 18) were associated with the greatest clinical improvement, with the magnitude of edema in these limbs exhibiting significantly lower levels of edema (p = 0.039) than nontreated limbs (n = 18). CONCLUSIONS: The successful reimplantation of a lymph node into a nodal excision site has the potential to restore lymphatic function and facilitate edema resolution. This result has important conceptual implications in the treatment of postsurgical lymphedema. PMID: 19730296 [PubMed - indexed for MEDLINE]

Discussion. Improvement of skin quality after fat grafting: clinical observation and an animal study.

Related Articles Discussion. Improvement of skin quality after fat grafting: clinical observation and an animal study. Plast Reconstr Surg. 2009 Sep;124(3):775-6 Authors: Lambros V PMID: 19730295 [PubMed - indexed for MEDLINE]

Improvement of skin quality after fat grafting: clinical observation and an animal study.

Improvement of skin quality after fat grafting: clinical observation and an animal study. Plast Reconstr Surg. 2009 Sep;124(3):765-74 Authors: Mojallal A, Lequeux C, Shipkov C, Breton P, Foyatier JL, Braye F, Damour O BACKGROUND: Restoration of volume and contour defects is a challenge in plastic surgery. Autologous fat tissue transfer is gaining increasing popularity in this field. The aim of this study was to investigate the histologic modifications of the skin after fat tissue grafting on an animal model. METHODS: Thirty nude mice, divided into three groups, were used in the experiment. All 30 mice received human fat tissue on one side. On the opposite side, 10 mice received nothing (negative control group), 10 mice received cell proliferation medium, and the remaining 10 mice received only subcutaneous tunneling. Eight weeks later, biopsies of the skin and subcutaneous tissue were performed and specimens were analyzed by hematoxylin-phloxin-saffron staining. Dermis thickness was measured. To differentiate human from murine collagen fibers, human and murine collagen type I antibodies were used. The other types of collagen were investigated by immunohistochemistry (immunostaining) using collagen type III, V, and VI antibodies. RESULTS: Fat tissue was found in all animals. Macroscopically, fat tissue presented normal aspects, with abundant peripheral neovascularization. Histologic examination showed abundant extracellular matrix around the injected human fat tissue. This was attributable to increased type I collagen fibers of murine origin as a result of the murine fibroblast stimulation by the grafted human fat tissue. Dermal thickness after fat grafting was significantly greater. This was not attributable to inflammatory reactions, because no modification was detected in our control groups. CONCLUSIONS: This study shows that fat tissue grafting stimulates a neosynthesis of collagen fibers at the recipient site and makes the dermis thicker. However, the long-term effects remain undetermined and need further investigation. PMID: 19730294 [PubMed - indexed for MEDLINE]

Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions.

Related Articles Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg. 2009 Sep;124(3):737-51 Authors: Massey MF, Spiegel AJ, Levine JL, Craigie JE, Kline RM, Khoobehi K, Erhard H, Greenspun DT, Allen RJ, Allen RJ, Perforator flap breast reconstruction is an accepted surgical option for breast cancer patients electing to restore their body image after mastectomy. Since the introduction of the deep inferior epigastric perforator flap, microsurgical techniques have evolved to support a 99 percent success rate for a variety of flaps with donor sites that include the abdomen, buttock, thigh, and trunk. Recent experience highlights the perforator flap as a proven solution for patients who have experienced failed breast implant-based reconstructions or those requiring irradiation. Current trends suggest an application of these techniques in patients previously felt to be unacceptable surgical candidates with a focus on safety, aesthetics, and increased sensitization. Future challenges include the propagation of these reconstructive techniques into the hands of future plastic surgeons with a focus on the development of septocutaneous flaps and vascularized lymph node transfers for the treatment of lymphedema. PMID: 19730293 [PubMed - indexed for MEDLINE]

Partial breast reconstruction: current perspectives.

Related Articles Partial breast reconstruction: current perspectives. Plast Reconstr Surg. 2009 Sep;124(3):722-36 Authors: Losken A, Hamdi M The popularity of breast conservation therapy for the management of women with breast cancer continues to rise. To preserve cosmesis or broaden the indications for breast conservation therapy in some situations, plastic surgeons are now being challenged with the reconstruction of partial mastectomy defects. Numerous techniques exist, either at the time of resection or following radiation, and the decision of which to use depends on breast size, tumor size, and tumor location. Women with unfavorable defects in smaller breasts will often benefit from volume replacement techniques, such as local fasciocutaneous or myocutaneous flaps, without the need for a symmetry procedure. Women with moderate or larger breasts (with or without ptosis) and the potential for an unfavorable result also have the option for volume displacement procedures using local tissue rearrangement techniques to reshape the breast mound. As these are volume reduction procedures, they often require a contralateral procedure for symmetry. The extent of resection (lumpectomy versus quandantectomy) will also influence the type of reconstruction. Patient selection, surgical technique, margin status, and appropriate follow-up are crucial to maximize both oncological safety and cosmesis. The reconstruction of partial mastectomy defects will likely gain popularity as we continue to demonstrate safe and effective treatment algorithms with larger series and longer follow-up in an attempt to minimize locoregional disease and maximize cosmetic outcome. PMID: 19730292 [PubMed - indexed for MEDLINE]

The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction.

Related Articles The retrograde limb of the internal mammary vein: an additional outflow option in DIEP flap breast reconstruction. Plast Reconstr Surg. 2009 Sep;124(3):717-21 Authors: Kerr-Valentic MA, Gottlieb LJ, Agarwal JP BACKGROUND: The deep inferior epigastric perforator (DIEP) flap has become an increasingly popular option for postmastectomy reconstruction. The purpose of this study was to evaluate the retrograde limb of the internal mammary vein as a recipient vein in DIEP breast reconstruction. METHODS: Fifteen consecutive DIEP flaps in 13 patients were transferred with anastomosis of one DIEP vena comitans to the antegrade internal mammary vein and the other DIEP vena comitans to the retrograde internal mammary vein. The deep inferior epigastric artery was anastomosed to the antegrade internal mammary artery. Blood flow through the retrograde internal mammary vein was evaluated with intraoperative duplex ultrasound. RESULTS: Thirty venous anastomoses in 15 DIEP flaps for breast reconstruction were performed over a 4-month period to investigate the retrograde limb of the internal mammary vein as a potential recipient vein. No evidence of intraoperative venous congestion was seen. Retrograde blood flow was demonstrated using intraoperative duplex imaging and clinical examination. All 15 flaps were successful. CONCLUSIONS: The retrograde limb of the internal mammary vein is an option as a recipient vein in DIEP breast reconstruction. This outflow option may prove useful in cases with intraoperative congestion in a single vein flap, in cases with co-dominant superficial and deep venous systems, and in cases in which double-pedicle free flaps are used for unilateral breast reconstruction. PMID: 19730291 [PubMed - indexed for MEDLINE]

Discussion. A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement.

Related Articles Discussion. A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement. Plast Reconstr Surg. 2009 Sep;124(3):715-6 Authors: Hidalgo DA PMID: 19730290 [PubMed - indexed for MEDLINE]

A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement.

A detailed analysis of the reduction mammaplasty learning curve: a statistical process model for approaching surgical performance improvement. Plast Reconstr Surg. 2009 Sep;124(3):706-14 Authors: Carty MJ, Chan R, Huckman R, Snow D, Orgill DP BACKGROUND: The increased focus on quality and efficiency improvement within academic surgery has met with variable success among plastic surgeons. Traditional surgical performance metrics, such as morbidity and mortality, are insufficient to improve the majority of today's plastic surgical procedures. In-process analyses that allow rapid feedback to the surgeon based on surrogate markers may provide a powerful method for quality improvement. METHODS: The authors reviewed performance data from all bilateral reduction mammaplasties performed at their institution by eight surgeons between 1995 and 2007. Multiple linear regression analyses were conducted to determine the relative impact of key factors on operative time. Explanatory learning curve models were generated, and complication data were analyzed to elucidate clinical outcomes and trends. RESULTS: A total of 1068 procedures were analyzed. The mean operative time for bilateral reduction mammaplasty was 134 +/- 34 minutes, with a mean operative experience of 11 +/- 4.7 years and total resection volume of 1680 +/- 930 g. Multiple linear regression analyses showed that operative time (R = 0.57) was most closely related to surgeon experience and resection volume. The complication rate diminished in a logarithmic fashion with increasing surgeon experience and in a linear fashion with declining operative time. CONCLUSIONS: The results of this study suggest a three-phase learning curve in which complication rates, variance in operative time, and operative time all decrease with surgeon experience. In-process statistical analyses may represent the beginning of a new paradigm in academic surgical quality and efficiency improvement in low-risk surgical procedures. PMID: 19730289 [PubMed - indexed for MEDLINE]

Discussion. The "neosubpectoral" pocket for the correction of symmastia.

Related Articles Discussion. The "neosubpectoral" pocket for the correction of symmastia. Plast Reconstr Surg. 2009 Sep;124(3):704-5 Authors: Hammond DC PMID: 19730288 [PubMed - indexed for MEDLINE]

Tendon transfers: Part II. Transfers for ulnar nerve palsy and median nerve palsy.

Related Articles Tendon transfers: Part II. Transfers for ulnar nerve palsy and median nerve palsy. Plast Reconstr Surg. 2009 Sep;124(3):212e-21e Authors: Sammer DM, Chung KC LEARNING OBJECTIVES: After reading this article (part II of II), the participant should be able to: 1. Describe the anatomy and function of the median and ulnar nerves in the forearm and hand. 2. Describe the clinical deficits associated with injury to each nerve. 3. Describe the indications, benefits, and drawbacks for various tendon transfer procedures used to treat median and ulnar nerve palsy. 4. Describe the treatment of combined nerve injuries. 5. Describe postoperative care and possible complications associated with these tendon transfer procedures. SUMMARY: This article discusses the use of tendon transfer procedures for treatment of median and ulnar nerve palsy and combined nerve palsies. Postoperative management and potential complications are also discussed. PMID: 19730287 [PubMed - indexed for MEDLINE]

The "neosubpectoral" pocket for the correction of symmastia.

The "neosubpectoral" pocket for the correction of symmastia. Plast Reconstr Surg. 2009 Sep;124(3):695-703 Authors: Spear SL, Dayan JH, Bogue D, Clemens MW, Newman M, Teitelbaum S, Maxwell GP BACKGROUND: Symmastia is a rare but challenging problem to correct. A number of techniques have been proposed, but each has drawbacks in terms of reliability, accuracy, and difficulty. A recently described technique to treat subpectoral symmastia is reported whereby a new pocket is created between the deep surface of the pectoralis major muscle and the anterior surface of the periprosthetic capsule, the boundaries of which are limited by the adherence between the capsule and overlying tissue. The "neosubpectoral" pocket is therefore not a "repair" of the excessively medialized symmastia pocket, but is a new pocket, limited at its perimeter by the patient's own tissues rather than by sutures or a patch. METHODS: A precise neosubpectoral plane is developed between the pectoralis major and the anterior implant capsule wall, with dissection limited to creating only the space necessary for proper placement of the implant. The technical details of this procedure are described. A chart review was conducted of all patients who underwent symmastia correction using this technique since December of 2003 at Georgetown University Hospital in the practices of Steven Teitelbaum, M.D., and G. Patrick Maxwell, M.D. RESULTS: A total of 23 patients underwent symmastia correction using the neosubpectoral technique. Several of these patients presented for recurrence after failed capsulorrhaphy. There has been no recurrence of symmastia to date in this study. The average follow-up was 22 months. One postoperative hematoma and one seroma occurred. One patient had uncorrected, underdiagnosed inferior malposition from an earlier procedure requiring revision. CONCLUSIONS: The neosubpectoral technique is a method for the correction of symmastia that may offer a more efficient, accurate, and effective solution in a single stage. It is an appealing concept that allows for a site change while maintaining the subpectoral position. This procedure is technically straightforward and may offer a reliable means of correcting many other forms of implant malposition and difficult reconstructions. PMID: 19363454 [PubMed - indexed for MEDLINE]

Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review.

Related Articles Abdominal wall following free TRAM or DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr Surg. 2009 Sep;124(3):752-64 Authors: Man LX, Selber JC, Serletti JM BACKGROUND: Numerous studies compare techniques for free flap breast reconstruction techniques, with no consensus regarding differences in complication rates. This study compared the risk of fat necrosis, partial flap loss, total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after deep inferior epigastric perforator (DIEP) and free transverse rectus abdominis myocutaneous (TRAM) flap surgery for breast reconstruction. METHODS: A MEDLINE and manual search of English-language articles on DIEP and free TRAM flap surgery published up to April of 2007 yielded 338 citations. Two levels of screening identified 37 relevant studies. The Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models were used to perform the meta-analysis. RESULTS: Six studies reporting both DIEP and free TRAM flap outcomes were used to estimate pooled relative risks of complications and confidence intervals. There was a twofold increase in the risk of fat necrosis (relative risk, 1.94; 95 percent CI, 1.28 to 2.93) and flap loss (relative risk, 2.05; 95 percent CI, 1.16 to 3.61) in DIEP patients compared with free TRAM patients. There was no difference in the risk for fat necrosis when the analysis was limited to studies using muscle-sparing free TRAM flaps (relative risk, 0.91; 95 percent CI, 0.47 to 1.78). DIEP patients had one-half the risk of abdominal bulge or hernia (relative risk, 0.49; 95 percent CI, 0.28 to 0.86). Sixteen studies reporting DIEP outcomes and 23 studies reporting free TRAM outcomes were used to estimate pooled complication rates. Pooled flap-related complication rates were higher in DIEP patients, whereas donor-site morbidity was higher in free TRAM patients. CONCLUSION: This analysis suggests that the DIEP flap reduces abdominal morbidity but increases flap-related complications compared with the free TRAM flap in breast reconstruction. PMID: 19342994 [PubMed - indexed for MEDLINE]