The 50 most-cited articles in Plastic & Reconstructive Surgery, 2018

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify skeletal differences that are treated with orthognathic surgery; describe the goals of orthognathic surgery; and understand modern virtual surgical planning of orthognathic movement of the mandible, maxilla, and chin. 2. Appreciate the surgical principles of maxilla- versus mandible-first surgery, and orthognathic surgery before orthodontic correction; and understand when an osseous genioplasty may be beneficial, and the potency of this bony movement. 3. Appreciate the utility of fat grafting as an adjunct to orthognathic bony movements, and demonstrate understanding of the utility of orthognathic surgery in the treatment of obstructive sleep apnea. 4. Be aware of associated complications and be able to critically assess outcomes following orthognathic surgery. SUMMARY: This CME article outlines the goals of orthognathic surgery, highlighting advances in the field and current controversies. The principles of the sequencing of osteotomies are discussed and literature is reviewed that may…

Background: Despite the increased understanding of surgical best practices, capsular contracture remains the most commonly reported complication and reason for reoperation following breast implant surgery. This study provides a long-term update to a previous investigation of potential contributing risk factors for capsular contracture in primary augmentation patients. Methods: The data used for this analysis include 5,122 implants in 2,565 primary augmentation patients implanted by 34 surgeons based on long-term results from Sientra’s clinical study. Potential risk factors, including patient and implant attributes, surgery characteristics, pocket irrigation, and postsurgery characteristics, were analyzed using frequency and multivariate models. Results: A total of 333 capsular contracture events in 224 patients were reported. The overall Kaplan–Meier rate for capsular contracture was 10.8% by device through 10 years. Results from the multivariate analysis found 8 factors to be independently associated with capsular contracture (implant placement, implant surface, incision site,…

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the diagnostic criteria for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL). 2. Appropriately evaluate a patient with suspected BIA-ALCL, including appropriate imaging, laboratory tests, and pathologic evaluation. 3. Understand the operative treatment of BIA-ALCL, and indications for systemic chemotherapy and/or radiation therapy in advanced disease. 4. Understand treatment outcomes and prognosis based on stage of disease. SUMMARY: The goal of this continuing medical education module is to present the assessment of a patient with suspected breast implant-associated anaplastic large cell lymphoma, the evaluation and diagnosis, the preoperative oncologic workup, the formation and execution of a surgical treatment plan, and the inclusion of adjunct treatments when indicated. In addition, staging and disease progression for treatment of breast implant-associated anaplastic large cell lymphoma are discussed.

BACKGROUND: Penile inversion vaginoplasty is the current gold standard procedure for male-to-female transgender patients seeking gender-confirming genital surgery. Although complication data have been reported extensively in the literature, studies on patient-reported outcomes are sparse. This study aimed to report both postoperative complications and patient-reported outcomes from the largest cohort in the United States to date to undergo penile inversion vaginoplasty. Ultimately, the authors hoped to identify the predictors of postoperative complications and patient satisfaction. METHODS: A retrospective chart review of a single surgeon's experience with penile inversion vaginoplasty was performed from July of 2014 to June of 2016. Patient demographic data, postoperative complications, and patient-reported outcome data were collected. Data were correlated by binary logistic regression to determine predictors of postoperative complications and patient satisfaction. RESULTS: A total of 117 patients underwent penile inversion vaginoplasty. The most common complications were…

BACKGROUND: It has been two centuries since Petrus Camper identified superficial fascia and over 175 years since Sir Astley Cooper wrote his book on the anatomy of the breast. In the 1990s, Ted Lockwood taught us the importance of the superficial fascia layers in body contouring procedures he pioneered. These descriptions, however, fail to explain the three-dimensional fascial system in the breast. The authors set out to discover and describe a theory of superficial fascia structures responsible for breast shape. METHODS: The nature of the superficial fascia system that surrounds the breast and its attachments to the chest were studied in 12 cadaver breast dissections and in clinical cases of both cosmetic and reconstructive breast procedures. RESULTS: The authors found a three-dimensional, closed system of fascia and fat surrounding the corpus mammae, which attaches to the skin by means of specialized vertical cutaneous ligaments, or Cooper ligaments, and which attaches to the chest wall by means of a three-dimensional zone of adherence at the breast's periphery. CONCLUSIONS: The…

BACKGROUND: The introduction of texture to the outer shell of breast implants was aimed at increasing tissue incorporation and reducing capsular contracture. It has also been shown that textured surfaces promote a higher growth of bacteria and are linked to the development of breast implant-associated anaplastic large cell lymphoma. METHODS: The authors aimed to measure the surface area and surface roughness of 11 available implants. In addition, the authors aimed to subject these implant shells to an in vitro bacterial attachment assay with four bacterial pathogens (Staphylococcus epidermidis, S. aureus, Pseudomonas aeruginosa, and Ralstonia pickettii) and study the relationship among surface area, surface roughness, and bacterial growth. RESULTS: Surface area measurement showed grouping of implants into high, intermediate, low, and minimal. Surface roughness showed a correlation with surface area. The in vitro assay showed a significant linear relationship between surface area and bacterial attachment/growth. The high surface area/roughness implant texture grew significantly more…

BACKGROUND: Integrated plastic surgery residency applicants sometimes complete research fellowships before residency. The average productivity and the impact of these fellowships on subsequent application to residency are unknown. The purpose of this study was to provide objective data to better understand the utility and productivity of a research fellowship. METHODS: A national survey was conducted in which integrated plastic surgery residency applicants from 2013 to 2016 were surveyed regarding their experiences with research fellowships. American Council of Academic Plastic Surgeons members were also surveyed to elicit their perspectives on the value of these fellowships. RESULTS: Six hundred twenty-one integrated plastic surgery applicants from 2013 to 2016 were included in the study. Twenty-five percent of applicants participated in a research fellowship. Applicants who completed research fellowships were more likely to match into plastic surgery compared to those who did not (97 percent versus 81 percent, respectively; p < 0.05). Fellows were highly satisfied with their…

BACKGROUND: Previous research has highlighted the gender-based disparities present throughout the field of surgery. This study aims to evaluate the breadth of the issues facing women in plastic surgery, worldwide. METHODS: A systematic scoping review was undertaken from October of 2016 to January of 2017, with no restrictions on date or language. A narrative synthesis of the literature according to themed issues was developed, together with a summary of relevant numeric data. RESULTS: From the 2247 articles identified, 55 articles were included in the analysis. The majority of articles were published from the United States. Eight themes were identified, as follows: (1) workforce figures; (2) gender bias and discrimination; (3) leadership and academia; (4) mentorship and role models; (5) pregnancy, parenting, and childcare; (6) relationships, work-life balance, and professional satisfaction; (7) patient/public preference; and (8) retirement and financial planning. Despite improvement in numbers over time, women plastic surgeons continue to be underrepresented in the United States,…

BACKGROUND: It is not easy to find a management-based classification of palatal fistula in the literature. A few attempts have been made to classify the wide variety of fistulae that do not describe the fistula details comprehensively and guide toward its management. The authors have come across a wide variety of fistulae that could not be classified according to any of the prevailing classification systems. The presented classification gives a clear and exact understanding of location and size of fistula/dehiscence. Palatal function has been included as one of the important determinants for devising a management plan. Based on this classification, the authors have proposed an algorithm that encompasses clear guidelines for surgical treatment of these fistulae. METHODS: Over the past 15 years, the authors' team operated on 2537 palatal fistula patients. The medical records of these patients were reviewed to determine the location, size, and velopharyngeal competence. A new classification and algorithm were developed. RESULTS: Of 2537 patients, 2258 had midline fistulae, 208 had…

BACKGROUND: Vascular anomalies currently are classified according to their clinical and histological characteristics. Recent advances in molecular genetics have enabled the identification of somatic mutations in most types of vascular anomalies. The purpose of this study was to collate information regarding the genetic basis of vascular anomalies. METHODS: The PubMed literature was reviewed for all citations that identified a mutation in a vascular anomaly between 1994 and 2017. Search terms included "vascular anomaly," "mutation," "gene," "hemangioma," "pyogenic granuloma," "kaposiform hemangioendothelioma," "capillary malformation," "venous malformation," lymphatic malformation," "arteriovenous malformation," and "syndrome." Articles that identified both germline and somatic mutations in vascular anomalies were analyzed. Mutations were categorized by type (germline or somatic), gene, signaling pathway, and cell(s) enriched for the mutation. RESULTS: The majority of vascular anomalies had associated mutations that commonly affected tyrosine kinase receptor signaling through the RAS…

BACKGROUND: The superficial (subcutaneous) facial fat compartments contribute to the signs of facial aging, but a comprehensive anatomical description of their location and their functional behavior during the application of soft-tissue fillers remains elusive. METHODS: The authors investigated 30 fresh frozen cephalic specimens from 13 male and 17 female Caucasian body donors (age, 78.3 ± 14.2 years; body mass index, 23.1 ± 5.3 kg/m(2)). Upright-position, contrast-enhanced computed tomographic scanning, and additional magnetic resonance imaging were performed. Three-dimensional reconstruction-based measures were conducted to evaluate the position of the applied contrast agent in each compartment separately. Successive anatomical dissections were performed to confirm the imaging findings. RESULTS: Positive correlations were detected between the amounts of injected material and the inferior displacement for the superficial nasolabial (rp = 0.92, p = 0.003), middle cheek (rp = 0.70, p = 0.05), and jowl (rp = 0.92, p = 0.03) compartments but not for the medial cheek (rp = 0.20, p =…

BACKGROUND: The treatment plan for cleft lip and palate varies among centers and requires long-term evaluation of its final outcome. METHODS: A consecutive series of patients born from 1994 to 1996 were reviewed. Inclusion criteria were complete unilateral cleft lip and palate, undergoing all treatment procedures performed by the team, and continuous follow-ups until 20 years of age. Exclusion criteria were incomplete data, having microform cleft lip on the contralateral side, presence of the Simonart band, and other abnormalities. RESULTS: A total of 72 patients were included. Average age at final evaluation was 21.3 years; 83.3 percent of patients underwent one-stage rotation-advancement lip repair and 16.7 percent underwent two-stage repair with an initial adhesion cheiloplasty. All patients underwent palate repair using the two-flap method at an average age of 12.3 months. Velopharyngeal insufficiency occurred and required surgical interventions in 19.4 percent during the preschool age and in 16.7 percent at the time of alveolar bone grafting; 56.9 percent of patients underwent…

BACKGROUND: Mesh infection remains the most feared complication after abdominal wall reconstruction, requiring prolonged hospitalizations and often, mesh removal. Understanding of current prevention and treatment strategies is necessary in the management of a common surgical problem. METHODS: A comprehensive review of the current surgical literature was performed to determine risk factors of mesh infection after abdominal wall reconstruction and best practices in their prevention and surgical management. RESULTS: Patient-related risk factors for mesh infections include smoking, obesity, diabetes mellitus, and COPD. Surgical risk factors such as prolonged operative time and prior enterotomy should also be considered. Prevention strategies emphasize reduction of modifiable risk factors, including obesity and diabetes among other comorbidities. Biologic or biosynthetic mesh is recommended in contaminated fields and use of delayed wound closure or vacuum-assisted closure therapy should be considered in high-risk patients. Conservative treatment with antibiotics, percutaneous or surgical…

BACKGROUND: Prepectoral acellular dermal matrix-assisted immediate implant-based breast reconstruction is gaining popularity, involving complete implant coverage with acellular dermal matrix. The authors aimed to compare pain, patient-reported outcome measures (including implant rippling), and safety of prepectoral and subpectoral Strattice-assisted implant-based breast reconstruction. METHODS: Consecutive patients were recruited prospectively, having either therapeutic or risk-reducing mastectomy. Patients scored their pain three times per day for the first 7 postoperative days on a Likert scale, and completed the BREAST-Q reconstruction module 3 months postoperatively. Clinical records and the authors' prospective complications database were used to compare the early morbidity of the two procedures. RESULTS: Forty patients were recruited into the study. There was no significant difference in pain scores between the prepectoral group (mean, 1.5) and the subpectoral cohort (mean, 1.5; p = 0.45) during the first 7 days. Thirty-one BREAST-Q questionnaires were returned; mean Q scores…

BACKGROUND: If safety is defined as the diminished ability to penetrate facial arteries, the goal of this study was to investigate whether different-sized cannulas are safer than correspondingly sized needles for the application of facial soft-tissue fillers. METHODS: Two hundred ninety-four penetration procedures of the facial and superficial temporal arteries were performed in four fresh frozen cephalic specimens using both needles (20-, 22-, 25-, and 27-gauge) and cannulas (22-, 25-, and 27-gauge). Continuously increasing force was applied and measured until intraarterial penetration occurred. RESULTS: No statistically significant differences were detected when comparing forces required to penetrate the facial arterial vasculature between different sexes, arteries, or sides of the face (all p > 0.05). Forces needed to penetrate significantly (p < 0.001) decreased with smaller diameter needles (20-gauge, 1.12 ± 0.29 N; 22-gauge, 1.08 ± 0.25 N; 25-gauge, 0.69 ± 0.24 N; and 27-gauge, 0.70 ± 0.29 N) and in cannulas (22-gauge, 1.50 ± 0.31 N; 25-gauge, 1.04 ± 0.36 N; and 27-gauge, 0.78…

BACKGROUND: Injection of soft-tissue fillers into the facial fat compartments is frequently performed to ameliorate the signs of facial aging. This study was designed to investigate the functional anatomy of the deep facial fat compartments and to provide information on the effects of injected material in relation to age and gender differences. METHODS: Forty fresh frozen cephalic specimens of 17 male and 23 female Caucasian body donors (mean age, 76.9 ± 13.1 years; mean body mass index, 23.6 ± 5.3 kg/m(2)) were investigated. Computed tomographic and magnetic resonance imaging procedures were carried out using colored contrast-enhanced materials with rheologic properties similar to commercially available soft-tissue fillers. Anatomical dissections were performed to guide conclusions. RESULTS: No statistically significant influences of age or gender were detected in the investigated sample. Increased amounts of injected contrast agent did not correlate with inferior displacement of the material in any of the investigated compartments: deep pyriform, deep medial cheek, deep lateral…

BACKGROUND: Masculinizing top surgery (bilateral mastectomy with chest wall reconstruction) is an important gender-affirming procedure sought by many transmasculine and nonbinary individuals. Current literature is focused primarily on details of surgical technique and complication rates, with limited data available on how top surgery affects subjective quality-of-life measures. METHODS: An anonymous online survey was distributed to 81 of the senior author's former top-surgery patients. The survey response rate was 72 percent (58 respondents). Responses were analyzed to investigate quality of life, sexual confidence, mental health, satisfaction with top surgery, and patient attitudes toward top surgery's role in gender affirmation. RESULTS: Following top surgery, measures of quality of life and sexual confidence improved significantly (p < 0.001). In addition, 86 percent reported improvement in gender dysphoria-related mental health conditions. All but one respondent reported that top surgery had an overall positive impact on their life. CONCLUSIONS: Top surgery had major positive…

BACKGROUND: Several innovations and modifications to the abdominal lipectomy procedure have been performed through the years. Despite recent improvements, the lack of natural results, including high scars, navel deformities, and "tense" abdomen, are still challenging. The objective of this study is to present an alternative technique of combined 360-degree truncal liposuction with abdominal definition, abdominoplasty, and neoumbilicoplasty. METHODS: From January of 2005 to June of 2017, 736 VASER-assisted lipoabdominoplasties were performed. Only healthy women with a body mass index below 33 were included. A three-step procedure was performed: (1) truncal liposculpture, (2) dermolipectomy and plication of the rectus abdominis muscle, and (3) neoumbilicoplasty through a butterfly technique. The follow-up included photographs and medical assessment with a mean of 2 years (up to 5 years). A nonstandardized survey was performed to self-evaluate the results. RESULTS: Six hundred seventy patients answered the survey (91 percent). Six hundred fifteen patients were satisfied with the…

BACKGROUND: Despite rapid growth, gluteal fat transplantation is an operation in search of science and a teachable technique. Long operating times, tedious syringe transfers, inability to shape the recipient site, and the risk of fat embolism all headline as impediments to clinical adoption of the procedure. Expansion vibration lipofilling is a syringe-free surgical strategy that is a logical extension of Separation, Aspiration, and Fat Equalization (SAFELipo). In expansion vibration lipofilling, there is simultaneous disruption of recipient-site connective tissue, internal expansion using exploded-tip cannulas, and backfilling of these spaces with roller pump-propelled fat. METHODS: Two thousand four hundred nineteen consecutive cases of expansion vibration lipofilling fat transplantation to the buttocks were reviewed. Average follow-up was 12 months. The technique of expansion vibration lipofilling is dependent on the use of larger caliber cannulas attached to a roller pump and to an oscillatory power-assisted liposuction device, which is less labor-intensive, potentially allowing…

BACKGROUND: Two-stage subpectoral implant-based breast reconstruction is the most common method for breast reconstruction. Recent advances in surgical techniques and technology have made prepectoral implant-based breast reconstruction feasible. There are limited data on outcomes after prepectoral implant-based breast reconstruction and postmastectomy radiation therapy. METHODS: A retrospective review of consecutive patients undergoing immediate two-stage prepectoral implant-based breast reconstruction with postmastectomy radiation therapy was performed. Outcomes of irradiated breasts were compared with nonirradiated breasts in bilateral cases. RESULTS: Ninety-three cases of prepectoral implant-based breast reconstruction in 54 women who underwent immediate two-stage reconstruction (39 bilateral and 15 unilateral) and unilateral postmastectomy radiation therapy were identified. Mean follow-up was 19 months from mastectomy and tissue expander reconstruction and 9 months from implant placement. Crude complication rates in irradiated versus nonirradiated sides were as follows:…

BACKGROUND: The principal approach to abdominal wall reconstruction requires implantation of mesh to decrease ventral hernia recurrence. This study compared current surgical outcomes and complications by location of anatomic mesh placement following ventral hernia repair with onlay, interposition, retromuscular, or underlay mesh reconstruction. METHODS: A systematic search of the PubMed database published from 2013 to 2018 was performed to identify patients who underwent abdominal wall reconstruction using either biologic or prosthetic mesh for ventral hernia repair. Demographic information and outcomes were obtained from each study. RESULTS: Fifty-one articles met inclusion criteria, resulting in 6,227 patients who underwent mesh repair of a ventral hernia. Mesh position included onlay in 7.6% of patients, interposition in 13.2%, retromuscular in 35.9%, and underlay placement in 43.4%. Prosthetic mesh was used in 68.5% of repairs and biological mesh in 31.5%. The mean patient age was 53.1 years (range, 18-95 years), and mean BMI was 29.1 kg/m(2) (range, 15-70.9 kg/m(2)). The mean…

BACKGROUND: The lymph system plays important roles in maintaining fluid balances, the immune system, and lipid metabolism. After tissue replantation or transfer, some cases suffer long-lasting edema or lymphedema caused by interruption of main lymph flows; however, this mechanism has yet to be clarified. METHODS: The medical charts of 38 patients who underwent indocyanine green lymphography after tissue replantation or free flap transfer were reviewed to obtain data regarding clinical demographics, intraoperative findings, and postoperative indocyanine green lymphographic findings. Postoperative lymph flow restoration based on indocyanine green lymphographic findings was evaluated according to intraoperative findings, including raw surface in lymph axiality and compatible lymph axiality. RESULTS: Lymph flow restoration was observed in 24 cases (63 percent). There were significant differences in positive lymph flow restoration with regard to sex (male, 78 percent; female, 40 percent; p = 0.017), cause of defect (trauma, 83 percent; others, 33 percent; p = 0.002), type of operation…

There is a paucity of literature directly comparing tongue-lip adhesion versus mandibular distraction osteogenesis in surgical treatment of patients with Pierre Robin sequence. This study comprehensively reviews the literature for evaluating airway and feeding outcomes following mandibular distraction osteogenesis and tongue-lip adhesion. A search was performed using the MEDLINE and Embase databases for publications between 1960 and June of 2017. English-language, original studies subjects were included. Extracted data included prevention of tracheostomy (primary airway outcome) and ability to feed exclusively by mouth (primary feeding outcome). A total of 67 studies were included. Ninety-five percent of subjects (657 of 693) treated with mandibular distraction osteogenesis avoided tracheostomy, compared to 89% of subjects (289 of 323) treated with tongue-lip adhesion. Eighty-seven percent of subjects (323 of 370) treated with mandibular distraction osteogenesis achieved full oral feeds at latest follow-up. Seventy percent of subjects (110 of 157) treated with tongue-lip adhesion…

Approximately 25 percent of major limb amputees will develop chronic localized symptomatic neuromas and phantom limb pain in the residual limb. A method to treat and possibly prevent these pain symptoms is targeted reinnervation. Previous studies prove that targeted reinnervation successfully treats and, in some cases, resolves peripheral neuropathy and phantom limb pain in patients who have undergone previous amputation (i.e., secondary targeted reinnervation). This article seeks to share the authors' clinical indications and surgical technique for targeted muscle reinnervation in below-knee amputation, a surgical description currently absent from our literature. Targeted reinnervation for the below-knee amputee has been performed on 22 patients at the authors' institution. Each patient has been followed on an outpatient basis for 1 year to evaluate symptoms of neuroma or phantom limb pain, patient satisfaction, and functionality. All subjects have denied neuroma pain following amputation. The majority of subjects reported phantom pain at 1 month. However, at 3 months, all patients…

As a service to our readers, Plastic and Reconstructive Surgery® reviews books, DVDs, practice management software, and electronic media items of educational interest to reconstructive and aesthetic surgeons. All items are copyrighted and available commercially. The Journal actively solicits information in digital format for review. Reviewers are selected on the basis of relevant interest. Reviews are solely the opinion of the reviewer; they are usually published as submitted, with only copy editing. Plastic and Reconstructive Surgery® does not endorse or recommend any review so published. Send books, DVDs, and any other material for consideration to: Arun K. Gosain, M.D., Review Editor, Plastic and Reconstructive Surgery, Brookriver Executive Center, 8150 Brookriver Drive, Suite S-415, Dallas, Texas 75247. Arun K. Gosain, M.D. Review EditorThe spectacular cover art for the book The Look of a Woman: Facial Feminization Surgery and the Aims of Trans- Medicine by Eric Plemons is the perfect illustration for what lies inside. A continuous line drawing of a beautiful and feminine face…

BACKGROUND: In 2006, Villa et al. published a review article concerning the use of thread-lift sutures and concluded that the technique was still in its infancy but had great potential to become a useful and effective procedure for nonsurgical lifting of sagged facial tissues. As 11 years have passed, the authors now performed again a systematic review to determine the real scientific current state of the art on the use of thread-lift sutures. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed database and using the Medical Subject Headings search term "Rhytidoplasty." "Rhytidoplasty" and the following entry terms were included by this Medical Subject Headings term: "facelift," "facelifts," "face Lift," "Face Lifts," "Lift," "Face," "Lifts," "Platysmotomy," "Platysmotomies," "Rhytidectomy," "Rhytidectomies," "Platysmaplasty," "and "Platysmaplasties." The Medical Subject Headings term "Rhytidoplasty" was combined with the following search terms: "Barbed suture," "Thread lift," "APTOS,"…

BACKGROUND: Prepectoral breast reconstruction following mastectomy has become a more widely performed technique in recent years because of its numerous benefits for women. These include full pectoralis muscle preservation, reduced loss of strength, reduced pain, and elimination of animation deformity. As with any breast reconstruction technique, widespread adoption is dependent on a low morbidity profile in the setting of postmastectomy radiation therapy, as this adjuvant therapy is routine in breast cancer treatment. The authors assess the clinical outcomes of patients undergoing postmastectomy radiation therapy following prepectoral breast reconstruction, and compare these to outcomes of patients undergoing postmastectomy radiation therapy with submuscular reconstruction. METHODS: A single surgeon's experience with immediate prepectoral breast reconstruction, followed by postmastectomy radiation therapy, from 2015 to 2017 was reviewed. Patient demographics and incidence of complications during the tissue expander stage were assessed. In addition, the morbidity profile of these…

BACKGROUND: The usefulness of patient-reported outcome measures is emphasized along with the development of patient-centered care. When implementing patient-reported outcome measures, evidence of the instrument's validity, reliability, and responsiveness in the target population is necessary to secure accurate reporting of the patient's experience. The aim of this study was to identify the literature in which structured patient-reported outcome measures have been used to evaluate the results of gender confirmation surgery, and to systematically evaluate the validity of these instruments. METHODS: A systematic review of the current literature was performed to identify structured patient-reported outcome measures used to evaluate the outcome of gender confirmation surgery. The identified instruments' validity in the transgender population was assessed for adherence to international guidelines for development and validation of health outcomes instruments. RESULTS: A total of 110 instruments were identified: 64 ad hoc; six generic; 24 evaluating psychiatric, social, or psychosocial…

BACKGROUND: Early intervention might improve the quality of surgical scars. Botulinum toxin type A has been shown to improve surgical scars in the past decade. The purpose of this study was to evaluate the effect of botulinum toxin type A on surgical facial scars. METHODS: In this prospective, split-scar, double-blind, randomized controlled trial, 16 consecutive patients who underwent facial surgery between June and October of 2015 were enrolled. Botulinum toxin type A was injected randomly into half of each surgical wound closure immediately after surgery. The scars were assessed independently by two plastic surgeons at a 6-month follow-up visit using the Vancouver Scar Scale and the visual analogue scale. The scar width was also measured. RESULTS: Fourteen patients completed the study. The visual analogue scale score and scar width measurements revealed a significant improvement in appearance and narrower scars for the botulinum toxin type A-treated halves of the scars (p = 0.046 and p = 0.001, respectively). The mean Vancouver Scar Scale score was 4.68 for the botulinum toxin…

BACKGROUND: This study aims to elucidate the important predicting factors for fat necrosis and abdominal morbidity in the patient undergoing deep inferior epigastric artery perforator flap reconstruction. METHODS: The authors conducted a retrospective review of 866 free-flap breast reconstructions performed at one institution from 2010 to 2016. Twenty-eight potential predictors were included in multivariable analyses to control for possible confounding interactions. RESULTS: Four hundred nine total deep inferior epigastric artery perforator flaps were included in the statistical analysis. Of these, 14.4 percent had flap fat necrosis, 21.3 percent had an abdominal wound or complication, and 6 percent had an abdominal bulge or hernia. Analysis showed an increase in the odds of fat necrosis with increasing flap weight (OR, 1.002 per 1-g increase; p = 0.0002). A decrease in the odds of fat necrosis was seen with lateral row (OR, 0.29; p = 0.001) and both medial and lateral row perforator flaps (OR, 0.21; p = 0.001), if indocyanine green angiography was used (OR, 0.46; p = 0.04), and…

New developments in primary tendon repair in recent decades include stronger core tendon repair techniques, judicious and adequate venting of critical pulleys, followed by a combination of passive and active digital flexion and extension. During repair, core sutures over the tendon should have sufficient suture purchase (no shorter than 0.7 to 1 cm) in each tendon end and must be sufficiently tensioned to resist loosening and gap formation between tendon ends. Slight or even modest bulkiness in the tendon substance at the repair site is not harmful, although marked bulkiness should always be avoided. To expose the tendon ends and reduce restriction to tendon gliding, the longest annular pulley in the fingers (i.e., the A2 pulley) can be vented partially with an incision over its distal or proximal sheath no longer than 1.5 to 2 cm; the annular pulley over the middle phalanx (i.e., the A4 pulley) can be vented entirely. Surgeons have not observed adverse effects on hand function after judicious and limited venting. The digital extension-flexion test to check the quality of the repair…

Design and preoperative planning of microsurgical flaps are fundamental steps for successful surgery. Currently, computed tomographic angiography is considered the gold standard, and new technologies such as thermography could complement its usefulness. The aim of this study was to determine the concordance between thermographic images obtained with a smartphone thermal camera and computed tomographic angiography for detecting perforators using the anterolateral thigh flap area as a model. A concordance study of diagnostic tests was performed in patients who underwent limb reconstruction in 2016. Perforators identified in thigh computed tomographic angiographic images and hotspots on thermographic images obtained by means of the FLIR ONE smartphone camera were compared based on the distance from the anterior superior iliac spine. The authors studied 20 patients, including 38 anterolateral thigh flap territories in total, and identified 117 perforators by computed tomographic angiography and 120 hotspots by thermography. The average mean distance from the anterior superior iliac…

BACKGROUND: In March 2012, the United States Food and Drug Administration approved Sientra's application for premarket approval of its portfolio of round and shaped silicone gel breast implants based on data from the largest silicone gel breast implant study to date. This article presents the results of Sientra's Core Study at the conclusion of 10 years. METHODS: The Sientra Core Study was a 10-year, open-label, prospective, multicenter clinical study designed to assess the safety and effectiveness of Sientra's breast implants in augmentation and reconstruction. A total of 1,788 patients (3,506 implants) were enrolled, including 1,116 primary augmentation, 363 revision-augmentation, 225 primary reconstruction, and 84 revision-reconstruction. RESULTS: Across all cohorts, the rate of rupture by patient was 8.6%, the rate of Baker grade III/IV capsular contracture was 13.5%, and the rate of reoperation was 31.5%. The rate of capsular contracture was statistically significantly lower for textured devices [9.0%; 95% confidence interval (CI), 7.0-11.5%] compared with smooth devices…

Although certain medical societies have released guidelines on the use of social media, plastic surgery, with its inherent visual nature and potential for sensationalism, could benefit from increasing direction regarding the ethical use of social media. The authors hypothesized that although general platitudes for use exist in the literature, guidelines articulating the boundaries of professional use are nonspecific. Systematic searches of MEDLINE, Embase.com, and Cochrane Central Register of Controlled Trials were completed on January 18, 2017. Searches consisted of a combination of Medical Subject Headings terms and title and abstract keywords for social media and professionalism concepts. In addition, the authors manually searched the three highest impact plastic surgery journals (ending in October of 2017). Two authors screened all titles and abstracts. Studies related to clinical medicine, patient care, and the physician-patient relationship were included for full-text review. Articles related to surgery merited final inclusion. The initial search strategy yielded 954 articles,…

BACKGROUND: Medical tourism is a growing, multi-billion dollar industry fueled by improvements in the global transportation infrastructure. The authors studied patients living in the United States who travel to other countries for plastic surgical procedures and returned to have their complications treated in the authors' center. METHODS: A retrospective patient evaluation was performed. Patients who had presented to an urban tertiary academic hospital plastic surgery service with complications or complaints associated with plastic surgery performed in a developing country were studied. The authors collected demographic information, types of surgery performed, destinations, insurance coverage, and complications. RESULTS: Seventy-eight patients were identified over 7 years. Most commonly, complications were seen following abdominoplasty (n = 35), breast augmentation (n = 25), and foreign body injections (n = 15). Eighteen patients underwent multiple procedures in one operative setting. The most common destination country was the Dominican Republic (n = 59). Complications included…

BACKGROUND: Many surgeons are hesitant to use interposition vein grafting in head and neck microvascular free flap surgery because of concerns for elevated risk of flap loss. METHODS: The authors conducted a review of patients who underwent head and neck free flap reconstruction between 2005 and 2015. The effect of vein grafts on flap compromise and flap loss was analyzed using univariate and multivariate models. RESULTS: A total of 3240 free flaps were performed. Vein grafts were used in 241 flaps (7.4 percent). The free flap compromise rate was 14.5 percent with vein grafts and 3.4 percent without vein grafts (p < 0.001). The free flap loss rate was 6.4 percent with vein grafts and 1.1 percent without vein grafts (p < 0.001). Radiation therapy, chemotherapy, prior neck dissection, prior free flap, osteoradionecrosis, and multiple free flap surgery were more frequent within the vein graft group (all p < 0.001). Despite this, vein grafting was associated with an increased risk of flap compromise (adjusted OR, 4.8; 95 percent CI, 3.2 to 7.3; p < 0.001) and flap loss (adjusted OR,…

BACKGROUND: Peripheral sensory nerve injuries present a significant yet common challenge in acute hand trauma surgery. Standard treatment remains microsurgical end-to-end nerve repair where appropriate. Permanent loss of sensitivity and painful neuroma formation are typical sequelae of unsuccessful surgery. The objective of this study was to evaluate whether the additional use of a chitosan nerve tube in primary nerve repair positively influences sensory recovery. METHODS: A randomized, controlled, two-center trial with parallel group design and double-blind assessment was conducted to demonstrate the superiority of the additional use of a chitosan nerve tube compared with microsurgical nerve repair alone. Seventy-four participants were enrolled. The primary outcome parameter used was degree of static two-point discrimination at 6 months after surgery. Additional secondary outcome parameters included filament recognition testing (Semmes-Weinstein); pain; neuroma development; and the Disabilities of the Arm, Shoulder and Hand score. RESULTS: Nerve repair with additional use of…

BACKGROUND: Masseter muscle hypertrophy manifests itself as enlargement of the masseter muscle. It can be associated with a square-angled lower face, pain, dental attrition, maxillary and mandibular bone resorption, and accelerated aging process of the lower face. The objective of this study was to assess the efficacy and safety of botulinum toxin type A in contouring the masseter and its impact on quality of life and the aging process of the lower face, and its role in full face rejuvenation. METHODS: A PubMed search was conducted for articles on masseter treatment with botulinum toxin type A, masseter muscle hypertrophy, and the aging process of the lower face. Key studies are reviewed and findings are summarized. RESULTS: Botulinum toxin type A can be injected into the lower posterior aspect of the masseter muscle. Treatment decreases muscle bulk and reshapes the lower face. Furthermore, patient quality-of-life measures, including pain and symptoms of grinding and clenching, are improved. Treatment can decrease shear stress on maxillary and mandibular bones and can possibly…

BACKGROUND: The intraoperative mortality and overall complication rate for gluteal augmentation with fat transplantation is unacceptably high. The current controversy among experts regarding safety is whether fat should be placed within the gluteus muscle or limited to only the subcutaneous space. The purpose of the present study was to test the hypothesis that under certain pressures, fat injected within the gluteal muscle can actually migrate out of the muscle and into a deeper plane containing critical neurovascular structures, by means of the process of deep intramuscular migration. METHODS: A total of eight human cadaver dissections were performed. Four hemibuttocks were selected for intramuscular fat injection. The patterns of subfascial fat migration were evaluated in three of these hemibuttocks by direct visual inspection and in one hemibuttock by endoscopic evaluation. Four other hemibuttocks were selected for subcutaneous or suprafascial fat injection. RESULTS: Proxy fat was found to migrate through the muscle and into the deep submuscular space with each intramuscular…

BACKGROUND: The effectiveness of gender-confirming surgery is best evaluated on the basis of patient-reported outcomes. This is the first explorative study using the BODY-Q chest module, administered in trans men before and after mastectomy. METHODS: Between October of 2016 and May of 2017, trans men were recruited to participate in a cross-sectional study. Data collection included standardized anamnesis and examination, screening questions on depression/anxiety, and seven BODY-Q scales, including new scales measuring satisfaction of the chest and nipples. Mean scores for preoperative and postoperative participants were compared, and regression analyses were conducted to identify factors associated with BODY-Q scores. RESULTS: In total, 101 persons participated (89 percent; 50 preoperatively and 51 postoperatively). Postoperative participants reported significantly higher (better) scores on the chest (67), nipple (58), body (58) (t tests, all p < 0.001), and psychological (60) (t test, p = 0.05) scales compared with preoperative patients. Postoperative chest and nipple mean scores…

BACKGROUND: Aloe vera has been used to treat wounds since ancient times. However, data regarding the efficacy of aloe vera for burns and split-thickness skin graft donor sites are inconclusive. METHODS: A double-blind, randomized, controlled trial was conducted. Patients who underwent split-thickness skin graft harvesting from the thigh were included. Split-thickness skin graft donor sites were divided into two groups: the aloe vera group and the placebo group. The visual analogue scale score was used to evaluate pain, and complete epithelialization was assessed. The authors searched electronic databases and included only international clinical trials published in the English language. RESULTS: Twelve patients with 24 donor sites participated. Times to complete epithelization for the aloe vera and placebo groups were 11.5 ± 1.45 and 13.67 ± 1.61 days, respectively (p < 0.05). Visual analogue scale scores after wound dressing for the aloe vera and placebo groups were 17.18 ± 13.17 and 18.63 ± 11.20, respectively. No statistical significance was found between groups. Five articles met…

BACKGROUND: The apoptosis of mature adipocytes after fat grafting can result in chronic inflammation, absorption, and fibrosis, leading to unpredictable outcomes. Selective elimination of mature adipocytes may result in better outcomes and a different underlying retention mode. The authors previously developed a mature adipocyte-free product, stromal vascular fraction gel, derived from lipoaspirate, which eliminates adipocytes and preserves the stromal vascular fraction. This study investigated the retention and regeneration mode of stromal vascular fraction gel grafting. METHODS: Nude mice were grafted with human-derived stromal vascular fraction gel or Coleman fat. Detailed cellular events over 3 months were investigated histologically and immunohistochemically. RESULTS: The retention rate 90 days after grafting was significantly higher for stromal vascular fraction gel grafts than for standard Coleman fat (82 ± 15 percent versus 42 ± 9 percent; p < 0.05). Histologic analysis suggested that, unlike Coleman fat grafts, stromal vascular fraction gel grafts did not include…

Prepectoral prosthetic breast reconstruction has become an acceptable option for women following mastectomy. Benefits include no animation deformity, absence of pectoralis major muscle spasm, and less pain and discomfort. Important aspects of prepectoral reconstruction include working with breast surgeons that are adept at performing an optimal mastectomy. Tissue perfusion and reasonable thickness of the mastectomy are critical components of success. Tissue necrosis, infection, and delayed healing can lead to reconstructive failure. Given the risks and benefits of this procedure, questions regarding indications, patient selection, and specific details related to technique remain because there is no consensus. Whether it is safe to perform prepectoral reconstruction in obese or previously irradiated patients is controversial. The use of acellular dermal matrix is common but not universal. The amount of acellular dermal matrix used is variable, with success being demonstrated with the partial and total wrap techniques. Device selection can vary but is critical in the prepectoral…

BACKGROUND: Hand surgery under local anesthesia only has been used more frequently in recent years. The purpose of this study was to compare perioperative time and cost for carpal tunnel release performed under local anesthesia ("wide-awake local anesthesia no tourniquet," or WALANT) only to carpal tunnel release performed under intravenous sedation. METHODS: A retrospective comparison of intraoperative (operating room) surgical time and postoperative (postanesthesia care unit) time for consecutive carpal tunnel release procedures performed under both intravenous sedation and wide-awake local anesthesia was undertaken. All operations were performed by the same surgeon using the same mini-open surgical technique. A cost analysis was performed by means of standardized anesthesia billing based on base units, time, and conversion rates. RESULTS: There were no significant differences between the two groups in terms of total operative time, 28 minutes in the intravenous sedation group versus 26 minutes in the wide-awake local anesthesia group. Postanesthesia care unit times were…

Occurring once in every 2000 live births, craniosynostosis is one of the most frequent congenital anomalies encountered by the craniofacial surgeon. Syndromic craniosynostoses account for approximately 15 percent of cases and demonstrate Mendelian patterns of inheritance with well-established genetic causes; however, nonsyndromic craniosynostoses, which account for approximately 85 percent of cases, are genetically heterogeneous and largely unexplored. Nonsyndromic craniosynostosis is sporadic in more than 95 percent of affected families; thus, surgeons have suggested for decades that nonsyndromic craniosynostosis is likely a fluke occurrence. Contrary to this, recent studies have established that genetics underlie a substantial fraction of nonsyndromic craniosynostosis risk. Given the predominantly sporadic occurrence of disease, parents are often bewildered by the primary occurrence of nonsyndromic craniosynostosis or even recurrence in their own families and request genetic testing. Existing genetic testing panels are useful when the phenotype strongly resembles a known syndrome,…

BACKGROUND: Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program. METHODS: The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed. RESULTS: Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had…

BACKGROUND: Robotic assistance in microsurgery could enhance human precision and dexterity to improve clinical outcomes. Because no robotic device has been designed primarily for microsurgery, the authors developed a dedicated microsurgical robotic system. This preclinical study investigates whether microsurgical anastomosis can be successfully completed on silicone vessels using a prototype of this new robotic system, and compares outcomes of robot-assisted versus conventional microsurgery. METHODS: Three participants at different levels of microsurgical training completed 10 anastomoses by hand and 10 anastomoses with robotic assistance. Four blinded, experienced microsurgeons evaluated the quality of the microsurgical skills using a modified version of the Structured Assessment of Microsurgical Skills. Time to perform the anastomosis and adverse events were recorded. RESULTS: The total time to perform the anastomoses with and without robotic assistance decreased to 35.1 minutes and 12.5 minutes, respectively, during the study. The overall performance and indicative skill of the…

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two…

BACKGROUND: The use of tranexamic acid for blood loss prevention has gained popularity in many specialties, including plastic surgery. However, its use in liposuction has not been studied. The authors present a prospective, double-blind, nonrandomized study evaluating the efficacy of tranexamic acid in reducing perioperative blood loss during liposuction. METHODS: Twenty women undergoing liposuction were divided into two cohorts. Group 1 (n = 10) received a standard dose of 10 mg/kg of tranexamic acid intravenously in the preoperative and postoperative periods, whereas group 2 (n = 10) received a placebo. Patient hematocrit levels were evaluated preoperatively and postoperatively. Blood volume in the infranatant of the lipoaspirate was also measured; t tests were used for statistical analysis. RESULTS: Age, body mass index, and volume of lipoaspirate were comparable between the two cohorts. The volume of blood loss for every liter of lipoaspirate was 56.2 percent less in the tranexamic group compared with the control group (p < 0.001). Hematocrit levels at day 7 postoperatively were…

The landscape of gender dysphoria has changed dramatically in recent years secondary to increased societal acceptance, legislative changes, and medical providers' increased awareness of the associated psychosocial burden associated with the diagnosis. National and global advocacy efforts, in conjunction with expanded third-party insurance coverage, have resulted in new health care opportunities for patients suffering from gender dysphoria. Delivering quality, streamlined health care to these patients requires a complex multidisciplinary approach, involving multiple medical and mental health disciplines, including plastic surgeons. To accommodate the expanding demand for gender-affirmation surgery, academic medical centers specializing in these procedures are gradually emerging. Advancing surgical techniques in the setting of rising patient demand encourage plastic surgeons to increasingly provide high-quality health care to this diverse patient population in an effort to optimize psychosocial functioning and minimize the burden of gender dysphoria. Although the current literature is…