The 50 most-cited articles in Plastic & Reconstructive Surgery, 2019

BACKGROUND: With breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) now accepted as a unique (iatrogenic) subtype of ALCL directly associated with textured breast implants, we are now at a point where a sound epidemiologic profile and risk estimate are required. The aim of this article is to provide a comprehensive and up-to-date global review of the available epidemiologic data and literature relating to the incidence, risk, and prevalence of BIA-ALCL. METHODS: All current literature relating to the epidemiology of BIA-ALCL was reviewed. Barriers relating to sound epidemiologic study were identified, and trends relating to geographical distribution, prevalence of breast implants, and implant characteristics were analyzed. RESULTS: Significant barriers exist to the accurate estimate of both the number of women with implants (denominator) and the number of cases of BIA-ALCL (numerator), including poor registries, underreporting, lack of awareness, cosmetic tourism, and fear of litigation. The incidence and risk of BIA-ALCL have increased dramatically from initial…

Lymphedema affects up to 250 million people worldwide. The understanding of the pathophysiology of the condition, however, is incomplete and a cure remains elusive. A growing body of evidence supports the effectiveness of modern surgical techniques in ameliorating the long-term disability and functional impairment inflicted by lymphedema on the lives of those affected. These procedures can be broadly categorized as physiologic, including lymphovenous bypass and using a vascularized lymph node transplant; or de bulking, by suction-assisted lipectomy or direct excisional procedures. The lymphovenous bypass procedure involves identification of obstructed lymphatic vessels and targeted bypass of these into neighboring venules. The vascularized lymph node transplant procedure involves microvascular anastomosis of functional lymph nodes into an extremity, either to an anatomical (orthotopic) or nonanatomical (heterotopic) location, to restore physiologic lymphatic function. In patients undergoing postmastectomy breast reconstruction, this may be performed by transferring a deep inferior…

The link between breast implants and systemic disease has been reported since the 1960s. Although many studies have looked at either supporting or refuting its existence, the issue still persists and has now been labeled "breast implant illness." The rise of patient advocacy and communication through social media has led to an increasing number of presentations to plastic surgeons. This article summarizes the history of breast implants and systemic disease, critically analyzes the literature (and any associated deficiencies), and suggests a way forward through systematic scientific study.

BACKGROUND: Injectable hyaluronic acid fillers are routinely used for correction of soft-tissue volume loss and facial rejuvenation. Product differentiation has primarily been based on the rheologic parameter known as elastic modulus (G'), although other physicochemical properties are being explored to characterize potential product performance. As clinical data regarding product performance are lacking, the practical experience of injectors provides a valuable bridge in the knowledge gap between product rheologic data and product use. METHODS: Rheologic and physicochemical measurements (swelling factor and cohesion) were collected for 18 products. To observe the impact of G' and hyaluronic acid concentration on swelling factor and cohesion, proportional relationships were evaluated. Contributing authors were queried regarding their G'-based selection of products when considering skin quality, degree of correction, injection depth, and anatomical location. RESULTS: Relationships were observable between G' and swelling factor and G' and cohesion only when limited to products…

BACKGROUND: The reconstruction module of the BREAST-Q patient-reported outcome measure is frequently used by investigators and in clinical practice. A minimal important difference establishes the smallest change in outcome measure score that patients perceive to be important. To enhance interpretability of the BREAST-Q reconstruction module, the authors determined minimal important difference estimates using distribution-based methods. METHODS: An analysis of prospectively collected data from 3052 Mastectomy Reconstruction Outcomes Consortium patients was performed. The authors used distribution-based methods to investigate the minimal important difference for the entire patient sample and three clinically relevant groups. The authors used both 0.2 SD units (effect size) and the standardized response mean value of 0.2 as distribution-based criteria. Clinical experience was used to guide and assess appropriateness of results. RESULTS: A total of 3052 patients had BREAST-Q data available for analysis. The average age and body mass index were 49.5 and 26.8, respectively. The minimal…

BACKGROUND: Postamputation pain affects a large number of individuals living with major limb loss. Regenerative peripheral nerve interfaces are constructs composed of a transected peripheral nerve implanted into an autologous free muscle graft. The authors have previously shown that regenerative peripheral nerve interfaces can be used to treat symptomatic end neuromas that develop after major limb amputation. In this study, they investigated the potential of prophylactic interfaces to prevent the formation of symptomatic neuromas and mitigate phantom limb pain. METHODS: Patients who underwent limb amputation with and without prophylactic regenerative peripheral nerve interface implantation were identified. A retrospective review was performed to ascertain patient demographics, level of amputation, and postoperative complications. Documentation of symptomatic neuromas and phantom limb pain was noted. RESULTS: Postoperative outcomes were evaluated in a total of 90 patients. Forty-five patients underwent interface implantation at the time of primary amputation, and 45 control patients…

BACKGROUND: The epidemiology and implant-specific risk for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL) has been previously reported for Australia and New Zealand. The authors now present updated data and risk assessment since their last report. METHODS: New cases in Australia and New Zealand were identified and analyzed. Updated sales data from three leading breast implant manufacturers (i.e., Mentor, Allergan, and Silimed) were secured to estimate implant-specific risk. RESULTS: A total of 26 new cases of BIA-ALCL were diagnosed between January of 2017 and April of 2018, increasing the total number of confirmed cases in Australia and New Zealand to 81. This represents a 47 percent increase in the number of reported cases over this period. The mean age and time to development remain unchanged. The implant-specific risk has increased for Silimed polyurethane (23.4 times higher) compared with Biocell, which has remained relatively static (16.5 times higher) compared with Siltex implants. CONCLUSIONS: The number of confirmed cases of BIA-ALCL in Australia and…

BACKGROUND: In January of 2011, the US Food and Drug Administration released a safety communication regarding the potential association between breast implants and anaplastic large cell lymphoma (ALCL). In August of 2012, the American Society of Plastic Surgeons, The Plastic Surgery Foundation, and the Food and Drug Administration signed a cooperative research and development agreement to develop a patient registry entitled the "Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology" (PROFILE). METHODS: The first report of the registry findings is presented here. RESULTS: From August of 2012 to March of 2018, a total of 186 distinct cases of breast implant-associated ALCL (BIA-ALCL) in the United States were reported to PROFILE. At the time of this present analysis, complete detailed case report forms have been received for 89 (48%) cases. Median time from implantation of any device to BIA-ALCL diagnosis was 11.0 years (range = 2-44 years; n = 89). At the time of presentation, 96% of cases had local symptoms and 9% had…

Management of flexor tendon injuries of the hand remains a major clinical problem. Even with intricate repair, adhesion formation remains a common complication. Significant progress has been made to better understand the mechanisms of healing and adhesion formation. However, there has been slow progress in the clinical prevention and reversal of flexor tendon adhesions. The goal of this article is to discuss recent literature relating to tendon development, tendon healing, and adhesion formation to identify areas in need of further research. Additional research is needed to understand and compare the molecular, cellular, and genetic mechanisms involved in flexor tendon morphogenesis, postoperative healing, and mechanical loading. Such knowledge is critical to determine how to improve repair outcomes and identify new therapeutic strategies to promote tissue regeneration and prevent adhesion formation.

BACKGROUND: Prior studies have shown a lack of diversity among plastic surgery trainees. The authors evaluate trends in minority representation among applicants to plastic surgery and the correlation with practicing residents, compared to other specialties. METHODS: The Association of American Medical Colleges Electronic Residency Application Service provided applicant data for integrated, independent plastic surgery, and other select specialties from 2010 to 2016. Journal of the American Medical Association Graduate Medical Education annual reports and Association of American Medical Colleges graduate student questionnaires provided resident and medical student data. Binomial distribution analysis was used to assess differences in Black, Hispanic, and female proportions of applicants and residents. Best-fit trend lines were compared among groups and specialties. RESULTS: Women have seen an increase in integrated and independent resident representation (+2.23 percent and +0.7 percent per year, respectively) over the past 7 years, despite a relative decrease in applicants. The…

BACKGROUND: The purpose of this article is to provide a comprehensive review based on images and discussion of the current understanding of the arterial supply of the face to facilitate safe minimally invasive antiaging procedures. METHODS: Contrast-enhanced computed tomographic scans of 40 fresh frozen heads from 17 male and 23 female Caucasian body donors with a mean age of 76.9 ± 13.1 years and a mean body mass index of 23.6 ± 5.3 kg/m(2) were retrospectively analyzed and compared to cadaveric dissections performed in more than 400 fresh cephalic specimens. RESULTS: This review presents the current understanding of the facial arteries based on existing literature, direct observation from cadaveric dissection, and the dissection experience of the two authors of the study. It reveals the constant three-dimensional locations of the facial and angular arteries: mandible, modiolus, and medial canthus as compared to their unpredictable course in other facial regions. In addition, the anatomy of the ophthalmic and central retinal arteries is discussed in the context of current treatment…

BACKGROUND: The objective of this narrative review of local anesthetic systemic toxicity is to provide an update on its prevention, diagnosis, and management. METHODS: The authors used a MEDLINE search of human studies, animal studies, and case reports and summarize findings following the American Society of Regional Anesthesia and Pain Medicine practice advisories on local anesthetic systemic toxicity. RESULTS: Between March of 2014 and November of 2016, there were 47 cases of systemic toxicity described. Twenty-two patients (47 percent) were treated with intravenous lipid emulsion and two patients (4.3 percent) died. Seizures were the most common presentation. The spectrum of presenting neurologic and cardiovascular symptoms and signs are broad and can be obscured by perioperative processes. Local anesthetic type, dosage, and volume; site of injection; and patient comorbidities influence the rate of absorption from the site of injection and biodegradation of local anesthetics. Consider discussing appropriate dosages as a component of the surgical "time-out." A large-volume depot…

BACKGROUND: To address functional and smile dysfunction associated with post-facial paralysis synkinesis, the senior author (B.A.) has offered "modified selective neurectomy" of the lower division of the facial nerve as a long-term solution. This article examines technical considerations and outcomes of this procedure. METHODS: A retrospective review was conducted of patients who underwent modified selective neurectomy of buccal and cervical branches of the facial nerve performed by a single surgeon over a 4½-year period. House-Brackmann facial grading scores, electronic clinician-graded facial function scale, and onabotulinumtoxinA (botulinum toxin type A) dosages were examined before and after the procedure. RESULTS: Sixty-three patients underwent modified selective neurectomy between June 20, 2013, and August 12, 2017. There were no serious complications. The revision rate was 17 percent. Temporary oral incompetence was reported in seven patients (11 percent) postoperatively. A statistically significant improvement was achieved in electronic clinician-graded facial function scale…

BACKGROUND: Computer-assisted mandibular reconstruction facilitates preoperative surgery simulation and transfers the virtual plan to a real operation. This systematic review and meta-analysis aimed to compare the accuracy, efficiency, postoperative complications, and economic viability between computer-assisted mandibular reconstruction and conventional freehand mandibular reconstruction. METHODS: The PubMed, Embase, Cochrane Library, and Google Scholar databases were searched up to November of 2018. The accuracy, efficiency, postoperative complications, and economic viability of computer-assisted mandibular reconstruction compared to conventional freehand mandibular reconstruction were systematically reviewed. Continuous and dichotomous data were pooled in mean difference (or standardized mean difference if necessary) and odds ratio, subsequently, with 95 percent confidence interval. RESULTS: A total of 12 studies were included in the systematic review, and data extracted from 11 of them were combined in meta-analysis. The accuracy of computer-assisted mandibular reconstruction…

BACKGROUND: Marko Godina, in his landmark paper in 1986, established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries. The aim of this study was to determine how timing influences outcomes in lower extremity traumatic free flap reconstruction based on Godina's original findings. METHODS: A retrospective review identified 358 soft-tissue free flaps from 1979 to 2016 for below knee trauma performed within 1 year of injury. Patients were stratified based on timing of coverage: 3 days or less (early), 4 to 90 days (delayed), and more than 90 days (late). The delayed group was further divided into two groups: 4 to 9 days and 10 to 90 days. Flap outcomes were examined based on timing of reconstruction. RESULTS: Flaps performed within 3 days after injury compared with between 4 to 90 days had decreased risk of major complications (OR, 0.40, p = 0.04). A receiver operating curve demonstrated day 10 to be the optimal day for predicting flap success. Flaps performed less than or equal to 3 days versus 4 to 9 days had no differences in any flap…

BACKGROUND: The incidence of nipple-sparing mastectomy is rising, but no single incision type has been proven to be superior. This study systematically evaluated the rate and efficacy of various nipple-sparing mastectomy incision locations, focusing on nipple-areola complex necrosis and reconstructive method. METHODS: A systematic literature review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines identifying studies on nipple-sparing mastectomy where incision type was described. Pooled descriptive statistics meta-analysis of overall (nipple-areola complex) necrosis rate and nipple-areola complex necrosis by incision type was performed. RESULTS: Fifty-one studies (9975 nipple-sparing mastectomies) were included. Thirty-two incision variations were identified and categorized into one of six groups: inframammary fold, radial, periareolar, mastopexy/prior scar/reduction, endoscopic, and other. The most common incision types were inframammary fold [3634 nipple-sparing mastectomies (37.8 percent)] and radial [3575 nipple-sparing…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection. SUMMARY: Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field…

BACKGROUND: Adipose tissue reaches cellular stasis after puberty, leaving adipocytes unable to significantly expand or renew under normal physiologic conditions. This is problematic in progressive lipodystrophies, in instances of scarring, and in soft-tissue damage resulting from lumpectomy and traumatic deformities, because adipose tissue will not self-renew once damaged. This yields significant clinical necessity for an off-the-shelf de novo soft-tissue replacement mechanism. METHODS: A process comprising separate steps of removing lipid and cellular materials from adipose tissue has been developed, creating an ambient temperature-stable allograft adipose matrix. Growth factors and matrix proteins relevant to angiogenesis and adipogenesis were identified by enzyme-linked immunosorbent assay and immunohistochemistry, and subcutaneous soft-tissue integration of the allograft adipose matrix was investigated in vivo in both the athymic mouse and the dorsum of the human wrist. RESULTS: Allograft adipose matrix maintained structural components and endogenous growth factors. In vitro,…

BACKGROUND: The management of deep partial-thickness and full-thickness skin defects remains a significant challenge. Particularly with massive defects, the current standard treatment, split-thickness skin grafting, is fraught with donor-site limitations and unsatisfactory long-term outcomes. A novel, autologous, bioengineered skin substitute was developed to address this problem. METHODS: To determine whether this skin substitute could safely provide permanent defect coverage, a phase I clinical trial was performed at the University Children's Hospital Zurich. Ten pediatric patients with acute or elective deep partial- or full-thickness skin defects were included. Skin grafts of 49 cm were bioengineered using autologous keratinocytes and fibroblasts isolated from a patient's small skin biopsy specimen (4 cm), incorporated in a collagen hydrogel. RESULTS: Graft take, epithelialization, infection, adverse events, skin quality, and histology were analyzed. Median graft take at 21 days postoperatively was 78 percent (range, 0 to 100 percent). Healed skin substitutes were stable and…

The purpose of this Special Topic article is to present the current state of scientific evidence related to the safety of silicone breast implants. There is presently overwhelming evidence to support the safety of silicone breast implants. Ultimately, the decision to obtain, keep, or remove breast implants is the choice of the patient. If a patient chooses to have her breast implants removed, it is important to find a board-certified plastic surgeon with expertise in breast surgery. Ongoing studies are strongly encouraged in all areas, from cancer detection to autoimmune disease, as we strive for improved patient safety, patient awareness, and patient education. To the best of our body of scientific knowledge to date, there have not been any concrete or evidence-based studies or peer-reviewed data concerning the formation of a new syndrome: "silicone implant illness." Silicone breast implants are used in nearly 300,000 breast augmentation and 100,000 breast reconstruction operations annually in the United States. Silicone gel-filled implants were first approved by the U.S. Food and…

BACKGROUND: The purpose of this systematic review was to comprehensively summarize barriers of access to breast reconstruction and evaluate access using the Penchansky and Thomas conceptual framework based on the six dimensions of access to care. METHODS: The authors performed a systematic review that focused on (1) breast reconstruction, (2) barriers, and (3) breast cancer. Eight databases (i.e., EMBASE, MEDLINE, PsycINFO, CINHAL, ePub MEDLINE, ProQuest, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials) were searched. English peer-reviewed articles published between 1996 and 2016 were included. RESULTS: The authors' search retrieved 4282 unique articles. Two independent reviewers screened texts, selecting 99 articles for inclusion. All studies were observational and qualitative in nature. The availability of breast reconstruction was highest in teaching hospitals, private hospitals, and national cancer institutions. Accessibility affected access, with lower likelihood of breast reconstruction in rural geographic locations. Affordability…

BACKGROUND: Acellular nerve allografts are a viable treatment modality for bridging nerve gaps. Several small studies have demonstrated results equal to those of autologous grafts; however, there is information lacking with regard to outcomes for wider indications. The authors evaluated the outcomes of patients treated with a nerve allograft in a variety of clinical situations. METHODS: A retrospective chart analysis was completed between April of 2009 and October of 2017. Inclusion criteria were age 18 years or older at the time of surgery and treatment with a nerve allograft. Patients were excluded if they had not been followed up for a minimum of 6 months. The modified Medical Research Council Classification was used to monitor motor and sensory changes in the postoperative period. RESULTS: Two hundred seven nerve allografts were used in 156 patients; of these, 129 patients with 171 nerve allografts fulfilled the inclusion criteria. Seventy-seven percent of patients achieved a sensory outcome score of S3 or above and 36 percent achieved a motor score of M3 or above. All patients…

BACKGROUND: Nasal hump relapse and its probable reasons or mechanisms have been less discussed after dorsal preservation rhinoplasty. In this article, the authors would like to share their experiences and offer solutions regarding this subject. METHODS: Five hundred twenty patients who underwent primary rhinoplasty between the years 2016 and 2018 were included in the study. The push-down method was used for noses with a hump less than 4 mm and the let-down procedure was performed for others. Hump height was measured from profile photographs. The cases were evaluated in terms of nasal dorsal problems and their probable mechanisms. RESULTS: Five hundred twenty patients, 448 with a straight nose and 72 with a deviated nose, were enrolled in this study. Mean follow-up was 13 months (range, 9 to 16 months). Visible dorsal hump recurrence was observed in 63 patients, and they appeared at 1 to 4 months postoperatively. Forty-one of these had a dorsal hump more than 4 mm preoperatively. Hump recurrence was not more than 2 mm in 34 patients, and they did not wish to have any revision…

BACKGROUND: Microsurgical lower extremity reconstruction remains a challenge. The use of perforator flaps in lower extremity reconstruction is expanding. The authors present an algorithm to guide in the selection of the ideal free perforator flap that can be tailored to each lower extremity defect. METHODS: The authors conducted a retrospective review of lower extremity reconstruction using free perforator flaps over a 7-year period. Demographics, comorbidities, defect characteristics, operative details, complications, and secondary procedures were documented. Pairwise comparisons of flap types were performed to differentiate flaps on the basis of flap size, thickness, and pedicle length. RESULTS: A total of 563 free perforator flaps were performed. The most common causes were trauma (36.5 percent) and diabetes (24.4 percent). Nine flaps were used, with the most common being superficial circumflex iliac perforator (51.2 percent) and anterolateral thigh (33.2 percent). Size differed significantly between flap types (p < 0.05), with the exception of thoracodorsal artery perforator…

BACKGROUND: Social media discussions are alive among plastic surgeons. This article represents a primer on beginning to understand how the public would seek out plastic surgeons and how demographics shape their preferences. METHODS: An anonymous 31-question survey was crowdsourced by means of MTurk. RESULTS: There were a total of 527 respondents. Of these respondents, 33 percent follow plastic surgeons on social media, with those aged younger than 35 years 3.9 times more likely to do so. Google was the first place people would look for a plastic surgeon (46 percent). When asked what was the most influential of all online methods for selecting a surgeon, practice website ranked first (25 percent), but social media platforms ranked higher as a whole (35 percent). Those considering surgical or noninvasive procedures are thee times more likely to select social media platforms as the most influential online method in selecting a surgeon and five times more likely to follow a plastic surgeon on social media. The majority would prefer not seeing the surgeon's private life displayed on…

BACKGROUND: The year 2017 marked the first year women comprised a majority of U.S. medical school matriculants. While more women are pursuing surgical training, within plastic surgery, there is a steady attrition of women advancing in leadership roles. The authors report the current status of women in academic plastic surgery, from trainees to chairwomen and national leadership positions. METHODS: The Electronic Residency Applications Service, San Francisco Match, National Resident Matching Program, Association of American Medical Colleges, American Council of Academic Plastic Surgeons, Plastic Surgery Education Network, and professional websites for journals and national societies were accessed for demographic information from 2007 to 2017. RESULTS: The number of female integrated pathway applicants remained stable (30 percent), with an increased proportion of female residents from 30 percent to 40 percent. There was an increase in female faculty members from 14.6 percent to 22.0 percent, an increase of less than 1 percent per year. Twelve percent of program directors and 8.7…

BACKGROUND: Although a large number of adult women worldwide are affected by lipedema, the physiologic conditions triggering onset and progression of this chronic disease remain enigmatic. In the present study, a descriptive epidemiologic situation of postoperative lipedema patients is presented. METHODS: The authors developed an online survey questionnaire for lipedema patients in Germany. The survey was conducted on 209 female patients who had been diagnosed with lipedema and had undergone tumescent liposuction. RESULTS: Most of the participants (average age, 38.5 years) had noticed a first manifestation of the disease at the age of 16. It took a mean of 15 years to accomplish diagnosis. Liposuction led to a significant reduction of pain, swelling, tenderness, and easy bruising as confirmed by the majority of patients. Hypothyroidism [n = 75 (35.9 percent) and depression [n = 48 (23.0 percent)] occurred at a frequency far beyond the average prevalence in the German population. The prevalence of diabetes type 1 [n = 3 (1.4 percent)], and diabetes type 2 [n = 2 (1 percent)] was…

BACKGROUND: The efficacy of autologous fat transplantation is reduced by fat absorption and fibrosis that are closely related to unsatisfactory vascularization. Extracellular vesicles are key components of the cell secretome, which can mirror the functional and molecular characteristics of their parental cells. Growing evidence has revealed that adipose-derived mesenchymal stem cells have the ability to enhance vascularization, which is partly ascribed to extracellular vesicles. The authors evaluated whether adipose-derived mesenchymal stem cell-derived extracellular vesicles improved vascularization of fat grafts and increased their retention rate. METHODS: To test the angiogenesis ability of adipose-derived mesenchymal stem cell-derived extracellular vesicles, they were isolated from the supernatant of cultured human adipose-derived mesenchymal stem cells and incubated with human umbilical vein endothelial cells in vitro. Then, the vesicles were co-transplanted with fat into nude mice subcutaneously. Three months after transplantation, the retention rate and inflammatory reaction…

BACKGROUND: With an increase in recent years in the number of people receiving cosmetic facial injection treatments of hyaluronic acid, the incidence of hyaluronic acid embolism has also increased commensurately. Hyaluronic acid embolism leads to serious complications, including blindness, eye and eyelid movement disorders, skin necrosis, and cerebral embolism. However, there is a lack of robust clinical evidence regarding the benefits of treatment for hyaluronic acid embolism by intraarterial thrombolysis therapy. METHODS: This study included 24 patients with a decrease in visual acuity and other complications induced by facial hyaluronic acid injection. Patients underwent emergency intraarterial thrombolysis therapy by injection of hyaluronidase (500 to 1500 units) alone or hyaluronidase (750 to 1500 units) combined with urokinase (100,000 to 250,000 units), followed in both cases by a general symptomatic treatment and nutritional therapy. RESULTS: Ten (42 percent) of 24 patients ultimately had improvements to visual acuity, even when the clinical application of the thrombolytic…

BACKGROUND: Various factors can influence outcomes in cleft palate care. This study sought to determine the impact of race on admissions, hospital costs, and short-term complications in cleft palate repair. METHODS: Cleft palate operations were identified in the Kids' Inpatient Database data, from 2000 to 2009. Data were combed for demographics, perioperatives, complications, and hospital characteristics. Bivariate and multivariate analyses were performed between races in total, primary, and revision cohorts. RESULTS: There were 3464 white, 1428 Hispanic, 413 black, 398 Asian/Pacific-Islander, and 470 patients of other races captured. Black patients experienced more emergent admissions (p = 0.005) and increased length of stay (p = 0.029). Hospital charges were highest for black and Hispanic patients and lowest for white patients (p = 0.019). Black patients had more total complications than non-black patients (p = 0.039), including higher rates of postoperative fistula (p = 0.020) and nonspecific complications among revision repairs (p = 0.003). Asian/Pacific Islander in the primary…

BACKGROUND: Control and maintenance of nasal tip position are critical in rhinoplasty. Two frequent methods of exerting tip control are columellar strut and caudal septal extension graft. However, no quantitative data exist comparing the two methods over time. The purpose of this study was to analyze maintenance of tip projection and rotation following either columellar strut or septal extension graft. METHODS: A retrospective cohort study of patients undergoing rhinoplasty was reviewed. Three-dimensional photogrammetric evaluation of patients with either columellar strut or septal extension graft to increase tip projection was performed. Anthropometric points were analyzed in a blinded fashion. Outcome variables were tip projection, nasal length, the Goode ratio, and tip rotation. Results were stratified based on technique and compared statistically. RESULTS: One hundred six patients were included. Overall, 66 percent were female, with an average age of 34.5 years. A columellar strut was used in 42 percent of cases (n = 45), and a septal extension graft was used in 57 percent (n =…

BACKGROUND: Exosomes derived from mesenchymal stem cells possess functional properties similar to those of their parent cells, suggesting that they could play a pivotal role in tissue repair and regeneration. METHODS: Using lipotransfer as a surrogate, exosomes were isolated from mouse adipose-derived stem cell-conditioned medium and characterized. Minced fat tissue mixed with exosomes, source cells (cell-assisted lipotransfer), or saline was implanted subcutaneously in the lower back of C57/BL mice bilaterally (n = 16 each). Transferred fat tissues were harvested and analyzed at 3 and 10 weeks. RESULTS: At 3 and 10 weeks after the transfer, fat grafts in groups of exosomes and cell-assisted lipotransfer showed better fat integrity, fewer oil cysts, and reduced fibrosis. At week 10, graft retention rates in cell-assisted lipotransfer (50.9 ± 2.4 percent; p = 0.03) and exosome groups (56.4 ± 1.6 percent; p < 0.001) were significantly higher than in the saline group (40.7 ± 4.7 percent). Further investigations of macrophage infiltration, inflammatory factors, angiogenic factors,…

BACKGROUND: Opioid overprescribing is a nationwide problem contributing to the current epidemic. This study evaluated opioid consumption, physician prescribing, and patient satisfaction with pain control following outpatient plastic surgery procedures. METHODS: Patients completed a questionnaire during their first postoperative visit. The authors queried about procedure type, quantity of opioids prescribed and consumed, days to opioid cessation, prescription refills, pain scores, use of nonopioid analgesics, and satisfaction with pain control. RESULTS: One hundred seventy patients were included. On average, 26 tablets were prescribed and 13 were consumed. Eighty percent of patients stopped opioids by postoperative day 5. Patients rated their worst pain at 6.1 and follow-up pain at 1.9. Approximately 50 percent of patients consumed nonopioid analgesics. Ninety-six percent of patients were satisfied with their pain control. Similar findings were observed across procedure subcategories. The number of pills prescribed was not correlated with satisfaction but was predictive of worst pain…

BACKGROUND: Intramedullary fixation of a comminuted subcapital metacarpal fracture using a headless compression screw was first described in 2010. The purpose of this study was to identify and evaluate all studies reporting clinical outcomes of intramedullary screw fixation of metacarpal fractures. METHODS: A comprehensive search of the literature was performed under Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify all relevant studies. Outcome measures included mean follow-up, evidence of radiographic union, functional outcomes, and quality-of-life measures. RESULTS: Nine articles for a total of 169 metacarpal fractures were identified. Average patient age was 32 years; 86.5 percent of the patients were men; and the majority of fractures occurred in the small finger (74 percent). Most fractures occurred in the neck (n = 66), followed by shaft (n = 31) and head (n = 10). The average follow-up was 11 months, with an average metacarpophalangeal joint flexion of 86 degrees (n = 83) and digit total active motion of 251 degrees (n = 72).…

Wide-awake local anesthesia no tourniquet surgery has been shown to decrease cost and hospital length of stay. The authors studied the use of virtual reality during wide-awake local anesthesia no tourniquet outpatient upper extremity surgery to assess its effect on patient pain, anxiety and fun. Patients undergoing wide-awake local anesthesia no tourniquet surgery were randomized to use (virtual reality) or not use (non-virtual reality) virtual reality during their procedures. Pain, fun, and anxiety were measured with a Likert scale at several time points, as were blood pressure and heart rate. A postoperative questionnaire was used to assess overall satisfaction. Virtual reality patients exhibited lower anxiety scores during injection, during the procedure, and at the end of the procedure. There were no differences in blood pressure, heart rate, or pain scores. Compared with non-virtual reality patients, virtual reality patients' fun scores were higher. Virtual reality patients felt the experience helped them to relax, and they would recommend virtual reality-assisted wide-awake…

Sir: Physicians are seeing an increase in breast implant illness, a phrase describing ill-defined symptoms attributed to breast implants.1,2 Because of extensive media attention on breast implant-related issues, it is understandable why patients may confuse breast implant illness with other breast implant-related diagnoses, including breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a type of non-Hodgkin lymphoma.3,4 Given the increasing role of online media in disseminating medical information, understanding information regarding breast implant illness on such platforms and how it impacts patients’ understanding of breast implant illness may inform physicians how to more effectively communicate with their patients.3 In this study, we assessed Google Trends and Twitter content to identify catalysts to the increased incidence of breast implant illness. We queried Google Trends for relative search volumes of “breast implant illness” from February of 2018 to 2019. Results demonstrate an exponential increase in search popularity (Fig. 1). Searches peaked during the…

BACKGROUND: Cleft lip results in disruption of the nasal foundation and collapse of tip structures. Most approaches to primary rhinoplasty focus on correction of lower lateral cartilages; however, recurrent deformity is common, and secondary revision is frequently required. The authors describe an alternate approach that focuses on the foundation to "upright the nose," without any nasal tip dissection. This study assessed changes with surgery and with growth. Secondary goals were to compare methods of sidewall reconstruction and septoplasty and to identify predictors of relapse. METHODS: Consecutive patients undergoing repair (n = 102) were assessed. Images were captured preoperatively, postoperatively, and at 5 years of age (when available) using three-dimensional stereophotogrammetry. Standard anthropometric and contemporary shape-based analysis (volume ratio, dorsal deviation, and alar-cheek definition) was performed to assess longitudinal changes. Images of age-matched normal control subjects were used for comparison. RESULTS: Significant changes in anthropometric and…

BACKGROUND: DaxibotulinumtoxinA for Injection (DAXI) is a novel botulinum toxin type A formulation in clinical development. A phase 2 dose-ranging study identified an optimal dose and demonstrated efficacy with a median duration of 24 weeks. METHODS: In two phase 3, multicenter, randomized, double-blind, placebo-controlled studies (SAKURA 1 and SAKURA 2), subjects with moderate or severe glabellar lines at maximum frown were assigned randomly to receive placebo or 40 U of DAXI. Glabellar lines were evaluated at least every 4 weeks for at least 24 weeks until severity returned to baseline (≤36 weeks). RESULTS: Overall, 609 subjects were enrolled (DAXI, n = 405; placebo, n = 204). DAXI was significantly more effective than placebo in achieving the primary efficacy outcome (≥2-point improvement in glabellar line severity at maximum frown at week 4 according to both investigator and subject ratings): 73.6 percent versus 0.0 percent (SAKURA 1), and 74.0 percent versus 1.0 percent (SAKURA 2) (both p < 0.0001). Composite investigator and subject ratings of maximum frown after DAXI…

BACKGROUND: The sensory recovery of the breast remains an undervalued aspect of autologous breast reconstruction. The aim of this study was to evaluate the effect of nerve coaptation on the sensory recovery of the breast following DIEP flap breast reconstruction and to assess the associations of length of follow-up and timing of the reconstruction. METHODS: A prospective comparative study was conducted of all patients who underwent either innervated or noninnervated DIEP flap breast reconstruction and returned for follow-up between September of 2015 and July of 2017. Nerve coaptation was performed to the anterior cutaneous branch of the third intercostal nerve. Semmes-Weinstein monofilaments were used for sensory testing of the native skin and flap skin. RESULTS: A total of 48 innervated DIEP flaps in 36 patients and 61 noninnervated DIEP flaps in 45 patients were tested at different follow-up time points. Nerve coaptation was significantly associated with lower monofilament values in all areas of the reconstructed breast (adjusted difference, -1.2; p < 0.001), which indicated that…

BACKGROUND: Academic plastic surgery has a history of underrepresentation of ethnic and racial minority groups. Recent policy shifts by national medical groups and plastic surgery societies have focused on reversing these inequalities. This study seeks to measure ethnic and racial representation at academic and leadership positions following recent changes. METHODS: A cross-sectional study was conducted in June of 2018, measuring ethnic and racial diversity of U.S. academic plastic surgery faculty. Among faculty, career qualifications, years of experience, faculty positions, and leadership ethnicity were compared. RESULTS: A total of 930 academic plastic surgeons were included in the study. Classified collectively as nonwhite, this group graduated more recently than other academic plastic surgeons (2006 versus 2001; p < 0.0001) and had greater rates of clinical fellowship attainment (OR, 1.62; 95 percent CI, 1.16 to 2.26). Nonwhite individuals were less likely to be employed in the full professor position compared with their white colleagues (OR, 0.6; 95 percent CI, 0.42 to 0.88; p…

BACKGROUND: Scleroderma is a chronic connective tissue disease that results in fibrosis of the skin and internal organs. Although internal organ involvement corresponds with poor prognosis, systemic agents are effective at improving the effects of scleroderma on internal organs. In contrast, skin manifestations are universally present in all patients diagnosed with scleroderma, yet no systemic agents have been shown to be successful. Fat grafting has been shown to improve skin quality and improve contour irregularities and may be helpful in the treatment of patients with scleroderma. METHODS: The authors performed a thorough review of the pathophysiology of scleroderma and the current treatment options for scleroderma. The efficacy of fat grafting for the treatment of scleroderma and the mechanism by which fat grafting improves outcomes was also discussed. RESULTS: Scleroderma is characterized by chronic inflammation and vascular compromise that leads to fibrosis of the skin and internal organs. Fat grafting has recently been the focus of significant basic science research. It has…

BACKGROUND: Recent technology developed by Tulip Medical Products allows clinicians to mechanically disaggregate fat tissue into small fat particles known as nanofat. The present study aimed to evaluate the cell yield obtained from nanofat generation in comparison to traditional methods involving enzymatic dissociation (stromal vascular fraction). METHODS: Nanofat preparations were characterized by cell content and viability, based on DNA quantification and image cytometry, respectively. DNA analysis was also used to determine the cell content in unprocessed dry lipoaspirate and native adipose tissue (excised adipose tissue). To evaluate cell yield, the authors compared the number of cells recovered from 1 g of lipoaspirate between stromal vascular fraction and nanofat preparations, and subsequently determined the final cell inoculum obtained following their respective protocols. RESULTS: The data showed that nanofat samples presented a cell burden of 7.3 million cells/g, close to 80 percent of unprocessed dry lipoaspirate, and 70 percent of native excised adipose tissue. Moreover,…

BACKGROUND: Lymphovenous anastomosis is technically challenging and can be successfully performed with an advanced operating microscope, supermicrosurgical instruments, and indocyanine green lymphography. This study compared the outcomes between side-to-end and end-to-end lymphovenous anastomosis configurations for unilateral extremity lymphedema. METHODS: Between April of 2013 and June of 2017, lymphovenous anastomosis was indicated for 58 patients who preoperatively had patent lymphatic ducts by indocyanine green lymphography, including 20 patients with upper limb lymphedema and 38 patients with lower limb lymphedema. Either an end-to-end or a side-to-end lymphovenous anastomosis was used to anastomose the subdermal venule to the lymphatic duct. The circumferential difference and episodes of cellulitis were used as outcome measurements. RESULTS: Twenty-three patients underwent an end-to-end lymphovenous anastomosis and 35 patients underwent side-to-end lymphovenous anastomosis. All patients had an immediate patency evaluated by indocyanine green lymphography and patent blue…

The technology used to add information to a real visual field is defined as augmented reality technology. Augmented reality technology that can interactively manipulate displayed information is called mixed reality technology. HoloLens from Microsoft, which is a head-mounted mixed reality device released in 2016, can display a precise three-dimensional model stably on the real visual field as hologram. If it is possible to accurately superimpose the position/direction of the hologram in the surgical field, surgical navigation-like use can be expected. However, in HoloLens, there was no such function. The authors devised a method that can align the surgical field and holograms precisely within a short time using a simple manual operation. The mechanism is to match the three points on the hologram to the corresponding marking points of the body surface. By making it possible to arbitrarily select any of the three points as a pivot/axis of the rotational movement of the hologram, alignment by manual operation becomes very easy. The alignment between the surgical field and the hologram…

BACKGROUND: Topical administration of tranexamic acid to reduce bleeding is receiving increasing attention, as it is inexpensive, simple, and possibly beneficial in most surgery. Concerns regarding potential systemic adverse effects such as thromboembolic events and seizures may prevent general use of tranexamic acid. Although serum concentrations after topical application are assumed to be low, proper pharmacokinetic studies of tranexamic acid after topical application are lacking. METHODS: The authors have investigated systemic absorption of tranexamic acid after two means of topical administration in patients undergoing abdominoplasty after massive weight loss: a bolus of 200 ml of 5 mg/ml into the wound cavity versus moistening the wound surface with 20 ml of 25 mg/ml. Twelve patients were recruited in each group. Serum concentrations achieved were compared with those after administration of 1 g as an intravenous bolus to arthroplasty patients. Serial blood samples for tranexamic acid analysis were obtained for up to 24 hours. RESULTS: After intravenous administration, the peak…

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.

BACKGROUND: Rates of breast reconstruction following mastectomy continue to increase. The objective of this study was to determine the frequency of elective revision surgery and the number of procedures required to achieve a stable breast reconstruction 2 years after mastectomy. METHODS: Women undergoing first-time breast reconstruction after mastectomy were enrolled and followed for 2 years, with completion of reconstruction occurring in 1996. Patients were classified based on the absence or presence of complications. Comparisons within cohorts were performed to determine factors associated with revisions and total procedures. Mixed-effects regression modeling identified factors associated with elective revisions and total operations. RESULTS: Overall, 1534 patients (76.9 percent) had no complications, among whom 40.2 percent underwent elective revisions. The average number of elective revisions differed by modality (p < 0.001), with abdominally based free autologous reconstruction patients undergoing the greatest number of elective revisions (mean, 0.7). The mean total number of…

BACKGROUND: Fibroproliferative disorders result in excessive scar formation, are associated with high morbidity, and cost billions of dollars every year. Of these, keloid disease presents a particularly challenging clinical problem because the cutaneous scars progress beyond the original site of injury. Altered mechanotransduction has been implicated in keloid development, but the mechanisms governing scar progression into the surrounding tissue remain unknown. The role of mechanotransduction in keloids is further complicated by the differential mechanical properties of keloids and the surrounding skin. METHODS: The authors used human mechanical testing, finite element modeling, and immunohistologic analyses of human specimens to clarify the complex interplay of mechanical stress, strain, and stiffness in keloid scar progression. RESULTS: Changes in human position (i.e., standing, sitting, and supine) are correlated to dynamic changes in local stress/strain distribution, particularly in regions with a predilection for keloids. Keloids are composed of stiff tissue, which displays a…

BACKGROUND: The prevalence of burnout is increasing among all physicians, including plastic surgeons. Burnout is not simply synonymous with being overworked. It is a complex physical, intellectual, and psychological entity that arises when the expectation and reality of the job do not match. In this article, the authors' goal is to define burnout, summarize its causes and consequences, and offer the plastic surgeons methods to prevent and address it. METHODS: A literature search of articles on burnout in medicine was performed. Articles that were relevant were selected, and were qualitatively analyzed to answer our questions on the definition, prevalence, causes, consequences, and treatments of burnout. RESULTS: Sixty-five relevant articles were included. The prevalence of burnout among physicians ranges between 29 and 55 percent. Risk factors for physician burnout include increased workload and call, junior academic rank, and fair physician health. There is significant overlap among burnout, depression, and substance abuse, and suicide is much more common among physicians than…

BACKGROUND: Male-to-female transgender patients desire to be identified, and treated, as female, in public and social settings. Facial feminization surgery entails a combination of highly visible changes in facial features. To study the effectiveness of facial feminization surgery, we investigated preoperative/postoperative gender-typing using facial recognition neural networks. METHODS: In this study, standardized frontal and lateral view preoperative and postoperative images of 20 male-to-female patients who completed hard- and soft-tissue facial feminization surgery procedures were used, along with control images of unoperated cisgender men and women (n = 120 images). Four public neural networks trained to identify gender based on facial features analyzed the images. Correct gender-typing, improvement in gender-typing (preoperatively to postoperatively), and confidence in femininity were analyzed. RESULTS: Cisgender male and female control frontal images were correctly identified 100 percent and 98 percent of the time, respectively. Preoperative facial feminization surgery images…