The 50 most-cited articles in Plastic & Reconstructive Surgery, 2020

BACKGROUND: No data exist on the prospective outcomes of facial feminization surgery. This study set out to determine the effects of facial feminization surgery on quality-of-life outcomes for gender-diverse patients. METHODS: A prospective, international, multicenter, cohort study with adult gender-diverse patients with gender dysphoria was undertaken. Facial feminization outcome score was calculated preoperatively and postoperatively (1-week to 1-month and >6 months). Photogrammetric cephalometries were measured at the same time points. Self-perceived preoperative masculinity and femininity were recorded. Externally rated gender appearance (scale of 1 to 5, with 1 being most feminine) and general aesthetics (scale of 1 to 10, with 10 being very good) for 10 facial feminization surgery patients were compared with those of five cisgender controls. Univariate linear regression analyses were used to predict outcomes from facial feminization surgery. RESULTS: Sixty-six consecutive patients were enrolled. Patients noted that their brows, jaws, and chins were the most masculine aspects…

The history of autologous breast reconstruction has been characterized by the desire for progressively increasing reliability with decreasing donor-site morbidity. The robotic deep inferior epigastric artery perforator flap permits the longest possible pedicle harvest through the smallest possible fascial incision and, for this reason, may be the next stage in the evolution of minimally invasive, autologous breast reconstruction.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the indications for implant-based breast reconstruction and the indications for nipple preservation compared to skin-sparing or skin-reducing patterns. 2. Understand the indications for direct-to-implant breast reconstruction versus tissue expander/implant breast reconstruction and the advantages and disadvantages of total, partial, or no muscle coverage. 3. Understand the role of acellular dermal matrix or mesh in reconstruction. 4. Learn the advantages and disadvantages of different types and styles of implants and develop a postoperative plan for care and pain management. SUMMARY: Breast reconstruction with implants has seen a decade of advances leading to more natural breast reconstructions and lower rates of complications.

Routine measurement of outcome of clinical care is increasingly considered important, but implementation in practice is challenging. This article describes (1) how the authors created and implemented a routine outcome measurement cohort of patients with hand and wrist conditions and (2) how these data are used to improve the quality of care and facilitate scientific research. Starting in 2011, routine outcome measurement was implemented at all practice sites (currently 22) of a specialized treatment center for hand and wrist conditions across The Netherlands. The authors developed five "measurement tracks," including measurements administered at predetermined time points covering all hand and wrist disorders and treatments. An online system automatically distributes measurements among patients, which can be accessed by health care professionals. Using this system, the total number of yearly assigned tracks increased up to over 16,500 in 2018, adding up to 85,000 tracks in 52,000 patients in total. All surgeons, therapists, and other staff have direct access to individual patient…

BACKGROUND: The authors' purpose was to evaluate the effects of body mass index, as defined by World Health Organization criteria, on complications and patient-reported outcomes in implant-based and autologous breast reconstruction. METHODS: Complications and BREAST-Q patient-reported outcomes were analyzed 2 years after breast reconstruction for women from 11 participating sites. Separate mixed-effects regressions were performed to assess body mass index effects on outcomes. RESULTS: A total of 2259 patients (1625 implant-based and 634 autologous) were included. Women with class II/III obesity had higher risks of any complication in both the implant (OR, 1.66; p = 0.03) and autologous (OR, 3.35; p < 0.001) groups, and higher risks of major complications in both the implant (OR, 1.71, p = 0.04) and autologous (OR, 2.72; p = 0.001) groups, compared with underweight/normal weight patients. Both class I (OR, 1.97; p = 0.03) and class II/III (OR, 3.30; p = 0.001) obesity patients experienced higher reconstructive failures in the implant cohort. Class I obesity implant patients reported…

BACKGROUND: Breast augmentation with fat grafting is used as an alternative to breast implants. However, a systematic evaluation of the complication rates after fat grafting using only studies with consecutive patients has not previously been performed. In this study, the authors compiled studies reporting complication rates and radiologic changes in consecutive patients undergoing cosmetic breast augmentation with fat grafting. METHODS: Studies reporting on consecutive patients undergoing breast augmentation with fat grafting were included. Complication rates, radiologic changes, Breast Imaging Reporting and Data System assessments, and the number of patients undergoing revision surgery were extracted. Mean complication rates and radiologic changes were calculated with meta-analytical methods. RESULTS: Twenty-two studies with 2073 patients were included. The rates of major complications were low (hematoma, 0.5 percent; infection, 0.6 percent; and seroma, 0.1 percent). None of these patients needed revision surgery. The most frequent minor complication was palpable cysts in 2.0…

BACKGROUND: Continued evolution of implant-based breast reconstruction involves immediate placement of the implant above the pectoralis muscle. The shift to prepectoral breast reconstruction is driven by goals of decreasing morbidity such as breast animation deformity, range-of-motion problems, and pain, and is made possible by improvements in mastectomy skin flap viability. To define clinical factors to guide patient selection for direct-to-implant prepectoral implant reconstruction, this study compares safety endpoints and risk factors between prepectoral and subpectoral direct-to-implant breast reconstruction cohorts. The authors hypothesized that prepectoral direct-to-implant breast reconstruction is a safe alternative to subpectoral direct-to-implant breast reconstruction. METHODS: Retrospective chart review identified patients who underwent prepectoral and subpectoral direct-to-implant breast reconstruction, performed by a team of five surgical oncologists and two plastic surgeons. Univariate analysis compared patient characteristics between cohorts. A penalized logistic…

SUMMARY: Facial aging is a multifactorial process governed by both intrinsic and extrinsic factors that impart a change to each component of the facial anatomy. Our understanding of the science of aging has evolved over the years. A recent and valuable addition to our understanding is the knowledge of both the superficial and deep facial fat compartments. The deep compartments provide structural support to the midface and the superficial fat compartments. Understanding the anatomy and the spectrum of their changes helps to tailor management options for facial rejuvenation. The authors present a review on facial aging as it relates to these fat compartments and provide a management algorithm based on the longitudinal changes seen during aging.

BACKGROUND: Traditionally, lymphovenous anastomosis is not routinely performed in patients with advanced stage lymphedema because of difficulty with identifying functioning lymphatics. This study presents the use of duplex ultrasound and magnetic resonance lymphangiography to identify functional lymphatics and reports the clinical outcome of lymphovenous anastomosis in advanced stage lower extremity lymphedema patients. METHODS: This was a retrospective study of 42 patients (50 lower limbs) with advanced lymphedema (late stage 2 or 3) that underwent functional lymphovenous anastomoses. Functional lymphatic vessels were identified preoperatively using magnetic resonance lymphangiography and duplex ultrasound. RESULTS: An average of 4.64 lymphovenous anastomoses were performed per limb using the lymphatics located in the deep fat underneath the superficial fascia. The average diameter of lymphatic vessels was 0.61 mm (range, 0.35 to 1 mm). The average limb volume was reduced 14.0 percent postoperatively, followed by 15.2 percent after 3 months, and 15.5 percent after 6 months and 1…

BACKGROUND: This review aimed to meta-analyze the quality of life of alloplastic versus autologous breast reconstruction, when measured with the BREAST-Q. METHODS: An electronic PubMed and EMBASE search was designed to find articles that compared alloplastic versus autologous breast reconstruction using the BREAST-Q. Studies that failed to present BREAST-Q scores and studies that did not compare alloplastic versus autologous breast reconstruction were excluded. Two authors independently extracted data from the included studies. A standardized data collection form was used. Quality was assessed using the Newcastle-Ottawa Scale. The mean difference and 95 percent confidence intervals between breast reconstruction means were estimated for each BREAST-Q subscale. Forest plots and the I statistic were used to assess heterogeneity and funnel plot publication bias. The Z test was used to assess overall effects. RESULTS: Two hundred eighty abstracts were found; 10 articles were included. Autologous breast reconstruction scored significantly higher in the five subscales than alloplastic…

BACKGROUND: Differences in quality-of-life outcomes after different surgical breast cancer treatment options, including breast reconstruction, are relevant for counseling individual patients in clinical decision-making, and for (societal) evaluations such as cost-effectiveness analyses. However, current literature shows contradictory results, because of use of different patient-reported outcome measures and study designs with limited patient numbers. The authors set out to improve this evidence using patient-reported outcome measures in a large, cross-sectional study for different surgical breast cancer treatment options. METHODS: Quality of life was assessed through the EQ-5D-5L, European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and BR23, and the BREAST-Q. Patients with different treatments were compared after propensity-weighted adjustment of pretreatment differences. The EQ-5D was used to value the effect of surgical complications. RESULTS: A total of 1871 breast cancer patients participated (breast-conserving surgery, n = 615;…

Effective control of nasal tip projection and rotation is a key component in modern rhinoplasty. Tip projection is a product of several anatomical factors: length and strength of lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle. Several cartilage grafts have been described for effectively altering nasal tip projection and rotation. Columellar struts and septal extension grafts are both commonly used in modern rhinoplasty to affect projection and rotation of the nasal tip. Although columellar strut grafts have shown moderate efficacy in maintaining tip projection and unifying the tip complex, their effect on increasing tip projection has been shown to be very limited. In comparison, septal extension grafts have been shown to effectively control tip projection, rotation, and shape by securing the nasal tip to the septum. Varieties of septal extension grafts have been described to support the medial crura and control tip shape, all of which depend on the presence of a stable caudal septum. The type of…

BACKGROUND: Autologous fat grafting is a dynamic modality used in plastic surgery as an adjunct to improve functional and aesthetic form. However, current practices in fat grafting for soft-tissue augmentation are plagued by tremendous variability in long-term graft retention, resulting in suboptimal outcomes and repetitive procedures. This systematic review identifies and critically appraises the evidence for various enrichment strategies that can be used to augment and improve the viability of fat grafts. METHODS: A comprehensive literature search of the Medline and PubMed databases was conducted for animal and human studies published through October of 2017 with multiple search terms related to adipose graft enrichment agents encompassing growth factors, platelet-rich plasma, adipose-derived and bone marrow stem cells, gene therapy, tissue engineering, and other strategies. Data on level of evidence, techniques, complications, and outcomes were collected. RESULTS: A total of 1382 articles were identified, of which 147 met inclusion criteria. The majority of enrichment strategies…

BACKGROUND: Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator. METHODS: Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 ± 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement. RESULTS: In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the…

BACKGROUND: Facial palsy assessment is nonstandardized. Clinician-graded scales are limited by subjectivity and observer bias. Computer-aided grading would be desirable to achieve conformity in facial palsy assessment and to compare the effectiveness of treatments. This research compares the clinician-graded eFACE scale to machine learning-derived automated assessments (auto-eFACE). METHODS: The Massachusetts Eye and Ear Infirmary Standard Facial Palsy Dataset was employed. Clinician-graded eFACE assessment was performed on 160 photographs. A Python script was used to automatically generate auto-eFACE scores on the same photographs. eFACE and auto-eFACE scores were compared for normal, flaccidly paralyzed, and synkinetic faces. RESULTS: Auto-eFACE and eFACE scores differentiated normal faces from those with facial palsy. Auto-eFACE produced significantly lower scores than eFACE for normal faces (93.83 ± 4.37 versus 100.00 ± 1.58; p = 0.01). Review of photographs revealed minor facial asymmetries in normal faces that clinicians tend to disregard. Auto-eFACE reported better facial…

BACKGROUND: The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.). METHODS: Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition,…

BACKGROUND: Antifibrinolytic medications, such as tranexamic acid, have recently garnered increased attention. Despite its ability to mitigate intraoperative blood loss and need for blood transfusion, there remains a paucity of research in breast reconstruction. The authors investigate whether intravenous tranexamic acid safely reduces the risk of hematoma following implant-based breast reconstruction. METHODS: A single-center retrospective cohort study was performed to analyze all consecutive patients undergoing immediate two-stage implant-based breast reconstruction following mastectomy between 2015 and 2016. The incidence of postoperative hematomas and thromboembolic events among all patients was reviewed. The patients in the intervention group received 1000 mg of intravenous tranexamic acid before mastectomy incision and 1000 mg at the conclusion of the procedure. Fisher's exact test and the Mann-Whitney-Wilcoxon test were used. Multivariate logistic regression models were performed to study the impact of intravenous tranexamic acid after adjusting for possible confounders.…

BACKGROUND: Nonsurgical rhinoplasty with injectable dermal fillers has become an increasingly popular alternative to surgical procedures, in view of its relative low cost, convenience and rapid recovery, and low risk profile. The safety and efficacy of nonsurgical rhinoplasty remains a relatively contentious and ambiguous matter, given that there are few large-scale series reporting results or complications. This study reports the experience of a single clinician performing nonsurgical rhinoplasty in the largest cohort to date. METHODS: Patient demographics, indications, treatment details, and outcomes of patients treated between March of 2016 and January of 2019 were reviewed. The nonsurgical rhinoplasty technique described previously by Harb was used using hyaluronic acid dermal filler. RESULTS: Nonsurgical rhinoplasty was performed in 5000 patients. The commonest indication was dorsal hump (44 percent). Swelling and erythema were self-limiting side effects encountered in approximately half of patients. Infection was seen in two patients, and localized skin necrosis was observed…

BACKGROUND: This study aims to characterize the effect of laser-assisted indocyanine green fluorescence angiography on fat necrosis and flap failure in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: A retrospective review was performed on 1000 free flaps for breast reconstruction at a single center from 2010 to 2017. Indocyanine green angiography was used after completion of recipient-site anastomoses to subjectively assess for areas of hypoperfusion. A multivariable logistical analysis was conducted with 24 demographic and surgical factors and their effects on fat necrosis and flap failure. RESULTS: Five hundred six DIEP flaps were included in the statistical analyses. Thirteen percent of flaps had fat necrosis. Indocyanine green angiography was used for 200 flaps and was independently associated with a decrease in the odds of fat necrosis (OR, 0.38; p = 0.004). There was no reduction in flap failure rates when using indocyanine green angiography (OR, 1.15; p = 0.85). However, there was a decrease in flap loss with increasing venous coupler…

BACKGROUND: Breast implants are frequently used in cosmetic and reconstructive breast surgery. Capsular contracture, the most common long-term complication, is usually graded using the Baker classification. Despite its widespread use, the reliability of the Baker classification has never been established. The aim of this study was to determine the interobserver reliability and agreement of the Baker classification. METHODS: Sixty women who had undergone cosmetic breast augmentation were included. They were examined independently by two plastic surgeons from an observer pool. The Baker score was determined, along with firmness, dislocation, symmetry, and pain using four-point scales. Patients were asked to complete the BREAST-Q postaugmentation module. The interobserver reliability and agreement were calculated for all variables with a quadratic weighted kappa. RESULTS: The interobserver reliability of the Baker classification was poor (kappa, 0.55; 95 percent CI, 0.37 to 0.72). Interobserver reliability of the clinical parameters firmness (0.64; 95 percent CI, 0.49 to 0.79),…

BACKGROUND: There is no accurate visual representation of the aging process, one that visually shows how the shape of the face changes with age in a rigorous and three-dimensional way. METHOD: A total of 594 subjects were studied. Two hundred eighty three-dimensional images of male faces and 305 three-dimensional images of female faces were categorized into "young" and "old" groups by sex. The mean age of the younger men was 33.6, and the mean age of the older men was 70.3. The mean age of the younger women was 24, and the mean age of the older women was 74. Landmarks were placed on all images, and in the male groups the distances between these landmarks were analyzed with an independent t test to compare the differences between age groups. These measurements were then used to develop validated three-dimensional averaged models of the different groups. These averages were formed into comparative image transitions and studied. RESULTS: The comparative image transitions of the average young and old faces in this series show accurate and registered age and shape changes. The faces of…

BACKGROUND: The resurgence of prepectoral breast reconstruction has brought strict patient inclusion and exclusion criteria by numerous authors. This article provides an overview of a single surgeon's experience with 201 patients, 313 breasts using immediate, direct-to-implant prepectoral breast reconstruction. The article compares surgical outcomes of different patient cohorts to elucidate risk factors that may predispose patients toward developing complications. METHODS: A retrospective chart review was performed, identifying all patients who underwent prepectoral, direct-to-implant breast reconstruction from June of 2016 to June of 2018. RESULTS: A total of 201 patients representing 313 breasts were included. A midlateral incision was used in 157 breasts (50.2 percent), followed by a skin-reducing, Wise-pattern in 90 breasts (28.8 percent). Acellular dermal matrix was used in 243 breasts (77.6 percent), free nipple grafts were used in 39 breasts (12.5 percent), and postmastectomy radiation therapy was used in 58 breasts (18.5 percent). Complications requiring operative…

BACKGROUND: As social media continue to be widely used, understanding the current trend in social media use by plastic surgeons will help determine how the specialty can better harness its power and respect its risks. In this study, the authors performed a survey study of trainees, candidates, and members of the American Society of Plastic Surgeons to determine current use and consensus on social media in plastic surgery. METHODS: An electronic survey was sent to plastic surgery trainees, candidates, and members of the American Society of Plastic Surgeons using SurveyMonkey. Demographic data, social media use patterns, and views on social media use were collected. RESULTS: When compared with salaried surgeons, private practitioners used social media for the promotion of their practice, such as patient acquisition (74.3 percent versus 28.3 percent) and branding (61 percent versus 21.7 percent). The majority of nonusers felt social media was too time consuming and susceptible to breach of patient privacy. The majority of social media users agreed that acceptable use included…

BACKGROUND: The first aim of this study was to determine the rate of revision carpal tunnel release in five urban hospitals over a period of 14 years. The secondary aim was to assess what demographic, condition-related, and treatment-related factors are associated with revision carpal tunnel release. METHODS: Between 2002 and 2015, 7464 patients underwent carpal tunnel release. After manually reviewing the medical records, the authors identified 113 patients who underwent revision surgery. Multivariable logistic regression analysis was performed to study association with demographics (age, sex, and race), unilateral or bilateral treated wrist(s) (including carpal tunnel release performed simultaneously and separately), and type of surgery (open or endoscopic). To gain further insight into these factors, a matched case-control analysis in a 1:3 ratio was performed. RESULTS: One hundred thirteen of 7464 patients (1.5 percent) underwent revision carpal tunnel surgery. The median (interquartile range) time to revision surgery was 1.23 years (0.47 to 3.89 years). In multivariable…

BACKGROUND: The authors compared long-term health care use and cost in women undergoing immediate autologous breast reconstruction and implant-based breast reconstruction. METHODS: This study was conducted using the OptumLabs Data Warehouse, which contains deidentified retrospective administrative claims data, including medical claims and eligibility information from a large U.S. health insurance plan. Women who underwent autologous or implant-based breast reconstruction between January of 2004 and December of 2014 were included. The authors compared 2-year use rates and predicted costs of care. Comparisons were tested using the t test. RESULTS: Overall, 12,296 women with immediate breast reconstruction were identified; 4257 with autologous (35 percent) and 8039 with implant-based (65 percent) breast reconstruction. The proportion of autologous breast reconstruction decreased from 47.2 percent in 2004 to 32.7 percent in 2014. The mean predicted reconstruction cost of autologous reconstruction was higher than that of implant-based reconstruction in both unilateral and bilateral…

BACKGROUND: Maxillofacial reconstruction with vascularized bone restores facial contour and provides structural support and a foundation for dental rehabilitation. Routine implant placement in such cases, however, remains uncommon. This study aims to determine dental implant survival in patients undergoing vascularized maxillary or mandibular reconstruction through a systematic review of the literature. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, the literature was queried for implant placement in reconstructed jaws using Medical Subject Headings terms on PubMed, Embase, and Cochrane platforms. Weighted implant survivals were calculated for the entire cohort and subcohorts stratified by radiotherapy. Meta-analyses were performed to estimate effect of radiation on implant osseointegration. RESULTS: Of 3965 publications identified, 42 were reviewed, including 1084 patients with 3636 dental implants. Weighted implant survival was 92.2 percent at a median follow-up of 36 months. Survival was 97.0 percent in 269 implants placed…

BACKGROUND: The supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer offers a viable option to enhance recovery of intrinsic function following ulnar nerve injury. However, in the setting of chronic ulnar nerve compression where the timing of onset of axonal loss is unclear, there is a deficit in the literature on outcomes after supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer. METHODS: A retrospective study of patients who underwent supercharge end-to-side anterior interosseous nerve-to-ulnar motor nerve transfer for severe cubital tunnel syndrome over a 5-year period was performed. The primary outcomes were improvement in first dorsal interosseous Medical Research Council grade at final follow-up and time to reinnervation. Change in key pinch strength; grip strength; and Disabilities of the Arm, Shoulder and Hand questionnaire scores were also evaluated using paired t tests and Wilcoxon signed rank tests. RESULTS: Forty-two patients with severe cubital tunnel syndrome were included in this study. Other than age, there…

BACKGROUND: An understanding of financial trends is important to advance agreeable reimbursement models in plastic surgery. This study aimed to evaluate trends in Medicare reimbursement rates for the 20 most commonly billed reconstructive plastic surgery procedures from 2000 to 2019. METHODS: The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to identify the 20 reconstructive procedures most commonly billed to Medicare by plastic surgeons in 2016. Reimbursement data were extracted from The Physician Fee Schedule Look-Up Tool from the Centers for Medicare and Medicaid Services for each CPT code. Monetary data were adjusted for inflation to 2019 U.S. dollars. Average annual and total percentage changes in reimbursement were calculated based on these adjusted trends. RESULTS: The average adjusted reimbursement for all procedures decreased by 14.0 percent from 2000 to 2019. The greatest mean decrease was observed in complex wound repair of the scalp, arms, or legs (-33.2 percent). The only procedure with an increased adjusted…

LEARNING OBJECTIVES: After studying this article and viewing the video, the participant should be able to: 1. Compare the relative stability and neurosensory changes following mandible distraction osteogenesis with those after traditional advancement and fixation. 2. Describe the condylar changes that can occur after mandible distraction osteogenesis and list three ways to mitigate these changes. 3. Propose clinical situations where segmental or rotational movements of the midface may allow improved outcomes compared to en bloc linear distraction advancement. 4. Summarize the advantages and risks associated with anterior and posterior cranial distraction osteogenesis compared to traditional one-stage expansion. SUMMARY: Over the past 30 years, distraction forces have been applied to the spectrum of craniofacial osteotomies. It is now time to assess critically the current understanding of distraction in craniofacial surgery, identifying both traditional procedures it has replaced and those it has not. This article provides a review of comparative studies and expert opinion on the…

Social interactions are largely dependent on the interpretation of information conveyed through facial expressions. Although facial reanimation seeks restoration of the facial expression of emotion, outcome measures have not addressed this directly. This study evaluates the use of a machine learning technology to directly measure facial expression before and after facial reanimation surgery. Fifteen study subjects with facial palsy were evaluated both before and after undergoing cross-facial nerve grafting and free gracilis muscle transfer. Eight healthy volunteers were assessed for control comparison. Video footage of subjects with their face in repose and with a posed, closed-lip smile was obtained. The video data were then analyzed using the Noldus FaceReader software application to measure the relative proportions of seven cardinal facial expressions detected within each clip. The facial expression recognition application detected a far greater happy signal in postoperative (42 percent) versus preoperative (13 percent) smile videos (p < 0.0001), compared to 53 percent in videos…

BACKGROUND: Blindness following facial filler procedures, although rare, is devastating, usually acute, permanent, and attributed to an ophthalmic artery embolus. However, blindness may be delayed for up to 2 weeks, sometimes following injection at remote sites, suggesting alternative pathways and pathogenesis. METHODS: Seeking solutions, fresh cadaver radiographic lead oxide injection, dissection, and histologic studies of the orbital and facial pathways of the ophthalmic angiosome, performed by the ophthalmic artery and vein, both isolated and together, and facial artery perfusions, were combined with total body archival arterial and venous investigations. RESULTS: These revealed (1) arteriovenous connections between the ophthalmic artery and vein in the orbit and between vessels in the inner canthus, allowing passage of large globules of lead oxide; (2) the glabella, inner canthi, and nasal dorsum are the most vulnerable injection sites because ophthalmic artery branches are anchored to the orbital rim as they exit, a plexus of large-caliber avalvular veins drain into the orbits,…

BACKGROUND: In deep inferior epigastric perforator (DIEP) flap breast reconstruction, many surgeons use preoperative imaging for perforator mapping as a method to plan the operation, reduce operative times, and potentially limit morbidity. This study compared operative times for specific portions of DIEP flap harvest with and without preoperative computed tomographic angiography imaging. METHODS: Two patient groups undergoing DIEP flap breast reconstruction were studied prospectively. In the experimental group, the harvesting surgeon was blinded to the preoperative computed tomographic angiography scan; in the control group, the harvesting surgeon assessed the scan preoperatively. Times for initial perforator identification, perforator selection, flap harvest time, and total procedure times were compared. Perforator choice was evaluated. Correlation of perforator choice preoperatively and intraoperatively was also performed. RESULTS: Times were recorded in 60 DIEP flaps (27 blinded and 33 unblinded). The nonblinded group was more efficient in all categories: time to first perforator…

BACKGROUND: Optimal treatment for distal radius fractures in older adults remains uncertain. No randomized trials comparing the most frequently used treatments in this population have been conducted. Surgical treatment rates vary widely, and the sustained benefits of surgery are uncertain. METHODS: The Wrist and Radius Injury Surgical Trial, a randomized, multicenter trial, enrolled 304 adults aged 60 years and older with isolated, unstable distal radius fractures at 24 institutions. Patients who wanted surgery (n = 187) were randomized to internal fixation, external fixation, or percutaneous pinning; patients who preferred conservative management (n = 117) received casting. The primary outcome was the 12-month Michigan Hand Outcomes Questionnaire (MHQ) summary score. RESULTS: At 12 months, there were no differences by treatment in primary outcome. Twelve-month MHQ summary scores differed between internal fixation and external fixation by 3 points (97.5 percent CI, 6.0 to 11.5) and between internal fixation and pinning by -0.14 (97.5 percent CI, -9.2 to 8.9). However, at 6 weeks,…

BACKGROUND: Prepectoral implant-based breast reconstruction has gained popularity because of advantages over the subpectoral technique. Acellular dermal matrix use with implant-based breast reconstruction has become common because of its perceived superior aesthetic outcome. Matrices are expensive, however, and recent evidence has pointed to several potential complications. This article reports a series of prepectoral implant-based breast reconstructions with and without acellular dermal matrix and compared their outcomes. METHODS: This is a single-surgeon retrospective review of patients who underwent staged prepectoral implant-based breast reconstruction following nipple-sparing mastectomy over two periods. Patients with well-perfused mastectomy skin flaps with a homogeneous thickness underwent reconstruction with acellular dermal matrix initially. On evolution of the practice, it was not used. Patient demographics, operative data, and complications were analyzed. Aesthetic outcome was measured by the BREAST-Q survey and the Aesthetic Item Scale. A cost analysis was also…

SUMMARY: Virtual reality and other technological advancements both inside and outside the operating room have shown an exponential increase in the past two decades. Surgical technique and finesse in delicate procedures have become ever more important, and the onus is on plastic surgeons and plastic surgery residents to meet these needs to provide the best outcomes possible to patients. The ability to learn, simulate, and practice operating in a fashion that poses no harm to any patient is truly a gift from technology to surgery that any surgeon could benefit from, whether trainee or attending. This application of technology and simulation has been demonstrated in other fields such as in the airline industry with flight simulation. The ability to learn, synthesize, and incorporate learned materials and ideas through virtual, augmented, and mixed reality tools offers a great opportunity to put our field at the forefront of a paradigm shift in surgical education. The critical utility of digital education could not be further emphasized any more than in the unfortunate and infrequent…

BACKGROUND: Plastic surgery continues to be one of the most competitive specialties in the residency match. Research productivity is a key component of the selection process. Nevertheless, potential applicants have a poor understanding of the strength of their research credentials in comparison to other applicants. METHODS: The authors identified successful applicants from the 2012 to 2017 integrated plastic surgery residency application cycles. The authors performed a bibliometric analysis of these residents using Scopus, PubMed, and Google Scholar to identify published articles at the time of application. The authors then calculated the h-index of each applicant at the time of application. RESULTS: The authors included 829 integrated residents. The median h-index was 0 (interquartile range, 0 to 3) and the median number of publications was 2 (interquartile range, 0 to 5) for all applicants. The proportion of applicants with at least one publication at the point of application increased significantly over time (60 percent in 2012 versus 76 percent in 2017; p = 0.0072). In addition,…

BACKGROUND: Preoperative planning of microsurgical perforator free flaps continues to be a discussion topic among microsurgeons. The purpose of this study was to compare the ability of three methods of preoperative vascular mapping-hand-held Doppler imaging, color Doppler ultrasonography, and computed tomographic angiography-to detect perforators and their concordance with surgical findings. METHODS: A prospective study was performed to evaluate the sensitivity, specificity, and accuracy of hand-held Doppler imaging, color Doppler ultrasonography, and computed tomographic angiography to detect free flap perforators. Each patient undergoing a free flap reconstruction was studied preoperatively with the three methods, and the results were compared to the intraoperative findings. RESULTS: Fifty-three patients undergoing autologous tissue reconstruction were included. Most reconstructions (71.7 percent) were performed with anterolateral thigh flaps. The positive predictive value (color Doppler ultrasonography, 100 percent; computed tomographic angiography, 100 percent; hand-held Doppler…

BACKGROUND: Patients with breast cancer-related lymphedema can be treated with a simultaneous deep inferior epigastric perforator (DIEP) flap, vascularized inguinal lymph node transfer, and lymphovenous anastomosis for aesthetic breast reconstruction and lymphedema in one operation. METHODS: The authors performed a comparison of prospectively followed patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer and anastomosis to a retrospective cohort of patients who underwent free flap breast reconstruction with vascularized inguinal lymph node transfer alone. RESULTS: Thirty-three patients underwent DIEP flap reconstruction with vascularized inguinal lymph node transfer and lymphovenous anastomosis, and 21 received a free flap with lymph node transfer alone. There were no significant differences in demographics, adjuvant chemotherapy, or radiation therapy. The average number of nodes removed was also equivalent (21.2 versus 21.4 nodes). Two anastomoses per patient, on average, were performed (range, one to four) in the combined cohort, and…

LEARNING OBJECTIVES: After reading this article, the participants should be able to: 1. List current nonsurgical and surgical strategies for addressing postamputation neuroma pain and discuss their limitations. 2. Summarize the indications and rationale for targeted muscle reinnervation. 3. Develop an operative plan for targeted muscle reinnervation in an acute or delayed fashion for upper and lower extremity amputations. 4. Propose a management algorithm for treatment of symptomatic neuromas in an intact limb. 5. Discuss the risk of neuroma development after primary revision digital amputation or secondary surgery for a digital neuroma. 6. Compare and contrast targeted muscle reinnervation to the historical gold standard neuroma treatment of excision and burying the involved nerve in muscle, bone, or vein graft. 7. Interpret and discuss the evidence that targeted muscle reinnervation improves postamputation neuroma and phantom pain when performed either acutely or in a delayed fashion to treat existing pain. SUMMARY: Symptomatic injured nerves resulting from amputations, extremity…

BACKGROUND: Spring-assisted surgery is an accepted alternative to cranial vault remodeling for treatment of sagittal craniosynostosis. The long-term safety and efficacy profiles of spring-assisted surgery have not been established. METHODS: This study is a retrospective examination of all patients treated with spring-assisted surgery (n = 175) or cranial vault remodeling (n = 50) for sagittal craniosynostosis at the authors' institution from 2003 to 2017. Data collected included demographic and operative parameters, preoperative and postoperative Cephalic Indices, and complications. Whitaker grades were assigned blindly by a craniofacial surgeon not involved in patients' care. RESULTS: The mean age at surgery was significantly lower for the spring-assisted surgery group compared with the cranial vault remodeling group (4.6 months versus 22.2 months; p < 0.001). Even when combining spring placement with spring removal operations, total surgical time (71.1 minutes versus 173.5 minutes), blood loss (25.0 ml versus 111.2 ml), and hospital stays (41.5 hours versus 90.0 hours) were…

BACKGROUND: Videos on YouTube can be posted without regulation or content oversight. Unfortunately, many patients use YouTube as a resource on aesthetic surgery, leading to misinformation. Currently, there are no objective assessments of the quality of information on YouTube about aesthetic surgery. METHODS: YouTube was queried for videos about the 12 most common aesthetic surgical procedures, identified from the 2015 American Society of Plastic Surgeons procedural statistics between May and June of 2016. The top 25 results for each search term were scored using the modified Ensuring Quality Information for Patients criteria based on video structure, content, and author identification. Average Ensuring Quality Information for Patients score, view count, and video duration were compared between authorship groups. RESULTS: A total of 523 videos were graded after excluding duplicates. The mean modified Ensuring Quality Information for Patients score for all videos was 13.1 (SE, 0.18) of a possible 27. The videos under the search "nose reshaping" had the lowest mean score of 10.24 (SE,…

BACKGROUND: Within the multidisciplinary management of breast cancer, variations exist in the reconstructive options offered and care provided. The authors evaluated plastic surgeon perspectives on important issues related to breast cancer management and reconstruction and provide some insight into factors that influence these perspectives. METHODS: Women diagnosed with early-stage breast cancer (stages 0 to II) between July of 2013 and September of 2014 were identified through the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries. These women were surveyed and identified their treating plastic surgeons. Surveys were sent to the identified plastic surgeons to collect data on specific reconstruction practices. RESULTS: Responses from 134 plastic surgeons (74.4 percent response rate) were received. Immediate reconstruction (79.7 percent) was the most common approach to timing, and expander/implant reconstruction (72.6 percent) was the most common technique reported. Nearly one-third of respondents (32.1 percent) reported that reimbursement influenced the…

SUMMARY: Wounds have been one of the most prominent pathologies since the beginning of humanity. For the last 5 decades, a drastic improvement of healing has been observed, thanks to new medical devices based on fluid aspiration capacities and the development of negative pressure wound therapy. Negative-pressure wound therapy was initially designed for a double action, fluid aspiration and mechanical stimulation of wound edges by a foam. Successive technical evolutions of negative pressure wound therapy were declined since 1997 when Argenta and Morykwas first presented their solution. The adjunct of instillation in 2009 was considered as the first interactive dressing, allowing topical wound solutions to sequentially reach the wound, in alternance with negative pressure. Other devices based on the same principle were designed to prevent postoperative infections when placed over a suture after surgery. This long evolution could enhance the armamentarium of possible solutions, considerably reducing the wound healing time.

BACKGROUND: The authors conducted a prospective study to compare patients' intraoperative experience of open carpal tunnel release under "wide awake, local anesthesia, no tourniquet" (WALANT) on the one hand and intravenous regional anesthesia on the other. The authors hypothesized that WALANT would offer a better intraoperative experience than intravenous regional anesthesia. METHODS: Twenty-four patients with bilateral carpal tunnel syndrome had one hand operated on using WALANT and the contralateral hand with the intravenous regional anesthesia method. At the postoperative second hour, patients completed a questionnaire to quantify their pain levels on a numerical rating scale and compare the operation with dental procedures. They were also asked about their expectations and feelings about reoperation with the anesthesia methods. The results were compared for the two anesthesia methods. RESULTS: There were no significant differences between numerical rating scale pain values during anesthetic administration or for surgical site pain on the WALANT and intravenous regional…

BACKGROUND: Capsular contracture following breast augmentation is prone to recurrence with conventional surgical therapy. Adding acellular dermal matrix improves results but significantly increases operating time and cost. This study tested a new treatment algorithm that uses acellular dermal matrix selectively to optimize success rates while minimizing its drawbacks. METHODS: All patients surgically treated by the authors for Baker grade III/IV capsular contracture between 2007 and 2018 were included in this retrospective cohort study. Data were collected on patient, breast augmentation, capsular contracture, and surgical treatment characteristics, in addition to follow-up findings. Treatment success was defined as Baker grade II or better. RESULTS: One hundred eighty patients underwent 217 surgical treatments for capsular contracture. Conventional treatment was used in 185 cases and acellular dermal matrix in 32. Twenty-six patients were treated for a second occurrence and four were treated for a third. The average follow-up was 2.4 years. Conventional treatment was successful in…

BACKGROUND: This study used coarsened exact matching to investigate the effectiveness of the LACE+ index (i.e., length of stay, acuity of admission, Charlson Comorbidity Index, and emergency department visits in the past 6 months) predictive tool in patients undergoing plastic surgery. METHODS: Coarsened exact matching was used to assess the predictive ability of the LACE+ index among plastic surgery patients over a 2-year period (2016 to 2018) at one health system (n = 5744). Subjects were matched on factors not included in the LACE+ index such as duration of surgery, body mass index, and race, among others. Outcomes studied included emergency room visits, hospital readmission, and unplanned return to the operating room. RESULTS: Three hundred sixty-six patients were matched and compared for quarter 1 to quarter 4 (n = 732, a 28.2 percent match rate); 504 patients were matched for quarter 2 to quarter 4 (n = 1008, a 36.7 percent match rate); 615 patients were matched for quarter 3 to quarter 4 (n = 1230, a 44.8 percent match rate). Increased LACE+ score significantly predicted…

BACKGROUND: During a deep inferior epigastric perforator (DIEP) flap harvest, the identification and localization of the epigastric arteries and its perforators are crucial. Holographic augmented reality is an innovative technique that can be used to visualize this patient-specific anatomy extracted from a computed tomographic scan directly on the patient. This study describes an innovative workflow to achieve this. METHODS: A software application for the Microsoft HoloLens was developed to visualize the anatomy as a hologram. By using abdominal nevi as natural landmarks, the anatomy hologram is registered to the patient. To ensure that the anatomy hologram remains correctly positioned when the patient or the user moves, real-time patient tracking is obtained with a quick response marker attached to the patient. RESULTS: Holographic augmented reality can be used to visualize the epigastric arteries and its perforators in preparation for a deep inferior epigastric perforator flap harvest. CONCLUSIONS: Potentially, this workflow can be used visualize the vessels intraoperatively.…

BACKGROUND: Lateral epicondylitis is a common overuse injury affecting approximately 1 to 3 percent of the population. Although symptoms may disappear spontaneously within 1 year, the clinical guidelines for conservative treatment are not clear. The authors' objective was to examine the outcomes of nonsurgical treatments for lateral epicondylitis through a meta-analysis and provide a treatment recommendation using the available evidence. METHODS: The authors searched the PubMed, EMBASE, Scopus, and Web of Science databases to identify primary research articles studying conservative treatments (electrophysiotherapy, physical therapy, and injections) for lateral epicondylitis. The authors included randomized controlled trials published in peer-reviewed journals. Data related to outcomes (pain, grip strength, Patient-Rated Tennis Elbow Evaluation score, and Disabilities of the Arm, Shoulder and Hand score) and complications were extracted. RESULTS: Fifty-eight randomized controlled trials were included in the meta-analysis. Electrophysiotherapy was effective in improving pain [mean…

BACKGROUND: Nonsurgical rhinoplasty using filler injections has become a common procedure in cosmetic practices. This is offered to patients that prefer a temporary outcome or would like to avoid general anesthesia. In addition, it can be used in postrhinoplasty patients to correct nasal deformities or irregularities. This systematic review highlights common filler types and injection techniques, and associated patient satisfaction and complications to further guide practitioners. METHODS: A systematic review was performed using keywords and Medical Subject Headings search terms. PubMed, EmBase, the Cochrane Library, and Scopus were searched using the appropriate search terms. Data collected from each study included patient satisfaction and complications, in addition to injection material, location, and technique. RESULTS: Four thousand six hundred thirty-two studies were found based on search criteria. After full-text screening for inclusion and exclusion criteria, 23 studies were included. A total of 1600 patients underwent nonsurgical rhinoplasty, most commonly with hyaluronic…

BACKGROUND: Various surgical techniques exist for lower extremity reconstruction, but limited high-quality data exist to inform treatment strategies. Using multi-institutional data and rigorous matching, the authors evaluated the effectiveness and cost of three common surgical reconstructive modalities. METHODS: All adult subjects with lower extremity wounds who received bilayer wound matrix, local tissue rearrangement, or free flap reconstruction were retrospectively reviewed (from 2010 to 2017). Cohorts' comorbidities and wound characteristics were balanced. Graft success at 180 days was the primary outcome; readmissions, reoperations, and costs were secondary outcomes. RESULTS: Five hundred one subjects (166 matrix, 190 rearrangement, and 145 free flap patients) were evaluated. Matched subjects (n = 312; 104/group) were analyzed. Reconstruction success at 180 days for matrix, local tissue rearrangement, and free flaps was 69.2 percent, 91.3 percent, and 93.3 percent (p < 0.001), and total costs per subject were $34,877, $35,220, and $53,492 (p < 0.001), respectively. Median…