The 50 most-cited articles in Plastic & Reconstructive Surgery, 2022

BACKGROUND: Ideal nerve repair involves tensionless direct repair, which may not be possible after resection. Bridging materials include nerve autograft, allograft, or conduit. This study aimed to perform a systematic literature review and meta-analysis to compare the meaningful recovery (MR) rates and postoperative complications following autograft, allograft, and conduit repairs in nerve gaps greater than 5 mm and less than 70 mm. A secondary aim was to perform a comparison of procedure costs. METHODS: The search was conducted in MEDLINE from January of 1980 to March of 2020, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included whether they reported nerve injury type, repair type, gap length, and outcomes for MR rates. Thirty-five studies with 1559 nerve repairs were identified. RESULTS: Overall MR for sensory and motor function was not significantly different between autograft ( n = 670) and allograft ( n = 711) across both short and long gaps. However, MR rates for autograft (81.6%) and allograft (87.1%) repairs were…

SUMMARY: Lymphedema is a progressive disease of the lymphatic system arising from impaired lymphatic drainage, accumulation of interstitial fluid, and fibroadipose deposition. Secondary lymphedema resulting from cancer treatment is the most common form of the disease in developed countries, affecting 15% to 40% of patients with breast cancer after lymph node dissection. Despite recent advances in microsurgery, outcomes remain variable and, in some cases, inadequate. Thus, development of novel treatment strategies is an important goal. Research over the past decade suggests that lymphatic injury initiates a chronic inflammatory response that regulates the pathophysiology of lymphedema. T-cell inflammation plays a key role in this response. In this review, the authors highlight the cellular and molecular mechanisms of lymphedema and discuss promising preclinical therapies.

BACKGROUND: Microsurgery has become standard of care for increasingly complex techniques in tissue harvest, replantation, reconstruction, allotransplantation, and supermicrosurgery on submillimetric vessels. As techniques become more challenging and are performed at smaller and smaller scale, there is greater potential application for robotic assistance in extreme motion scaling and tremor reduction. METHODS: The Symani Surgical System (Medical Microinstruments, S.p.A, Calci, Pisa, Italy), a robotic platform designed for microsurgery, was used in a robot-assisted microsurgical free flap reconstruction using a perforator-to-perforator flap technique. This procedure utilized robot-assisted anastomosis of an artery and vein. RESULTS: The procedure was completed successfully, with vessels fully patent immediately following and 20 minutes after anastomosis. The flap was viable, no re-exploration of the anastomosis was necessary postoperatively, and no flap loss occurred. CONCLUSIONS: This novel, dedicated robotic platform with wristed microsurgical instruments was shown to be feasible…

BACKGROUND: Axillary lymph node dissection (ALND) remains the leading cause of lymphedema nationally, and there is still no cure for the disease. The lymphatic microsurgical preventive healing approach (LYMPHA) is a promising option for lymphedema prophylaxis in patients undergoing ALND, but long-term outcomes of the LYMPHA are not well established. METHODS: The authors conducted a retrospective review of patients undergoing ALND at their center from November of 2012 to November of 2016 and assembled two cohorts, those who received the LYMPHA and those who did not (non-LYMPHA). Patient data were collected to evaluate lymphedema risk and long-term lymphedema incidence of each group. RESULTS: Forty-five women were included in both our LYMPHA and non-LYMPHA cohorts. Mean body mass index (27.7 kg/m2 versus 29.9 kg/m2; P = 0.15) and radiation therapy rates (60.0% versus 68.9%; P = 0.51) did not differ between groups. Non-LYMPHA patients underwent complete mastectomy more frequently than LYMPHA patients (97.8% versus 77.8%; P = 0.007), but had a similar number of nodes removed during ALND…

SUMMARY: Structural preservation rhinoplasty merges two popular philosophies of rhinoplasty-structure rhinoplasty and preservation rhinoplasty-in an effort to maximize patient outcomes, aesthetics, and function. This allows the surgeon to both preserve the favorable attributes of the nose, and also to structure the nasal tip and dorsum with grafts to maximize contour and support. The concept of dorsal preservation is to preserve favorable dorsal aesthetic lines without the creation of an "open roof." However, the addition of some structure concepts can expand the utility of dorsal preservation in primary rhinoplasty patients. The authors discuss these structure concepts and their applicability to dorsal preservation.

SUMMARY: The hypertrophied temporalis and masseter muscles give a muscular shaped and bulky contour to the face. Botulinum neurotoxin injection methods are commonly used for facial contouring; however, adverse effects have been reported owing to a lack of delicate anatomical information. The anatomical considerations when injecting botulinum neurotoxin into the temporalis and masseter muscles were reviewed in the present study. Current knowledge on the localization of the botulinum neurotoxin injection point with more recent anatomical dissection and modified Sihler staining procedures was assessed. The authors found that, for the muscles, the injection point can be more precisely demarcated. Optimal injection sites are presented for the temporalis and masseter muscles, and the injection technique is suggested. The authors propose the optimal injection sites in relation to external anatomical landmarks for the frequently injected muscles of the face to facilitate the efficiency of botulinum neurotoxin injections. In addition, these guidelines would aid in more precise practice…

BACKGROUND: Success or failure of plastic surgery procedures relies on cosmetic results. Understanding the objective perception of favorable aesthetic results is critical to ensure patient satisfaction. The aim of this study was to develop and validate a new facial rating scale that could objectively assess face- and neck-lift outcomes: the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale. METHODS: One thousand White patients were included in the authors' study and assessed. To validate the authors' scale, the interrater reliability and the test-retest reliability were analyzed. The Rasch model was used as part of the scale validation process. RESULTS: Eleven scales for face- and neck-lift outcomes assessment were developed. All scales exceeded criteria for acceptability, reliability, and validity. The interrater and intrarater reliabilities were good, with a substantial or virtually perfect interrater reliability for the total score ( P = 0.15). CONCLUSIONS: The authors' results allowed us to validate the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale…

BACKGROUND: Although high-bleed surgery routinely utilizes the antifibrinolytic drug tranexamic acid, most plastic surgical procedures are conducted in soft tissue with low-volume bleeding. Unease regarding possible systemic adverse effects prevents widespread systemic use, but local use of tranexamic acid is gaining popularity among plastic surgeons. Randomized controlled trials on topical use of tranexamic acid are mainly from high-bleed surgeries, and few studies address the effect in soft tissue. This article reviews the scientific evidence regarding local use of tranexamic acid in soft-tissue surgery, discusses pharmacological effects and possible adverse reactions, and presents recommendations for use in plastic surgery. METHODS: A systematic search of databases for studies on local use of tranexamic acid in soft-tissue surgery was performed. Randomized controlled trials were included for a systematic review on effect; a narrative review regarding other clinically relevant aspects is based on extensive literature searches combined with the authors' own research. RESULTS:…

SUMMARY: A multidisciplinary work group involving stakeholders from various backgrounds and societies convened to revise the guideline for reduction mammaplasty. The goal was to develop evidence-based patient care recommendations using the new American Society of Plastic Surgeons guideline methodology. The work group prioritized reviewing the evidence around the need for surgery as first-line treatment, regardless of resection weight or volume. Other factors evaluated included the need for drains, the need for postoperative oral antibiotics, risk factors that increase complications, a comparison in outcomes between the two most popular techniques (inferior and superomedial), the impact of local anesthetic on narcotic use and other nonnarcotic pain management strategies, the use of epinephrine, and the need for specimen pathology. A systematic literature review was performed, and an established appraisal process was used to rate the quality of relevant scientific research (Grading of Recommendations Assessment, Development and Evaluation methodology). Evidence-based recommendations…

BACKGROUND: The perioperative use of tranexamic acid (TXA) has become popular among plastic surgeons for a variety of surgical procedures. The aim of this study was to perform a systematic review and meta-analysis on the results reported in the literature regarding the effect of perioperative systemic TXA administration in breast surgery. METHODS: The PubMed, MEDLINE, Embase, CENTRAL, and CINAHL databases were searched for both randomized clinical trials and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio with corresponding 95% confidence interval. RESULTS: A total of five studies encompassing 1139 patients undergoing mastectomy with or without immediate implant or free flap-based breast reconstruction or breast-conserving surgery with or without axillary lymph node dissection were included. Perioperative intravenous administration of TXA significantly reduced the risk for hematoma (7.3% versus 12.9%; OR, 0.43; 95% CI, 0.23 to 0.81) and seroma formation (11.5% versus 19.9%; OR, 0.57; 95% CI, 0.35 to…

BACKGROUND: Mesenchymal stem cell-derived exosomes are known to produce effects similar to those of source cells and therefore represent a new approach in cell-free regenerative medicine. Their potential clinical application demands efficient isolation of stable and functional exosomes from a large volume of biological fluid. METHODS: Exosomes from adipose-tissue conditioned medium of the same volume were isolated using either (1) ultrafiltration with size exclusion or (2) ExoQuick-TC. The isolated exosomes were characterized by protein concentration, particle size, exosomal marker expression, RNA expression profiles, and roles in dermal fibroblast proliferation and migration. RESULTS: Both isolation methods produced exosomes within the size range defined for exosomes (50 to 200 nm) and common markers were enriched. Compared to the ExoQuick-TC precipitation method, the ultrafiltration method produced a significantly higher protein yield (p < 0.001) but a lower particle-to-protein ratio (p < 0.05); it also yielded higher RNA contents from the same fat tissue indicated by housekeeping…

BACKGROUND: Striae distensae evaluation criteria have been recently described, but none is focused on objective striae assessment. With the purpose of better and objectively estimating the severity of striae distensae, the Objective Stretch Marks Assessment Scale has been developed by the authors' team. METHODS: Seven hundred White patients were included in the study and assessed. To assess the severity of striae distensae, abdomen, breasts, hips, gluteal area, back area, thighs, calves, and upper limbs photonumeric grading scales were developed. The Rasch model was used as part of the validation process. A score was attributed to each patient, based on the scales we developed. The interrater reliability and test-retest reliability were analyzed. RESULTS: Eight photonumeric scales for striae distensae treatment outcomes assessment were developed. All scales exceeded criteria for acceptability, reliability and validity. The interrater and intrarater reliabilities were good, with a substantial or virtually perfect interrater reliability for the total score (P = 0.16). CONCLUSIONS: The…

BACKGROUND: New treatment methods to improve and enhance the appearance of the buttocks require globally accepted scales for aesthetic research and patient evaluation. The purpose of this study was to develop a set of grading scales for objective assessment of the gluteal region and assess their reliability and validity. METHODS: Twelve photonumeric grading scales were created. Eleven aesthetic experts rated photographs of 650 women in two validation sessions. Responses were analyzed to assess interrater and intrarater reliability. The Rasch model was used as part of the validation process. RESULTS: All the scales exceeded criteria for acceptability, reliability, and validity. Overall interrater reliability and intrarater reliability were both "almost perfect" ( p = 0.15 and p = 0.16, respectively). CONCLUSION: Consistent outcomes between raters and by individual raters at two time points confirm the reliability of the Objective Buttocks Assessment Scale in female patients and suggest it will be a valuable tool for use in research and clinical practice.

BACKGROUND: Prepectoral placement of tissue expanders for two-stage implant-based breast reconstruction potentially minimizes chest wall morbidity and postoperative pain. The authors explored 90-day clinical and health-related quality-of-life outcomes for prepectoral versus subpectoral tissue expander breast reconstruction. METHODS: The authors conducted a propensity score-matching analysis (nearest neighbor, 1:1 matching without replacement) of patients who underwent immediate prepectoral or subpectoral tissue expander breast reconstruction between December of 2017 and January of 2019. Matched covariates included age, body mass index, race/ethnicity, smoking status, chemotherapy, radiotherapy, nipple-sparing mastectomy, and laterality of reconstruction. Outcomes of interest were perioperative analgesia use, 90-day postoperative patient-reported pain, complication rates, and BREAST-Q physical well-being of the chest scores. RESULTS: Of the initial cohort of 921 patients, 238 were propensity-matched and included in the final analysis. The matched cohort had no differences in baseline…

SUMMARY: For V-shaped nasal bones, the authors consider that ostectomy of the dorsal keystone area can be avoided, and this has led to the development of a new preservation technique: the spare roof technique B (or Ferreira-Ishida technique), where the bony cap is preserved. It includes six main steps, as follows. Step 1, draw on the surface of the skin the desired dorsal brow-tip aesthetic lines, the pyriform aperture, the rhinion, and the amount of triangular bone that has to be taken out to allow pushing-down the bony cap, and the transversal line in the beginning of the nasal hump. Step 2, release the upper lateral cartilages from the dorsal septum ("high septal strip"). Step 3, take out the amount of dorsal septum necessary to dehump. Step 4, perform the paramedian high parallel osteotomies exactly below the marked brow-tip dorsal aesthetic lines. Then, perform the second group of lower osteotomies, until the E-point, to achieve a triangular shape of bone in each side of the bony cap. Perform the ostectomy of the mentioned triangular areas. Release the lateral keystone area.…

BACKGROUND: Lower extremity amputations are common, and postoperative neuropathic pain (phantom limb pain or symptomatic neuroma) is frequently reported. The use of active treatment of the nerve end has been shown to reduce pain but requires additional resources and should therefore be performed primarily in high-risk patients. The aim of this study was to identify the factors associated with the development of neuropathic pain following above-the-knee amputation, knee disarticulation, or below-the-knee amputation. METHODS: Retrospectively, 1565 patients with an average follow-up of 4.3 years who underwent a primary above-the-knee amputation, knee disarticulation, or below-the-knee amputation were identified. Amputation levels for above-the-knee amputations and knee disarticulations were combined as proximal amputation level, with below-the-knee amputations being performed in 61 percent of patients. The primary outcome was neuropathic pain (i.e., phantom limb pain or symptomatic neuroma) based on medical chart review. Multivariable logistic regression was performed to identify…

BACKGROUND: Primary cadaveric studies were reviewed to give a contemporary overview of what is known about innervation of the female breast and nipple/nipple-areola complex. METHODS: The authors performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis. The authors searched four electronic databases for studies investigating which nerve branches supply the female breast and nipple/nipple-areola complex or describing the trajectory and other anatomical features of these nerves. Inclusion criteria for meta-analysis were at least five studies of known sample size and with numerical observed values. Pooled prevalence estimates of nerve branches supplying the nipple/nipple-areola complex were calculated using random-effects meta-analyses; the remaining results were structured using qualitative synthesis. Risk of bias within individual studies was assessed with the Anatomical Quality Assurance checklist. RESULTS: Of 3653 studies identified, 19 were eligible for qualitative synthesis and seven for meta-analysis. The breast…

BACKGROUND: Revision rhinoplasty is undoubtedly one of the most challenging procedures in facial plastic surgery. The complexity is compounded when there is a paucity of native septal cartilage to perform the required framework reconstruction. Harvest of autologous costal cartilage can result in increased operative times and possible secondary-site complications such as contour irregularity, poor scarring, and even pneumothorax. METHODS: A retrospective review was conducted of the senior author's (R.J.R.) patients from 2011 to 2020 who underwent primary or revision rhinoplasty. Inclusion criteria consisted of patients with fresh frozen off-the-shelf cartilage used in revision rhinoplasty only with a minimum of 6 months' follow-up. Outcomes for evaluation were warping, resorption, displacement, and infection. RESULTS: The authors identified 226 patients who underwent open rhinoplasty with the use of fresh frozen rib cartilage grafts and met inclusion criteria. The mean follow-up period was 12.18 months (range, 6 months to 8 years). The majority of patients had undergone one prior…

BACKGROUND: Robotic surgery is emerging as a viable tool in reconstructive surgery. Harvesting of the deep inferior epigastric perforator flap is typically performed through an anterior approach, which involves a long fascial incision. A robotic approach allows the deep inferior epigastric pedicle to be harvested from the posterior surface. This approach reduces the length of the fascial incision and should decrease the abdominal morbidity associated with large fascial dissections. METHODS: A case series study of 21 patients who underwent a robotic deep inferior epigastric perforator or during a 12-month period for breast reconstruction was performed. Patient demographics, surgical characteristics, and complications were assessed. RESULTS: Mean patient age was 54.6 ± 7.6 years, and mean body mass index was 30.4 ± 3.9 kg/m2. Mean fascial incision and pedicle length were 3.6 ± 1.6 cm and 13.3 ± 1 cm, respectively. None of the patients required conversion to open harvest. Mean length of hospital stay was 3.8 ± 0.9 days. Surgical site occurrences were identified in five patients (31.3…

BACKGROUND: Repair of nerve injuries can fail to achieve adequate functional recovery. Electrical stimulation applied at the time of nerve repair can accelerate axon regeneration, which may improve the likelihood of recovery. However, widespread use of electrical stimulation may be limited by treatment protocols that increase operative time and complexity. This study evaluated whether a short-duration electrical stimulation protocol (10 minutes) was efficacious to enhance regeneration following nerve repair using rat models. METHODS: Lewis and Thy1-green fluorescent protein rats were randomized to three groups: 0 minutes of electrical stimulation (no electrical stimulation; control), 10 minutes of electrical stimulation, and 60 minutes of electrical stimulation. All groups underwent tibial nerve transection and repair. In the intervention groups, electrical stimulation was delivered after nerve repair. Outcomes were assessed using immunohistochemistry, histology, and serial walking track analysis. RESULTS: Two weeks after nerve repair, Thy1-green fluorescent protein rats…

SUMMARY: Fat grafting is one of the most revolutionary surgical techniques of our century, and it has changed the field of plastic surgery and regenerative medicine. Early reports of fat grafting date back to the late nineteenth century, but the results were unsatisfactory because of minimal graft retention. It was not until Sydney R. Coleman challenged the dogma and introduced a standardized approach to fat grafting after years of research and learning from experts across the world. The Coleman technique represents an evolutionary approach to fat grafting, with three main components: harvesting, refinement, and placement. The Coleman technique has been adopted and modified by surgeons around the world because it has allowed a reliable increase in fat graft survival through a standardized process. This article discusses the influencing factors and milestones that led to this world-known technique, in addition to Dr. Coleman's current practices, pearls, pitfalls, and lessons learned over the years. The knowledge of the true potential and usefulness of fat is in its infancy, with its…

BACKGROUND: Dorsal augmentation rhinoplasty addresses the aesthetic and functional impairments caused by a deficient nasal dorsum. Augmentation rhinoplasty can be performed using a variety of different surgical techniques and grafting materials that all have distinct advantages and disadvantages. METHODS: Grafting materials have unique characteristics, uses, and safety profiles. A detailed overview of various grafting materials and their uses, risks, and benefits is provided. RESULTS: Autologous grafting materials include septal cartilage, auricular cartilage, and costal cartilage. These donor sites can provide various amounts of en bloc or diced cartilage. Alternatively, bone may be used when strong structural stability is required, and soft tissue may be used to fill mild to moderate defects. Homologous grafts (e.g., irradiated and nonirradiated rib) and acellular dermal matrices are alternatives to autologous graft with many similar advantages and no need for an additional surgical site. Lastly, alloplastic implants may be successfully used for dorsal augmentation if both patient…

SUMMARY: Over the past 30 years, there has been a dramatic increase in the use of autologous fat grafting for soft-tissue augmentation and to improve facial skin quality. Several studies have highlighted the impact of aging on adipose tissue, leading to a decrease of adipose tissue volume and preadipocyte proliferation and increase of fibrosis. Recently, there has been a rising interest in adipose tissue components, including adipose-derived stem/stromal cells (ASCs) because of their regenerative potential, including inflammation, fibrosis, and vascularization modulation. Because of their differentiation potential and paracrine function, ASCs have been largely used for fat grafting procedures, as they are described to be a key component in fat graft survival. However, many parameters as surgical procedures or adipose tissue biology could change clinical outcomes. Variation on fat grafting methods have led to numerous inconsistent clinical outcomes. Donor-to-donor variation could also be imputed to ASCs, tissue inflammatory state, or tissue origin. In this review, the authors aim to…

BACKGROUND: Capsular contracture is the most frequent complication of breast implant augmentation. Although studies indicate that textured implants have a low incidence of contracture, they have been associated with anaplastic cell lymphoma, which influences the choice of surface. This study estimated and compared the annual capsular contracture rate of both smooth and textured implants in primary breast implants. METHODS: Two hundred fifty-three patients (506 implants) were evaluated from January of 2017 to July of 2019; 42.2 percent of the implants were smooth and 57.8 percent were textured. The inframammary approach was used in the subfascial (55.3 percent) and submuscular (44.7 percent) pockets. The primary outcome was the appearance of capsular contracture (Baker grade II, III, and IV) within the first postoperative year. RESULTS: Smooth implants had a higher capsular contracture rate at 1 year postoperatively compared with textured implants, although with borderline statistical significance (p = 0.06). Smooth surface breast implants in the subfascial plane had a 4-fold higher…

BACKGROUND: The chin is important for facial appearance, affecting overall balance and harmony of the face. The purpose of this study was to evaluate effectiveness of the hyaluronic acid filler Restylane Defyne for chin augmentation and correction of chin retrusion versus a no-treatment control. METHODS: Male and female subjects, aged 22 years or older, with mild to moderate chin retrusion, were randomized 3:1 to the hyaluronic acid filler Restylane Defyne ( n = 107) or no treatment ( n = 33). Assessments included live, blinded evaluations on a validated chin retrusion scale (Galderma Chin Retrusion Scale), aesthetic improvement (Global Aesthetic Improvement Scale), subject-reported FACE-Q Satisfaction with Chin, and safety follow-up. RESULTS: Galderma Chin Retrusion Scale responder rate (≥1 grade improvement) was higher for the hyaluronic acid filler Restylane Defyne (81 percent) than for control (6 percent) ( p < 0.001) at week 12, and remained higher at week 48 (74 percent versus 11 percent; p < 0.001). Aesthetic improvement rates were high throughout the study as reported by…

BACKGROUND: Mastectomy skin flap necrosis following breast reconstruction may lead to wound dehiscence, infection, implant exposure, and reconstructive failure. The absence of a standardized definition for it has led to variation in estimated incidence, from as low as 2 percent to greater than 40 percent. The authors systematically reviewed the literature on mastectomy skin flap necrosis to characterize existing definitions and provide a framework for future classification. METHODS: A systematic review of the PubMed and Cochrane databases identified studies reporting a discrete definition of mastectomy skin flap necrosis and corresponding outcomes in breast reconstruction. Provided definitions were extracted, categorized, and comparatively analyzed. RESULTS: Fifty-nine studies met inclusion criteria, with a combined total of 14,368 patients and 18,920 breasts. Thirty-four studies (57.6 percent) reported mastectomy skin flap necrosis solely as a function of total breasts, and 11 (18.6 percent) reported mastectomy skin flap necrosis solely as a function of total patients. Only 14…

BACKGROUND: Intraoperative hemostasis should be performed with great caution because bleeding is a huge enemy of patient safety during surgery. Tranexamic acid is a lysine synthetic derivate that inhibits fibrinolysis and diminishes the bleeding by blocking the five lysine-binding sites for plasminogen. The authors compare the efficacy of tranexamic acid versus placebo as a hemostatic agent in liposculpture procedures. METHODS: The authors conducted a multicenter, double-blind, randomized, controlled clinical trial in patients who were scheduled for liposculpture in three plastic surgery centers (Colombia and Mexico) between January of 2019 and February of 2020. One hundred forty-one patients were randomly assigned into three groups: intravenous (1 g of tranexamic acid), subcutaneous (1 g of tranexamic acid), and placebo (normal saline). Forty-seven patients were assigned to each group. There were 30 male patients and 111 female patients. The main outcome was to evaluate the amount of postoperative bleeding between groups. The primary outcome was measured by the hemoglobin point…

BACKGROUND: Despite an increasing demand for surgical treatment of lipedema, the evidence for liposuction is still limited. Little is known about the influence of disease stage, patient age, body mass index, or existing comorbidities on clinical outcomes. It was hypothesized that younger patients with lower body mass index and stage would report better results. METHODS: This retrospective, single-center, noncomparative study included lipedema patients who underwent liposuction between July of 2009 and July of 2019. After a minimum of 6 months since the last surgery, all patients completed a disease-related questionnaire. The primary endpoint was the need for complex decongestive therapy based on a composite score. Secondary endpoints were the severity of disease-related complaints measured on a visual analogue scale. RESULTS: One hundred six patients underwent a total of 298 large-volume liposuctions (mean lipoaspirate, 6355 ± 2797 ml). After a median follow-up of 20 months, a median complex decongestive therapy score reduction of 37.5 percent (interquartile range, 0 to 88.8…

SUMMARY: Without meaningful and intuitive sensory feedback, even the most advanced prosthetic limbs remain insensate and impose an enormous cognitive burden during use. The regenerative peripheral nerve interface can serve as a novel bidirectional motor and sensory neuroprosthetic interface. In previous human studies, regenerative peripheral nerve interfaces demonstrated stable high-amplitude motor electromyography signals with excellent signal-to-noise ratio for prosthetic control. In addition, they can treat and prevent postamputation pain by mitigating neuroma formation. In this study, the authors investigated whether electrical stimulation applied to regenerative peripheral nerve interfaces could produce appreciable proprioceptive and/or tactile sensations in two participants with upper limb amputations. Stimulation of the interfaces resulted in both participants reporting proprioceptive sensations in the phantom hand. Specifically, stimulation of participant 1's median nerve regenerative peripheral nerve interface activated a flexion sensation in the thumb or index finger,…

BACKGROUND: Primary rhinoplasty during correction of unilateral cleft lip continues to be a topic of debate because of concerns that early nasal intervention may affect nasal and maxillary development over the long term. This study aims to determine the volume and quality of evidence for and against primary unilateral cleft rhinoplasty. METHODS: A systematic review was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles were pulled from PubMed and EMBASE and screened by title and abstract. Studies with human participants undergoing rhinoplasty at the time of unilateral cleft lip repair and some evaluation of the nasal outcome were included. Studies with a large proportion of syndromic patients, case reports, editorials, letters, reviews, studies exclusive to bilateral clefts, and studies not available in English were excluded. Those that met criteria were then systematically reviewed. RESULTS: Twenty-five articles were included. Ten articles that assessed the results of primary rhinoplasty subjectively all supported cleft lip…

BACKGROUND: High-definition liposculpture (HDL) emerged as an innovative surgical technique that allowed plastic surgeons to achieve improved aesthetic results with a natural and athletic appearance using minimal incisions and with imperceptible scarring. Its targets are high aesthetic standards and patient safety. PURPOSE: This article summarizes the evolution of HDL by explaining upgrades to the original technique and comparing the complication rates among them. METHODS: The authors retrospectively reviewed records from four private medical centers (Evolution Medical Center, Santa Barbara Medical Center, and Dhara Clinic in Bogota and FOSCAL in Bucaramanga, Colombia) of patients who underwent HDL performed by the senior author (A.E.H) over an 18-year period (2002 through 2019). Patients were classified into three groups: suction-assisted lipoplasty (period 1), vibration amplification of sound energy at resonance-assisted HDL (period 2), and dynamic definition liposculpture (period 3). RESULTS: The authors established a cohort of 5052 patients (4300 women and 752 men): 923 in…

BACKGROUND: The aim of this study was to report the results of prepectoral direct-to-implant reconstruction in nipple-sparing mastectomy without acellular dermal matrices or mesh. METHODS: A multicenter cohort of patients undergoing prophylactic or therapeutic nipple-sparing mastectomy was included from 2013 to 2020. All sizes and types of breasts were included, except those with previously failed reconstruction, previous radiotherapy with severe skin damage, locally advanced breast cancer, gigantomasty, severe degree of ptosis, tumors close to the nipple-areola complex (<1 cm on magnetic resonance imaging), or combined autologous-based reconstruction. RESULTS: A total of 280 immediate breast reconstructions were performed in 195 patients. The mean age was 45 years and 32.8 percent of patients were postmenopausal. The mean follow-up period was 16.5 (±17.43) months. Eighty-five patients (43.6 percent) underwent bilateral mastectomy; 116 mastectomies (41.4 percent) were prophylactic and 164 (58.6 percent) were therapeutic. Sixty-eight reconstructions (24 percent) had at least one…

BACKGROUND: Knowledge of detailed lymphatic anatomy in humans is limited, as the small size of lymphatic channels makes it difficult to image. Most current knowledge of the superficial lymphatic system has been obtained from cadaveric dissections. METHODS: Indocyanine green lymphography was performed preoperatively to map the functional arm lymphatics in breast cancer patients without clinical or objective evidence of lymphedema. A retrospective review was performed to extract demographic, indocyanine green imaging, and surgical data. RESULTS: Three main functional forearm channels with variable connections to two upper arm pathways were identified. The median forearm channel predominantly courses in the volar forearm (99 percent). The ulnar forearm channel courses in the volar forearm in the majority of patients (66 percent). The radial forearm channel courses in the dorsal forearm in the majority of patients (92 percent). Median (100 percent), radial (91 percent), and ulnar (96 percent) channels almost universally connect to the medial upper arm channel. In contrast, connections…

BACKGROUND: Nonsyndromic craniosynostosis is one of the most common anomalies treated by craniofacial surgeons. Despite optimal surgical management, nearly half of affected children have subtle neurocognitive deficits. Whereas timing and type of surgical intervention have been studied, the possibility of genetic influence on neurodevelopment in nonsyndromic craniosynostosis patients remains unexplored. METHODS: The authors performed whole-exome sequencing for 404 case-parent trios with sporadic nonsyndromic craniosynostosis. Statistical analyses were performed to assess the burden of de novo mutations in cases compared to both expectation and 1789 healthy control trios. Individuals with and without each mutation class were analyzed, and the presence or absence of various types of neurodevelopmental delay were recorded alongside demographic information. RESULTS: The authors identified a highly significant burden of damaging de novo mutations in mutation-intolerant [probability of loss of function intolerance (pLI) >0.9] genes in nonsyndromic craniosynostosis probands (p = 5.9 ×…

BACKGROUND: Of the primary procedures associated with facial gender confirmation surgery, those involving the mentomandibular complex have received the least attention in the literature. METHODS: The authors present their experience with 837 trans feminine patients operated on for facial gender confirmation surgery who underwent mandibular bone contouring procedures, including bone contouring, chin and mandibular body and angle ostectomies, and osteotomies to reposition the chin. The authors describe the surgical techniques and materials used, and present a customized lower border-supported cutting guide designed by their team and used with 205 patients. A femininity perception score was calculated preoperatively and 12 months postoperatively, and satisfaction with the results was measured 12 months postoperatively. RESULTS: The postoperative follow-up ranged from 12 to 110 months. The mean femininity perception score increased from 47.86 preoperatively to 76.41 at 12 months postoperatively (p < 0.001). No emergency surgical operations were required. In no case was there any…

BACKGROUND: Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface. METHODS: This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known…

BACKGROUND: The incidence of facial skin necrosis has increased considerably because of the growth in the popularity of dermal fillers. This study describes the patterns and severity of facial skin ischemia, along with associated neuro-ophthalmologic injuries, in the published literature through the introduction of the facial artery, ophthalmic artery, distal external carotid artery, internal maxillary artery (FOEM) facial angiosome scoring system and grading scale. METHODS: A systematic review of all photographic cases of facial skin ischemia attributable to vascular occlusion with dermal fillers and injectable materials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. RESULTS: A total of 243 cases were identified, with 738 digital clinical photographs retrieved. The facial artery (58% of cases) and ophthalmic artery (48% of cases) angiosomes were most commonly affected. The frontonasal and angulonasal territories were the most common facial skin segments injured by filler-induced vascular occlusion. Cutaneous involvement of…

BACKGROUND: The use of acellular dermal matrices (ADMs) and synthetic mesh as part of implant-based breast reconstruction (IBBR) has been widely adopted. The authors investigated the clinical efficacy and safety of human ADM (HADM), xenograft ADM (XADM), and synthetic mesh as part of IBBR in postmastectomy patients as compared with previous standard implant reconstruction techniques using only a submuscular pocket for coverage. METHODS: A systematic search for randomized controlled trials and observational studies was performed. A frequentist network meta-analysis was conducted using the R packages netmeta and Shiny. RESULTS: Thirty-one of 2375 studies identified met the predefined inclusion criteria. Traditional submuscular placement (no ADM or mesh) had fewer overall complications compared with HADM [OR, 0.51; credible interval (CrI), 0.34 to 0.74], but there was no significant difference between no ADM or mesh and XADM (OR, 0.63; CrI, 0.29 to 1.32) or synthetic mesh (OR, 0.77; CrI, 0.44 to 1.30). No one treatment was superior with regards to implant loss. No ADM or mesh was…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the autologous graft options available to the rhinoplasty surgeon, including septal cartilage, auricular cartilage, costal cartilage, and bone. 2. Understand the autograft and allograft options available to the rhinoplasty surgeon, including cadaveric costal cartilage, silicone, Medpor, and Gore-Tex. 3. Identify the ideal situations to use each of these implant materials. 4. Understand the advantages and disadvantages of the different autografts, allografts, and implants in rhinoplasty. SUMMARY: This review focuses on the graft options available to the modern rhinoplasty surgeon. Autologous options are varied in the quality of cartilage harvested and the morbidity of the donor site. In addition, surgeons should understand the allograft options should autologous grafting be unfeasible or undesirable. New technological advances in processing of allograft cartilage makes this an attractive secondary option.

BACKGROUND: Prepectoral implant-based breast reconstruction is gaining in popularity. Acellular dermal matrices are an integral part of prepectoral reconstruction. However, large quantities of acellular dermal matrix are required for total implant coverage, and the cost of acellular dermal matrices could be a deterrent to reconstruction. To minimize the cost, the authors have resorted to the use of a bioabsorbable mesh, GalaFLEX, as a partial replacement to acellular dermal matrices. This study evaluates the comparative safety of using a GalaFLEX-AlloDerm construct versus AlloDerm alone in prepectoral reconstruction. METHODS: Consecutive patients who underwent immediate, expander-implant, prepectoral breast reconstruction were included in this retrospective study. Patients were stratified into two groups: those who received the GalaFLEX-AlloDerm combination versus AlloDerm alone. In GalaFLEX-AlloDerm reconstructions, the lower third of the expander was covered by the AlloDerm, whereas the rest of the expander was covered by GalaFLEX. Complications following reconstruction were…

BACKGROUND: Breast cancer-related lymphedema is a progressive disease that poses tremendous physical, psychosocial, and financial burden on patients. Immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection is emerging as a potential therapeutic paradigm to decrease the incidence of breast cancer-related lymphedema in high-risk patients. METHODS: Eighty-one consecutive patients underwent reverse lymphatic mapping and, when feasible, supermicrosurgical immediate lymphaticovenular anastomosis at the time of axillary lymph node dissection at a tertiary care cancer center. Patients were followed prospectively in a multidisciplinary lymphedema clinic (plastic surgery, certified lymphatic therapy, dietary, case management) at 3-month intervals with clinical examination, circumferential limb girth measurements, and bioimpedance spectroscopy. An institutional control cohort was assessed for the presence of objectively diagnosed and treated breast cancer-related lymphedema. Data were analyzed by a university statistician. RESULTS: Seventy-eight patients met…

BACKGROUND: Because of the expansion of telehealth services through the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act, the potential of telemedicine in plastic surgery has gained visibility. This study aims to identify populations who may have limited access to telemedicine. METHODS: The authors created a telemedicine literacy index (TLI) using a multivariate regression model and data from the US Census and Pew Research Institute survey. A multivariate regression model was created using backwards elimination, with TLI as the dependent variable and demographics as independent variables. The resulting regression coefficients were applied to data from the 2018 US Census at the county level to create a county-specific technological literacy index (cTLI). Significance was set at P < 0.05. RESULTS: On multivariable analysis, the following factors were found to be significantly associated with telemedicine literacy: age, sex, race, employment status, income level, marital status, educational attainment, and urban or rural classification. Counties in the lowest tertile had…

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the craniofacial dysmorphology of craniosynostosis, and the variation of each type. 2. Identify the functional concerns and learn the rationale behind timing of operative intervention. 3. Approach each dysmorphology critically and identify the operative intervention needed to improve form and function 4. Understand and address the specific issues related to syndromic craniosynostosis and be able to delineate management plan. SUMMARY: Craniosynostosis is a condition in which premature fusion of one or more cranial sutures lead to abnormal head shape and growth restriction of the brain. Nonsyndromic craniosynostosis occurs in isolation, and usually involves a single suture, whereas syndromic craniosynostosis may involve multiple sutures and is associated with extracraniofacial findings. Although surgical management can be similar, the treatment plan must take into consideration issues specific to the syndromes. This article aims to provide a concise overview of the authors' current…

SUMMARY: Autologous fat grafting has long been regarded as an ideal filler, lauded for its ability to restore soft-tissue contour. In recent times, fat grafting has exhibited regenerative capacity, largely secondary to the action of adipose-derived stem cells and preadipocytes in the stromal vascular fraction of adipose tissue. This has birthed a new field of regenerative surgery with benefits germane to scarring, fibrosis, atrophy, burns, neuropathic pain, and autoimmune disease. The broad clinical applications of regenerative fat grafting have the potential to improve quality of life through functional and aesthetic improvement. Fat grafting has the potential to serve as a regenerative option for difficult clinical problems that cannot be treated effectively at the present time. Fat grafting also exhibits angiogenic and immunomodulatory properties in the context of autoimmune disease. The broad clinical applications of regenerative fat grafting have the potential to improve quality of life both functionally and aesthetically. It may present a less invasive avenue for clinical…

BACKGROUND: Cleft lip and/or palate affects approximately one in 700 live births. Optimal timing for repair of cleft lip has yet to be objectively validated. Earlier repair takes advantage of a high degree of plasticity within the nasal cartilage and maxilla. The authors present patients enrolled in an early cleft lip repair protocol facilitating effective repair of the cleft lip and nostril. METHODS: American Society of Anesthesiologists class I to II patients with unilateral cleft lip and/or palate undergoing repair before 3 months of age were enrolled over 5 years. Perioperative data, surgical and anesthetic complications, preoperative and postoperative nostril breadth, nostril width, nasal angle, lip length, frontal nasal breadth, and commissure length measured as ratios between the cleft and noncleft sides were abstracted. Early cleft lip repair and nasoalveolar molding patients were matched for cleft lip severity using the cleft width ratios and compared. RESULTS: The surgical and anesthetic complication rate for 100 early cleft lip repair patients was 2 percent. Operative and…

BACKGROUND: Despite many treatment options available, no consensus on the optimal surgical management of symptomatic peripheral nerve neuroma has been reached. The aim of this systematic review and meta-analysis was to evaluate the effectiveness of different surgical techniques for treating painful neuromas and to help guide surgeons in electing optimal treatment. METHODS: Four databases (Embase, MEDLINE, Web of Science, and Cochrane Central) were searched. Studies that reported either numerical (visual analogue scale/numeric rating scale) or nonnumeric postoperative pain scores after surgical treatment of peripheral neuroma were identified. RESULTS: Thirty-two articles met the eligibility criteria and were analyzed for qualitative review. Thirty studies were included in qualitative analysis, for a total of 1150 neuromas. Surgical treatment of peripheral neuroma achieved good postoperative results in 70 percent of treated neuromas (95 percent CI, 64 to 77 percent). Proportions between techniques ranged between 60 and 92 percent. In a post hoc analysis, targeted muscle reinnervation…

BACKGROUND: Implant-based breast reconstruction has evolved, with a recent resurgence of prepectoral techniques. Comparative reconstructive outcomes and complications have not been elucidated fully among the total submuscular, dual-plane, and prepectoral planes of implant placement. METHODS: All immediate implant-based breast reconstructions from March of 2017 through August of 2019 were reviewed retrospectively. Cases were divided into total submuscular, dual-plane, and prepectoral cohorts. Demographics, operative techniques, and reconstructive outcomes and complications were compared among groups. RESULTS: A total of 826 cases (510 patients) were identified and divided into total submuscular ( n = 392), dual-plane ( n = 358), and prepectoral ( n = 76) cohorts. Average follow-up for all patients was 27 months. The prepectoral cohort had a higher average body mass index and rate of previous reduction or mastopexy. Overall complications were lowest in the total submuscular group, although this difference was not statistically significant. Major infection occurred more frequently in…

BACKGROUND: Novel imaging methods have provided new insights into the layered anatomy of the forehead. This study seeks to critically reevaluate the layered anatomy of the forehead by using ultrasound imaging and cadaveric dissection to provide an accurate anatomical description that can be used to guide safer surgical and minimally invasive frontal procedures. METHODS: This study used ultrasound imaging in a sample of 20 volunteers (12 female and eight male volunteers; aged 35.25 ± 4.2 years; body mass index, 24.28 ± 3.5 kg/m2) and cadaveric dissections of 16 body donors (12 female and four male body donors; aged 72.76 ± 9.5 years) to reevaluate the layered anatomy of the forehead. Layer-by-layer dissections and ultrasound-based measurements of the frontal structures guided conclusions. RESULTS: The following layered arrangement was identified: layer 1, skin; layer 2, superficial fatty layer; layer 3, suprafrontalis fascia; layer 4, orbicularis oculi and frontalis muscle (same plane); layer 5, a homogenous layer of fat [preseptal fat (in the upper eyelid), retro-orbicularis fat…

BACKGROUND: Developing effective strategies to manage perioperative pain remains a focus of cleft care. The present study's purpose was to systematically review perioperative pain control strategies for cleft lip and palate repair. METHODS: A systematic review and meta-analysis of randomized controlled trials was performed. Primary outcomes included pain scale scores and time to analgesia failure. Cohen d normalized effect size permitted comparison between studies, and a fixed-effects model was used for analysis. I2 and Q-statistic p values were calculated. RESULTS: Twenty-three studies were included: eight of 23 studies provided data for meta-analytic comparison. Meta-analyses evaluated the efficacy of intraoperative nerve blocks on postoperative pain management. Meta-analysis included a total of 475 treatment and control patients. Cleft lip studies demonstrated significantly improved pain control with a nerve block versus placebo by means of pain scale scores ( p < 0.001) and time to analgesia failure ( p < 0.001). Measurement of effect size over time demonstrated statistically…

SUMMARY: Vein grafts enable soft-tissue reconstruction in cases of insufficient pedicle length, a lack of nearby recipient vessels, and a wide zone of injury caused by trauma or radiation therapy. The purpose of this article is to provide a comprehensive review of vein grafts in free flap reconstruction focusing on the timing of arteriovenous loops, complications, and surgical technique. Vein graft indications, types of vein grafts, and location-specific considerations are also reviewed. Three reconstructive microsurgeons at high-volume centers were asked to offer institutional pearls on the order of anastomosis, selection of donor veins, and timing of arteriovenous loops. In terms of gap length, vessel gaps less than 10 cm may be reconstructed with an interposition or transposition vein graft. For longer gaps, surgeons should consider the use of arteriovenous loops, transposition arteriovenous loops, or flow-through flaps. Both one and two-stage arteriovenous loops are used, depending on patient comorbidities, potential exposure of critical structures, and surgeon preference.…