Ann Plast Surg Research Articles

A Three-Dimensional Approach To Male Chest Enhancement: A Surgical Algorithm Based On 300 Cases.

Gynecomastia is defined as a benign condition of the male caused by tissue overgrowth (Blau and Hazani in Plast Reconstruct Surg 135(2): 425-432, 2015). Its incidence ranges widely in the world population, ranging from 32 to 65% (Innocenti et al. in Ann Plast Surg 78(5):492-496, 2017). Pseudogynecomastia is a condition characterized by deposits of adipose tissue with alteration of the profile of the male thorax. It appears clinically similar to gynecomastia (Hoyos et al. in Plast Reconstr Surg 147:1072-1083, 2021). Several classification systems that characterize the severity of male breast hypertrophy have been described in the literature, and many surgical algorithms have been formulated for its treatment (Holzmer et al. in Plast Reconstruct Surg-Global Open 8:e3161, 2020). The purpose of this original article is to provide a comprehensive surgical algorithm for the management of male chest enhancement based on severity, as defined by the Moschella scale (Tambasco et al. in J Plast Reconstruct Aesthet Surg 90:99-100, 2024). A total of 300 patients treated for bilateral breast hypertrophy are included and reviewed in this retrospective study. Patients have been diversified according to the Moschella scale. For each grade up to grade III, two subgroups were distinguished: A) pinch test less than 0.7 cm and B) pinch test greater than 0.7 cm. For Grade IV, we distinguished: subgroup A) where the distance between the inframammary fold and the nipple was < 3 cm; and subgroup B) where the distance between the inframammary fold and the nipple was > 3 cm. We developed an algorithm, based on this experience, to help to choose the best surgical techniques to perform a three-dimensional result. All patients were treated using multiple surgical techniques. In all cases, we made a reduction in the hypertrophy of the chest, obtaining the three dimensionality. Associate techniques include ultrasound-assisted liposuction (UAL) and helium plasma radiofrequency technology (HPRF). A round block mastectomy (RBm) or skin-reducing mastectomy T inverted (SRM Tinv) is reserved only in limited cases.Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Letter to the Editor: Comment on McLaughlin et al. Comparison of Tumescent Anesthesia Versus Pectoral Nerve Block in Bilateral Reduction Mammaplasty ( Ann Plast Surg 2023; 90(6S Suppl 5):S533-S537).

Letter to the Editor: Comment on McLaughlin et al. Comparison of Tumescent Anesthesia Versus Pectoral Nerve Block in Bilateral Reduction Mammaplasty ( Ann Plast Surg 2023; 90(6S Suppl 5):S533-S537).

A novel and easily reproducible technique for determining nipple placement in chest masculinization surgery

The rate of chest masculinization surgery for gender affirming purposes is increasing in the United States. This rise in popularity can be attributed to greater awareness of the needs of the transgender population and improved insurance coverage for gender affirming care. 1 American Society of Plastic Surgeons2019 Plastic Surgery Statistics Report. 2019; : 1-23〈http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Plastic+Surgery+Statistics+Report#1〉 Google Scholar , 2 Cohen W.A. Shah N.R. Iwanicki M. et al. Female-to-Male Transgender Chest Contouring: A Systematic Review of Outcomes and Knowledge Gaps. Ann Plast Surg. 2019; 83: 589-593https://doi.org/10.1097/SAP.0000000000001896 Crossref PubMed Scopus (21) Google Scholar Although there is a growing body of literature detailing techniques, algorithms, and outcomes of chest contouring, relatively little attention has been paid to management of the nipple-areolar complex (NAC). 1 American Society of Plastic Surgeons2019 Plastic Surgery Statistics Report. 2019; : 1-23〈http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Plastic+Surgery+Statistics+Report#1〉 Google Scholar , 3 Agarwal C.A. Wall V.T. Mehta S.T. et al. Creation of an Aesthetic Male Nipple Areolar Complex in Female-to-Male Transgender Chest Reconstruction. Aesthetic Plast Surg. 2017; 41: 1305-1310https://doi.org/10.1007/s00266-017-0935-7 Crossref Scopus (24) Google Scholar , 4 Canner J.K. Harfouch O. Kodadek L.M. et al. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg. 2018; 153: 609https://doi.org/10.1001/jamasurg.2017.6231 Crossref PubMed Scopus (162) Google Scholar In comparison to surgery for cisgender males, the neo-NAC for transgender males is formed from a NAC which tends to have a larger areola, more prominent nipple, and different anatomic location. Incorrect positioning of the NAC (most often too high and too medial) is a common pitfall in chest masculinization surgery. 1 American Society of Plastic Surgeons2019 Plastic Surgery Statistics Report. 2019; : 1-23〈http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Plastic+Surgery+Statistics+Report#1〉 Google Scholar , 5 Lane M. Ives G.C. Sluiter E.C. et al. Trends in gender-affirming surgery in insured patients in the United States. Plast Reconstr Surg - Glob Open. 2018; 6https://doi.org/10.1097/GOX.0000000000001738 Crossref Scopus (93) Google Scholar Management of the NAC in chest masculinization surgery additionally requires understanding the dynamic response of the body to the chosen techniques. This is influenced by multiple factors including the breast size, excess skin, degree of ptosis, and pre-operative positioning of the NAC.

Non-Medication Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-analysis

INTRODUCTION: Treatments for refractory and intractable migraine have been of growing interest, particularly given the diversity and utility of novel treatments. Neuromodulators, nerve blocks, botulinum toxin A (BT-A), and surgery for migraine headache all offer new avenues for patients who do not sufficiently respond to conventional therapies or tolerate the side effects of medications. However, no studies have compared outcomes for these treatments. Furthermore, although headache frequency is an important factor that is often analyzed, headache intensity and duration are essential aspects of migraine treatment inherent to quality of life improvement but are often underreported.[1-4] Thus, this study is the most rigorous analysis and the first to compare the effectiveness of these contemporary treatments for migraine based on changes in the frequency, duration, and severity of migraines in adults. METHODS: Pubmed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared BT-A, nerve block, neurostimulation, or migraine surgery to placebo for preventive migraine treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed. RESULTS: After exclusion, there were four studies with 137 patients for nerve block, ten studies with 1857 patients for BT-A, ten studies with 416 patients for nerve stimulator, and four studies with 185 patients who underwent surgical treatment. There was a significant decrease in headache frequency of 5.69 days in patients who underwent nerve block (95% CI: 0.37, 11.01; p=0.04). p=0.04) and 4.58 days in surgery (95% CI: 2.26, 6.90; p<0.001). Headache severity (VAS score 1-3) was significantly decreased in all four treatments. Duration of headaches was significantly reduced for the BT-A cohort by 4.58 days (95% CI: 2.26, 6.90; p<0.001) and the surgery cohort by 0.44 days (95% CI: 0.13, 0.74; p=0.01). Quality of life as demonstrated by MIDAS score was improved significantly for patients who underwent treatment with BT-A (95% CI: 0.31, 0.52; p<0.001). Adverse events were significantly higher in the BT-A group only (95% 0.32, 0.88; p<0.001). CONCLUSION: Of these treatments, only migraine surgery and BT-A significantly improved migraine severity and duration, the first study to do so. Migraine surgery is a cost-effective treatment to reduce headache frequency, severity, and duration without significant risk of complications compared to placebo. BT-A is also effective in reducing severity and duration with improved migraine burden, but is associated with significantly more adverse events and greater lifetime cost. REFERENCES: 1. Moisset X, Pereira B, Ciampi de Andrade D, et al., Neuromodulation techniques for acute and preventive migraine treatment: a systematic review and meta-analysis of randomized controlled trials. J Headache Pain. 2020; 21(1): p. 142. 2. Nagori SA, Jose A, and Roychoudhury A, Surgical Management of Migraine Headaches: A Systematic Review and Meta-analysis. Ann Plast Surg. 2019; 83(2): p. 232-240. 3. Shauly O, Gould DJ, Sahai-Srivastava S, and Patel KM, Greater Occipital Nerve Block for the Treatment of Chronic Migraine Headaches: A Systematic Review and Meta-Analysis. Plast Reconstr Surg. 2019; 144(4): p. 943-952. 4. Bruloy E, Sinna R, Grolleau JL, et al., Botulinum Toxin versus Placebo: A Meta-Analysis of Prophylactic Treatment for Migraine. Plast Reconstr Surg. 2019; 143(1): p. 239-250.

Comorbidity Trends in Patients Requiring Sternectomy and Reconstruction: Updated Data Analysis From 2005 to 2020.

Comorbidity trends after median sternectomy were studied at our institution by Vasconze et al (Comorbidity trends in patients requiring sternectomy and reconstruction. Ann Plast Surg. 2005;54:5). Although techniques for sternal reconstruction have remained unchanged, the patient population has become more complex in recent years. This study offers insight into changing trends in this patient population. A retrospective review was performed of patients who underwent median sternectomy followed by flap reconstruction at out institution between 2005 and 2020. Comorbidities, reconstruction method, average laboratory values, and complications were analyzed. A total of 105 patients were identified. Comorbidities noted were diabetes (27%), immunosuppression (16%), hypertension (58%), renal insufficiency (23%), chronic obstructive pulmonary disease (16%), and tobacco utilization (24%). The most common reconstruction methods were omentum (45%) or pectoralis major flaps (34%). Thirty-day mortality rates were 10%, and presence of at least 1 complication was 34% (hematoma, seroma, osteomyelitis, dehiscence, wound infection, flap failure, and graft exposure). Univariate analysis demonstrated that sex (P = 0.048), renal insufficiency, surgical site complication, wound dehiscence, and flap failure (P < 0.05) had statistically significant associations with mortality. In addition, body mass index, creatinine, and albumin had a significant univariate association with mortality (P < 0.05). Similar to the original study, there is an association between renal insufficiency and mortality. However, the mortality rate is decreased to 10%, likely because of improved medical management of patients with increasing comorbidities (80% with greater than one comorbidity). This has led to the increased use of omentum as a first-line option. Subsequent wound dehiscence and flap failure demonstrate an association with mortality, suggesting that increasingly complex patients are requiring a method of reconstruction once used a last resort as a first-line option.

Commentary: Lymph-axiality concept awareness reduces trauma-induced lymphedema (commentary on JPRAS-D-20-01255: Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosis)

Depending on the stage of secondary lymphedema, surgical treatments can be categorized into reconstructive (e.g., lymphovenous bypass and vascularized lymph nodes transfers 1 Cheng M.H. Chen S.C. Henry S.L. et al. Vascularized groin lymph node flap transfer for postmastectomy upper limb lymphedema: flap anatomy, recipient sites, and outcomes. Plast Reconstr Surg. 2013; 131: 1286-1298 Google Scholar ) and debulking procedures (e.g., lipoaspiration 2 Brorson H. Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998; 102 (discussion 1068): 1058-1067 Google Scholar , modified Charles’ procedures 3 van der Walt J.C. Perks T.J. Zeeman B.J. et al. Modified Charles procedure using negative pressure dressings for primary lymphedema: a functional assessment. Ann Plast Surg. 2009; 62: 669-675 Google Scholar ). Lymph-interpositional-flap transfer (LIFT) based on lymph-axiality concept: Simultaneous soft tissue and lymphatic reconstruction without lymph node transfer or lymphatic anastomosisJournal of Plastic, Reconstructive & Aesthetic SurgeryVol. 74Issue 10PreviewLymphatic system is important to maintain homeostasis. Lymph-axiality concept has been reported, which suggests possibility of lymphatic reconstruction using flap transfer without lymph node or supermicrosurgical lymphatic anastomosis. Full-Text PDF

The Opportunity Cost of Resident Involvement in Craniofacial Surgery: An Analysis of Relative Value Units

PURPOSE: Within the academic surgical setting, it has been well-established that resident involvement confers longer operative times. While academic faculty have historically prioritized the education and training of residents, the increasing pressures to maximize clinical productivity and decreasing reimbursement rates may conflict with these principles. Using relative value unit (RVU)-based analysis, the purpose of this study is to calculate the opportunity cost of resident involvement in a myriad of common craniofacial surgical procedures. METHODS: Retrospective analysis was conducted with patients who underwent craniofacial procedures from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2012. Patients were selected based on relevant Current Procedural Terminology (CPT) codes for five common craniofacial pathologies (ie, trauma, head and neck reconstruction, orthognathic surgery, and facial reanimation). Variables collected included patient demographics, operative time, presence or absence of resident trainee, and postgraduate year (PGY) level. Average RVUs were calculated to determine the opportunity cost of resident involvement for each craniofacial procedure. Independent student t-test were used for statistical analysis. P < 0.05 was considered significant. RESULTS: In total, 2189 patients were identified after reviewing the ACS-NSQIP database from 2005 to 2012. Resident involvement was associated with a statistically significant higher operative time (P < 0.001) for facial reanimation, facial trauma, orthognathic surgery, and head and neck reconstruction. The opportunity costs associated with resident involvement were the highest for head and neck reconstruction ($1,468.04), followed by orthognathic surgery ($1247.03), facial trauma ($533.03), and facial reanimation ($358.32). Resident involvement was associated with a higher rate of complications for head and neck reconstruction (P < 0.043). CONCLUSIONS: Resident involvement is largely associated with longer operative times, higher complications, and higher re-operations, compared with attending-exclusive surgical care. With increasing pressures to maximize clinical productivity and shifts toward value-based care, one may consider how reimbursements should reflect resident involvement and ultimately, align incentives for academic surgeons to promote resident education and training. REFERENCES: 1. Zhu W, Beletsky A, Kordahi A, et al. The cost to attending surgeons of resident involvement in academic hand surgery. Ann Plast Surg. 2019;82:S285–S288. 2. Aibel K, Truong T, Shammas RL, et al. Assessing the effort associated with teaching residents. J Plast Reconstr Aesthet Surg. 2017;70:1725–1731. 3. Sasor S, Flores RL, Wooden WA, et al. The cost of intraoperative plastic surgery education. J Surg Educ 2013;70(5):655–659. 4. Nguyen K, Gart MS, Smetona, JT, et al. The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures. ePlasty 2012;12:500–510. 5. American College of Surgeons. American College of Surgeons national surgical quality improvement. Available at: https://www.facs.org/Quality-Programs/ACS-NSQIP. Published 2020. Retrieved February 28, 2021.

ENDOBRONCHIAL GLOMUS TUMOR: AN UNUSUAL LOCATION FOR A RARE MALIGNANCY

TOPIC: Lung Cancer TYPE: Medical Student/Resident Case Reports INTRODUCTION: Glomus tumors are rare neoplasms which usually arise from the glomus bodies in the subungual dermis of the hands and feet. Cases of endobronchial glomus tumors present an already rare malignancy in an exceedingly rare location. CASE PRESENTATION: A 76 year-old female who presented with productive cough and progressive dyspnea underwent a CT chest which indicated a 16x14x17 mm right lower-lobe endobronchial mass. Bronchoscopy demonstrated a completely obstructing and vascular appearing mass in right lower lobe which was followed by endobronchial biopsy and incomplete tumor resection. Histological examination confirmed the diagnosis of glomus tumor. Patient was evaluated by radiation oncology and approved for radiation therapy but declined, given symptomatic improvement following partial resection. DISCUSSION: Glomus tumors are rare, typically benign, malignancies that arise from neuromyoarterial glomus bodies, which have a strong predilection for subungual location. These malignancies account for 2% of soft tissue tumors. Rarely, these tumors can occur in extra-cutaneous sites such as bone, gastrointestinal tract and lungs. Most cases of endobronchial glomus tumors are asymptomatic but depending on size and location of tumor, patients may present with dyspnea, wheeze, or other respiratory complaints. Most glomus tumors are benign but malignant characteristics include: >2cm in size, visceral in location, and containing atypical mitotic figures. Glomus tumors are slow growing neoplasms that are characterized as small, uniform, and containing round nuclei with each cell surrounded by basal lamina. CONCLUSIONS: Due to the rarity of extracutaneous glomus tumors reported in the literature their clinical course and prognosis are unknown. Most clinicians recommend surgical resection as definitive treatment but endobronchial therapy such as ablation can be considered. If lesion is intrapulmonary, a sub-lobar resection may be sufficient but lobectomy may be required for large masses that are centrally located. In our case, the patient forwent further treatment given the asymptomatic nature of her post-operative course and opted for serial monitoring for tumor recurrence. This case highlights an exceedingly rare location for a fortunately benign malignancy. REFERENCE #1: Chou T, Pan SC, Shieh SJ, Lee JW, Chiu HY, Ho CL. Glomus Tumor: Twenty-Year Experience and Literature Review. Ann Plast Surg. 2016 Mar;76 Suppl 1:S35-40. doi: 10.1097/SAP.0000000000000684. PMID: 26808758. REFERENCE #2: Valle, Javier Alonso Baena-Del, et al. "Glomus Tumour of the Lung: A Case Report and Literature Review." Cirugía y Cirujanos (English Edition), Elsevier, 20 Apr. 2016, www.sciencedirect.com/science/article/pii/S2444050715000650. REFERENCE #3: Yun, Ju Sik, et al. "Synchronous Primary Glomus Tumor in a Patient with Adenocarcinoma of the Ipsilateral Lung." Thoracic Cancer, John Wiley & Sons Australia, Ltd, May 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6501053/. DISCLOSURES: No relevant relationships by Joseph Flynn, source=Web Response No relevant relationships by Stephen Mitchell, source=Web Response No relevant relationships by John Wynne, source=Web Response

Orofacial clefts: treatment based on a multidisciplinary approach

Orofacial clefts: treatment based on a multidisciplinary approach

A Cost–Utility Analysis Comparing Immediate Oncoplastic Surgery to Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients

PURPOSE: Oncoplastic surgery allows for lower positive margin rates and improved aesthetic outcomes compared with traditional breast conservation surgery.1 A Level 2 volume displacement oncoplastic surgery (LVOS) (also known as an oncoplastic reduction) allows for a large partial mastectomy through a reduction mammoplasty incision and is ideal for breast cancer patients with macromastia. Typically, a concurrent ipsilateral reduction mammoplasty is also performed.2,3 However, if the patient is a smoker, the decision to perform a concurrent reconstruction is challenging. It can be argued that in order to allow sufficient time for the patient to stop smoking, reconstruction should be delayed until after adjuvant radiation. However, radiation can also cause poor wound healing and can increase the risk of a wound-related complication. LVOS with immediate and delayed reconstruction are associated with different clinical outcomes and costs. Our aim was to examine the cost–utility of immediate versus delayed reconstruction in LVOS when operating on a smoking patient with macromastia and a long-term commitment to smoking cessation. METHODS: A literature review was performed to determine the probabilities and outcomes related to the treatment of unilateral breast cancer with immediate or delayed reconstruction with LVOS.1–3 Reported utility scores were used to estimate the quality adjusted life years associated with a successful procedure as well as postoperative complications. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy. An incremental cost–utility ratio was calculated. Single variable and probabilistic sensitivity analyses were performed to validate the robustness of the results. RESULTS: Immediate LVOS is associated with a higher clinical effectiveness (quality adjusted life years) of 33.3 compared with delayed (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative incremental cost–utility ratio of −50,194, which was in favor of immediate reconstruction, indicating a dominant strategy. In 1-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery costs less and is the more effective strategy. CONCLUSIONS: Despite the known risk of postoperative complications associated with smoking, immediate LVOS is more cost-effective compared with delayed LVOS. The risks of postoperative complications are higher when operating on a radiated breast in the delayed setting, thus favoring immediate LVOS. REFERENCES: 1. Munhoz AM, Aldrighi CM, Montag E, et al. Outcome analysis of immediate and delayed conservative breast surgery reconstruction with mastopexy and reduction mammaplasty techniques. Ann Plast Surg. 2011;67:220–225. 2. Asban A, Homsy C, Chen C, et al. A cost-utility analysis comparing large volume displacement oncoplastic surgery to mastectomy with single stage implant reconstruction in the treatment of breast cancer. Breast. 2018;41:159–164. 3. Chatterjee A, Offodile II AC, Asban A, et al. A cost-utility analysis comparing oncoplastic breast surgery to standard lumpectomy in large breasted women. Adv Breast Cancer Res. 2018;7:187–200.

The Silent Majority: A Mixed Methods Analysis on the Perspectives of Women Who Forgo Post Mastectomy Breast Reconstruction

PURPOSE: Post mastectomy breast reconstruction (PMBR) is an important component of breast cancer care that is associated with improved psychosocial well-being and survival.1–3 The Women’s Heath and Cancer Rights Act of 1998 mandated insurance coverage for reconstruction; however, rates of PMBR remain stagnant at approximately 40%.4 There is a paucity of research on women who forgo reconstruction despite representing the majority of the post mastectomy patient population.5 This study addresses that gap by investigating barriers in the preoperative pathway faced by patients who forgo PMBR. METHODS: A mixed-methods study was performed using in-depth qualitative interviews and the BREAST-Q questionnaire. The study population consisted of women who received a referral to plastic surgery but choose to forgo PMBR. Women were stratified into 2 groups based on utilization of the referral to plastic surgery or lack thereof. Separate interview guides were developed for both groups, and interviews were conducted until data saturation was reached. Interviews were coded and analyzed using iterative methodologies (eg, open, axial, and selective coding) under the grounded-theory framework. The qualitative interview data and quantitative BREAST-Q data were analyzed using concurrent triangulation methodology. Reliability and validation checks included member-checking and inter-rater reliability using Cohen’s kappa statistic (mean kappa = 0.99). RESULTS: Interviews with 8 patients who forwent PMBR revealed: (1) lack of trust in both breast and plastic surgeons was salient; (2) reliance on self-developed support networks and resources; (3) association between lower post mastectomy BREAST-Q scores and decreased utilization of referral to plastic surgery; and (4) dissonance between numerical BREAST-Q scores for psychosocial well-being and reported satisfaction. CONCLUSIONS: These findings lay the conceptual groundwork acknowledging that nonlegislative and nonfinancial barriers, such as physician distrust and lack of resources and patient-tailored information, contributes to underutilization of PMBR in certain populations. Use of qualitative methodology uncovered deficits in the current pathway to reconstruction faced by the silent majority of women who forgo PMBR including lack of trust in physicians, resources, and counseling. These findings suggest unmet needs of patients considering PMBR which necessitates efforts to address these deficits and increase quality of life and satisfaction after mastectomy by empowering vulnerable patient groups. REFERENCES: 1. Ng SK, Hare RM, Kuang RJ, et al. Breast reconstruction post mastectomy: patient satisfaction and decision making. Ann Plast Surg. 2016;76:640–644. 2. Lee CN, Deal AM, Huh R, et al. Quality of patient decisions about breast reconstruction after mastectomy. JAMA Surg. 2017;152:741–748. 3. Sheehan J, Sherman KA, Lam T, et al. Association of information satisfaction, psychological distress and monitoring coping style with post-decision regret following breast reconstruction. Psychooncology. 2007;16:342–351. 4. American Cancer Society. What are the key statistics about breast cancer? Available at http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-key-statistics. 5. Alderman AK, Hawley ST, Janz NK, et al. Racial and ethnic disparities in the use of postmastectomy breast reconstruction: results from a population-based study. J Clin Oncol. 2009;27:5325–5330.

Economizing the Septal Cartilage for Grafts During Rhinoplasty, 40 Years' Experience.

During rhinoplasty, it is typically necessary to use cartilage to shape and support the final nasal construct to provide both form and function to the nose (Tanna et al. in Plast Reconstr Surg 141(1):137e-151e, 2018; Guyuron in Plast Reconstr Surg 105(6):2257-2259, 2000; Kim et al. in Ann Plast Surg 65(6):519-523, 2010). The septal cartilage is the ideal graft both for its ease of access and quality of cartilage. However, this graft is a limited resource, and economy of its use is important as to negate the need to harvest cartilage from the ear or rib. 1. To share the senior author's 40years' experience with the economy of septal cartilage. 2. To identify the areas of the septal cartilage most suitable for a particular graft. 3. To discuss the common grafts that are used in rhinoplasty. 4. To identify when other sources of cartilage are needed and where to best use those grafts. 5. To present option for preservation of the leftover septal cartilage. Overall consideration should focus on the size, thickness, and curvature of the graft contemplating the structural and functional needs of the rhinoplasty maneuvers. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Quick and Reliable Method to Decellularize a Gracilis Flap: A Crucial Step Toward Building a Muscle.

Tissue loss as a consequence of congenital anomalies, trauma, malignancy, or gangrene represents a major health care problem in the United States. Because younger individuals are disproportionately affected, the costs are magnified over time and the resultant individual and societal effects are tremendous. The currently available options to restore soft tissue defects are associated with donor site morbidities. Vascularized composite allotransplantation may provide form, function, and esthetics without a donor site; however, it comes with the significant risk associated with toxic immunosuppression (Biomaterials. 2015;61:246-256, Ann Plast Surg. 2015;75(1):112-116, Transplantation. 2009;88(2):203-210). Engineered tissues offer promise in finding viable alternatives to allograft and autologous tissues. In this study, we present our simple and quick method to decellularize a muscle without disrupting the vascular network integrity or the extracellular matrix. Optimizing the decellularization process is a crucial step toward creating an "off-the-shelf" flap that can be used for soft tissue reconstruction. The superficial gracilis muscle of 20 rats were harvested on their circulation and decellularized using perfusion with Krebs-Henseleit buffer and sodium dodecyl sulfate for 6 hours. These flaps were evaluated by gross morphology, histology, DNA quantification, integrity of the vascular network, scanning electron microscopy, and transmission electron microscopy. All samples were decellularized successfully as determined by DNA content and histological analysis for cellular content. The vascular network was preserved in all samples. We present a quick, simple, and affordable method to decellularize a muscle flap through the vascular network. Our proposed method is efficient and can be completed in a significantly shorter time when compared with other methods. It is also safe and does not affect integrity of tissue, and this is essential for a reliable recellularization.

Evidence appraisal of Wiser I, Plonski L, Shimon N, Freidman T, Heller L. Surgical site infection risk factor analysis in postbariatric patients undergoing body contouring surgery: a nested case-control study. Ann Plast Surg. 2019;82(5):493-498.

Evidence appraisal of Wiser I, Plonski L, Shimon N, Freidman T, Heller L. Surgical site infection risk factor analysis in postbariatric patients undergoing body contouring surgery: a nested case-control study. Ann Plast Surg. 2019;82(5):493-498.

Retracted or Withdrawn Publications in Journals Relating to Plastic Surgery.

The aim of this study was to determine how many papers have been retracted or withdrawn, and for what reason, in journals relating to plastic surgery.PubMed and SCOPUS were used, with the search terms (retracted OR withdrawn) AND (article OR publication OR paper) AND {(plastic surgery) OR (cosmetic surgery) OR (maxillofacial surgery) OR (craniofacial surgery)}. The papers were analyzed and classified according to the reason for retraction or withdrawal, journal name, publication year, and author. In the PubMed and SCOPUS, 227 and 114 titles were found, respectively, from which 34 duplicate titles were removed. An additional 261 titles which did not include "retracted" or "withdrawn" were removed, leaving 46 papers and 6 mined papers were added. The 52 full texts (42 "retracted" and 10 "withdrawn") were analyzed.The most frequent reason for retraction or withdrawal was duplication (17, 32.7%) followed by the author's request (9, 17.3%), plagiarism (7, 13.5%), and lack of permission (5, 9.6%). Retraction was most common in Plast Reconstr Surg (6, 12%) followed by Aesthetic Plast Surg (4, 7.9%), Ann Plast Surg (2, 3.9%), J Plast Reconstr Aesthet Surg (2, 3.9%), and Surg Res (2, 3.9%). Most authors retracted a paper just once; however, 6 authors retracted a paper twice or more. The first retraction was found in 1991, and the number of retractions showed a tendency to increase over time. However, the duplication rate did not change over time (R = 0.178, P = 0.117).Journal reviewers, as well as production editors, should check for duplication, plagiarism, or permission-related problems.

Abstract: Referrals of Plastic Surgery Patients to Integrative Medicine Centers: A Review of Resource Utility

INTRODUCTION: Integrative medicine (IM) centers are becoming increasingly more established nationwide and provide an expansive range of therapeutic services. With a high prevalence of IM usage among plastic surgery patients,1 we seek to define the rate of referrals to IM centers by plastic surgeons to define resource utility. METHODS: Institutions with plastic surgery residency programs and IM centers were identified. A survey questionnaire was sent to center directors to ascertain referral patterns. RESULTS: Out of a total of 96 institutions with plastic and reconstructive surgery programs in North America, 24(25%) have affiliated named IM centers, of which we attained a survey response from 13 (54.5%). 10 (76.9%) of these centers evaluate over 50 patients per week. Patient referrals were primarily from the Department of Medicine (73.8%) as opposed to Surgery (13.1%) (p<0.0001). An average of 0.77% of surgical referrals, or 0.077% of all referrals, arise from plastic and reconstructive surgery. CONCLUSION: IM centers surveyed are infrequently referred patients from plastic surgeons. Given the high prevalence of IM usage among our patient population, IM centers are an underutilized adjunct in the care of our patients. Further study into specific IM services that may benefit our patients would be helpful in increasing IM utilization in our field. Referral Citations: 1. Patel N, Pierson J, Lee T, et al. Utilization and Perception of Integrative Medicine Among Plastic Surgery Patients. Ann Plast Surg. Oct 17 2016.

Abstract: Incisional Negative-Pressure Therapy Decreases Complications in Ventral Hernia Repair with Simultaneous Panniculectomy

INTRODUCTION: Ventral hernia repair with simultaneous panniculectomy is associated with high wound complication rates.1 Some surgeons believe negative-pressure therapy (NPT) after primary closure of the surgical incision may lower wound complications. Although NPT has been shown to decrease complications in sternal and groin incisions, the benefit in ventral hernia repair is unknown and NPT in ventral hernia repair with simultaneous panniculectomy has not been studied.2–4The purpose of this study is to retrospectively analyze if patients undergoing ventral hernia repair with simultaneous panniculectomy have improved outcomes with NPT. METHODS: An eight-year retrospective study (2007–2015) was performed on patients undergoing ventral hernia repair with panniculectomy at University of Maryland Medical Center / R Adams Cowley Shock Trauma Center. Patients who underwent ventral hernia repair with simultaneous panniculectomy and incisional negative-pressure therapy using the Prevena V.A.C system (KCI, San Antonio, Tx) were compared to patients who underwent ventral hernia repair with simultaneous panniculectomy and standard sterile dressings (SSD). Patient characteristics and post-operative complications were compared between these groups. Wound complications were defined as skin dehiscence, skin necrosis, development of chronic wound, surgical site infection, seroma, and hematoma. RESULTS: A total of 106 patients were analyzed; 64 in the NPT group and 42 in the SSD group. The two groups were similar in terms of BMI (39 kg/m2 vs 37 ± 8 kg/m2, p=0.288), gender (84% female vs 79% female, p=0.446), and smoking status (30% vs 22%, p=0.382). Patients in the NPT group were older (56 vs 50, p=0.013), had larger hernia size (120 cm2 vs 55cm2, p=0.029), were more likely to have a history of recurrent hernias (80% vs 55%, p=0.006) and required component separation at the time of VHR (80% vs 50%, p=0.001). Nevertheless, despite having higher risk factors, patients in the NPT group had less wound complications (45% vs 69%, p=0.016). CONCLUSION: This study showed that incisional negative pressure therapy in ventral hernia repair with simultaneous panniculectomy decreases wound complications. Reference Citations: 1. Koolen PGL, Ibrahim AMS, Kim K, et al. Patient selection optimization following combined abdominal procedures: analysis of 4925 patients undergoing panniculectomy/abdominoplasty with or without concurrent hernia repair. Plast Reconstr Surg. 2014;134(4):539e-50e. 2. Pauli EM, Krpata DM, Novitsky YW, Rosen MJ. Negative pressure therapy for high-risk abdominal wall reconstruction incisions. Surg Infect (Larchmt). 2013;14(3):270–274. doi:10.1089/sur.2012.059. 3. Matatov T, Reddy KN, Doucet LD, Zhao CX, Zhang WW. Experience with a new negative pressure incision management system in prevention of groin wound infection in vascular surgery patients. J Vasc Surg. 2013;57(3):791–795. 4. Conde-Green A, Chung TL, Holton LH 3rd, et al. Incisional negative-pressure wound therapy versus conventional dressings following abdominal wall reconstruction: a comparative study. Ann Plast Surg. 2013;71(4):394–397.

Outcome of Dupuytren Contractures After Collagenase Clostridium Histolyticum Injection: A Single-institution Experience.

Collagenase clostridium histolyticum (CCH) injection is an alternative to surgery for patients with Dupuytren disease (DD) of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. The success of surgical and nonsurgical treatment modalities for DD is reported to vary widely between 25% and 80% (J Bone Joint Surg Am. 1985;67:1439-1443; Plast Reconstr Surg. 2007;120:44e-54e; J Bone Joint Surg Am. 2007;89:189-198; J Hand Surg Am. 2011:36:936-942; J Hand Surg Am. 1990;15:755-761; J Hand Surg Br. 1996;21:797-800; J Bone Joint Surg Br. 2000;82:90-94; Plast Reconstr Surg. 2005;115:802-810; Ann Plast Surg. 2006;57:13-17). This study presents the outcomes of patients with DD contractures treated with CCH injections at a single institution. An institutional review board-approved retrospective study was conducted of patients with DD of the hand treated with CCH injections in a single institution from February 2010 to April 2015. All patients received the recommended dose of 0.58 mg of CCH and returned for joint manipulation the following day. Data for follow-up at 7 and 30 days postoperatively and up to 5 years for patients who returned seeking further therapy for recurrent symptoms were reviewed. One hundred thirteen patients with a total of 146 affected joints (72 MCP; 74 PIP) were treated with CCH injections (95 males; 18 females; age, 40-92 y). Successful CCH therapy occurred in 75% of injected joints (109/146 joints; 59 MCP; 50 PIP), as defined by less than 5 degrees of contracture after treatment. Twenty-three percent of treated joints had partial correction (34/146 joints; 13 MCP; 21 PIP), as defined by between 5 and 30 degrees of residual contracture after treatment. Three patients (2%) had a failure of treatment, as defined by unchanged or worsened contracture from pretreatment baseline measurements. Fifteen patients (13%) returned to the clinic seeking additional therapy for recurrent joint contracture symptoms in 17 joints over a span of 1.5 months to 4 years after initial successful or partially successful treatment (17/143, 12%; 5 MCP; 12 PIP). Recurrence was defined as patients who sought treatment for a return of symptoms or greater than 20 degrees contracture in the setting of a palpable cord after initial full or partial contracture correction. Our 5-year outcome of CCH injections for DD contractures revealed full correction in 75% and partial correction in 23% of treated joints, with failure of treatment seen in only 2% of patients. Thirteen percent of the patients returned for additional treatment because of symptoms resulting from contracture recurrence in 12% of initially corrected or partially corrected joints. These positive outcomes are comparable with current surgical treatment modalities (J Hand Surg Am. 1990;15:755-761; J Bone Joint Surg Am. 1962;44B:602-613; J Clin Epidemiol. 2000;53:291-296). The use of CCH injections is an important nonsurgical treatment alternative for DD contractures of the MCP and PIP joints.

Paravertebral Blocks Reduce Narcotic Use Without Affecting Perfusion in Patients Undergoing Autologous Breast Reconstruction.

Autologous breast reconstruction offers excellent long term outcomes after mastectomy. However, maintaining adequate postoperative analgesia remains challenging. Use of paravertebral blocks (PVBs) reduces postoperative narcotic use and length of stay, and enhanced recovery protocols with mixed analgesia methods are gaining popularity, but few studies have explored the intraoperative effects of these interventions. Patients who underwent abdominally based autologous breast reconstruction between 2010 and 2016 were compiled into a retrospective database. We used electronic medical records to determine demographics, as well as perioperative and intraoperative vital signs and narcotic, anxiolytic, crystalloid, colloid, blood product, and vasopressor requirements, and postoperative complications. Results were compared between patients who had a PVB and those who did not and those who had a PVB alone and those who followed our enhanced recovery protocol using standard statistical methods and adjusting for preoperative values. A total of 170 patients were included in the study. Sixty-six had a PVB, and 104 did not. Of the 66 who had a PVB, 19 followed our enhanced recovery protocol. Patients who did not have a PVB required 171.6mg of total narcotic medication in the perioperative period, those with a PVB alone required 146.9mg, and those who followed the ERAS protocol 95.2mg (p=0.01). There was no difference in intraoperative mean arterial pressure, time with mean arterial pressure <80% of baseline, vasopressor use, or fluid requirement. There was no difference in complication rate. PVBs and an enhanced recovery protocol reduce the use of narcotic medications in autologous breast reconstruction without impacting intraoperative hemodynamics. Breast reconstruction after mastectomy restores body image and improves health-related quality of life, satisfaction with appearance and physical, psychosocial, and sexual well-being (Donovan et al. in J Clin Oncol 7(7):959-968, 1989; Eltahir et al. in Plast Reconstr Surg 132(2):201e-209e, 2013; Jagsi et al. in Ann Surg 261(6):1198-1206, 2015). For patients pursuing breast reconstruction, there are two major options: prosthetic (tissue expander/implant) or autologous reconstruction. However, while providing exceptional long-term outcomes, postoperative pain and length of hospital stay remains a major challenge preventing more widespread adoption of autologous breast reconstruction (Albornoz et al. in Plast Reconstr Surg 131(1):15-23, 2013; Gurunluoglu et al. in Ann Plast Surg 70(1):103-110, 2013; Kulkarni et al. in Plast Reconstr Surg 132(3):534-541, 2013; Sbitany et al. in Plast Reconstr Surg 124(6):1781-1789, 2009). Acute postoperative pain contributes to prolonged hospital stays, increased narcotic use, and associated risks of the aforementioned.

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Since 1-stage phallic reconstruction using the radial forearm free flap was reported in 1984 by Chang and Hwang 1 Chang T.S. Hwang W.Y. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984; 74: 251-258 Crossref PubMed Scopus (323) Google Scholar and Kao et al, 2 Kao X.S. Kao J.H. Ho C.L. Yang Z.N. Shi H.R. One-stage reconstruction of the penis with free skin flap: report of three cases. J Reconstr Microsurg. 1984; 1: 149 Crossref PubMed Scopus (30) Google Scholar the radial forearm free flap has become the most frequently used flap in penile reconstruction. Massanyi et al reported positive results using this technique in patients with exstrophy. 3 Massanyi E.Z. Gupta A. Goel S. et al. Radial forearm free flap phalloplasty for penile inadequacy in patients with exstrophy. J Urol. 2013; 190: 1577-1582 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The technique of phallic reconstruction using radial forearm free flap is universally considered the standard technique for penile reconstruction. 4 Hage J.J. Bout C.A. Bloem J.J. Megens J.A. Phalloplasty in female-to-male transsexuals: what do our patients ask for?. Ann Plast Surg. 1993; 30: 323-326 Crossref PubMed Scopus (85) Google Scholar , 5 Fang R.H. Kao Y.S. Ma S. Lin J.T. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999; 52: 217-222 Abstract Full Text PDF PubMed Scopus (100) Google Scholar , 6 Monstrey S. Hoebeke P. Dhont M. et al. Radial forearm phalloplasty: a review of 81 cases. Eur J Plast Surg. 2005; 28: 206-212 Crossref Scopus (59) Google Scholar , 7 Monstrey S. Hoebeke P. Selvaggi G. et al. Penile reconstruction: is the radial forearm really the standard technique?. Plast Reconstr Surg. 2009; 124: 510-518 Crossref PubMed Scopus (191) Google Scholar