Augmentation Mastopexy with Surgical Excision of the Lower Pole to Avoid Waterfall Deformity: A Surgical Technique and Nipple Areolar Complex Case Series.

Purpose of this article is to demonstrate a way of avoiding the waterfall deformity in augmentation mastopexy patients. We will show a case series of results and explain how this technique gives satisfying aesthetic results for patients seeking breast augmentation who also require mastopexy. We will show how addressing the breast parenchyma on the lower pole via direct excision can give reliable results and avoids the waterfall deformity. The surgical technique used by the senior author combines the principles of breast augmentation, mastopexy, and breast reduction. We apply these principles during the initial single operation. Our goal is to achieve the best anatomical results for the patient. We describe 1538 consecutive patients whom underwent single-stage breast augmentation with mastopexy. All implants were submuscular with 12% being saline and 88% were silicone implants. Vertical mastopexies were performed in 8% and wise pattern incisions were used in 92%. There were no life-threatening complications such as deep vein thrombosis, pulmonary embolism, and so on. Tissue-related complications included wound infection (1%) and hematomas (1%). Implant-related complications included malposition or implant displacement 9% and capsular contracture 1%. Aesthetic complications included dystopia of NAC (4%) and volume asymmetries (10%). Revision surgery was tissue related (2%), implant related (3%), and aesthetic related (10%). There were no cases of waterfall deformity seen in the cohort. In conclusion, we believe that the technique detailed here is easy to do, uses principles already known of breast augmentation and reduction and gives consistent results with low reoperation rates.

Le présent article vise à établir un moyen d'éviter les malformations en cascades chez les patientes ayant subi une mastopexie d'augmentation. Les auteurs présentent une série de cas et expliquent en quoi leur technique donne des résultats esthétiques satisfaisants pour les patientes qui veulent une augmentation mammaire et ont également besoin d'une mastopexie. Ils démontrent en quoi le traitement d'un parenchyme mammaire du pôle inférieur par excision directe peut donner des résultats fiables et éviter une malformation en cascades. La technique chirurgicale utilisée par l'auteur principal combine les principes d'augmentation mammaire, de mastopexie et de réduction mammaire. Les auteurs appliquent ces principes pendant l'opération initiale unique. Ils avaient l'objectif de réaliser les meilleurs résultats anatomiques pour les patients. Les auteurs ont décrit 1 538 patients consécutifs qui avaient subi une augmentation mammaire en une étape accompagnée d'une mastopexie. Tous les implants étaient sous-musculaires, 12 % étaient remplis de solution saline et 88 % étaient en silicone. Des mastopexies verticales ont été effectuées dans 8 % des cas, et des incisions en motifs prudents, dans 92 % des cas. Il n'y a pas eu de complications au potentiel mortel comme des thromboses veineuses profondes, des embolies pulmonaires, etc. Les complications tissulaires incluaient les infections des plaies (1 %) et les hématomes (1 %). Les complications liées aux implants incluaient une malposition ou un déplacement des implants dans 9 % des cas, et une contracture capsulaire dans 1% des cas. Les complications esthétiques incluaient la dystopie N-acétylcystéine (4 %) et l'asymétrie des volumes (10 %). Les opérations de révision étaient liées aux tissus (2 %), aux implants (3 %) et aux anesthésiques (10 %). Il n'y a pas eu de malformation en cascades dans la cohorte. Pour terminer, les auteurs sont d'avis que la technique est facile à effectuer, fait appel à des principes d'augmentation et de réduction mammaires déjà connus et donne des résultats uniformes liés à un faible taux de réopération.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

Reverse Radial Artery Flap Perforator Anatomy and Clinical Applications.

The pedicled reverse radial forearm flap is a well-known option for the treatment of a variety of soft tissue wounds including dorsal hand wounds. We document the number, emerging diameter, length from origin, course, and location of all perforators of the radial artery in a series of 6 fresh human cadavers after whole body lead oxide and gelatin injection to confirm and comprehensively document the anatomy of the radial artery perforators. This data provide an anatomic basis for a modification to the reversed radial forearm flap used to decrease venous congestion in the postoperative period. Two case reports are presented to provide clinical demonstration of the importance of this modification.

Characterization of the cell surface properties of drinking water pathogens by microbial adhesion to hydrocarbon and electrophoretic mobility measurements.

The surface characteristics of microbial cells directly influence their mobility and behavior within aqueous environments. The cell surface hydrophobicity (CSH) and electrophoretic mobility (EPM) of microbial cells impact a number of interactions and processes including aggregation, adhesion to surfaces, and stability of the cells within the aqueous environments. These cell characteristics are unique to the bacterial species and are a reflection of the large diversity of surface structures, proteins, and appendages of microorganisms. CSH and EPM of bacterial cells contribute substantially to the effectiveness of drinking water treatment to remove them, and therefore an investigation of these properties will be useful in predicting their removal through drinking water treatment processes and transport through drinking water distribution systems. EPM and CSH measurements of six microbiological pathogen or surrogate species suspended in phosphate-buffered water are reported in this work. Two strains of Vibrio cholerae were hydrophobic, while three strains of Escherichia coli were hydrophilic. Bacillus cereus was categorized as moderately hydrophobic. The strains of E. coli had the highest (most negative) EPM. Based on the measurements, E. coli species is predicted to be most difficult to remove from water while V. cholerae will be the easiest to remove.

Endospore surface properties of commonly used Bacillus anthracis surrogates vary in aqueous solution.

The hydrophobic character and electrophoretic mobility (EPM) of microorganisms are vital aspects of understanding their interactions with the environment. These properties are fundamental in fate-and-transport, physiological, and virulence studies, and thus integral in surrogate selection. Hydrophobic and electrostatic forces are significant contributors to particle and microorganism mobility in the environment. Herein, the surface properties of commonly used Bacillus anthracis surrogate endospores were tested under comparable conditions with respect to culture, endospore purification, buffer type and strength. Additionally, data is presented of endospores suspended in dechlorinated tap water to evaluate the surrogates in regard to a breach of water infrastructure security. The surface properties of B. anthracis were found to be the most hydrophobic and least electronegative among the six Bacillus species tested across buffer strength. The effect of EPM on hydrophobicity varies in a species-specific manner. This study demonstrates that surrogate surface properties differ and care must be taken when choosing the most suitable surrogate. Moreover, it is shown that Bacillus thuringensis best represents Bacillus anthracis-Sterne with respect to both EPM and hydrophobicity across all test buffers.

Breast reduction scars: a prospective survey of patient preferences.

BACKGROUND: Studies have shown that scarring is a primary reason for patient dissatisfaction with reduction mammaplasty. OBJECTIVES: The authors prospectively evaluated patient preferences for the 3 most common breast reduction scar patterns: horizontal, vertical, and Wise. METHODS: Sixty-six patients were recruited for the study before receiving their reduction mammaplasty consultation. Each patient was shown line drawings and postoperative photographs of the 3 breast reduction techniques and scored the scars on a modified 10-point Likert scale (1 = unacceptable; 10 = acceptable). The survey responses had no impact on the patients' medical care. A nonparametric Friedman test was used to compare the mean scores, and univariate generalized linear regression analysis was performed to adjust for confounding factors. Post hoc analysis was performed using the Bonferroni method. Significance was set at P < .001. RESULTS: Sixty patients completed the study. The mean preference ranking was significantly higher for the horizontal scar pattern versus vertical and Wise (P < .001). The mean score difference between the horizontal and Wise patterns was 2.982. The mean difference between the horizontal and vertical patterns was 2.27. There was no significant difference in preference between the vertical and Wise patterns. Linear regression analysis showed that age, body mass index, and torso/bra size had no significant effect on preference. CONCLUSIONS: To our knowledge, this is the first study designed to prospectively evaluate patient preferences regarding postoperative scars. Results indicate that the horizontal technique is preferable with respect to scar placement.

International plastic surgery missions: a framework for resident education using the CanMEDS competencies.

Residency education has shifted over the past decade in an attempt to graduate well-rounded physicians. There is a recognition that a physician's abilities must extend beyond medical knowledge. The Royal College of Physicians and Surgeons of Canada introduced the CanMEDS physician competency framework in 2005. The framework provides 7 areas of competencies that are aimed at providing improved patient care. These competencies are medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Teaching and evaluating many of these competencies is often challenging for residency training programs. We believe that international surgical missions provide a prime opportunity to teach and evaluate all CanMEDS' roles.Plastic surgery is a field with many different organizations involved in international surgery. Many plastic surgery training programs offer opportunities for residents to become involved in these international surgical missions. Through these trips, residents gain surgical experience, see a variety and volume of clinical cases, and have the opportunity to travel to a foreign country and experience different cultures. We believe that international plastic surgery surgical missions also provide an exceptional micro environment for the teaching of CanMEDS roles. Using examples from residents' personal experiences on international plastic surgery missions to China, Mali, and Cambodia, we describe the benefits of these missions in transferring the CanMEDS competencies to resident training.

The horizontal breast reduction: Surgical tips for maintaining projection.

Reduction mammoplasty is one of the most common procedures performed by plastic surgeons in Canada. The Wise and vertical scar techniques are two of the most commonly published and performed. Although the horizontal breast reduction is a less commonly used technique, it offers added benefits over other procedures. These include elimination of the vertical scar and a consistently round nipple. However, one of the criticisms of the horizontal technique is the loss of projection of the breast mound. The present article outlines several important points that can aid in achieving an optimal aesthetic result when performing a horizontal breast reduction.

La plastie de réduction mammaire est l'une des interventions que les plasticiens du Canada pratiquent le plus. Les incisions verticales et de type Wise font partie des plus exécutées et des plus publiées. La technique de réduction mammaire horizontale est moins utilisée, mais elle a des avantages par rapport aux autres, y compris la disparition de la cicatrice verticale et le maintien d'un mamelon rond. Cependant, elle s'associe à des critiques sur la perte de projection de la protubérance mammaire. Le présent article expose plusieurs points importants qui peuvent contribuer à obtenir un résultat esthétique optimal dans le cadre d'une plastie de réduction mammaire horizontale.

Effect of pH on the electrophoretic mobility of spores of Bacillus anthracis and its surrogates in aqueous solutions.

The electrophoretic mobility (EPM) of endospores of Bacillus anthracis and surrogates was measured in aqueous solution across a broad pH range and several ionic strengths. EPM values trended around phylogenetic clustering based on the 16S rRNA gene. Measurements reported here provide new insight for Bacillus anthracis surrogate selection and for attachment/detachment and transport studies.

Microbial survey of a full-scale, biologically active filter for treatment of drinking water.

The microbial community of a full-scale, biologically active drinking water filter was surveyed using molecular techniques. Nitrosomonas, Nitrospira, Sphingomonadales, and Rhizobiales dominated the clone libraries. The results elucidate the microbial ecology of biological filters and demonstrate that biological treatment of drinking water should be considered a viable alternative to physicochemical methods.

Axon counts of potential nerve transfer donors for peroneal nerve reconstruction.

BACKGROUND: The common peroneal nerve is the most commonly injured nerve in the lower limb. Nerve transfer using expendable donor nerves is emerging in the literature as an alternative surgical procedure to traditional treatments. OBJECTIVE: To identify potential donors of motor axons from the tibial nerve that can be transferred to the common peroneal nerve branches. METHODS: Using 10 human cadaveric lower extremities, all motor nerve branches of the tibial nerve were identified and biopsied. These were compared with the motor branches to tibialis anterior and extensor hallucis longus (branches of the deep peroneal nerve). RESULTS: The most suitable donor nerves with respect to cross-sectional area to tibialis anterior (cross sectional area [mean ± SD] 0.255±0.111 mm) was the motor branch to lateral gastrocnemius (0.256±0.105 mm). When comparing the total number of axons, the branch to the tibialis anterior had a mean of 3363±1997 axons. The branch to the popliteus was most similar, with 3317±1467 axons. The most suitable donor nerves for the motor branch to extensor hallucis longus (cross sectional area 0.197±0.302 mm) with respect to cross-sectional area was the motor branch to flexor hallucis longus (0.234±0.147 mm). When comparing the total number of axons, the branch to the extensor hallucis longus had an average of 2062±2314 axons. The branch to the lateral gastrocnemius was most similar with 2352±1249 axons and was a suitable donor. CONCLUSION: Nerve transfers should be included in the armamentarium for lower extremity reinnervation, as it is in the upper limb.

HISTORIQUE: Le nerf péronier commun est le nerf des membres inférieurs qui subit le plus de blessures. Le transfert nerveux au moyen de nerfs sacrifiables de donneurs émerge dans les publications comme une intervention chirurgicale qui remplace les traitements classiques. OBJECTIF: Déterminer les donneurs potentiels d'axones moteurs du nerf tibial qui peuvent être transférés aux branches du nerf péronier commun. MÉTHODOLOGIE: Au moyen de dix membres inférieurs cadavériques humains, les chercheurs ont repéré toutes les branches nerveuses motrices du nerf tibial et en ont fait la biopsie. Ils les ont comparées avec les branches motrices du muscle tibial antérieur et du muscle long extenseur de l'hallux (branches du nerf péronier profond). RÉSULTATS: Les nerfs de donneurs qui convenaient le mieux à l'égard de la région transversale du muscle tibial antérieur (région transversale [moyenne±ÉT] de 0,255±0,111 mm) étaient la branche motrice du muscle gastrocnémien latéral (0,256±0,105 mm). Par rapport au nombre total d'axones, la branche du muscle tibial antérieur présentait une moyenne de 3 363±1 997 axones. La branche du muscle poplité était la plus similaire, avec 3 317±1 467 axones. Les nerfs de donneurs qui convenaient le mieux à la branche motrice du muscle long extenseur de l'hallux (région transversale de 0,197±0,302 mm) à l'égard de la région transversale étaient la branche motrice du muscle long fléchisseur de l'hallux (0,234±0,147 mm). Par rapport au nombre total d'axones, la branche du muscle long extenseur de l'hallux avait une moyenne de 2 062±2 314 axones. La branche du muscle gastrocnémien latéral était la plus similaire, avec 2 352±1 249 axones, et constituait un donneur convenable. CONCLUSION: Les transferts nerveux devraient faire partie de l'armada de réinnervation des membres inférieurs, comme ils le sont dans les membres supérieurs.

The usefulness of the bilobed flap for lateral cheek defects.

The cheek and nose are common areas for skin cancers. There are multiple approaches to surgical excision and reconstruction, depending on the size of defect, tissue quality, adjacent cosmetic units and hairline. An effective solution to skin defects of the lateral cheek is the bilobed flap. This flap tends to be underused in the lateral cheek area because primary closure and skin grafts are perceived to be easier methods of reconstruction. However, the use of the bilobed flap for lateral cheek and other defect closures is encouraged. There are several basic principles that are key when performing this flap. These components of the procedure are highlighted.

La joue et le nez sont des zones courantes de cancer de la peau. Il existe de multiples modes d'excision et de reconstruction chirurgicales, selon la dimension de l'anomalie, la qualité des unités esthétiques adjacentes et la ligne des cheveux. Le lambeau bilobé constitue une solution efficace aux anomalies cutanées de la joue latérale. Ce lambeau tend à être sous-utilisé dans cette zone, parce que la fermeture primaire et les greffes cutanées sont perçues comme des modes de reconstruction plus simples. Cependant, les auteurs encouragent l'utilisation du lambeau bilobé pour refermer les anomalies de la joue latérale et d'autres anomalies. Il faut respecter plusieurs principes de base lorsqu'on utilise ce lambeau. Les éléments de l'intervention sont soulignés.

Fluid Retention over the Menstrual Cycle: 1-Year Data from the Prospective Ovulation Cohort.

We report menstrual and mid-cycle patterns of self-reported "fluid retention" in 765 menstrual cycles in 62 healthy women. Self-reported "fluid retention," commonly described as bloating, is one element of the clinical assessment and diagnosis of premenstrual symptoms. These daily diary data were collected as part of an observational prospective one-year study of bone changes in healthy women of differing exercise characteristics. Ovulation was documented by quantitative basal temperature analysis, and serum estradiol and progesterone levels were available from initial and final cycles. Fluid retention scores (on a 0-4 scale) peaked on the first day of menstrual flow (mean ± SE : 0.9 ± 0.1), were lowest during the mid-follicular period, and gradually increased from 0.22 ± 0.05 to 0.50 ± 0.09 over the 11 days surrounding ovulation. Mid-cycle, but not premenstrual, fluid scores tended to be lower in anovulatory cycles (ANOVA P = 0.065), and scores were higher around menstruation than at midcycle (P < 0.0001). Neither estradiol nor progesterone levels were significantly associated with fluid retention scores. The peak day of average fluid retention was the first day of flow. There were no significant differences in women's self-perceived fluid retention between ovulatory and anovulatory cycles.

Foot reanimation via nerve transfer to the peroneal nerve using the nerve branch to the lateral gastrocnemius: case report.

Injury to the peroneal nerve can be devastating to a patient's daily function. By paralyzing the ankle dorsiflexors, peroneal neuropathy results in foot drop. Gait difficulties and other functional limitations impede these patients on a daily basis. Knee and ankle injuries, lacerations, and compression are only a few of many etiologies which make peroneal nerve palsy the most common neuropathy of the lower limb. We present a case of peroneal nerve palsy secondary to an ACL and lateral collateral ligament tears. This 18 year old male underwent foot reanimation via nerve transfer to the peroneal nerve using the branch from the lateral gastrocenus to tibalias anterior muscle branch. The patient was followed and assessed for function during the subsequent two years. This case reports provides a synopsis of this patient's surgical treatment, as well as a glance into the literature surrounding peroneal nerve transfer.