Anatomical Study of Domain Rescue of Palatal Length in Patients With a Wide Cleft Palate: Buccal Flap Reconstruction in Primary Palatoplasty.

BACKGROUND: This study characterizes the potential loss of velar length in patients with a wide cleft and rescue of this loss of domain by local flap reconstruction, providing anatomic evidence in support of primary lengthening of the soft palate during palatoplasty. METHODS: A retrospective review was conducted of all patients with a cleft palate at least 10mm in width, who underwent primary palatoplasty with a buccal flap prior to 18 months of age over a 2-year period. All patients underwent primary palatoplasty with horizontal transection of the nasal mucosa, which was performed after nasal mucosa repair, but prior to muscular reconstruction. The resulting palatal lengthening was measured and the mucosal defect was reconstructed with a buccal flap. RESULTS: Of the 22 patients included, 3 (13.6%) had a history of Pierre Robin sequence, and 5 (22.7%) had an associated syndrome. No patients had a Veau I cleft, 7 (31.8%) had a Veau II, 12 (54.5%) had a Veau III, and 3 had (13.6%) a Veau IV cleft. All patients had a right buccal flap during primary palatoplasty. The mean cleft width at the posterior nasal spine was 10.6 ± 2.82mm, and mean lengthening of the velum after horizontal transection of the nasal mucosa closure was 10.5 ± 2.23mm. There were 2 (9.1%) fistulas, 1 (4.5%) wound dehiscence, 1 (4.5%) 30-day readmission, and no bleeding complications. CONCLUSIONS: Patients with a wide cleft palate have a potential loss of 1cm velar length. The buccal flap can rescue the loss of domain in palatal length, and potentially improve palatal excursion.

A novel treatment of pediatric bilateral condylar fractures with lateral dislocation of the temporomandibular joint (TMJ) using transfacial pinning.

A 3-year-old patient sustained a tripartite mandibular fracture, including bilateral condylar fractures with lateral dislocation of the left condyle and symphyseal fracture. Staged lower jaw reconstruction with closed reduction of the laterally dislocated condyle, transfacial pinning between the mandibular angles, MMF using circummandibular wiring and intermaxillary fixation screws was performed.

The Underused Superomedial Pedicle Reduction Mammaplasty: Safe and Effective Outcomes.

BACKGROUND: The superomedial pedicle for reduction mammaplasty remains less commonly performed than the inferior pedicle. This study seeks to delineate the complication profiles and outcomes for reduction mammaplasty using a superomedial pedicle technique in a large series. METHODS: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. All consecutive superomedial pedicle reduction mammaplasty cases for benign symptomatic macromastia were included. RESULTS: A total of 462 breasts were analyzed. Mean age was 38.3 ± 13.38 years, mean body mass index was 28.5 ± 4.95, and mean reduction weight was 644.4 ± 299.16 g. Regarding surgical technique, a superomedial pedicle was used in all cases; Wise-pattern incision was used in 81.4%, and short-scar incision was used in 18.6%. The mean sternal notch-to-nipple measurement was 31.2 ± 4.54 cm. There was a 19.7% rate of any complication, the majority of which were minor in nature, including any wound healing complications treated with local wound care (7.5%) and scarring with intervention in the office (8.6%). There was no statistically significant difference in breast reduction complications and outcomes using the superomedial pedicle, regardless of sternal notch-to-nipple distance. Body mass index ( P = 0.029) and breast reduction specimen operative weight ( P = 0.004) were the only significant risk factors for a surgical complication, and with each additional gram of reduction weight, the odds of a surgical complication increased by 1.001. Mean follow-up time was 40.5 ± 7.1 months. CONCLUSION: The superomedial pedicle is an excellent option for reduction mammaplasty, portending a favorable complication profile and long-term outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Analysis of Incidentally Found Proliferative Lesions in Oncoplastic and Macromastia Breast Reductions.

BACKGROUND: Reduction mammaplasty pathologic specimens can reveal incidentally found proliferative lesions. However, there is a lack of data investigating the comparative incidences and risk factors for such lesions. METHODS: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single large academic medical institution in a metropolitan city by two plastic surgeons over a 2-year period. All reduction mammaplasties, symmetrizing reductions, and oncoplastic reductions performed were included. There were no exclusion criteria. RESULTS: A total of 632 breasts were analyzed-502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions-in 342 patients. Mean age was 43.9 ± 15.9 years, mean body mass index was 29.2 ± 5.7 kg/m 2 , and mean reduction weight was 610.0 ± 313.1 g. Patients who underwent reduction mammaplasty for benign macromastia had a significantly lower incidence (3.6%) of incidentally found breast cancers and proliferative lesions compared with patients with oncoplastic reductions (13.3%) and symmetrizing reductions (17.6%) ( P < 0.001). On univariate analysis, personal history of breast cancer ( P < 0.001), first-degree family history of breast cancer ( P = 0.008), age ( P < 0.001), and tobacco use ( P = 0.033) were all statistically significant risk factors. Using a backward elimination stepwise reduced multivariable logistic regression model for risk factors associated with breast cancer or proliferative lesions, age ( P < 0.001) was the only retained significant risk factor. CONCLUSIONS: Proliferative lesions and carcinomas of the breast found in reduction mammaplasty pathologic specimens may be more common than previously reported. The incidence of newly found proliferative lesions was significantly lower in cases of benign macromastia compared with oncoplastic and symmetrizing reductions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Transpalpebral Eyelid Approach for Supraorbital Frontal Craniotomy and Access to the Anterior Cranial Fossa.

SUMMARY: The transpalpebral eyelid approach is an innovative alternative to traditional incisions for exposure of the anterior cranial fossa for neurosurgery. However, there is a paucity of data on this surgical technique in the plastic surgery literature for accessing the anterior cranial fossa. A retrospective review was performed of patients who underwent supraorbital frontal craniotomy using an anterior skull base approach with transpalpebral exposure over 8 years by a single plastic surgeon. Surgical techniques, medical comorbidities, intraoperative complications, and long-term complications were assessed. Twenty patients (mean age 52 ± 12 years, 55% male, 45% female) underwent supraorbital frontal craniotomy using an anterior skull base approach with upper transpalpebral exposure. Operative indications included the following: 75% had anterior communicating aneurysms, with a mean aneurysm size of 5.36 ± 1.91 mm; 10% had meningiomas; 10% had dural fistulas; and 5% had an orbital hemangioma. A total of 60% of patients had a smoking history. No intraoperative complications were encountered, and no cases required conversion to a traditional open approach. Mean length of hospital stay was 3.2 ± 1.5 days. Postoperative imaging revealed no residual or recurrent pathology. Mean follow-up time was 62.2 ± 30.6 months. No long-term neurologic or ophthalmologic complications or infections occurred. No forehead paresthesias, brow ptosis, or brow paralysis were noted. The transpalpebral technique is a safe, minimally invasive method to approach lesions of the anterior cranial fossa. Successful application may require appropriate management of the frontal sinus and supraorbital nerve. This approach does not limit neurosurgical access or results and led to no neurosurgical complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Quantifying Surgical Complications for Reduction Mammaplasty in Adolescents.

BACKGROUND: Reduction mammaplasty is a safe, effective procedure to alleviate symptoms of adolescent macromastia. However, there remain limited data on surgical complications associated with reduction mammaplasty in adolescents, which may not be concordant with those cited for adults seeking reduction mammaplasty. METHODS: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases for symptomatic macromastia in patients aged 20 years and younger over a 7-year period from 2014 to 2021. RESULTS: One hundred sixty total breasts were analyzed in 80 patients. Mean age was 18.3 ± 1.4 years, with an age range from 15 to 20 years. Mean body mass index was 27.17 ± 5.49 kg/m 2 . Mean reduction weight was 584.79 ± 261.19 g. A medial pedicle was used in 91%, and an inferior pedicle was used in 9%. For skin incision, a Wise pattern was used in 60%, and a short-scar was used in 40%. There was a 16.3% rate of any surgical complication, which included wound healing by secondary intention treated with local wound care. There were no significant risk factors for a surgical complication in reduction mammaplasty, and no differences in surgical complications related to skin incision type, pedicle use, or breast reduction weight. Performance of a receiver operating characteristic curve for age at surgery and complication demonstrated that there was no age cutoff where the risk of surgical complication was appreciably increased or decreased. CONCLUSIONS: Age was not identified as a risk factor for surgical complications in adolescent reduction mammaplasty. Overall, complication rates were very low and minor in nature for adolescent reduction mammaplasty, with no significant risk factors identified. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Revisiting Reduction Mammaplasty: Complications of Oncoplastic and Symptomatic Macromastia Reductions.

BACKGROUND: Oncoplastic breast reduction has been shown to be an effective and safe approach to breast conservation surgery in women with macromastia. However, there remains a paucity of data investigating the comparative outcomes. This study seeks to delineate the complication profiles for oncoplastic and symmetrizing breast reductions versus mammaplasty for benign macromastia. METHODS: A retrospective review was conducted of all consecutively performed reduction mammaplasty cases at a single institution by two plastic surgeons over a 2-year period. RESULTS: A total of 632 breasts were analyzed: 502 reduction mammaplasties, 85 symmetrizing reductions, and 45 oncoplastic reductions in 342 patients. Mean age was 43.9 ± 15.93 years, mean body mass index was 29.15 ± 5.66 kg/m2, and mean reduction weight was 610.03 ± 313.13 g. Regarding surgical technique, a medial pedicle was used in 86% of cases. There were similar postoperative complication outcomes for nipple necrosis, wound healing, scar revision, fat necrosis, seroma, hematoma, and overall complication rates for all procedures. However, the rate of postoperative revision among reduction mammaplasty (2%), oncoplastic reduction (6.7%), and symmetrizing reduction (5.9%) was significantly different (P = 0.027). In univariate analysis, diabetes (P = 0.011), smoking (P = 0.007), higher body mass index (P = 0.003), larger reduction weight (P = 0.011), longer nipple-to-inframammary fold measurement (P = 0.014), and longer sternal notch-to-nipple measurement (P = 0.039) were all significant risk factors for a surgical complication in reductions performed for any indication. Using a multivariate logistic regression model, diabetes (P = 0.047), smoking (P = 0.025), and higher body mass index (P = 0.002) were all retained as statistically significant risk factors. CONCLUSION: The complication profiles for both oncoplastic breast reductions and breast reductions for symptomatic macromastia are similar and acceptably low. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Free Fibula Flap for the Treatment of Agnathia in a 10-Year-Old With Severe Agnathia-Otocephaly Complex.

Agnathia-otocephaly complex (AOC), a first branchial arch defect, is characterized by mandibular hypoplasia or aplasia, ear abnormalities, microstomia, and macroglossia and is a rare and often fatal diagnosis. Herein, the technical considerations and details of mandibular reconstruction using virtual surgical planning (VSP) and a vascularized free fibula flap for further mandibular reconstruction in a 10-year-old boy are presented. The patient's preoperative examination was consistent with agnathia (absence of mandibular symphysis, bilateral mandibular bodies, condyles, coronoids, rami, and temporomandibular joint), severe microstomia, and a Tessier # 30 cleft (maintained to allow oral access until later in treatment). Virtual surgical planning was utilized to plan a 3-segment fibula for the reconstruction of the mandibular symphysis and bilateral body segments, and bilateral costochondral grafts were planned for the rami. To the authors' knowledge, this represents the first application of virtual surgical planning for mandibular reconstruction with a vascularized free fibula flap in a pediatric patient with severe agnathia-otocephaly complex.

Not Just a Linear Closure: Aesthetic Flat Closure after Mastectomy.

Currently, there is an increasing trend in women seeking aesthetic flat closure after mastectomy. To date, there is no plastic surgery literature on specific techniques to achieve an aesthetic flat closure after mastectomy. As plastic surgeons, we need to continue to innovate and to iterate new surgical techniques in our reconstructive armamentarium to address the desires of and to optimize the outcomes for our reconstructive breast surgery patients. Herein, we seek to delineate key considerations and employed techniques for reconstructive plastic surgeons performing aesthetic flat closure after mastectomy. Namely, it is crucial to listen to the patient, and to fully understand the patient's concerns, wishes, and particular aesthetic desired. From a technical perspective, the key surgical pearls include completely obliterating the inframammary fold, ensuring the same size and flap thickness bilaterally, appropriately de-fatting medially on the chest wall to allow for a smooth contour, obviating any presence of dog ears medially or laterally with precise tissue excision, and confirming that the incisions are entirely symmetric bilaterally. Intraoperatively, it is important to sit these patients up to assess soft tissue re-draping, and to confirm that there are no dog ears nor any excess tissue that could compromise the perfectly flat aesthetic chest closure. With the increasing demand for flat closures after mastectomy, plastic surgeons need to be keen on employing modified surgical techniques to best optimize the desired aesthetic flat closure reconstructions for these patients, as these reconstructions are not simply linear closures.

Robin Sequence: Neonatal Mandibular Distraction.

Pierre Robin sequence is defined by the clinical triad: mandibular hypoplasia, glossoptosis, and airway obstruction. Mandibular distraction osteogenesis (MDO) is a standard treatment of Robin sequence associated with severe airway obstruction and is the only intervention that directly corrects the underlying anatomic pathologic condition. Compared with tongue-lip adhesion, MDO has demonstrated more success in treating airway obstruction in infants with Pierre Robin sequence, including patients with syndromic diagnoses and concomitant anomalies. This article provides a current, comprehensive review of neonatal mandibular distraction and offers treatment guidelines based on a combined surgical experience of more than 400 patients.

Poly-4-hydroxybutyrate (Phasix™) mesh onlay in complex abdominal wall repair.

BACKGROUND: Poly-4-hydroxybutyric acid (P4HB, Phasix™) is a biosynthetic polymer that degrades by hydrolysis that can be woven into a mesh for use in soft tissue reinforcement. Herein, we describe our initial experience performing complex abdominal wall repair (CAWR) utilizing component separation and P4HB mesh as onlay reinforcement. METHODS: All patients undergoing CAWR between June 2014 and May 2017 were followed prospectively for postoperative outcomes. Only those patients who underwent components separation with primary repair of the fascial edges followed by onlay of P4HB mesh were included in this study. RESULTS: 105 patients (52 male, 53 female; mean age 59.2 years, range 22-84) met inclusion criteria. Mean BMI was 29.1 (range 16-48); 52% patients had prior attempted hernia repair, most with multiple medical comorbidities (71% of patients with ASA 3 or greater). 30% of cases were not clean at the time of repair (CDC class 2 or greater). Median follow-up was 36 months (range 9-63). Eighteen patients (17%) developed a hernia recurrence ranging from 2 to 36 months postoperatively. Five (5%) patients developed a localized superficial infection treated with antibiotics, three (2.8%) required re-operation for non-healing wounds, and six (6%) patients developed seroma. CONCLUSIONS: These data demonstrate a relatively low rate of hernia recurrence, seroma, and other common complications of CAWR in a highly morbid patient population. Importantly, the rate of mesh infection was low and no patients required complete mesh removal, even when placed into a contaminated or infected surgical field.

State of Microsurgery Training in 2020: Survey of Hand Surgery Fellowship Program Directors.

BACKGROUND: Given the current national conundrum of decreasing microsurgery case volume performed by hand surgery fellows despite interest, program directors were surveyed to evaluate opinions of exposure gaps in training and to determine the current state of microsurgery training in 2020. METHODS: Anonymous national surveys were distributed to hand surgery fellowship program directors by the American Society for Surgery of the Hand. Subgroups were compared by training location and size of the fellowship program. Accreditation Council for Graduate Medical Education public national data on graduate case log procedures by hand surgery fellows were reviewed. RESULTS: Eighty-eight surveys were distributed by the American Society for Surgery of the Hand to hand surgery fellowship program directors with a 44% (n = 39) response rate. Hand surgery fellowship programs from 19 US states participated. Most program's fellows had previous orthopedic surgery residency training with 41.03% of programs surveyed having 100% orthopedic surgery-trained fellows. The average number of weekly vascular microsurgical cases ranged from 25% of fellowships having no microsurgery cases per week, 46.2% having 1 per week, and only 7.7% having 5 or more cases per week. However, 60.5% of program directors prioritized a microvascular surgery case as the most valuable educational opportunity for fellows. Most program directors agreed (79.5%) that a 1-year hand surgery fellowship is sufficient to train a competent hand surgeon, who is proficient in microsurgery. In contrast, the majority disagreed (53.8%) that hand surgery microsurgery skills after a 1-year hand surgery fellowship are equivalent among graduates, regardless of a prior plastic surgery or orthopedic surgery residency training. There was a statistically significant difference in program directors' responses by geographic location regarding prior residency background impacting microsurgical skills (Kendall τ, -0.439; P = 0.001). Graduate case log data revealed an increasing trend in the number of microsurgery procedures performed by orthopedic hand surgery fellows until 2014, with a decline in cases per year and stagnating trend at 7% thereafter. CONCLUSIONS: In 2020, most hand surgery fellowship program directors highly value and prioritize microsurgery exposure for their hand surgery fellows' education despite the decrease in case volume for hand surgery fellows.

Facilitated self-assembly of a prevascularized dermal/epidermal collagen scaffold.

Introduction: Resurfacing complex full thickness wounds requires free tissue transfer which creates donor site morbidity. We describe a method to fabricate a skin flap equivalent with a hierarchical microvascular network. Materials & methods: We fabricated a flap of skin-like tissue containing a hierarchical vascular network by sacrificing Pluronic® F127 macrofibers and interwoven microfibers within collagen encapsulating human pericytes and fibroblasts. Channels were seeded with smooth muscle and endothelial cells. Constructs were topically seeded with keratinocytes. Results: After 28 days in culture, multiphoton microscopy revealed a hierarchical interconnected network of macro- and micro-vessels; larger vessels (>100 µm) were lined with a monolayer endothelial neointima and a subendothelial smooth muscle neomedia. Neoangiogenic sprouts formed in the collagen protodermis and pericytes self-assembled around both fabricated vessels and neoangiogenic sprouts. Conclusion: We fabricated a prevascularized scaffold containing a hierarchical 3D network of interconnected macro- and microchannels within a collagen protodermis subjacent to an overlying protoepidermis with the potential for recipient microvascular anastomosis.

Results of XPAND II: A Multicenter, Prospective, Continued-Access Clinical Trial Using the AeroForm Tissue Expander for Two-Stage Breast Reconstruction.

BACKGROUND: XPAND II was a prospective, multicenter, single-arm, open-label, continued-access study designed to confirm the results from the XPAND study, a multicenter, prospective, randomized study for breast reconstruction. The AeroForm device received clearance from the U.S. Food and Drug Administration in December 2016 based on the results of the pivotal XPAND trial, which compared the AeroForm to saline expanders. METHODS: Fifty women were treated in the XPAND II study and implanted with the AeroForm device (86 devices). The study endpoint was successful completion of the second-stage surgery, and secondary endpoints were days to complete expansion and reconstruction, and patient/physician satisfaction. Following implantation, women were administered 10-cc doses of carbon dioxide at home up to three times daily. When adequate expansion was achieved, the expanders were exchanged for standard breast implants. RESULTS: The primary endpoint (successful exchange to standard breast implant, precluding non-device-related failures) is 100 percent. All-cause interim success is 95 percent, with three subjects (four breasts) failing primary exchange because of non-device-related reasons. Median time to complete expansion was 21 days (range, 5 to 117 days). Median time to complete the reconstruction was 112 days (range, 55 to 329 days). Ninety-six percent of the subjects were very or moderately satisfied with the AeroForm expansion process. CONCLUSIONS: Results of the XPAND II continued access study confirm and improve on previous results from the randomized trial (XPAND). These results validate that the AeroForm patient-controlled, needle-free carbon dioxide tissue expander is safe and effective for two-stage breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Microstructured hydrogel scaffolds containing differential density interfaces promote rapid cellular invasion and vascularization.

INTRODUCTION: Insufficient vascularization of currently available clinical biomaterials has limited their application to optimal wound beds. We designed a hydrogel scaffold with a unique internal microstructure of differential collagen densities to induce cellular invasion and neovascularization. METHODS: Microsphere scaffolds (MSS) were fabricated by encasing 1% (w/v) type 1 collagen microspheres 50-150 µm in diameter in 0.3% collagen bulk. 1% and 0.3% monophase collagen scaffolds and Integra® disks served as controls. Mechanical characterization as well as in vitro and in vivo invasion assays were performed. Cell number and depth of invasion were analyzed using Imaris™. Cell identity was assessed immunohistochemically. RESULTS: In vitro, MSS exhibited significantly greater average depth of cellular invasion than Integra® and monophase collagen controls. MSS also demonstrated significantly higher cell counts than controls. In vivo, MSS revealed significantly more cellular invasion spanning the entire scaffold depth at 14 days than Integra®. CD31+ expressing luminal structures suggestive of neovasculature were seen within MSS at 7 days and were more prevalent after 14 days. Multiphoton microscopy of MSS demonstrated erythrocytes within luminal structures after 14 days. CONCLUSION: By harnessing simple architectural cues to induce cellular migration, MSS holds great potential for clinical translation as the next generation dermal replacement product. STATEMENT OF SIGNIFICANCE: Large skin wounds require tissue engineered dermal substitutes in order to promote healing. Currently available dermal replacement products do not always adequately incorporate into the body, especially in complex wounds, due to poor neovascularization. In this paper, we present a hydrogel with an innovative microarchitecture that is composed of dense type I collagen microspheres suspended in a less-dense collagen bulk. We show that cell invasion into the scaffold is driven solely by mechanical cues inherent within this differential density interface, and that this induces robust vascular cell invasion both in vitro and in a rodent model. Our hydrogel performs favorably compared to the current clinical gold standard, Integra®. We believe this hydrogel scaffold may be the first of the next generation of dermal replacement products.

Tissue engineering the human auricle by auricular chondrocyte-mesenchymal stem cell co-implantation.

Children suffering from microtia have few options for auricular reconstruction. Tissue engineering approaches attempt to replicate the complex anatomy and structure of the ear with autologous cartilage but have been limited by access to clinically accessible cell sources. Here we present a full-scale, patient-based human ear generated by implantation of human auricular chondrocytes and human mesenchymal stem cells in a 1:1 ratio. Additional disc construct surrogates were generated with 1:0, 1:1, and 0:1 combinations of auricular chondrocytes and mesenchymal stem cells. After 3 months in vivo, monocellular auricular chondrocyte discs and 1:1 disc and ear constructs displayed bundled collagen fibers in a perichondrial layer, rich proteoglycan deposition, and elastin fiber network formation similar to native human auricular cartilage, with the protein composition and mechanical stiffness of native tissue. Full ear constructs with a 1:1 cell combination maintained gross ear structure and developed a cartilaginous appearance following implantation. These studies demonstrate the successful engineering of a patient-specific human auricle using exclusively human cell sources without extensive in vitro tissue culture prior to implantation, a critical step towards the clinical application of tissue engineering for auricular reconstruction.

Financial Implications of Atypical Mycobacterial Infections After Cosmetic Tourism: Is It Worth the Risk?

BACKGROUND: Cosmetic tourism has become increasingly popular despite many associated risks. The economic impact of atypical mycobacterial infections in cosmetic tourism is poorly defined in the literature. We sought to investigate the costs and clinical course of patients with these infections. METHODS: A retrospective review of all patients managed by the Plastic Surgery Division at Columbia University Medical Center from 2013 to 2014 with atypical mycobacterial surgical site infections after cosmetic surgery outside the United States was performed. Data including patient demographics, procedure costs, clinical course, impact on daily life, and costs associated with complications were collected using hospital billing information, patient questionnaires, telephone interviews, and clinical charts. Cost analysis was done to identify the personal and societal costs of these complications. RESULTS: Data from 10 patients were collected and analyzed. Management of mycobacterial infections cost an average of $98,835.09 in medical charges. The indirect cost of these infections was $24,401 with a mean return to work time of 6.7 months. Total patient savings from cosmetic tourism was $3419. The total cost of a mycobacterial infection was greater than $123,236.47. Although the incidence of mycobacterial infection abroad is unknown, the potential cost of an infection alone outweighs the financial benefits of cosmetic tourism if the risk exceeds 2.77%. CONCLUSIONS: Atypical mycobacterial infections as a result of cosmetic tourism come at considerable cost to patients and the health care system. When our results are taken into consideration with other risks of cosmetic tourism, the financial risks likely far outweigh the benefits.

Twenty-Year Outcome Experience With Open Craniosynostosis Repairs: An Analysis of Reoperation and Complication Rates.

BACKGROUND: Surgical intervention during infancy for both syndromic and nonsyndromic patients with craniosynostosis remains the criterion standard of treatment with the 2 main options being open vault remodeling versus minimally invasive surgery. Although open cranial vault remodeling was initially considered a high-risk procedure, many advances have improved its safety. Despite this, there is a paucity of literature on the long-term outcomes of contemporary open craniosynostosis repair. METHODS: A retrospective review of all patients who underwent primary open cranial vault repair for craniosynostosis by a single surgeon (J.A.A.) at New York-Presbyterian Hospital from 1995 to 2015 was performed. RESULTS: For primary open repair, 81 patients (46 males, 35 females) were analyzed, and affected sutures included unicoronal (28), bicoronal (7), metopic (24), sagittal (11), lambdoid (2), and multisuture (9). Fourteen patients (17.3%) were syndromic. Mean (SD) operative patient age was 13.81 (16.24) months: 34 (42%) were 0 to 6 months; 26 (32%), 7 to 12 months; and 21 (26%), 12 months of age or older. There were no intraoperative complications. Mean (SD) estimated blood loss for the plastic surgery portion of all cases was 74.53 (72.34) mL, and total estimated blood loss was 174.93 (182.23) mL. Mean (SD) hospital length of stay was 4.31 (1.59) days. One syndromic patient was readmitted for a wound infection (1.2%) that was successfully treated with antibiotics, and 2 syndromic patients (2.5%) had reoperation for fronto-orbital readvancement. CONCLUSIONS: This 20-year experience demonstrates the safety of modern open craniosynostosis repairs at a large academic medical center with low rates of mortality (0%), complications (1.2%), and reoperations (2.5%).

Functional and Aesthetic Outcomes in Free Flap Reconstruction of Intraoral Defects With Lip-Split Versus Non-Lip-Split Incisions.

BACKGROUND: Traditional free flap reconstruction of complex intraoral defects often uses large lip-splitting incisions. To reduce morbidity and preserve aesthetics, we have adopted a more technically demanding visor technique obviating an incision through the lower lip through which the resection and reconstruction are performed. METHODS: A retrospective review was performed of patients who underwent free flap reconstruction of intraoral defects over 7 years by a single plastic surgeon (C.H.R.) at a single institution. Patients were included if they underwent a resection from the mandible, tongue, or floor of mouth followed by free tissue transfer as a reconstructive approach. Patients were excluded if they underwent reconstruction of an area that does not traditionally require a lip incision, such as a maxillectomy or laryngeal defect. An ablative approach was taken via a lip-split technique or visor technique. Wound complications, margins of resection, and functional outcomes were assessed. Two standardized questionnaires (Derriford Appearance Scale Short Form and Quality of Life Questionnaire for Head and Neck Cancer) were used to assess psychological distress and dysfunction from disfigurement, speech quality, and oral function. Preoperative and postoperative patient photos were evaluated. RESULTS: Of 27 patients (mean ± SD age, 58.33 ± 13.02 years), 52% (14) had visor reconstructions whereas 48% (13) had lip-splitting reconstructions. About 78.6% of visor patients had widely-free margins compared with 46.2% of the lip-split patients. No differences in surgical-site complications between the lip-split and visor group (38.5% vs 28.6%) or in operative times were observed. Ninety-three percent of visor patients versus 54% of lip-split patients tolerated oral feeds at 1 year. Lip-split patients rated their quality of eating and speech worse than the visor patients (Quality of Life Questionnaire for Head and Neck Cancer mean score, 2.2 vs 1.56). Patients and clinical staff deemed visor reconstructions resulted in less visible sequelae. CONCLUSIONS: A visor technique with no lip-split incision for intraoral free flap reconstruction is an oncologically safe technique to consider that may improve cosmetic and functional outcomes for head and neck reconstruction patients.

Evolving Approaches to Tissue Expander Design and Application.

Prosthetic reconstruction utilizing a 2-stage saline tissue expander-to-implant procedure is the most common technique for breast reconstruction in the United States. For nearly the past 50 years, 2-stage breast reconstruction using saline tissue expanders has been the standard of care. However, in December 2016, a carbon dioxide-filled, remote-controlled tissue expander received U.S. Food and Drug Administration clearance. This tissue expander, known as the AeroForm Tissue Expander System (AirXpanders, Inc., Palo Alto, Calif.), is a novel, patient-controlled, needle-free expander operated by a wireless remote control device, which allows patients the comfort and convenience of home expansion, precluding the need for percutaneous saline injections. A multicenter, randomized, prospective clinical trial has revealed statistically significant shorter times to full expansion as well as shorter overall reconstructive times. It is the first tissue expander device designed successfully with an alternative filling medium to saline, namely carbon dioxide. This CO2-filled expander thus provides several potential advantages over previous expander designs, including patient-controlled expansion, obviation of saline injections, and shorter expansion times.