Evaluating current functional airway surgery during rhinoplasty: a survey of the American Society of Plastic Surgeons.

BACKGROUND: Despite numerous reports outlining technical modifications in rhinoplasty, few publications discuss the importance of the perioperative assessment and surgical management of the nasal airway. This study's objective is to increase awareness regarding the functional aspects of rhinoplasty surgery and to encourage surgeons to incorporate functional airway management into their rhinoplasty practice. METHODS: A web-based survey was given to all members of the American Society of Plastic Surgeons (ASPS). Survey results were analysed to determine if surgeons' experience, annual rhinoplasty volume, or postgraduate training affected their results. The relationship between surgeon satisfaction with the outcome of the airway management and the frequency of performing an inferior turbinate reduction was investigated. RESULTS: Of the 4,383 listed ASPS members, 671 (21%) completed the web-based survey. Surgeons who performed a preoperative internal nasal exam were more satisfied with their results (p = 0.016) and report lower rates of postoperative nasal airway obstruction (p = 0.054). Inferior turbinate reduction did correlate to postoperative satisfaction with the nasal airway (p < 0.001). Overall, 85% of respondents were satisfied with their management of the nasal airway and 87% of respondents agreed that there is a need for more instructional courses on this topic. CONCLUSION: There is considerable variation in the results and techniques of assessment and treatment of the nasal airway. Rhinoplasty volume and inferior turbinate reduction are associated with surgeon satisfaction of management of the nasal airway. Functional airway considerations should be incorporated into routine rhinoplasty training, assessment, and treatment. LEVEL OF EVIDENCE V: 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.

Biomechanical comparison of calcium phosphate cements for split cranial bone graft donor sites.

BACKGROUND: Although harvesting of in situ split cranial bone is a well-established technique, few data have been generated regarding the biomechanical effect of bone harvest on the cranial bone donor site, and even fewer data have been generated regarding the biomechanical effect of calcium phosphate bone cement inlay on the donor site. The authors documented the weakening of the skull at the in situ cranial harvest site and determined the benefit, if any, when the site is inlayed with calcium phosphate cements. METHODS: Cadaver skulls were divided into three groups: group 1, an in situ cranial bone defect was created in the frontal bone area on one side and the mirror-image, full-thickness area was untreated; group 2, a similar defect was created in the parietal area and repaired with calcium phosphate bone cement inlay, and on the opposite side, a similar defect was created but not repaired; and group 3, donor sites were created in the parietal area bilaterally and reconstructed with different cements. Mirror-image areas were harvested and testing was performed. The Wilcoxon rank sum test was used to evaluate all mirror-image specimens. RESULTS: There was a statistically significant difference in strength to fracture when the in situ defect was compared with the in situ calcium phosphate construct (p = 0.008). No difference was demonstrated when the defect was compared with full-thickness bone or when calcium phosphate cements were compared. CONCLUSION: Repair of the defect with calcium phosphate cement significantly increased strength at the donor site and may provide added safety from injury.

Dermaplaning, topical oxygen, and photodynamic therapy: a systematic review of the literature.

BACKGROUND: Noninvasive procedures for facial rejuvenation are becoming an increasingly popular component of a comprehensive skin care regimen. Concurrently, many new treatment methods are now available to both the plastic surgeon and the aesthetician. Because these techniques have become an integral part of many cosmetic practices, this study aimed to assess the existing evidence-based literature as to their clinical efficacy; to provide an objective overview of some of the most popular noninvasive rejuvenation strategies such as dermaplaning, oxygen therapy, and light therapy; to discuss recent pertinent scientific evidence-based literature; and to provide treatment recommendations based on these findings. METHODS: A systematic review was performed in August 2009 using PubMed and the following keywords: "dermaplaning," "oxygen therapy," and "light therapy." All peer-reviewed articles then were screened independently by three plastic surgeons. RESULTS: The search identified 42 English-written, peer-reviewed manuscripts. The overall amount of scientific data supporting these methods was found to be scarce, anecdotal, and not well documented. Nevertheless, all three noninvasive therapies have become increasingly popular in the cosmetic market because many patients and physicians or surgeons report being pleased with their results. CONCLUSION: Although the evidence supporting these nonsurgical methods is suboptimal, their uses continue to expand. As with any plastic surgery procedure, providing patients with realistic expectations is essential to achieving optimal outcomes and patient satisfaction. Therefore, critical investigation is warranted. In addition, these methods are most effective when included within a comprehensive skin care regimen consisting of sunscreen, vitamin therapy, and lifestyle modification.

Hand surgery volume and the US economy: is there a statistical correlation?

BACKGROUND: To the best of our knowledge, there have been no previous studies evaluating the correlation of the US economy and hand surgery volume. Therefore, in light of the current recession, our objective was to study our institution's hand surgery volume over the last 17 years in relation to the nation's economy. METHODS: A retrospective analysis of our institution's hand surgery volume, as represented by our most common procedure (ie, carpal tunnel release), was performed between January 1992 and October 2008. Liposuction and breast augmentation volumes were chosen to serve as cosmetic plastic surgery comparison groups. Pearson correlation statistics were used to estimate the relationship between the surgical volume and the US economy, as represented by the 3 market indices (Dow Jones, NASDAQ, and S&P500). RESULTS: A combined total of 7884 hand surgery carpal tunnel release (open or endoscopic) patients were identified. There were 1927 (24%) and 5957 (76%) patients within the departments of plastic and orthopedic surgery, respectively. In the plastic surgery department, there was a strong negative (ie, inverse relationship) correlation between hand surgery volume and the economy (P < 0.001). In converse, the orthopedic department's hand surgery volume demonstrated a positive (ie, parallel) correlation (P < 0.001). The volumes of liposuction and breast augmentation also showed a positive correlation (P < 0.001). CONCLUSION: To our knowledge, we have demonstrated for the first time an inverse (ie, negative) correlation between hand surgery volumes performed by plastic surgeons in relation to the US economy, as represented by the 3 major market indices. In contrast, orthopedic hand surgery volume and cosmetic surgery show a parallel (ie, positive) correlation. This data suggests that plastic surgeons are increasing their cosmetic surgery-to-reconstructive/hand surgery ratio during strong economic times and vice versa during times of economic slowdown.

Calcium phosphate cements in skull reconstruction: a meta-analysis.

BACKGROUND: This work addresses the controversy regarding the indications and results of calcium phosphate cements in skull reconstruction through a meta-analysis of the published literature. METHODS: A PubMed search for articles reporting the use of calcium phosphate cements for skull reconstruction was performed. Data collected included age, volume of cement, defect size, material used, length of follow-up, placement in communication with paranasal sinuses or in irradiated fields, and complications. RESULTS: Nineteen articles met the authors' inclusion criteria. The mean rates of complications were as follows: total complications, 13 percent (range, 0 to 62 percent); major complications, 9 percent (range, 0 to 62 percent); minor complications, 2 percent (range, 0 to 5 percent); infection, 5 percent (range, 0 to 22 percent); reoperation, 14 percent (range, 0 to 62 percent); and secondary surgery for contour correction, 1 percent (range, 0 to 12 percent). There was significant heterogeneity in the estimated rate of total and major complications, infection, and reoperation (p < 0.001), but minor complications and secondary contour correction had less heterogeneity (p = 0.58 and p = 0.78, respectively). Radiotherapy and communication with the paranasal sinuses significantly increased the complication rate (p < 0.05). Duration between surgery and complications averaged 17.5 months (range, 1 to 89 months). CONCLUSIONS: When mean complication rate and complication range of calcium phosphate cements in our meta-analysis were compared with previous large cranioplasty studies using methylmethacrylate or autogenous bone, calcium phosphate fared no better, and sometimes fared worse, than these other modalities. Calcium phosphate, therefore, should only be used selectively, and prospective long-term studies are needed to further refine its role in skull reconstruction.

Cosmetic surgery volume and its correlation with the major US stock market indices.

BACKGROUND: As a consumer-driven industry, cosmetic plastic surgery is subject to ebbs and flows as the economy changes. There have been many predictions about the short, intermediate, and long-term impact on cosmetic plastic surgery as a result of difficulties in the current economic climate, but no studies published in the literature have quantified a direct correlation. OBJECTIVES: The authors investigate a possible correlation between cosmetic surgery volume and the economic trends of the three major US stock market indices. METHODS: A volume analysis for the time period from January 1992 to October 2008 was performed (n = 7360 patients, n = 8205 procedures). Four cosmetic procedures-forehead lift (FL), rhytidectomy (Rh), breast augmentation (BA), and liposuction (Li)-were chosen; breast reduction (BRd), breast reconstruction (BRc), and carpal tunnel release (CTR) were selected for comparison. Case volumes for each procedure and fiscal quarter were compared to the trends of the S&P 500, Dow Jones (DOW), and NASDAQ (NASD) indices. Pearson correlation statistics were used to evaluate a relationship between the market index trends and surgical volume. P values <.05 were considered statistically significant. RESULTS: Three of the four cosmetic surgery procedures investigated (Rh, n = 1540; Li, n = 1291; BA, n = 1959) demonstrated a direct (ie, positive) statistical correlation to all three major market indices. FL (n =312) only correlated to the NASD (P = .021) and did not reach significance with the S&P 500 (P = .077) or DOW (P = .14). BRd and BRc demonstrated a direct correlation to two of the three stock market indices, whereas CTR showed an inverse (ie, negative) correlation to two of the three indices. CONCLUSIONS: This study, to our knowledge, is the first to suggest a direct correlation of four cosmetic and two reconstructive plastic surgery procedures to the three major US stock market indices and further emphasizes the importance of a broad-based plastic surgery practice in times of economic recession.

Hemodynamic changes and fluid shifts after large-volume fluid infiltration: results from a porcine model.

While certain parameters such as blood loss and serum lidocaine levels following liposuction have been well studied, fluid shifts between the intravascular and extravascular space have not. With the advent of large volume liposuction, prudent fluid management has become obligatory. Hence, the reason for our study.To test the impact of large volume infiltration on intercompartmental fluid shifts, we measured urine output and hemodynamic changes in 10 anesthetized female Yorkshire pigs weighing between 50 and 85 kg. Eight pigs were infused with 5 to 10 L of tumescent fluid. Two pigs were anesthetized, received no wetting solution, and served as controls. Hemodynamic variables were recorded before infusion and hourly for 48 hours. Animals were extubated after 4 hours of anesthesia. Plasma volume was measured using Evan's Blue Dye, and intravascular fluid shifts were calculated using Foldager's method.Total fluid shift into the intravascular space ranged between 511 and 1036 mL per animal with a mean of 767 mL in the first 3 hours. Higher volumes of fluid infiltration did not lead to fluid overload in the experimental group. Hemodynamic changes were characterized by significant increases in central venous pressure, cardiac output, pulmonary artery pressure, and heart rate consistent with the increase in intravascular volume. Hemodynamic parameters returned to baseline 20 hours following tumescent fluid infiltration.In this porcine model, animals were able to tolerate large fluid challenges delivered by clysis with statistically significant but only modest increases in hemodynamic parameters which gradually returned to baseline within 20 hours.

The Cleveland Clinic FACES Score: a preliminary assessment tool for identifying the optimal face transplant candidate.

In lieu of limited resources, our multidisciplinary face transplant team requires a preliminary, supplemental objective grading scheme for identifying the optimal face transplant candidate. Therefore, our objective was to develop an effective method for evaluating "facial deficit," which could also be used in the future for the allocation of limited facial organs, analogous to liver transplantation.Each candidate is screened using our institutional review board-approved protocol's current inclusion/exclusion criteria. Five categories were conceptualized to be of significance in evaluating patients in pursuit of facial allotransplantation as per our recent experience, as determined by the face transplant team. All patients with unfavorable characteristics such as evidence of poor medical compliance, an unsatisfactory psychosocial evaluation by our team's transplant psychiatrist, and/or end-stage organ disease suggestive of significant comorbidity were excluded.This study resulted in a reproducible scoring system allowing our team the unprecedented ability to stratify facial deficit in a standardized fashion. The FACES scores ranged from 10 (minimum) to 60 (maximum). Besides being used as a supplemental prescreening and/or postscreening tool, the FACES score has also provided an unprecedented framework for establishing a face transplant candidate registry within our institution, with the optimal recipients receiving the highest of scores.This FACES score objectively stratifies face transplant candidates for their facial deficit during multiple steps throughout the screening process and affords our institution the means of creating a registry. If substantiated, this supplemental score may ultimately predict successful outcomes, determine optimal utility, and provide insight toward prognosis with respect to facial composite tissue allotransplantation.

The world's experience with facial transplantation: what have we learned thus far?

The objective of this review article is to summarize the published details and media citations for all seven face transplants performed to date to point out deficiencies in those reports so as to provide the basis for examining where the field of face transplantation stands, and to act as a stimulus to enhance the quality of future reports and functional outcomes. Overall long-term function of facial alloflaps has been reported satisfactorily in all seven cases. Sensory recovery ranges between 3 and 6 months, and acceptable motor recovery ranges between 9 and 12 months. The risks and benefits of facial composite tissue allotransplantation, which involves mandatory lifelong immunosuppression analogous to kidney transplants, should be deliberated by each institution's multidisciplinary face transplant team. Face transplantation has been shown thus far to be a viable option in some patients suffering severe facial deficits which are not amenable to modern-day reconstructive technique.

Disorders of the female breast in the pediatric age group.

SUMMARY: Disorders of the female breast in the pediatric age group are a relatively common finding; however, there is limited information in the current literature. The plastic surgeon treating these patients is faced with a wide range of reconstructive problems. By understanding the various breast disorders, the plastic surgeon can better diagnose and treat this patient population appropriately.

Review of bone substitutes.

Bone substitutes are being increasingly used in craniofacial surgery and craniomaxillofacial trauma. We will review the history of the biomaterials and describe the ideal characteristics of bone substitutes, with a specific emphasis on craniofacial reconstruction. Some of the most commonly used bone substitutes are discussed in more depth, such as calcium phosphate and hydroxyapatite ceramics and cements, bioactive glass, and polymer products. Areas of active research and future directions include tissue engineering, with an increasing emphasis on bioactivity of the implant.

Nonsyndromic craniosynostosis: current treatment options.

The significance and etiology of abnormal skull shape have been under investigation since ancient times. Nonsyndromic, or isolated, craniosynostosis predominates and is defined as suture fusion that creates functional impairments related to local effects of the fusion. The purpose of this article is to present our current approach to patients with nonsyndromic craniosynostosis, outlining the place of both open, conventional approaches and newer, minimally invasive, endoscopic assisted craniosynostosis correction.

Comparison of open versus minimally invasive craniosynostosis procedures from the perspective of the parent.

Craniosynostosis, or the premature closure of the sutures of the skull, has historically been repaired in an open manner and included extensive cranial reconstruction. In recent years, technological advancements have given surgeons the ability to perform repairs with minimal surgical invasion. With the advent of endoscopy and bioresorbable plates, recent reports [J Craniofac Surg 2002;13(4):578-82] have emphasized attempts at decreased morbidity. Recently, researchers have been able to compare the results of traditional open and minimally invasive techniques in 45 craniosynostosis cases, demonstrating decreased operating room time, blood loss, transfusions, complications, and hospital stay in minimally invasive patients [Clin Plast Surg 2004;31(3):429-42]. Many of the parameters comparing the 2 types of procedures are easily quantified and comparable, but a variety of other considerations, such as the parent's reaction to the stress of surgery, arise. The purpose of this study was to compare the effects of these surgical procedures on the parent's level of stress at the time of operation. To accomplish this, we measured stress postoperatively using the Parenting Stress Index-Short Form. Subjects undergoing surgical treatment of craniosynostosis were placed into 2 groups: open versus minimally invasive. To test for confounding factors, subjects were subcategorized for sex, parent's sex, ethnicity, and parent's marital status. Analysis of our data reveals a statistically significant decrease in total stress in the households of minimally invasive patients.

Patterns of venous reflux and obstruction in patients with skin damage due to chronic venous disease.

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease (P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group (P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls (P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

Uncommon leg ulcers in the lower extremity.

OBJECTIVE: To determine the prevalence of uncommon ulcers, unrelated to venous or arterial etiology, in patients presenting to vascular clinics. METHODS: This was a multicenter prospective study of consecutive patients presenting with lower extremity ulceration. The settings were university hospital outpatient centers and venous clinics. A total of 799 limbs in 710 patients with leg ulcers were evaluated. Patients with venous ulcer disease and with evidence of arterial disease with an ankle-brachial index less than 0.7 were excluded from the study. Out of 710 patients, 17 patients with a total of 21 limbs fit the criteria for inclusion. All limbs included in this study underwent physical examination, ankle-brachial index measurements, duplex ultrasonography, and skin biopsies. RESULTS: The mean age of patients with uncommon ulcers was 65.6 years, and the mean duration was 5.5 years. A total of 2.1% of all leg ulcers seen were due to uncommon etiology unrelated to venous or arterial pathology. Most of these ulcers were located in the medial lower calf (n = 19). In six patients with ulcers, the histology did not reveal any specific cause; five had a neoplasia, three had chronic inflammation, two had sickle cell disease, two had vasculitis, one had rheumatoid arthritis, one had pyoderma gangrenosum, and one had ulcer due to hydroxyurea. CONCLUSIONS: The prevalence of leg ulcers unrelated to arterial and venous disease that presented with signs and symptoms of chronic venous disease was 2.1%. Their etiology is variable, most often including vasculitis, neoplasia, metabolic disorders, infection, and other rare causes. Early identification of uncommon ulcers may facilitate timely and appropriate management.

Outcomes in pharyngoplasty: a 10-year experience.

OBJECTIVE: The outcomes of 61 patients who underwent a pharyngoplasty for velopharyngeal insufficiency were reviewed to determine potential risk factors for reoperation. DESIGN: This was a retrospective chart review of 61 consecutive patients over approximately 10 years (1993 to 2003). Variables analyzed included gender, cleft type, age at the time of pharyngoplasty, length of time between palate repair and pharyngoplasty, and associated syndromes. PARTICIPANTS: Of the 61 patients, 20 (34%) had a unilateral cleft lip and palate, 5 (8%) had a bilateral cleft lip and palate, 13 (21%) had an isolated cleft palate, 7 (11%) had a submucous cleft palate, and 16 (26%) were diagnosed with noncleft velopharyngeal insufficiency. RESULTS: Of the 61 patients, 10 (16%) required surgical revision. No statistically significant difference was found among gender, cleft type, age at the time of pharyngoplasty, the length of time between palate repair and pharyngoplasty, and associated congenital syndromes, with respect to the need for surgical revision (p > .05). Of the surgical revisions, 50% (5) were performed for a pharyngoplasty that was placed too low. CONCLUSIONS: Because 50% of the pharyngoplasty revisions had evidence of poor velopharyngeal closure and associated hypernasality resulting from low placement of the sphincter, the pharyngoplasty needs to be placed at a high level to reduce the risk for revisional surgery. The pharyngoplasty is a good operation for velopharyngeal insufficiency with an overall success rate of 84% (51 of 61) after one operation and greater than 98% (60 of 61) after two operations.

Definition of venous reflux in lower-extremity veins.

PURPOSE: This prospective study was designed to determine the upper limits of normal for duration and maximum velocity of retrograde flow (RF) in lower extremity veins. METHODS: Eighty limbs in 40 healthy subjects and 60 limbs in 45 patients with chronic venous disease were examined with duplex scanning in the standing and supine positions. Each limb was assessed for reflux at 16 venous sites, including the common femoral, deep femoral, and proximal and distal femoral veins; proximal and distal popliteal veins; gastrocnemial vein; anterior and posterior tibial veins; peroneal vein; greater saphenous vein, at the saphenofemoral junction, thigh, upper calf, and lower calf; and lesser saphenous vein, at the saphenopopliteal junction and mid-calf. Perforator veins along the course of these veins were also assessed. In the healthy volunteers, 1553 vein segments were assessed, including 480 superficial vein segments, 800 deep vein segments, and 273 perforator vein segments; and in the patients, 1272 vein segments were assessed, including 360 superficial vein segments, 600 deep vein segments, and 312 perforator vein segments. Detection and measurement of reflux were performed at duplex scanning. Standard pneumatic cuff compression pressure was used to elicit reflux. Duration of RF and peak vein velocity were measured immediately after release of compression. RESULTS: Duration of RF in the superficial veins ranged from 0 to 2400 ms (mean, 210 ms), and was less than 500 ms in 96.7% of these veins. In the perforator veins, regardless of location, outward flow ranged from 0 to 760 ms (mean, 170 ms), and was less than 350 ms in 97% of these veins. In the deep veins, RF ranged from 0 to 2600 ms. Mean RF in the deep femoral veins and calf veins was 190 ms, and was less than 500 ms in 97.6% of these veins. In the femoropopliteal veins, mean RF was 390 ms, and ranged from 510 to 2600 ms in 21 of 400 segments; however, RF was less than 990 ms in 99% of these veins. Duration of RF was significantly longer in all three veins systems in patients (P <.0001 for all comparisons). With a cutoff value of more than 1000 ms rather than more than 500 ms, prevalence of abnormal RF in the femoropopliteal veins was significantly reduced, from 29% to 18% (P =.002). Thirty-seven vein segments (2.4%) had RF greater than 500 ms in the supine position, compared with less than 500 ms in 22 of these vein segments (59%) in the standing position. Of the 48 vein segments (3.1%) with RF greater than 500 ms in the standing position, RF was less than 500 ms in 6 of these vein segments (13%) in the supine position. Similar observations were noted in patient veins. There was no association between RF and peak vein velocity. Peak vein velocity had no significance in determining reflux. CONCLUSIONS: The cutoff value for reflux in the superficial and deep calf veins is greater than 500 ms. However, the reflux cutoff value for the femoropopliteal veins should be greater than 1000 ms. Outward flow in the perforating veins should be considered abnormal at greater than 350 ms. Reflux testing should be performed with the patient standing.