Personalized Computational Models of Tissue-Rearrangement in the Scalp Predict the Mechanical Stress Signature of Rotation Flaps.

OBJECTIVE: To elucidate the mechanics of scalp rotation flaps through 3D imaging and computational modeling. Excessive tension near a wound or sutured region can delay wound healing or trigger complications. Measuring tension in the operating room is challenging, instead, noninvasive methods to improve surgical planning are needed. DESIGN: Multi-view stereo allows creation of 3D patient-specific geometries based on a set of photographs. The patient-specific 3D geometry is imported into a finite element (FE) platform to perform a virtual procedure. The simulation is compared with the clinical outcome. Additional simulations quantify the effect of individual flap parameters on the resulting tension distribution. PARTICIPANTS: Rotation flaps for reconstruction of scalp defects following melanoma resection in 2 cases are presented. Rotation flaps were designed without preoperative FE preparation. MAIN OUTCOME MEASURE: Tension distribution over the operated region. RESULTS: The tension from FE shows peaks at the base and distal ends of the scalp rotation flap. The predicted geometry from the simulation aligns with postoperative photographs. Simulations exploring the flap design parameters show variation in the tension. Lower tensions were achieved when rotation was oriented with respect to skin tension lines (horizontal tissue fibers) and smaller rotation angles. CONCLUSIONS: Tension distribution following rotation of scalp flaps can be predicted through personalized FE simulations. Flaps can be designed to reduce tension using FE, which may greatly improve the reliability of scalp reconstruction in craniofacial surgery, critical in complex cases when scalp reconstruction is essential for coverage of hardware, implants, and/or bone graft.

Incidence of Obstetric Lacerations and Episiotomy Following Labiaplasty.

BACKGROUND: A significant proportion of patients seeking labiaplasty are nulliparous and may experience later changes to their labia following vaginal delivery. OBJECTIVES: In the present study, the authors reported the long-term outcomes of a single surgeon's patient cohort who had vaginal delivery after labiaplasty. METHODS: A retrospective chart review of the senior author's database was conducted. All patients who underwent in-office labiaplasty from 2007 to 2018 were surveyed. The resulting cohort was stratified into patients who had delivered children prior to labiaplasty and those who delivered after labiaplasty. RESULTS: A total of 204 patients responded to a phone survey. Seventy patients had children prior to undergoing labiaplasty, and 33 had children after labiaplasty. The rate of vaginal delivery was lower in the women who had children before labiaplasty (82.6% vs 91.8%, P = 0.015). The tear/episiotomy rate for vaginal deliveries was lower in women who had children prior to labiaplasty compared with after labiaplasty (3.1% vs 17.8%, P < 0.001). Among the women who had children only after labiaplasty, the reported tear/episiotomy rate was 7/39 vaginal deliveries (17.9%). CONCLUSION: Patients in our cohort had over 90% success with vaginal deliveries after labiaplasty. For nulliparous patients contemplating the procedure, the data we present suggest the risk of episiotomy or vaginal tear risk with vaginal birth after labiaplasty is comparable with or lower than the general population, further supporting the safety of this procedure. For patients with previous delivery, the data are more limited but suggest no increased risk in this small cohort.

Photographic Misrepresentation on Instagram After Facial Cosmetic Surgery: Is Increased Photography Bias Associated With Greater User Engagement?

BACKGROUND: Before-and-after images are commonly used on Instagram (Menlo Park, CA) to advertise aesthetic surgical treatments and are a powerful means of engaging prospective patients. Consistency between before-and-after images accurately demonstrating the postoperative result on Instagram, however, has not been systematically assessed. OBJECTIVES: The aim of this study was to systematically assess facial cosmetic surgery before-and-after photography bias on Instagram. METHODS: The authors queried 19 Instagram facial aesthetic surgery-related hashtags on 3 dates in May 2020. The "top" 9 posts associated with each hashtag (291 posts) were analyzed by 3 plastic surgeons by means of a 5-item rubric quantifying photographic discrepancies between preoperative and postoperative images. Duplicate posts and those that did not include before-and-after images of facial aesthetic surgery procedures were excluded. RESULTS: A total of 3,477,178 posts were queried. Photography conditions were observed to favor visual enhancement of the postoperative result in 282/291 analyzed top posts, with an average bias score of 1.71 [1.01] out of 5. Plastic surgeons accounted for only 27.5% of top posts. Physicians practicing outside their scope of practice accounted for 2.8% of top posts. Accounts with a greater number of followers (P = 0.017) and posts originating from Asia (P = 0.013) were significantly associated with a higher postoperative photography bias score. CONCLUSIONS: Photographic misrepresentation, with photography conditions biased towards enhancing the appearance of the postoperative result, is pervasive on Instagram. This pattern was observed across all physician specialties and raises significant concerns. Accounts with a greater number of followers demonstrated significantly greater postoperative photography bias, suggesting photographic misrepresentation is rewarded by greater user engagement.

Novel Passage of Dermis-Fat Graft for Augmentation of Vermilion Deficiency Following Cleft Lip Repair.

Despite timely repair of cleft lip, secondary deformities such as vermilion notching or "whistle deformity" often require further surgical treatment. The use of dermis-fat graft for soft tissue augmentation of the upper lip is an established technique. We propose an innovation on this technique, by which the dermis-fat graft can be placed reliably and with minimal dissection by use of a soft red rubber sheath to protect the Keith needle while delivering the graft through the submucosal pocket in the dry vermilion, thereby avoiding the needle inadvertently catching soft tissue inside the pocket. We recommend using an 8F red rubber catheter, cutting the catheter to be just shorter than a 2.5-inch Keith needle. This provides a sheath through which the Keith needle can be passed within the submucosal vermilion tunnel. We believe this to be much more reliable for vermilion augmentation than other techniques, including fat injection, and makes graft inset more predictable, faster, and simpler.

Anterior and Posterior Commissuroplasty: Taking Labiaplasty to the Next Level.

As the popularity of female cosmetic genital surgery has grown, so has the number of publications detailing surgical techniques, particularly regarding labiaplasty. As a nascent surgical field, much room remains for finesse and exploration of new techniques to optimize outcomes and patient satisfaction. We present the techniques for anterior and posterior commissuroplasty the senior author (O.J.P.) has developed. Anterior commissuroplasty is efficacious in addressing a number of anatomic variations to achieve the appearance of a single midline cleft, which is commonly requested by patients. Posterior commissuroplasty was developed to address skin excess at the posterior fourchette that may develop as a result of labiaplasty. Either technique may be used in combination with labiaplasty or as a stand-alone procedure. These tools may be a useful addition to the repertoire of a surgeon practicing female genital surgery.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting.

BACKGROUND: Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. OBJECTIVES: The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. METHODS: Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. RESULTS: The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. CONCLUSIONS: The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

Major Complications and 30-Day Morbidity for Single Jaw Versus Bimaxillary Orthognathic Surgery as Reported by NSQIP.

OBJECTIVE: Acute complications in orthognathic surgery are reported in single-institution studies with small sample sizes. We aimed to analyze risk factors for acute complications using a national data set to better inform surgical decision-making. METHODS: 2005-2015 National Surgical Quality Improvement Program (NSQIP) data sets were analyzed for patients undergoing Le Fort 1 and/or bilateral sagittal split osteotomies (BSSO) for nontraumatic indications. Demographics, comorbidities, medical, and surgical 30-day complications were tabulated. A logistic regression model was used to determine predictors of complications. RESULTS: Five hundred eight patients met the inclusion criteria: 228 underwent Le Fort I osteotomies, 152 BSSO, and 128 patients underwent both during a single surgical encounter. Overall complication rate was 4.5% (23/508). Superficial infection was the most common complication (11 in BSSO and 2 in Le Fort I cohorts). Increasing age and undergoing BSSO alone were associated with higher overall complication rates (P < .05) and surgical complications specifically (P < .05). Patients undergoing the combined procedure had shorter operative time (208 minutes) than the times for Le Fort I osteotomies alone (177 minutes) and BSSO alone (155 minutes) added together and did not have a longer hospital stay (P = .608) or increased need for transfusion (P = 1.0) compared to the surgeries being done separately. CONCLUSION: This is the first complication risk factor analysis for Le Fort I osteotomy and BSSO using the multi-institutional NSQIP data set. Combining BSSO and Le Fort I osteotomy leads to a shorter overall operative time and does not increase hospital stay duration or 30-day complication rate when compared to the 2 procedures being done separately.

Fibrous Dysplasia and Juvenile Psammomatoid Ossifying Fibroma: A Case of Mistaken Identity.

Juvenile psammomatoid ossifying fibroma (JPOF) is a rare benign osseous tumor, usually presenting in the midface. There are many similarities in location, presentation, and radiographic appearance between fibrous dysplasia (FD) and JPOF. Awareness of this entity is important for craniofacial surgeons, as surgical timing and intraoperative management differ between these tumors. Findings that should raise suspicion of JPOF preoperatively include rapid growth, a shell of cortical bone surrounding the lesion, and clearly demarcated borders of the lesion on imaging, as opposed to a gradual transition between normal and abnormal bone. Definitive excision is the treatment of choice, and earlier surgery may provide better results by addressing the lesion at the smallest size possible. In contrast to FD, JPOF is not known to "burn out," so there is minimal benefit to be gained from delay. We present a summary of the evidence for diagnosis and treatment of JPOF as well our experience with JPOF in an 11-year-old female who was initially diagnosed with FD. We aim to draw attention to the similar presentations of these entities so the reader will be able to more accurately manage these patients.

Google Ranking of Plastic Surgeons Values Social Media Presence Over Academic Pedigree and Experience.

BACKGROUND: Patients increasingly rely on online resources to make healthcare decisions. Google dominates the search engine market; first-page results receive most of the web traffic and therefore serve as an important indicator of consumer reach. OBJECTIVES: Our objective was to analyze the respective importance of physician academic pedigree, experience, and social media presence on plastic surgeon Google first-page search result placement. METHODS: A Google.com search was conducted in the top 25 United States metropolitan areas to identify the top 20 websites of board-certified plastic surgeons. Social media presence was quantified by tracking the number of followers on Facebook, Twitter, and Instagram for every surgeon as well as medical school and year of graduation. The primary outcome was website ranking in the first page of Google search results. To identify the independent predictors of presence on the front page, we performed a multivariate logistic regression. RESULTS: Total number of social medial followers was associated with Google front-page placement (P < 0.001), whereas medical school ranking and years in practice were not (P = 0.17 and 0.39, respectively). A total 19.6% of plastic surgeon practices in our study cohort still had no social media accounts whatsoever. CONCLUSIONS: For the past few decades, plastic surgery practices relied on referrals, word of mouth, and the surgeon's reputation and academic pedigree to attract new patients. It is now clear that this practice-building model is being rapidly supplanted by a new paradigm based on social media presence to reach potential patients.

Digital analysis yields more reliable and accurate measures of dermal and epidermal thickness in histologically processed specimens compared to traditional methods.

Changes in the thickness of the dermis and epidermis have been described in the scenario of tissue expansion as well as inflammatory skin processes (psoriasis, contact hypersensitivity and so on). These changes have previously been quantified using ocular micrometers to obtain and then average a limited number of spot measurements, leading to suboptimal accuracy. We describe a rapid method of using freely available ImageJ software to analyze digitized images of fixed skin specimens. By determining the cross-sectional area and surface length of a skin layer, a simple calculation produces more accurate and reproducible measurements of its thickness compared to historical methods, with excellent inter-rater reliability.

How Big is Too Big: Pushing the Obesity Limits in Microsurgical Breast Reconstruction.

PURPOSE: Obesity is a major public health concern in the United States, affecting nearly 79 million people. There have been promising results performing microvascular breast reconstruction in patients with obesity; however, the definition of obesity is often poorly defined or does not extend above a body mass index (BMI) of 35. Our goal was to examine outcomes of microvascular breast reconstruction in this questionably more risky population. METHODS: A retrospective review from 2013 to 2016 was performed of 2 surgeons' experience with abdominally based microvascular breast reconstructions. Women were categorized by BMI into the following groups: normal (18.5-24.9 kg/m), overweight (25.1-29.0 kg/m), class I (30.0-34.9 kg/m), class II (35.0-39.9 kg/m), and class III (>40 kg/m). Demographics included history of tobacco use, breast cancer diagnosis, adjuvant care, and comorbidities. Complications evaluated included donor site (delayed wound healing, fat necrosis, dehiscence, infection, abdominal hernia/bulge, and seroma), recipient site (delayed wound healing and fat necrosis), and need for reoperation. Statistical analyses were performed using analysis of variance and χ test. RESULTS: A total of 90 women (117 breasts) underwent microsurgical breast reconstruction using abdominal tissue. Twenty-seven women (48 breasts) met criteria for class II and class III obesity (BMI 35-53). Mean follow-up was 24 months. No statistically significant difference was found in demographics among all groups. There was a trend toward variability in overall complications across the BMI groups (P = 0.149). Donor site complications had a significant variation across the different BMI groups (P = 0.016). The rate of donor site complications was similar in class II (8/14) and class III (7/13) obese women. Recipient site complications were similar across the BMI groups. CONCLUSIONS: We found obese women to have a higher rate of abdominal donor site complications; however, this risk seems to level off at class I or II obesity. We have modified our surgical technique of managing the abdominal donor site to optimize our outcomes in the morbidly obese patient population.

Decreasing ALT donor site morbidity with the keystone flap.

BACKGROUND: The anterolateral thigh (ALT) flap is a workhorse flap for a variety of wounds. The primary disadvantage of ALT flaps is donor site morbidity associated with large skin paddle defects. We present a strategy of managing the donor site with the Keystone flap to avoid skin grafts in cases where primary closure is not possible. METHODS: A retrospective, multi-institutional review from December 2015 to March 2017 based on a single surgeon's experience was performed. Inclusion criteria were harvest of an ALT flap and closure of the thigh donor site with a keystone flap. RESULTS: Six patients underwent reconstruction of the ALT donor site with a keystone flap. The average width of the ALT skin paddle was 7.8 cm (range 7-8 cm) and the defects could not be closed primarily or with wide undermining. Surface area of the ALT flaps averaged 96.8 cm2 (range 64-152 cm2 ). Mean patient BMI was 24.6 (range 16-37). Keystone flap dimensions averaged 9.5 × 17.8 cm. There were no major donor or recipient site complications, and one ×minor complication of delayed wound healing. No patients exhibited decreased range of motion at the hip or knee. CONCLUSIONS: Primary closure of the ALT donor site is preferred, but becomes difficult as skin paddle width approaches 8 cm. Managing the ALT flap donor site with a keystone flap is safe, does not appear to have significant morbidity, and can allow the surgeon to avoid the morbidity and secondary donor site associated with skin grafting.

Labial Incompetence in Mobius Syndrome: LeFort I Impaction Case Report and Review of Management Strategies.

Difficulty with speech intelligibility in Mobius syndrome patients due to bilabial incompetence is common yet rarely discussed. We present a patient with Mobius syndrome who underwent counterclockwise LeFort I impaction to improve her labial competence. In addition, we present a literature review of management strategies for labial incompetence correction in Mobius patients. At 7-year follow-up after LeFort 1 impaction, the patient reports improvement in speech intelligibility, specifically regarding the ability to pronounce bilabial consonants. This is the first published report of LeFort I impaction to improve labial competence and bilabial consonant pronunciation in a Mobius syndrome patient.

The Greater Palatine "Notch": Clinical Sequelae of an Incomplete Greater Palatine Foramen.

The anatomy of the greater palatine foramen has variation with regard to location, but there have been no reports on the absence of a complete foramen. We present 2 cases of pediatric patients with cleft palates possessing a greater palatine "notch" as opposed to a bony foramen. Awareness of this anomaly is advantageous in preventing injury to the greater palatine vessels during palatoplasty.

Current Practices in the Management of Postoperative Arterial Vasospasm in Microsurgery.

BACKGROUND: Postoperative microvascular arterial vasospasm is a rare clinical entity. There are no published management algorithms and also the pathophysiology of this phenomenon has not been elucidated. METHODS: An email survey of American Society for Reconstructive Microsurgery (ASRM) and World Society for Reconstructive Microsurgery (WSRM) members regarding their experiences with postoperative arterial vasospasm was conducted, returning 116 responses. A comprehensive literature search was conducted regarding the current body of knowledge on this entity. RESULTS: Sixty-five percent of respondents encountered cases where postoperative arterial vasospasm was clearly the cause of flap ischemia. The majority (62%) of surgeons believed a damaged segment of the artery was responsible for the spasm, with technical issues cited as the most likely cause. Sixty-two percent and 50% of surgeons used segmental resection of the recipient and donor vessels, respectively.Rated for proclivity to vasospasm, superficial inferior epigastric artery (SIEA) was the flap, superior thyroid artery (STA) the recipient vessel, and the lower limb the anatomic region most frequently mentioned.Most widely used management strategies were: topical vasodilators (91%), adventitial stripping (82%), and dilation of recipient and donor vessels (76%). Over 50% of surgeons used some type of vessel resection technique. CONCLUSIONS: When flap ischemia is encountered without mechanical issues or thrombus, vasospasm can be the root cause. Certain vessels (SIEA, STA) and anatomic regions (lower limb) pose a higher risk for this phenomenon. When a vessel is affected, it is common practice to excise the questionable segment and use a graft as needed. Vessel resection as part of a multimodal approach can result in a reasonable salvage rate.

Bioabsorbable Polydioxanone Mesh for Soft Tissue Reinforcement in Revisional Breast Surgery.

Background: The need for revision procedures after breast implant surgery often arises from the failure of soft tissues to provide a stable implant pocket. Meshes or dermal matrices have been used to reinforce the implant's soft tissue support. Durasorb (Surgical Innovation Associates, Chicago, IL) is a resorbable polydioxanone (PDO) mesh indicated for soft tissue reinforcement. Its monofilament, macroporous design allows for ease of handling and rapid tissue incorporation. The extended timeline of PDO bioabsorption provides support during the critical portions of soft tissue healing while avoiding long-term complications of permanent products. Objectives: Evaluate the efficacy of Durasorb PDO mesh for soft tissue reinforcement in revision breast surgery. Methods: This is a prospective case series of 17 patients (27 breasts) undergoing revision breast implant surgery with Durasorb PDO mesh. Results: Five patients (5 breasts) presented for revision after implant placement for breast reconstruction, with the remaining 22 presenting for revision after implant placement for cosmetic indications. Average patient age was 47.9 years, and average BMI 24.3. Indications for surgery were implant malposition (37%), capsular contracture (30%), poor cosmesis/asymmetry (26%), and recurrent soft tissue ptosis (7%). Follow up averaged 355 days (range 174 to 799 days, SD=155). One patient experienced a seroma 2 weeks post-operatively, which resolved after a single aspiration. No infections, wound healing problems, or recurrences of implant malposition/capsular contracture were encountered. Conclusions: Durasorb PDO mesh appears to be efficacious as a breast implant pocket reinforcement in the reoperative setting with a low complication rate and durable results.

Wealth Management and Retirement.

SUMMARY: The purpose of this publication is to introduce basic financial planning concepts and highlight their use in creating a retirement savings plan. These tools may help young surgeons set their financial targets and create a plan to meet them, whereas surgeons later in their careers may reflect on their choices and implement adjustments, or be inspired to pass on the lessons they learned to the next generation. This publication is limited by design and should be thought of as a primer, not a comprehensive treatise. The topic of personal financial management is as vague as it is broad, and there are many concepts and situations that are outside the scope of this publication. Unique goals, income and expense streams, and risk tolerances necessitate individualized solutions, but there are fundamental concepts listed below that are more universally applicable. The discussion is tailored to the high income stream that plastic surgeons can expect, albeit one that starts relatively late in their careers compared to nonphysician colleagues. There are three foundational principles the reader should take away: having a plan is crucial in achieving any financial goal; starting any savings/investment endeavors as early as possible is as or more important than the amount of capital committed to them; and lastly, individual investors (professional and amateur) have consistently demonstrated an inability to consistently do better than the market over the long run.