Volumetric Assessment of the Anterior Digastric Muscles: A Deeper Understanding of the Volumetric Changes With Aging.

BACKGROUND: Targeting the deeper, subplatysmal structures in the neck has recently grown in popularity. In particular, interventions targeting the "bulky" anterior digastric (AD) muscle have been described with excellent results. However, much remains to be understood about the deep anatomy of the neck and the age-associated changes of the AD. OBJECTIVES: The aim of this study was to examine the relationship between AD volume and age. METHODS: This retrospective study calculated the AD volume from MRI segmentation in subjects between the ages of 20 to 92 years, scans of whom had previously been recorded. Those with compromised imaging due to pathology or artifact were excluded. Subjects were divided into 4 age-defined cohorts for clinical applicability. RESULTS: This study included 129 patients (male n = 64) with a mean age of 52.3. The AD volume of the reference group was 3.2 cm3. A linear decrease in muscle volume was observed with age compared with the reference group: 2.95 cm3 in the 45- to 54-year-old cohort (P = 0.3), 2.7 cm3 in the 55- to 64-year-old cohort (P = 0.05), and 2.45 cm3 in the >65-year-old cohort (P < 0.001). Male sex (P = 0.0001) and laterality (P = 0.003) were associated with significantly larger volumes. Overweight and obese BMI classification was not associated with a significantly different volume than normal or underweight subjects (P = 0.067). CONCLUSIONS: The study findings suggest an age-associated reduction in AD volume. Gender and laterality significantly affected volume, whereas BMI did not. Although the results do not support the theory of muscular hypertrophy with aging, they reveal that the perceived bulkiness may be due to changes in the surrounding anatomy affecting the morphology of the AD and subsequent blunting of the cervicomental angle.

The Pocket Flap: A Pericranial Galeal-Frontalis Flap for Lining and Graft Coverage in Nasal Reconstruction.

ABSTRACT: Complex nasal defects can necessitate nasal lining, bone and cartilage, and skin reconstruction. Defects requiring lining and structural support without the need for skin resurfacing are relatively uncommon. The following case report describes in detail a pericranial galeal-frontalis flap that is used to both reconstruct the nasal lining and provide adequate cartilage graft coverage. The pericranial galeal-frontalis flap provides yet another option for the reconstructive surgeon faced with complex defects of the nasal dorsum.

Contact Cooling of Random-Pattern Cutaneous Flaps: Does it Increase Necrosis?

BACKGROUND: Cooling after surgery reduces pain, swelling and ecchymosis. However, the fear of adverse effects of vasoconstriction caused by cooling may prevent its use when the skin is undermined extensively, for example, after rhytidectomy. The purpose of this study is to determine whether the contact cooling of random-pattern skin flaps increases the area of necrosis observed. METHODS: Twenty-eight random-pattern skin flaps (4 × 10 cm) were raised on four pigs. Flaps were divided into three groups: control, intermittently cooled and continuously cooled. Pads connected to a ThermaZone cooling device delivered local hypothermia in the range of 4-6 °C for 24 h postoperatively. ImageJ software was used to calculate the area of necrosis on each flap on postoperative day 7, confirmed with histological analysis. RESULTS: The average areas of necrosis observed were as follows: control (17.61 cm2; SD 5.23), intermittent cooling (15.65 cm2; SD 3.76) and continuous cooling (14.16 cm2; SD 3.91). An ANOVA revealed no statistically significant differences between the three interventions (p = 0.35). CONCLUSIONS: Postoperative continuous or intermittent cooling does not increase the area of necrosis in random-pattern flaps. In fact, a trend was observed, demonstrating decreasing area of necrosis with increased periods of hypothermia. NO LEVEL ASSIGNED: 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 .

Postnatal Pancraniosynostosis in a Patient With Infantile Hypophosphatasia.

Hypophosphatasia is a rare metabolic bone disorder that predisposes patients to craniosynostosis. Typically, patients born with hypophosphatasia will exhibit fused cranial sutures at birth. This is the first reported case of delayed onset of pancraniosynostosis in a patient with infantile hypophosphatasia. The severity of onset and delayed presentation in this patient are of interest and should give pause to those care providers who treat and evaluate patients with hypophosphatasia.

Gender-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults.

BACKGROUND: Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments. STUDY DESIGN: The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes. RESULTS: A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants. CONCLUSIONS: In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.

The challenging patient in autologous breast reconstruction: obesity, breast ptosis and beyond.

Autologous breast reconstruction has consistently demonstrated excellent patient satisfaction, ideal aesthetic results, and a low risk of complications. With the increasing incidence of breast cancer diagnoses and higher reconstruction rates, surgeons encounter a broader spectrum of patients. Obese patients undergoing breast reconstruction are more likely to experience a surgical complication. While free tissue transfer carries a higher donor site complication rate, implant-based reconstruction carries a higher loss of reconstruction in this population. Additionally, autologous reconstruction consistently demonstrates better patient-reported outcomes. Oncoplastic reconstruction is an oncologically safe alternative to free tissue transfer and implant reconstruction which reduces the risk of complications and the risk of delaying adjuvant therapy. Particularly in obese patients for whom radiation is indicated based on tumor size or nodal involvement, oncoplastic reconstruction is maximally beneficial. The Goldilocks mastectomy is yet another alternative to free tissue transfer or implant reconstruction which carries an acceptable risk profile, especially when augmentation with tissue expander or implant is delayed and performed at a second stage. In patients with breast ptosis undergoing skin-sparing mastectomy, vertical skin reduction allows an acceptable aesthetic result while minimizing the risk for mastectomy flap necrosis (MFN), especially in comparison to Wise pattern skin reduction. If a nipple-sparing mastectomy (NSM) is to be performed in the setting of breast ptosis, a nipple delay or a pre-mastectomy reduction/mastopexy is the safest and most conservative approach, but can alter the timeline for primary cancer resection and therefore is predominantly performed in patients with a genetic predisposition or those undergoing a prophylactic mastectomy. Patients with obesity, breast ptosis, advanced age, active smoking history, prior radiation therapy, or abdominal procedures can carry an increased risk of complications and present a challenge to plastic surgeons. We review the most recent literature published regarding reconstruction in these patient groups and seek to provide practical information to help inform clinical decision-making and operative execution.

The Central Mound Pedicle: A Safe and Effective Technique for Reduction Mammaplasty.

BACKGROUND: The central mound technique offers a relatively less common approach for breast reduction. This study evaluated the expected safety and efficacy outcomes using this technique in a large patient series. METHODS: A retrospective review of all patients undergoing central mound breast reduction at the authors' institution between June of 1999 and November of 2018 was performed. Both bilateral macromastia and unilateral symmetrizing reduction patients were included but evaluated separately for some outcomes. Patient demographics and comorbidities, operative details, postoperative adverse events, and BREAST-Q scores were recorded. Associations between preoperative variables and outcomes were assessed with chi-square tests, Wilcoxon tests, and Kendall tau-b correlations. RESULTS: A total of 325 patients were identified for inclusion (227 bilateral and 98 unilateral; 552 breasts). The average patient age was 46 years, and the average body mass index was 27.4 kg/m. Among the bilateral macromastia patients, the average operative time was 3 hours 34 minutes, and average breast tissue removed was 533 g (right breast) and 560 g (left breast). Among all patients, average follow-up was 169 days. On a per-breast basis for all patients, the following complication rates were observed: seroma, 0.2 percent; hematoma, 1.1 percent; dehiscence, 2.9 percent; infection, 1.5 percent; hypertrophic scar, 4.6 percent; nipple necrosis, 0.4 percent; fat necrosis, 0.9 percent; and skin flap necrosis, 1.7 percent. Using the BREAST-Q Reduction/Mastopexy questions on a Likert scale ranging from 1 to 5, restricted to the bilateral macromastia patient population, all scores improved with statistical significance. CONCLUSION: The central mound pedicle is a safe and effective approach for reduction mammaplasty for both bilateral macromastia patients and unilateral symmetrizing operations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Neurotoxins: Expanding Uses of Neuromodulators in Medicine--Headache.

Over the course of the past 17 years, since the initial discovery of the association between botulinum toxin-A (BT-A) and the reduction of headache symptoms, the use of this neurotoxin has greatly evolved. BT-A has emerged as an alternative to prophylactic pharmacological therapies in the prevention of chronic migraine headaches, with an excellent safety profile and proven efficacy, and is Food and Drug Administration-approved for on-label use since October 2010. The mechanism of BT-A involves its effect at the neuromuscular junction, inhibition of neuropeptide and neurotransmitter release in peripheral sensory neurons, and retrograde axonal transport allowing for its direct effect on inhibiting central sensitization. Through its diagnostic and therapeutic utility, BT-A has proven to be an integral part in the treatment of chronic headache disorders.

A retrospective review of the outcomes of migraine surgery in the adolescent population.

BACKGROUND: Migraine surgery has been studied extensively in adult patients with refractory headaches. The purpose of this study was to review a single surgeon's outcomes following migraine surgery in an adolescent population. METHODS: A retrospective review of all patients operated on by the senior author (B.G.) from 2000 to 2014 was performed. All patients aged 18 years or younger with at least 1 year of follow-up after surgery were included. Preoperative and postoperative migraine frequency, duration, severity, and migraine headache days and migraine index were analyzed for statistical significance. RESULTS: A total of 14 patients and 15 operations were analyzed. After an average follow-up of 38.2 months, the frequency of migraine headaches per 30-day period was reduced from 25 to 5 (p < 0.0001), the migraine headache index decreased from 148.1 to 12.4 (p < 0.0001), the duration of headaches (number of hours per 24 hours) declined from 0.71 to 0.25 (p = 0.002), severity of headaches diminished from 8.2 to 4.3 (p = 0.0004), and migraine days per month declined from 25 to 5 (p < 0.0001). Five patients remained free of any symptoms following surgery. One patient had no improvement in frequency of headaches, but did have improvement in severity and duration of headaches. No postoperative complications were noted in this group of patients. CONCLUSION: In the adolescent population with migraine headaches refractory to traditional medical management, migraine surgery may offer symptomatic improvement of migraine headache frequency, duration, and severity in patients with identifiable anatomical trigger sites. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Current Means for Detection of Migraine Headache Trigger Sites.

The authors' 15-year experience with migraine surgery has led them to believe that the most common reasons for incomplete response are failure to detect all of the trigger sites or, on rare occasions, inadequate surgery on the trigger sites. Thus, accurate identification of trigger sites is essential. The purpose of this article is to share the authors' current stepwise algorithm for accurately detecting the migraine trigger sites, which has evolved through surgery on nearly 1000 patients. To begin, a thorough history is taken. Each patient's constellation of symptoms can point toward one or multiple trigger points. The patient is asked to point to the most frequent site from which migraine headaches originate with one fingertip, and then the site is explored with a Doppler. If an arterial Doppler signal is identified at the site, it is considered an active arterial trigger site. Response to a nerve block with a local anesthetic in a patient with an active migraine headache confirms the presence of a trigger site. If the patient does not have pain at the time of the office visit, an injection of botulinum toxin A at the suspected trigger site may be considered. Although positive responses to botulinum toxin A and nerve block are very helpful and reliable in confirming the trigger sites, negative responses must be interpreted with extreme caution. In patients with a migraine headache starting from the retrobulbar site, a computed tomography scan of the paranasal sinuses is obtained to look for contact points and other pathology that would confirm rhinogenic trigger sites.