A Simple and Effective Intraoperative Technique for Correction of Severe Congenital Breast Asymmetry.

BACKGROUND: One severe type of congenital breast asymmetry, with a hypoplastic breast on one side and a hyperplastic breast on the other side, has been recognized in the author's practice. Although breast augmentation, mastopexy, and breast reduction used separately or in combination are the most common procedures performed to correct congenital asymmetrical breasts, an effective approach for the correction of such a congenital breast asymmetry has not been established in the literature. In this article, a simple and effective intraoperative approach is described for correction of severe congenital breast asymmetry. METHOD: Breast augmentation with an implant for the hypoplastic side and mastopexy or small breast reduction for the hyperplastic side were performed. Symmetry was achieved intraoperatively by an implant for breast augmentation on the hypoplastic side and mastopexy or small reduction, determined by a tailor-tacking technique, on the hyperplastic side. RESULTS: In the past 2 years, a total of 4 patients with severe congenital breast asymmetry was operated on by the author with this established approach. All patients were pleased about their symmetry and cosmetic outcome without any surgical complications. The resulted breast scars are minimal and well tolerated by patients. No revision or subsequent surgery has even been needed during follow-op. CONCLUSION: Correction of severe congenital breast asymmetry is not an easy task and can be difficult. This simple and effective intraoperative approach provides a relatively easy and logical way as a 1-stage procedure for this subgroup of patients with symmetrical and cosmetically pleasing outcome.

Reoperative Microsurgical Free Flap Surgery: Lessons Learned.

ABSTRACT: Microsurgical free flap surgery has revolutionized reconstructive surgery at most academic centers worldwide. However, free flap failures still occur even in the hands of the most experienced microsurgeon. Although we have achieved a great deal of success performing microsurgical free flap reconstruction for various indications, complications from initial free flap surgery that result in reoperation remain a small, but steady percentage. Venous flap congestion is one of the most challenging conditions that result in free flap failure if not resolved promptly. It can be caused by several conditions, and salvage for venous congestion is often difficult and time consuming. Over 20 years, the senior author has encountered 2 unique situations that resulted in venous congestion of the flap requiring reoperative surgery for flap salvage or a second free flap. Several medical conditions can compromise free flap surgery and result in total flap loss. The senior author has also encountered 2 medical conditions resulting in total flap loss. However, both patients received successful second free tissue transfers when combined with unique perioperative management strategies. It is our hope that this review will highlight some unique management strategies for reoperative microsurgical free tissue transfer and serve as "lessons learned" for initial salvage procedures and a second free tissue transfer. We also hope our reoperative approach demonstrated in this review will help the future generation of microsurgeons to avoid such complications altogether so that overall outcome after microsurgical free flap surgery can further be improved.

Free Tissue Transfer to the Knee for a Complex Wound Coverage When Good Recipient Vessels Are Not Available.

Free tissue transfer to the knee can be difficult due to limited options for reliable recipient vessels and vein grafts or arteriovenous loops may also be associated with an increased risk of flap failure. In this study, the authors describe our experience with creating proper recipient vessels for free flap reconstructions around the knee using the descending branch (DB) of the lateral circumflex femoral vessels (LCFV) or anterior tibial vessels (ATV). Three patients underwent free flap reconstruction of knee wounds secondary to trauma, prosthesis infection, and radiation therapy. The anterolateral thigh, rectus abdominis, and latissimus dorsi flaps were used to close the wounds, respectively. Dissection of the DB of LCFV was carried between the rectus femoris and vastus lateralis, and between the peroneus longus and brevis for the ATV. These recipient's vessels were created and placed in a more desirable location adjacent to the defect for microvascular anastomoses. The DB of LCFV and ATV were dissected successfully and both arterial and venous micro-anastomose were performed in an end-to-end manner with the recipient's vessels. All patients had successful free tissue reconstructions with uneventful postoperative courses. The flaps remained viable and reliable soft tissue coverage with acceptable contour had been accomplished during follow-up. Either DB of LCFV or ATV can serve as adequate recipient vessels after being placed adjacently to soft tissue defects for a straightforward free tissue transfer to the knee. The creation of such recipient vessels avoids vein grafts or arteriovenous loops and allows for a reliable free flap reconstruction of the knee.

An Updated Definition of Plastic Surgery.

ABSTRACT: Modern medicine tends to provide comprehensive medical services based on disease or pathological features. As a result, the overlap between plastic surgery and other surgical departments greatly deepened. What was exclusively done by plastic surgeons are nowadays frequently practiced by other surgeons as well. Thus, generating confusion as to whether plastic surgery is an independent subject or a tool. Therefore, in this new era of modern medicine, it is necessary to reconsider the definition of plastic surgery.

The Second Free Tissue Transfer After the First Free Flap Loss for a Complex Scalp Reconstruction: Our Strategy to Success With a Staged Approach.

ABSTRACT: Scalp reconstruction for a critical neurosurgical patient, as lifesaving efforts continued, can be challenging and a free tissue transfer is often needed to achieve reliable soft tissue coverage. However, the patient's labile perioperative condition may compromise successful reconstruction and perioperative hypotension is one of the major known factors for the failure of free tissue transfer. In this report, the authors encountered such an instance, and present our strategy in overcoming this hurdle toward obtaining successful scalp reconstruction with second free tissue transfer after the first free flap loss. After optimizing the patient's medical condition, the second free tissue transfer was performed in 2 stages with recipient vessel dissection during the first stage and the flap harvest and microvascular anastomoses during the second stage. Our staged approach is warranted to ensure the patient can tolerate the stressor of general anesthesia and to precondition the patient for ultimate successful second free tissue transfer.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach.

BACKGROUND: Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp. METHODS: In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described. SUMMARY: Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction. CONCLUSION: We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

Advancing the Specialty of Plastic Surgery While Helping and Supporting Other Surgical Services at an Academic Medical Center.

ABSTRACT: While helping and supporting other surgical services at our academic medical center, we noticed that many clinical problems presented to our plastic surgery team are truly unique and challenging. Many of the necessary reconstructive procedures, performed by the senior author, had never been published in plastic surgery textbooks or the literature before. Because of the plastic surgeon's creative problem-solving ability, we use reconstructive treatment plans that also innovate and advance the field of plastic surgery. In this case series, we share our experience with creative solutions for the management of novel and challenging clinical problems faced by our plastic surgery service. The resultant and effective solutions for each challenging case have all been published in reputable plastic surgery journals by the senior author. Once published, our inventive reconstructive solutions can be harnessed by other plastic surgeons and trainees and new standardized techniques or solutions for these unique and challenging clinical problems can be established. Ultimately, plastic surgeons can evolve their specialty through helping and supporting other surgical services at an academic medical center by establishing innovative solutions for ever arising challenging clinical problems. Once again, the plastic surgery team in a tertiary hospital supports many surgical services so that more complex surgical procedures can be performed safely and complications from other surgical services can be managed successfully. Therefore, adequate support for a plastic surgery service, by the hospital or department, is critical in developing a strong plastic surgery program at an academic medical center.

Contemporary Breast Augmentation Practice in the United States.

ABSTRACT: Breast augmentation is one of the most commonly performed cosmetic surgical procedures in the United States. Modern breast augmentation has evolved with the development of various implant options, as well as surgical techniques. To achieve ideal result, it is important for the surgeon to develop a systematic approach to evaluate each patient. The 5 key steps in determining the best surgical plan include: (1) assess the need for concurrent mastopexy, (2) implant selection, (3) pocket plane, (4) inframammary fold position, (5) choice of incision. The purpose of this review is to discuss the principles behind each of these key concepts and how to utilize them in achieving the optimal outcome in breast augmentation.

Achieving an Optimal Outcome in Immediate Breast Reconstruction.

ABSTRACT: Performing immediate breast reconstruction requires careful consideration of preoperative, intraoperative, and postoperative factors. One of the fundamental necessities is a well-coordinated multidisciplinary team to achieve successful reconstruction. Clear and effective communication between the oncological surgeon and plastic surgeon is imperative. The treatment plan must take into account any potential neoadjuvant and adjuvant therapies. Surgical planning and incisional approach must be carefully considered to optimize a safe oncologic surgery and ensure a viable reconstructive outcome. Furthermore, there are fundamentals to immediate breast reconstruction that must be met to obtain an aesthetically pleasing and structurally durable breast reconstruction. The goal of this article was to highlight important considerations in surgical planning and execution of immediate breast reconstruction so that an optimal outcome can be accomplished after either autologous or implant-based breast reconstruction.

Asian Upper Blepharoplasty in Women: A Comprehensive Approach for a Natural and Aesthetically Pleasing Outcome.

BACKGROUND: Asian upper blepharoplasty is the most popular cosmetic procedure for Asian women. However, there is no standardized approach to this procedure and suboptimal results are still common. OBJECTIVES: The aim of this article was to describe a comprehensive approach to Asian upper blepharoplasty in women and report the clinical outcomes obtained with this approach. METHODS: The comprehensive approach described here for Asian upper blepharoplasty in women includes: (1) determining the height and length of the upper eyelid skin crease; (2) creating a more optimal anatomy of the upper eyelid by removing excess eyelid skin, a portion of the orbicularis oculi muscle, and septal fat; (3) reconstructing the desired anatomic structures of the upper eyelid skin crease through plication of the levator aponeurosis, if necessary, and closure of the upper eyelid skin incision through the septum and the mobile portion of the levator aponeurosis; (4) adding a medial epicanthoplasty if needed to enhance final cosmetic results. RESULTS: Over a 5-year period, 332 Asian women underwent upper blepharoplasty for creation of double eyelids, or conversion from less visible to more ideal double eyelids, with the above comprehensive approach. There were no surgical complications postoperatively and 326 patients (98.2%) rated their outcome satisfactory over a 5-year follow-up. Only 6 patients (1.8%) required surgical revision for asymmetry or suboptimal shape of the upper eyelid. CONCLUSIONS: The comprehensive approach to Asian upper blepharoplasty described here can be used for Asian women and produces a natural and aesthetically pleasing outcome and low revision rates.

What Do We Know Now About Autologous Fat Grafting?

Autologous fat grafting has remained part of the plastic surgeon's armamentarium. Although there have been numerous articles written on this topic, its scientific basis has recently come under some scrutiny with authors questioning what we really know about fat grafting. This article reviews the various fat grafting techniques used today based on the volume and specific need of the patient. Moreover, this review acts as a guideline to the plastic and reconstructive surgeon to choose the fat grafting technique tailored to the specific goal of the procedure. Once volume of fat and the final goal of the procedure is determined, fat grafting becomes a more individualized approach for our patients. While fat grafting is not a cookie-cutter procedure, it can be defined by the volume needed and divided into 3 categories of small, mega or large, and nanofat grafting techniques. A discussion of these 3 main categories of fat grafting techniques will be presented, along with a discussion of the mechanisms of adipocyte survival after transplant based on the graft survival and graft replacement theories. Finally, the role of adipose-derived stem cells in fat grafting based on clinical studies will be delineated. It is our hope to provide the most updated information on what do we know now about autologous fat grafting.

Fat Grafting for Facial Rejuvenation and Contouring: A Rationalized Approach.

The clinical outcome after fat grafting for facial rejuvenation and contouring can be less optimal because lack of standardized techniques is performed by the surgeon for the procedure. In this review, the author has tried to provide a rationalized approach to fat grafting for facial rejuvenation and contouring. The preferred donor sites include low abdomen and inner thigh especially in younger patients. Fat grafts should be harvested with low negative pressure via syringe liposuction technique to ensure the integrity as well as the optimal level of cellular function. Fat grafts should be processed with proper centrifugation that can reliably produce purified fat and concentrated growth factors and adipose-derived stem cells, all of which are beneficial to improve graft survival. Fat grafts should be placed after certain principles with gentle injection of small amount during the withdraw phase of each pass in multiple tissue planes and levels with multiple passes to ensure maximal contact of graft with vascularized tissue in the recipient site. The approach described in this review is supported by the most recent scientific studies and thus can likely provide a more predictable long-lasting result if performed properly.

The Soleus Muscle Flap: An Overview of Its Clinical Applications for Lower Extremity Reconstruction.

Lower extremity reconstruction often poses several challenges for the reconstructive surgeon. Because of limited local tissue options, patients who sustain extensive middle to distal third tibia fractures used to be at higher risk of limb loss without adequate soft tissue coverage. The traditional principle of reconstructing middle and distal third leg wounds with free tissue transfer is being challenged by advances in understanding of local muscle flap anatomy and surgical techniques to improve the efficacy of local flaps. In this article, we examine contemporary considerations, developed by the authors, for the appropriate indications of free tissue transfer versus use of local flaps such as the soleus muscle flap. We review the versatility and reliability of the soleus muscle as a local muscle option once the technique is mastered on how to safely and effectively design and execute this flap. We highlight the importance of an algorithmic approach to soft-tissue reconstruction of the lower extremity based on the best surgical option for the patient. This includes factors such as medical history, appropriate surgical candidacy, as well as the size and mechanism of injury to decide the most viable option for lower extremity reconstruction. We show that the medial hemisoleus muscle flap is a reliable local option, both by itself or in conjunction with other local flaps, to reconstruct less extensive wounds in the middle to distal third of the leg. Ultimately, such a local muscle flap must be mastered by the reconstructive surgeon to augment his or her armamentarium to provide a well-rounded reconstructive plan in managing the soft-tissue wound, while minimizing donor-site morbidity and potentially be more cost-effective in nature.

Character of Gluteal Region Morphology in Young Chinese Females.

BACKGROUND: The female gluteal morphology is an important secondary sexual characteristic and helps accentuate and define the female body shape. Despite the increasing prevalence of gluteal augmentations in our country, little data exist regarding the morphology of the gluteal region in young Chinese females. This study analyzed a convenience sample of Chinese females and their gluteal region. METHODS: Data, measurements, and photos of the following parameters were taken: age, weight, height, and body mass index (BMI). Morphology was classified into four types: A shape, V shape, round shape, and square shape. Aesthetic characteristics of each buttock were recorded. Height, weight, BMI, and gluteal projection ratio differences in different shape groups were analyzed. RESULTS: The study sample consisted of 103 women, with ages from 23 to 27 years. The V-shaped buttock was not found in this sample. The A shape, square shape, and round shape occupied 55.3%, 38.8%, and 5.8% accordingly. Short infragluteal fold, supragluteal fossettes, lateral depression, and V-shaped crease appeared in 42.7%, 14.6%, 11.7%, and 2.9% of samples, respectively. Of the 103 samples, 39 (37.9%) fulfilled the aesthetic gluteal projection(ratio ≥ 2). The average BMI was statistically significant between each gluteal shape (P = 0.009). Height, weight, and gluteal projection ratio showed no significant difference with the buttock shapes. CONCLUSIONS: We are the first to describe gluteal morphology in young Chinese woman using gluteal anthropometrics. The findings of the study may provide a guideline for plastic surgeons who perform gluteal augmentation in Asian patients.

Beveled Incisions: What is the Evidence?

BACKGROUND: Although many aesthetic surgeons believe that beveling the angle of an incision improves the aesthetic outcome with regard to scaring, the literature remains scarce largely because few studies have been conducted. OBJECTIVE: This systematic review therefore aims to identify whether using a beveled incision adds an aesthetic benefit, to determine whether there is a specific angle that yields a superior outcome, and for the first time, to present a complete discussion of this subject for practicing surgeons. METHODS: A comprehensive literature search was performed using the PubMed database to search for primary articles. The main inclusion criteria were primary journal articles investigating the use of a beveled angle via a controlled study. RESULTS: A total of fifty-four publications were reviewed, with only four publications including 124 patients suitable for use in this systematic review. All the studies concluded that the use of a beveled angle incision improved aesthetic outcomes, with the ideal angle ranging from 10° to 45°. CONCLUSIONS: The use of a beveled angle incision can improve scar aesthetics and encourages the regrowth of hair follicles and shafts through the scars via multiple mechanisms. Nevertheless, the paucity of literature available to the practitioner compels further research assessing this important topic. LEVEL OF EVIDENCE III: 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 .

The Omental Free Flap-A Review of Usage and Physiology.

BACKGROUND: The omental flap has a rich history of use over the last century, and specifically as a free flap in the last four decades. It has a wide variety of applications in reconstructive surgery and has shown itself to be a reliable donor tissue. We seek to review the properties that make the omental free flap a valuable tool in reconstruction, as well as its many surgical applications in all anatomic regions of the body. METHODS: We conducted a narrative review of the literature on Medline and Google Scholar. We reviewed basic science articles discussing the intrinsic properties of omental tissue, along with clinical papers describing its applications. RESULTS: The omental free flap is anatomically suitable for harvest and wound coverage and has molecular properties that promote healing and improve function at recipient sites. It has demonstrated utility in a wide variety of reconstructive procedures spanning the head and neck, extremities, and viscera and for several purposes, including wound coverage, lymphedema treatment, and vascularization. It is also occasionally employed in the thoracic cavity and chest wall, though more often as a pedicled flap. More novel uses include its use for cerebrospinal fluid leaks. CONCLUSIONS: The omental free flap is a valuable option for reconstructive efforts in nearly all anatomic regions. This is a result of its inherent anatomy and vascularity, and its angiogenic, immunogenic, and lymphatic properties.

The Role of Plastic Surgery at an Academic Medical Center in the United States.

BACKGROUND: Plastic surgery may have traditionally been labelled as a "less essential" service at many academic medical centers in the United States. The purpose of this study is to evaluate the role of the plastic surgery team as a valuable service at an academic medical center. METHODS: We performed a 10-year retrospective case review of a single plastic surgeon's case log at 2 academic medical institutions, each with an active plastic surgery training program. Plastic surgical procedures performed in combination with other services and surgical management of complications from nonplastic surgical procedures was evaluated. Plastic surgical procedures performed for all types of reconstruction as a primary service, including breast reconstruction were excluded. The role of the plastic surgery service was evaluated to identify the types of assistance provided, which primary services were involved and what the most common procedures performed were for each service. RESULTS: The type of assistance provided by the plastic surgery service was divided into 2 common categories. The first type involved a concurrent or combined surgical case where the procedure required plastic surgery's participation. The second group included management of complications that occurred on another service, which then required assistance by the plastic surgery team. A total of thirteen primary services were identified as benefitting from involvement with plastic surgery. The most commonly performed reconstructive procedures provided for each service were identified. CONCLUSIONS: The plastic surgery team provides invaluable support to other services in a tertiary teaching hospital. Its input allows for more complex surgical procedures to be performed safely and for complications of surgery to be managed successfully. Clearly, plastic surgery plays a critical role at academic medical centers in the United States.

The Plastic Surgeon as Employee: A Pilot Survey of the California Society of Plastic Surgeons.

INTRODUCTION: Plastic surgeons endure years of training yet remain poorly equipped to negotiate first employment contracts. Our aims were to evaluate typical plastic surgeon employment contracts and assess contract comprehensiveness. We sought elements that should be included to better preserve varied interests. METHODS: A brief, anonymous, e-mailed survey was sent to California Society of Plastic Surgeons members and responses collected over 2 months. We collected information such as years in practice, geographic area, types of practices and number of surgeons within them, and legal standing of partnerships. We asked whether respondents sought legal assistance and specific elements were elaborated. We asked how content they were with their contracts while allowing commentary. RESULTS: Our survey generated 113 responses. 50.0% of respondents reported being in practice for at least 20 years; 2.68% had been in practice for up to 5 years. 62.5% reported being in private practice and 27.7% reported being in academia. In-state geographic distribution of respondents accounted for 85.6%, whereas 14.4% reported practicing out-of-state.Practice size was diverse, with 41.4% of respondents having worked in a group practice of 3 or more, 27.9% in partnership, and 23.4% in solo practice. For partnerships, 29.9% had made formal legal arrangements, whereas 20.6% had made informal arrangements. 74.5% of respondents did not seek legal assistance.Malpractice coverage varied from 51.6% with claims-made, to 21.7% with tail, to 33.0% with no coverage at all. 63.9% reported having no group disability policy. 26.4% reported annual income of less than US $100,000; 49.1% reported US $101,000 to US $200,000; 17.9% reported US $201,000 to US $300,000; 6.60% reported greater than US $300,000. Using a 5-point scale, 7.69% of respondents reported being "extremely dissatisfied" with their first employment contracts (score of 1), whereas 24.0% were "perfectly happy" (5).Eighty-two respondents offered advice. Common themes included seeking legal counsel; considering eventual solo practice; planning long-term; seeking mentorship; and cautioning against third party interests. CONCLUSIONS: New plastic surgeons will find themselves employed by institutions. Seeking attorneys familiar with the profession is advisable. Lack of awareness regarding malpractice options and disability coverage are 2 areas of concern. We reveal critical contract elements that surgeons should negotiate to ensure smooth transition to practice.