Putting it all together: recommendations for improving pain management in body contouring.

SUMMARY: The authors present a review of pain management in body-contouring surgery. They also provide personal perspectives and recommendations given the senior author's (A.M.) extensive experience with body-contouring procedures. A review of preoperative, intraoperative, and postoperative considerations is discussed.

Simplifying the management of caudal septal deviation in rhinoplasty.

SUMMARY: Correction of the deviated nose poses a challenge in even the most experienced hands. Frequently, the surgeon is faced with both a functional (airway obstruction) and an aesthetic problem that must be addressed conjointly. Accurate preoperative analysis and intraoperative diagnosis are integral to good outcomes. Caudal septal deviation is frequently present in patients presenting for rhinoplasty. The authors' current graduated technique for simplifying the management of the caudally deviated septum both aesthetically and functionally is described. If there is a persistent caudal septal deviation that has not been addressed by standard maneuvers, the caudal portion of the anterior septum is resected at the osseocartilaginous junction with the anterior nasal spine and maxillary crest and then sutured back to the periosteum of the anterior nasal spine with 5-0 polydioxanone. We have found this to be a safe and effective way of addressing the caudally deviated septum in the majority of cases.

The ever-changing role of biofilms in plastic surgery.

The goal of this article is to present a brief background of biofilms and how they pertain to plastic surgery. Of particular interest are how biofilms affect breast prosthesis and their subsequent complications. The authors also present information on how biofilms are involved in soft-tissue filler complications. After a brief review of the pathophysiology of biofilms and their effect on plastic surgery, the authors propose a revised algorithm to assist in guiding the plastic surgeon when faced with complications that involve biofilms that involves more rapid diagnosis and treatment using polymerase chain reaction technology. This article is a review of recent literature.

Lift-and-fill face lift: integrating the fat compartments.

BACKGROUND: Recent discovery of the numerous fat compartments of the face has improved our ability to more precisely restore facial volume while rejuvenating it through differential superficial musculoaponeurotic system treatment. Incorporation of selective fat compartment volume restoration along with superficial musculoaponeurotic system manipulation allows for improved control in recontouring while addressing one of the key problems in facial aging, namely, volume deflation. This theory was evaluated by assessing the contour changes from simultaneous face "lifting" and "filling" through fat compartment-guided facial fat transfer. METHODS: A review of 100 face-lift patients was performed. All patients had an individualized component face lift with fat grafting to the nasolabial fold, deep malar, and high/lateral malar fat compartment locations. Photographic analysis using a computer program was conducted on oblique facial views preoperatively and postoperatively, to obtain the most projected malar contour point. Two independent observers visually evaluated the malar prominence and nasolabial fold improvements based on standardized photographs. RESULTS: Nasolabial fold improved by at least one grade in 81 percent and by over one grade in 11 percent. Malar prominence average projection increase was 13.47 percent and the average amount of lift was 12.24 percent. The malar prominence score improved by at least one grade in 62 percent of the patients postoperatively, and 9 percent had a greater than one grade improvement. Twenty-eight percent of the patients had a convex malar prominence postoperatively compared with 6 percent preoperatively. Malar prominence improved by at least one grade in 63 percent and by over one grade in 10 percent. CONCLUSIONS: The lift-and-fill face lift merges two key concepts in facial rejuvenation: (1) effective tissue manipulation by means of lifting and tightening in differential vectors according to original facial asymmetry and shape; and (2) selective fat compartment filling of deep malar and high malar locations and nasolabial fold fat grafting to precisely control facial contouring. This was shown with objective numerical grading and through observer assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reconstruction of the nasal soft triangle subunit.

BACKGROUND: Of all nine subunits, the soft triangle is perhaps the most challenging to recreate. The complexity of soft triangle reconstruction resides in its proximity to such important structures as the nasal tip, nasal ala, and distal columella. If the soft triangle is not properly reconstructed, problems with nasal function and aesthetics often arise. Anatomical asymmetries in the lower third and abnormal shadowing can occur following insufficient restoration. METHODS: A retrospective review was completed of all patients undergoing reconstruction of the nasal soft triangle subunit at the University of Texas Southwestern Medical Center in Dallas, Texas, from 1995 to 2010. Defects with only external skin intact were classified as type I. Defects involving both skin and underlying soft tissue with intact mucosa were classified as type II. Finally, transmural defects with violated mucosa were classified as type III. Surgical outcomes were graded on a scale of I to IV. Grades given were based on the complexity of the existing defect and restoration of the soft triangle, with higher grades given when adjacent structures were not distorted. RESULTS: Of the 14 cases reviewed, two (14 percent) were type I defects, nine (64 percent) were type II defects, and three (21 percent) were type III defects. Three patients (21 percent) required revision with subsequent resurfacing and two (14 percent) required resurfacing alone. All but one patient (93 percent) had a grade of 2.0 or better, with the one patient opting not to undergo revision. CONCLUSIONS: The authors believe their method of soft triangle reconstruction using the proposed algorithm is an easy approach to soft triangle reconstruction that will yield consistent surgical and clinical success from aesthetic and functional perspectives. Furthermore, the authors were able to achieve excellent aesthetic outcomes without compromise or facing any structural complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Validation of a laser-assisted wound measurement device for measuring wound volume.

BACKGROUND: Accurate and precise wound measurement is an essential part of the medical record when monitoring a patient with a chronic wound. This study was designed to determine if a new device, a laser-assisted wound measurement (LAWM) device, provides valid measurements for wound area, depth, and volume. METHODS: We compared four methods to evaluate the area and volume of 12 wounds of differing size and depth that were created on the dorsum of a sacrificed pig. We evaluated the LAWM device, digital photograph assessment with National Institutes of Health ImageJ software, measurements of depth with a ruler, and weight-to-volume assessment with dental paste. We then sought to cross validate this data with further analyses obtained from these measurements using a Play-Doh®-based wound as a model for constant area with different depths. RESULTS: We demonstrate that the LAWM device measures wound area accurately. Depth (and therefore volume) measurements, however, are artificially low. This inaccuracy is the same for shallow and deep wounds. CONCLUSIONS: The inaccuracy in the depth and volume measurements with the LAWM device results in an artificially low measurement. However, this may not affect percentage difference measurements. Further studies will need to be performed to determine if this device can accurately determine wound changes in the clinical setting.

Lower third nasal reconstruction: when is skin grafting an appropriate option?

BACKGROUND: A full-thickness skin graft is generally not considered the ideal replacement for the thick, sebaceous skin of the nasal tip, ala, lower sidewalls, or dorsum. Instead, many clinicians prefer to reconstruct these defects with local or axial composite flaps that incorporate skin, subcutaneous tissue, and fat. METHODS: The authors conducted a retrospective analysis of 55 consecutive patients who underwent reconstruction of lower third nasal defects with full-thickness skin grafts between 2002 and 2007 performed by the senior author (J.F.T.). All of the patients in this review underwent skin cancer ablation by means of Mohs' micrographic surgery. RESULTS: Good aesthetic results, based on preoperative and postoperative photographic analysis of contour and pigmentation, have been achieved in both the recipient and donor sites in 52 of 55 patients. Three patients, all of whom were smokers, experienced loss of the skin graft requiring alternative reconstructive techniques. CONCLUSIONS: Under certain conditions, skin grafting of defects of the caudal third of the nose offers a viable reconstructive option that yields good contour and color match. Careful analysis of defect size, location, and depth and consideration of donor-site skin thickness and pigmentation are vital for accurate replacement of the thick, pitted, sebaceous skin of the caudal nose. An evolution in technique has revealed that the forehead donor skin often provides a more consistent color and contour match in such reconstructions. Secondary dermabrasion of the graft provides a critical step for obtaining final aesthetic contour and color.

Nasal reconstruction: an overview and nuances.

Nasal reconstruction continues to be a formidable challenge for most plastic surgeons. This article provides an overview of nasal reconstruction with brief descriptions of subtle nuances involving certain techniques that the authors believe help their overall outcomes. The major aspects of nasal reconstruction are included: lining, support, skin coverage, local nasal flaps, nasolabial flap, and paramedian forehead flap. The controversy of the subunit reconstruction versus defect-only reconstruction is briefly discussed. The authors believe that strictly adhering to one principle or another limits one's options, and the patient will benefit more if one is able to apply a variety of options for each individualized defect. A different approach to full-thickness skin grafting is also briefly discussed as the authors propose its utility in lower third reconstruction. In general, the surgeon should approach each patient as a distinct individual with a unique defect and thus tailor each reconstruction to fit the patient's needs and expectations. Postoperative care, including dermabrasion, skin care, and counseling, cannot be understated.