Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series.

BACKGROUND: As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area. METHODS: Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic. RESULTS: The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery. CONCLUSIONS: Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.

Guidelines for the Standardization of Genital Photography.

Plastic surgery relies on photography for both clinical practice and research. The Photographic Standards in Plastic Surgery laid the foundation for standardized photography in plastic surgery. Despite these advancements, the current literature lacks guidelines for genital photography, thus resulting in a discordance of documentation. The authors propose photographic standards for the male and female genitalia to establish homogeneity in which information can be accurately exchanged. All medical photographs include a sky-blue background, proper lighting, removal of distractors, consistent camera framing, and standard camera angles. We propose the following guidelines to standardize genital photography. In the anterior upright position, feet are shoulder-width apart, and arms are placed posteriorly. The frame is bounded superiorly by the xiphoid-umbilicus midpoint and inferiorly by the patella. For circumferential documentation, frontal 180 degree capture via 45 degree intervals is often sufficient. Images in standard lithotomy position should be captured at both parallel and 45 degrees above the horizontal. Images of the phallus should include both the flaccid and erect states. Despite the increasing incidence of genital procedures, there lacks a standardized methodology in which to document the genitalia, resulting in a substantial heterogeneity in the current literature. Our standardized techniques for genital photography set forth to establish a uniform language that promotes more effective communication with both the patient as well as with colleagues. The proposed photography guidelines provide optimal visualization and standard documentation of the genitalia, allowing for accurate education, meaningful collaborations, and advancement in genital surgery.

An Updated View of the Integrated Plastic Surgery Match.

BACKGROUND: Plastic surgery is one the most competitive residency programs. Data on match trends for plastic surgery residencies and traits of successful applicants are necessary for individuals applying into this highly desirable specialty. AIM: Analyze recent trends in the independent and integrated match as well as to describe attributes of successful applicants. METHODS: Data from National Resident Matching Program and San Francisco Match Program for 2007 to 2014 were compiled and analyzed. Statistical analysis and figure creation were performed using the R software package. For bivariate associations, χ or Fisher's exact test was used. RESULTS: The number of available integrated plastic surgery positions through National Resident Matching Program has increased since 2007, whereas the number of independent residencies offered through the SF Match has steadily decreased. The average Step 2 scores, The number of research presentations, publications, abstracts, and the percent of students ranking plastic surgery only have increased. In a break from previous trends, percent of applicants with Alpha Omega Alpha (AOA) membership and mean Step 1 board scores decreased. United States medical school applicants who matched were more likely to be AOA members and graduates from a top 40 medical school. There was no significant association between having an additional academic degree and successfully matching into integrated plastic surgery. CONCLUSIONS: Integrated plastic surgery residency programs continue to be highly competitive, with overall increasing research experience, but slightly lower Step 1 scores and AOA membership than that in previous years. If the trend of decreasing independent and increasing integrated positions continues, the applicant only interested in plastic surgery may find the integrated pathway a more feasible option.

Variance in the origin of the pectoralis major muscle: implications for implant-based breast reconstruction.

BACKGROUND: The pectoralis major muscle plays a crucial role in implant-based breast reconstruction. The goal of this study is to document variations of the origin of the pectoralis major muscle (PM). We hope to understand how many women have anatomy allowing for total submuscular coverage of an implant with the PM alone in immediate breast reconstruction. METHODS: Fifty patients undergoing mastectomy were recruited. Breast width and the costal origin of the natural inframammary fold (IMF) were measured preoperatively and intraoperatively. The PM width at its origin and the rib origin of the PM were measured intraoperatively. A ratio of the PM origin width to breast width was calculated. RESULTS: Forty-four percent of breasts studied had the IMF at the level of the seventh rib, 53% at the sixth rib, and 3% at the fifth rib. Twenty percent of PM muscles originated from the seventh rib, 68% from the sixth rib, and 12% from the fifth rib. Thirty-six percent of chests showed a PM originating one rib level above the IMF, 61% at the same level, and 3% one level below the IMF. Seventy-seven percent of chests showed a PM origin width to breast width ratio of <0.8. CONCLUSIONS: Overall, 72% of chests had either a high origin of the PM, a narrow PM relative to the breast width, or both. This anatomy is suboptimal for implant coverage using the PM alone. Surgeons performing implant-based breast reconstruction should be prepared to utilize wide dissection, alternative muscle recruitment, or supplemental acellular dermal matrix.

Smoking as a risk factor for breast reduction: An analysis of 13,503 cases.

BACKGROUND: Reduction mammaplasty is one of the most common reconstructive procedures performed by plastic surgeons. Over 100,000 procedures are performed annually. Although important for relieving the painful symptoms associated with macromastia, complication rates of this procedure are not insignificant. They are reported in up to half the cases. Reported risk factors for adverse outcomes include obesity, preoperative wound infection, and advanced American Society of Anesthesiologists status. Smoking has been described as a risk factor for breast reduction. There is disagreement in the literature regarding the effect of smoking on patient outcomes. To further describe and investigate smoking as a risk factor, we undertook the largest multicenter retrospective study on this subject. METHODS: Data on 13,984 patients was identified from the 2009-2014 American College of Surgeons National Surgical Quality Improvement Program. Smoker and nonsmoker cohorts were compared to assess unadjusted differences in demographics, comorbidities, intraoperative details, 30-day outcomes, and readmission rates. Univariate analysis was performed using chi-square or Fisher's exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications and readmission. Odds ratios were computed at the 95% confidence interval. RESULTS: After adjusting for potential confounders, smokers had a higher likelihood of any wound complication (OR 1.72; p = 0.001) following reduction mammaplasty compared to nonsmokers. CONCLUSION: Smoking has been shown to be a significant risk factor for wound complications following reduction mammaplasty. Comprehensive preoperative counseling and documentation should be performed with patients who smoke regarding the potential for increased risk of adverse outcomes.

Urban Myths in Plastic Surgery: Postoperative Management of Surgical Drains.

BACKGROUND: Surgical patients are frequently discharged with surgical drains to assist in wound closure that could be disrupted by postoperative hematomas, lymphoceles, or seromas. In clinical practice, duration of drain use is typically dependent on daily output. OBJECTIVE: The aim of this paper was to examine the origins and justifications of drain removal criteria. The authors considered factors that may influence recommendations such as duration, area of surgical site, and risk of infection. METHODS: A literature review was performed regarding the indications for drain removal in patients undergoing reconstructive and breast surgeries. PubMed was queried for publications up to May 2015 with the following search terms: drain removal, hematomas, lymphoceles, seroma, volume, reconstruction, and mastectomy. Clinical trials, retrospective reviews, meta-analyses, and literature reviews were included. RESULTS: Most plastic surgeons remove drains based on volume criteria; however, some evidence supports early, fixed-duration drain removal. Patients who produce large volumes of fluid from the surgical site are more likely to continue to do so after drain removal and may require increased duration of drain use. Surgical site surface area may also be a factor to consider when pulling a drain. CONCLUSION: Though drain-associated infection rates are low and appear unaffected by duration, poor outcomes such as implant loss and need for reoperation may be mitigated by antisepsis strategies.

Prelamination of Neourethra with Uterine Mucosa in Radial Forearm Osteocutaneous Free Flap Phalloplasty in the Female-to-Male Transgender Patient.

Radial forearm free flap phalloplasty is the most commonly performed flap for neophallus construction in the female-to-male (FtM) transgender patient. Urological complications, however, can arise quite frequently and can prevent the patient from urinating in the standing position, an important postsurgical goal for many. Using mucosa to construct the fixed urethra and to prelaminate the penile urethra has been successful in reducing urologic complications, particularly strictures and fistulas. Until now, only buccal, vaginal, colonic, and bladder sites have been described as sources for these mucosal grafts. We present the successful use of uterine mucosa for prelamination of the neourethra in an FtM patient who underwent hysterectomy and vaginectomy at the prelamination stage of a radial forearm phalloplasty. Three months postoperatively, the patient was able to void while standing and showed no evidence of stricture or fistula on retrograde cystogram. These results suggest that uterine mucosa may be used for prelamination of the penile neourethra in patients undergoing phalloplasty.

Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair.

BACKGROUND: In-hospital mortality rates for left-sided infective endocarditis (IE) exceed 20%. We investigated the outcomes of an aggressive approach to mitral valve IE that emphasizes early surgical intervention and preferential performance of mitral valve repair. METHODS: We reviewed 89 consecutive operations in 87 patients for native mitral valve IE at a single institution from 2002 to 2007. Operations occurred promptly after completion of preoperative studies. Independent risk factors for death were investigated using multivariable logistic regression. RESULTS: Mitral valve repair was accomplished in 56 of 89 patients (63%). Perioperative mortality was 4.4% (n = 4). Survival rates at 1 and 5 years were 89.9% (80 of 89) and 82.0% (73 of 90). There was a survival benefit for repair vs replacement at 1 (p = 0.03) and 5 years (p = 0.0017). Repair vs replacement (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.06 to 0.72), diabetes (OR, 4.43; 95% CI, 1.18 to 16.66), and renal failure (OR, 3.65; 95% CI, 1.3 to 12.91) were independent risk factors for late mortality. Among 59 patients with active IE, preoperative head computed tomography (CT) showed 29 (49%) had abnormalities, including 12 (41%) with intracerebral hemorrhage. The median interval was 4 days from admission to operation. The rate of permanent postoperative stroke was 1.1% (1 of 89). CONCLUSIONS: These results support early surgical therapy for mitral valve IE. Head CT abnormalities do not warrant delay of operation. Mitral valve repair was associated with a long-term survival advantage compared with valve replacement.

HIV gp120-induced interaction between CD4 and CCR5 requires cholesterol-rich microenvironments revealed by live cell fluorescence resonance energy transfer imaging.

Binding of the human immunodeficiency virus (HIV) envelope gp120 glycoprotein to CD4 and CCR5 receptors on the plasma membrane initiates the viral entry process. Although plasma membrane cholesterol plays an important role in HIV entry, its modulating effect on the viral entry process is unclear. Using fluorescence resonance energy transfer imaging, we have provided evidence here that CD4 and CCR5 localize in different microenvironments on the surface of resting cells. Binding of the third variable region V3-containing gp120 core to CD4 and CCR5 induced association between these receptors, which could be directly monitored by fluorescence resonance energy transfer on the plasma membrane of live cells. Depletion of cholesterol from the plasma membrane abolished the gp120 core-induced associations between CD4 and CCR5, and reloading cholesterol restored the associations in live cells. Our studies suggest that, during the first step of the HIV entry process, gp120 binding alters the microenvironments of unbound CD4 and CCR5, with plasma membrane cholesterol required for the formation of the HIV entry complex.