The Northeastern Society of Plastic Surgeons: The First 40 Years.

ABSTRACT: The concept for creating the Northeastern Society of Plastic Surgeons originated in May 1982, at the American Association of Plastic Surgeons in Colorado Springs Colorado. The new society would supplement, not supplant, existing state and small regional societies. Two hundred fifty-seven northeastern plastic surgeons joined the charter membership. The inaugural meeting of the Northeastern Society of Plastic Surgeons was held in Philadelphia, September 1984. The following historical account highlights our society's founding principles and leadership throughout the first 40 years.

Comparison of Tumescent Anesthesia Versus Pectoral Nerve Block in Bilateral Reduction Mammaplasty.

INTRODUCTION: With an increasing focus on multimodal pain control to reduce opioid requirements, regional and local anesthesia techniques have been investigated in bilateral reduction mammaplasty with variable results. The purpose of this study is to compare tumescent anesthesia with pectoral nerve block II (PECS II) in patients undergoing bilateral reduction mammaplasty with respect to postoperative pain and nausea, opioid consumption, length of stay, and cost. METHODS: A retrospective review of patients undergoing bilateral reduction mammaplasty for macromastia between November 2020 and December 2021 was performed. Demographic information, operative and anesthesia times, antiemetic and morphine equivalent requirements, postoperative numeric pain rating scales, and time until hospital discharge were compared between groups. χ2 and Fisher exact tests examined subgroup differences in categorical variables. Two-sample t test and Wilcoxon rank-sum test evaluated differences in continuous parametric and nonparametric variables, respectively. RESULTS: Fifty-three patients underwent bilateral reduction mammaplasty by 3 surgeons, 71.7% (n = 38) with tumescent anesthesia infiltrated by the operating surgeon before the start of the procedure and 28.3% (n = 15) with bilateral PECS II blocks performed by anesthesia before the start of the procedure. There was no difference in age, body mass index, weight resected, intraoperative medication, or immediate postoperative complications. Postoperative pain scores and opioid requirements were similar between the 2 groups. Twenty-one percent (n = 8) of tumescent patients compared with 66.7% (n = 10) of block patients required 1 or more doses of postoperative antiemetics ( P = 0.002). Patients who received blocks spent longer in the postoperative recovery area (5.3 vs 7.1 hours, P < 0.01). However, this did not translate to a significant increase in overnight stays. The block group had significantly higher hospitalization cost by an average of $4000, driven by pharmacy and procedural cost ( P < 0.01). CONCLUSION: In this cohort of multimodal perioperative pain-controlled reduction mammaplasty patients, tumescent anesthesia was associated with decreased antiemetic requirements, less time in recovery before discharge, and lower cost compared with PECS II blocks. Therefore, tumescent anesthesia may be favored over PECS II blocks when considering multimodal pain control strategies in reduction mammaplasty patients.

The role of physical arm function and demographic disparities in breast cancer survivors' ability to return to work.

PURPOSE: Ability to return to work (RTW) is an important aspect of breast cancer that is limited for many survivors. With 90% survivorship in the USA, it is imperative that focus shifts toward the improvement of physical arm function to improve survivors' ability to RTW. This narrative review discusses the role of physical arm function and demographic disparities in breast cancer survivor RTW. METHODS: Literature on physical function, arm function, and demographic disparities following breast cancer treatment and their implications for RTW is discussed. RESULTS: The ability to RTW is a key component of recovery for breast cancer survivors, but challenges and inequalities persist. Treatment effects can induce and prolong functional disability, affecting survivors' ability to RTW. These effects may be compounded for survivors whose occupation requires physical arm function. The RTW landscape, including the occupations survivors have, the physical function required for job tasks, and availability of workplace accommodations, is also unclear. Additional demographic disparities (e.g., income, live in rural area) exist, but the extent to which these factors influence RTW is not well understood. More work is needed to understand the compounded impact of treatment effects, demographic disparities, and occupational factors on RTW. Multidisciplinary rehabilitation that includes occupational counseling and exercise is a promising approach, but widespread adoption in the US healthcare model presents an ongoing challenge. Areas for further research are highlighted. CONCLUSION: There is an incomplete understanding of the effects of treatment on physical arm function and the role of demographic disparities on breast cancer survivor RTW.

Smooth Versus Textured Tissue Expander Breast Reconstruction: Complications and Efficacy.

INTRODUCTION: Ongoing recognition of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and its link with textured devices has brought a paradigm shift in prosthetic-based breast reconstruction. Many institutions no longer offer textured expansion devices for staged reconstruction. However, there is a paucity of data regarding the efficacy of smooth tissue expanders (TE). We hypothesized that the time to final reconstruction and complication profile between smooth and textured TEs would be similar in breast reconstruction patients. METHODS: A retrospective chart review was performed of all patients who underwent TE breast reconstruction during a 6-year period at the Penn State Hershey Medical Center. Rates of complications treated nonoperatively and those requiring reoperation were assessed. Mechanical complications, including expander malposition and rupture, were evaluated. Time to final breast reconstruction was quantified. Mixed-effects logistic regression and linear regression models, as appropriate, were used to compare textured to smooth TEs. Patient characteristics and anatomic plane placement were adjusted for in all analyses of outcomes. RESULTS: Data were collected on 389 patients, encompassing 140 smooth and 604 textured TEs. Textured devices had an increased incidence of complications treated nonsurgically (16.7% vs 10.7%; P = 0.14). However, smooth TEs had an increased incidence of reoperation (12.1% vs 7.6%; P = 0.06). Most noteworthy was that although smooth TEs had a 40-fold increase in malposition (13.6% vs 0.3%; P < 0.001), no reoperation for this complication was warranted. Further, the time to final reconstruction was comparable between the 2 devices (textured expanders: 221 days and smooth expanders: 234 days; P = 0.15). CONCLUSIONS: Staged, implant-based reconstruction is the most common surgical approach to recreate the breast mound following mastectomy. Textured TEs were the cornerstone to this approach. Unfortunately, the association between textured devices and BIA-ALCL now mandates an alternative. We postulated that smooth expanders would compare favorably for breast reconstruction. Although our study suggests that smooth TEs suffer more malposition, this has a negligible impact on the reconstructive timeline. Thus, smooth TEs may prove beneficial when considering the risk of BIA-ALCL associated with textured devices.

Aesthetic Surgery in Plastic Surgery Academia.

BACKGROUND: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. OBJECTIVES: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. METHODS: A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson's chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. RESULTS: Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery-focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). CONCLUSIONS: The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.

Restoring the Severed Breast and Chest following Seat Belt Trauma.

In this article, we presented 2 cases of rare clinical presentation of 3-point lap-diagonal seat belt injuries and provided a brief overview of the spectrum of the associated deformity and morbidity. Both of our patients presented in a delayed fashion during the subacute period at 12 and 4 months, respectively, following their traumatic seat belt injuries, which improved with surgical intervention. Ideally, these injuries should be repaired during the subacute period once any life-threatening injuries have been addressed, because seat belt-restraint injuries may otherwise lead to chronic pain, functional loss, and physical deformity.

The influence of mastectomy and reconstruction on residual upper limb function in breast cancer survivors.

PURPOSE: Breast cancer survivorship is common (90% of women survive 5 or more years), but many women are not able to return to full function and well-being after treatment due to functional limitations, persistent pain, and inability to perform daily activities. Since each surgical reconstructive option (e.g., autologous tissue flaps versus implants) can impact shoulder and arm function differently, it is important to understand how shoulder and upper limb strength, mobility, and function are influenced by the type of surgical intervention. Efforts can then focus on prehabiliation strategies to prevent the onset of limitations and on developing rehabilitation protocols that directly target shortcomings. METHODS: The current paper presents a review summarizing how shoulder and upper limb function may be affected by surgical mastectomy and breast reconstruction. RESULTS: Mastectomy and breast reconstruction with implants or autologous tissues present different functional outcomes for patients. Each surgical procedure is associated with unique sequelae derived from the tissues and procedures associated with each surgery. Characterizing the specific functional outcomes associated with each surgical approach will promote the development of targeted rehabilitation strategies that can be implemented into a multidisciplinary treatment planning pathway for breast cancer patients. CONCLUSIONS: Surgical treatments for breast cancer, including mastectomy and breast reconstruction, can have negative effects. Focused efforts are needed to better understand treatment-specific effects so that targeted rehabilitation can be developed to improve patient function, QoL, and ability to return to work and life activities post-breast cancer.

A Prospective Approach to Inform and Treat 1340 Patients at Risk for BIA-ALCL.

BACKGROUND: The increasing incidence and associated mortality of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has become alarming. However, many patients remain unaware of their risk for BIA-ALCL and may overlook early warning signs of the cancer. The authors aim to contact all breast implant patients at a single institution to educate them on the disease and provide screening and treatment as indicated. METHODS: All patients who had breast implants placed at Penn State Hershey Medical Center from 1979 to November of 2017 were mailed a letter to describe BIA-ALCL and to encourage a follow-up visit. Patient information regarding demographics, implant type, the number of calls and follow-up visits, physical examination findings, and patient decisions after being informed of the disease were recorded prospectively. RESULTS: One thousand two hundred eighty-four letters were mailed to 1020 patients (79.4 percent) with smooth implants and 264 patients (20.6 percent) with textured implants. Seventy-six calls were received and 100 patients (84 smooth and 16 textured) were evaluated within the first 2 months. Of the 16 patients with textured implants, nine are undergoing secondary surgery to remove or replace their textured device. CONCLUSIONS: Informing patients at risk for BIA-ALCL is an important endeavor. Patients educated on the disease will likely be diagnosed and treated earlier, which can prevent the need for adjuvant chemotherapy and/or radiation therapy and decrease mortality. The authors provide a method, supporting documents, and preliminary data to help other institutions contact their breast implant patients at risk for BIA-ALCL.

How Breast Implant Surface Type Is Influenced by Breast Implant-associated Anaplastic Large Cell Lymphoma: A Survey of the American Society of Plastic Surgeons.

INTRODUCTION: Breast implant selection is multifactorial and must assess risk profiles of the implants. Textured implants are available in an anatomically shaped form and are thought to have lower rates of capsular contracture. However, evidence is mounting that they carry a significantly higher risk of breast implant associated anaplastic large cell lymphoma. Given this relationship, we aimed to assess breast implant preferences and device selection for members of the American Society of Plastic Surgeons (ASPS). METHODS: An online survey of all active members of ASPS was performed. Questions analyzed the surgeons' demographic data as well as implant and tissue expander choices for patients receiving either breast augmentation or reconstruction. Logistic regression models of summarized data were used to assess surgeons' implant choices. RESULTS: The survey was sent to 5000 members and was completed by 824 for a response rate of 16.5%. Demographic data indicate a homogenous sampling of ASPS members from all geographical areas. A majority of surgeons reported that they perform 21-50 implant cases in the last year (n = 219, 28.5%), followed closely by surgeons performing greater than 100 cases (n = 194, 25.3%) and those placing between 51 and 100 (n = 189, 24.6%). Almost one-half of respondents (n = 361, 46.9%) stated that the majority (>50%) of the implants they placed were for cosmetic purposes. Conversely, 306 (37.9%) respondents stated that the majority of implants they placed were for reconstructive purposes and 102 (13.3%) respondents indicated equal placement of cosmetic and reconstructive implants. There were 40.9% (n = 318) surgeons who continue to use textured implants, whereas 59.1% (n = 460) report using only smooth implants. This data includes 47.7% (n = 363) of respondents who report switching to only smooth implants due to awareness of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). CONCLUSIONS: The incidence of BIA-ALCL continues to rise. All known cases have some link to textured implants. With equally efficacious alternatives available with smooth implants, surgeons and patients are altering their implant choices.

Breast Implant-Associated Anaplastic Large Cell Lymphoma: A Systematic Review.

IMPORTANCE: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), a rare peripheral T-cell lymphoma, is increasing in incidence. However, many practitioners who treat patients with breast cancer are not aware of this disease. OBJECTIVES: To assess how BIA-ALCL develops, its risk factors, diagnosis, and subsequent treatment and to disseminate information about this entity to the medical field. EVIDENCE REVIEW: A literature review was performed in an academic medical setting. All review articles, case reports, original research articles, and any other articles relevant to BIA-ALCL were included. Data on BIA-ALCL, such as pathophysiology, patient demographics, presentation, diagnosis, treatment, and outcomes, were extracted. Particular focus was paid to age, time to onset, implant type, initial symptoms, treatment, and survival. The search was conducted in January 2017 for studies published in any year. FINDINGS: After duplicates were excluded, 304 relevant articles were assessed, and 115 were included from the first documented case in August 1997 through January 2017. Thirty review articles, 44 case reports or series, 15 original research articles, and 26 "other" articles (eg, techniques, special topics, letters) were reviewed. A total of 93 cases have been reported in the literature, and with the addition of 2 unreported cases from the Penn State Health Milton S. Hershey Medical Center, 95 patients were included in this systematic review. Almost all documented BIA-ALCL cases have been associated with a textured device. The underlying mechanism is thought to be due to chronic inflammation from indolent infections, leading to malignant transformation of T cells that are anaplastic lymphoma kinase (ALK) negative and CD30 positive. The mean time to presentation is approximately 10 years after implant placement, with 55 of 83 (66%) patients initially seen with an isolated late-onset seroma and 7 of 83 (8%) with an isolated new breast mass. Ultrasonography with fluid aspiration can be used for diagnosis. Treatment must include removal of the implant and surrounding capsule. More advanced disease may require chemotherapy, radiotherapy, and lymph node dissection. CONCLUSIONS AND RELEVANCE: Breast implant-associated anaplastic large cell lymphoma is a rare cancer in patients with breast implants but is increasing in incidence. It is important for all physicians involved in the care of patients with breast implants to be aware of this entity and be able to recognize initial symptoms.

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique.

BACKGROUND: Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution. METHODS: We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence. RESULTS: Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%). CONCLUSIONS: Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction.

BACKGROUND: Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias. METHODS: The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement. RESULTS: The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations. CONCLUSION: Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Analysis of clinically significant seroma formation in breast reconstruction using acellular dermal grafts.

With a rise in tissue expander-based breast reconstructions (TEBRs) using acellular dermal matrix (ADM), we have seen an increase in ADM-specific complications. In this study, we aimed to evaluate clinically significant seroma (CSS) formation-defined by the need for a drainage procedure-to determine if there was a difference in incidence between product types: AlloDerm (AL), DermaMatrix (DM), and FlexHD (FHD). This was a retrospective review of consecutive patients who underwent TEBR at a single institution. The total number of reconstructed breasts was separated into the following 4 groups according to the product type: AL, DM, FHD, or no ADM. We identified the total number of CSSs and compared these data between product types. A logistic regression was performed in an attempt to identify independent risk factors associated with seroma formation. In total, we identified 284 consecutive TEBRs. Overall, there were 17 (7.7%) seromas in 220 breast reconstructions in which ADM was used. When comparing the number of CSS between groups-AL (n = 2, 4.0%), DM (n = 6, 5.4%), FHD (n = 9, 14.75%), and no ADM (n = 1, 1.5%)-we found a significant difference in seroma incidence between product types (P = 0.016). Multivariate analysis identified a strong trend toward FHD as an independent predictor of seroma formation (P = 0.061). Our review suggests that there is strong trend in CSS formation with the use of FHD as compared to other product types and reconstructions in which no ADM was used.

Nurse training with simulation: an innovative approach to teach complex microsurgery patient care.

Simulation has become an integral part of education at all levels within the medical field. The ability to allow personnel to practice and learn in a safe and controlled environment makes it a valuable tool for initial training and continued competence verification. An area of specific interest to the reconstructive microsurgeon is assurance that the nursing staff has adequate training and experience to provide optimum care for microsurgery patients. Plastic surgeons in institutions where few microsurgeries are performed face challenges teaching nurses how to care for these complex patients. Because no standard exists to educate microsurgery nurses, learning often happens by chance on-the-job encounters. Outcomes, therefore, may be affected by poor handoffs between inexperienced personnel. Our objective is to create a course that augments such random clinical experience and teaches the knowledge and skills necessary for successful microsurgery through simulated patient scenarios. Quality care reviews at our institution served as the foundation to develop an accredited nursing course providing clinical training for the care of microsurgery patients. The course combined lectures on microsurgery, pharmacology, and flap monitoring as well as simulated operating room, surgical intensive care unit, postanesthesia care unit, Trauma Bay, and Floor scenarios. Evaluation of participants included precourse examination, postcourse examination, and a 6-month follow-up. Average test scores were 72% precourse and 92% postcourse. Educational value, effectiveness of lectures and simulation, and overall course quality was rated very high or high by 86% of respondents; 0% respondents rated it as low. Six-month follow-up test score average was 88%. Learning to care for microsurgery patients should not be left to chance patient encounters on the job. Simulation provides a safe, reproducible, and controlled clinical experience. Our results show that simulation is a highly rated and effective way to teach nurses microsurgery patient care. Simulated patient care training should be considered to augment the clinical experience in hospitals where microsurgery is performed.

Complications in tissue expander breast reconstruction: a comparison of AlloDerm, DermaMatrix, and FlexHD acellular inferior pole dermal slings.

Acellular dermal matrix (ADM) is frequently used in tissue expander breast reconstruction (TEBR) for coverage of the inferior pole. Several published studies have suggested increased rates of complications with the use of ADM. It is unknown, however, if the type of ADM used for TEBR impacts complication rates. The aim of this study is to compare 3 different types of ADM for TEBR in regard to clinically significant complications, specifically infection. We performed a retrospective analysis of primary breast cancer-related TEBR with or without ADM. Exclusion criteria consisted of prior major breast surgery, inadequate data, or loss to follow-up. Reconstructions were grouped by dermal sling type, AlloDerm, DermaMatrix (DM), FlexHD (FHD), or no ADM. Complications included cellulitis, abscess, seroma, expander leak or puncture, skin necrosis, wound dehiscence, or hematoma. Those requiring admission to hospital or reoperation were considered significant. Of 284 breasts reconstructed, 49 used AlloDerm, 110 used DM, 62 used FHD, and 64 used no ADM. The total complication rate with AlloDerm was 22% [95% confidence interval (CI), 11-34], with DM was 15% (95% CI, 8-21), and with FHD was 18% (95% CI, 8-28) (P=0.47). Infectious complication rates for AlloDerm, DM, and FHD were equal at 10% (P=0.97). The total complication rate of all ADM reconstructions as a grouped cohort was 17% compared to 11% without ADM (P=0.48). The overall incidence of infectious complications with ADM was 10% compared to 2% without ADM (P=0.09). There is no difference in the clinically significant overall complication rate or incidence of infection between AlloDerm, DM, and FHD. Isolating infectious complications, there is a trend toward increased incidence with ADM compared to reconstructions without.

Technique for seroma drainage in implant-based breast reconstruction.

Seromas are a common complication associated with breast reconstructive surgery. In expander based breast reconstructions, a seroma can pose a particularly difficult problem related to final tissue envelope shape as well as an increase in the risk of infection and possible tissue necrosis. Unfortunately, the literature describes few non-image related techniques to drain a seroma with a breast implant in place. We present a technique to drain a seroma associated with expander based breast reconstruction in conjunction with expander inflation, minimizing the risk of expander puncture, utilizing the same equipment necessary for expander inflation in the office. The benefit to this technique is that diagnostic and therapeutic imaging is not necessary and the risk of expander damage is minimized.

Technical variations of the bipedicled TRAM flap in unilateral breast reconstruction: effects of conventional versus microsurgical techniques of pedicle transfer on complications rates.

In cases of unilateral breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap, poorly perfused tissue, which is normally excised to avoid subsequent fat necrosis, must sometimes be used to achieve adequate breast size and projection. In such cases, incorporation of a second vascular pedicle into the flap design improves perfusion. The authors retrospectively examined their experience with bipedicled TRAM flap-based unilateral breast reconstruction to determine whether the use of microsurgical rather than conventional (nonmicrosurgical) techniques for flap transfer resulted in lower incidences of flap-site fat necrosis and donor-site hernia/bulge. The authors retrospectively reviewed the medical records of all patients who underwent unilateral breast reconstruction with a bipedicled TRAM or deep inferior epigastric perforator flap between January of 1991 and March of 2001. Group 1 consisted of patients who had undergone flap transfer using a conventional technique for both pedicles; group 2, patients who had flap transfer using a conventional technique for one pedicle and a microsurgical technique for the other; and group 3, patients who had flap transfer using a microsurgical technique for both pedicles. Of the 863 patients identified, 72 (8.3 percent) had undergone reconstruction using a bipedicled flap. There were 43 patients in group 1, 24 patients in group 2, and five patients in group 3. Only one case of total flap loss had occurred (group 1). Partial flap loss occurred in two patients in group 1 (5 percent) and three patients in group 2 (13 percent). Fat necrosis occurred more frequently in groups 1 (23 percent) and 2 (29 percent) than in group 3 (0 percent) (p = 0.5, Fisher's exact test). Similarly, bulge or hernia was more common in groups 1 (12 percent) and 2 (4 percent) than in group 3 (0 percent) (p = 0.6, Fisher's exact test). In this study, patients who received a bipedicled TRAM flap using microsurgical techniques alone (group 3) appeared to have better flap perfusion and less frequent hernia/bulge than did patients who underwent flap transfer using conventional (group 1) or combined techniques (group 2). However, these differences were not statistically significant, and this trend must be verified in a larger study.

Minimally invasive Le Fort III distraction.

Recent applications of distraction osteogenesis to the Le Fort III osteotomy in patients with craniofacial dysostosis have proven promising (1-3). Distraction has allowed the midfacial segment to be brought further forward and maintained in position with greater stability when compared with the standard technique of intraoperative advancement. Because no bone grafts or plates must be placed, access incisions are necessary only for performance of the osteotomy. In an effort to minimize the morbidity of the procedure, we have begun performing the Le Fort III osteotomy without the coronal incision. Instead, the nasofrontal junction is approached using the medial aspect of an upper blepharoplasty incision. A lower eyelid and gingivobuccal sulcus incision are also used to complete the osteotomy. This technique has resulted in a shorter operative time and decreased blood loss when compared with the Le Fort III distraction procedure using the standard coronal incision.