Medium- and Long-Term Outcomes of Autologous Fat Grafting to Hands and Feet for Patients With Raynaud Phenomenon.

BACKGROUND: Autologous fat grafting (AFG) has emerged as a promising treatment option for Raynaud phenomenon. However, existing studies are limited by short follow-up, and there is little evidence regarding predictive factors for successful outcomes. METHODS: A retrospective chart review and standardized phone interviews were performed for all patients (n = 17, 65% response rate) treated with AFG to the hands or feet at our institution for primary or secondary Raynaud from 2010 to 2021. Each occurrence of AFG was defined as a separate surgery (n = 23), with an average follow-up of 3.7 years. RESULTS: At follow-up, patients reported a 31% reduction in cold attack frequency, a 45% reduction in the intensity of individual attacks, a 29% reduction in the duration of attacks, and a 40% improvement in overall Raynaud Condition Score (P < 0.01). Although initial AFG to an extremity significantly improved symptoms, subsequent attempts were not shown to statistically improve outcomes. Digital ulcers were present in 65% of cases, and AFG resulted in ulcer healing in 87% of those cases. Median duration of maximum symptom relief was 1 year postoperatively, with 74% of patients reporting diminishing symptom relief by 4 years postoperatively. Those with a BMI ≥25, with primary Raynaud phenomenon or without preoperative ulcers experienced significantly longer symptom relief (P < 0.05). Average patient satisfaction was 7.7 of 10, and 91% would recommend the procedure to others. CONCLUSIONS: Autologous fat grafting is an effective, albeit sometimes temporary, treatment for Raynaud and digital ulcers. Certain patients may be more likely to experience lasting symptom relief beyond 1 year.

Branding a Plastic Surgery Group Practice: A Case Study.

BACKGROUND: You only get one opportunity to make a first impression. In today's era, that first impression is frequently a digital one. The authors' old digital brand "face" was stale and not a true representation of how they view themselves as a practice. In an evolving arena of competition and surgical scope, the authors felt compelled to engage in rebranding their practice. METHODS: This article details the steps the authors took to launch a new website, generate collateral branded material, and execute a social media marketing plan. The authors attempt to keep the outline general enough to be applicable to the range of practice types of the Journal 's readership, and present relevant results of the process. RESULTS: Samples of "creative" products are shown. Quantifiable outcomes were direct website traffic (91% increase), website sessions (82% increase), unique users (55% increase), page views (118% increase), and time spent browsing (100% increase). The authors experienced a 21% increase in new patient volume and a similar increase in total cases performed. CONCLUSIONS: This article outlines steps the authors took to rebrand their practice in the face of current challenges in the plastic surgery landscape and how prospective patients seek surgeons. Benchmarking the steps of a successful branding process is crucial and informative to developing and executing a plan. Although there are many potential contributors to the growth of a practice, the impact of our branding appears to be a significant factor.

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm.

Post-mastectomy pain syndrome and the less well-described post-breast surgery pain syndrome are long-term neuropathic pain conditions that may affect more than 50% of patients after mastectomy and breast surgery. While the etiology, risk factors, and management have been reviewed in our literature, we offer here a focused outline that will gear the plastic surgeon with tools to lead a multidisciplinary, algorithmic approach to the care of patients with post-mastectomy pain syndrome/post-breast surgery pain syndrome. After reading this article, we hope the reader will have improved awareness of post-mastectomy pain syndrome/post-breast surgery pain syndrome, and thus be able to incorporate appropriate treatments and preventative steps into their primary surgical routine.

Incidence, Impact, and Management of Incidentalomas on Preoperative Computed Tomographic Angiograms for Breast Cancer Patients with and without Genetic Mutations.

BACKGROUND: Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings. METHODS: All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management. RESULTS: Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas. CONCLUSIONS: The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.

Umbilical Ablation During Deep Inferior Epigastric Perforator Flap Harvest Decreases Donor Site Complications.

BACKGROUND: Donor site complications are a significant source of morbidity for patients undergoing abdominal-based free flap breast reconstruction, but there is a paucity of data regarding minimizing these postoperative complications. We hypothesize that selective ablation of the umbilicus at the time of deep inferior epigastric perforator (DIEP) harvest decreases the incidence of umbilical and abdominal wall complications in high-risk patients. METHODS: A retrospective review was performed of all patients (n = 117) who underwent DIEP harvest with concomitant umbilical ablation from 2010 to 2015. This cohort was paired with 117 patients who underwent DIEP harvest without umbilical ablation. Preoperative risk factors, intraoperative factors, and postoperative complications were compared. RESULTS: The umbilical ablation group had significantly higher body mass index (30.9 vs 27.4 kg/m, P < 0.001), presence of umbilical scar (20.9% vs 5.3%, P < 0.001), umbilical hernia (82.9% vs 8.5% P < 0.001), ventral hernia (23.9% vs 1.7%, P < 0.001), and rectus diastasis (10.3% vs 2.6%, P = 0.016). There were no significant differences of smoking, diabetes mellitus, hypertension, prior abdominal surgery, or midline abdominal scar. The umbilical ablation group had a significantly lower rate of postoperative abdominal wound dehiscence and skin loss (11.1% vs 22.2%, P = 0.023) and overall donor site complications (24.8% vs 39.3%, P = 0.017). There was no significant difference in incidence of cellulitis, seroma, or abscess. Mean follow-up time was 1.8 years. CONCLUSIONS: Selective umbilical ablation in high-risk patients at the time of abdominal flap harvest can result in significantly fewer donor site wound complications, even in the setting of increased risk factors for poor wound healing. This is likely due to avoidance of umbilical incisions and decreased upper abdominal skin undermining. We conclude that umbilical ablation is a viable option to minimize donor site complications, especially in high-risk patients.

Distant blunt forceps dissection in tissue expander insertion: A novel technique.

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.

L'expansion tissulaire à l'aide d'implants produit un excédent de tissus utile pour reconstruire des lésions telles que des cicatrices consécutives à des brûlures. Les auteurs décrivent leur technique d'incisions éloignées du foyer de l'expanseur et leur méthode d'hydrodissection par pinces mousse à distance de la poche d'expanseur. Au total, ils ont inséré 81 expanseurs chez 30 patients consécutifs, dont 81 % pour reconstruire des cicatrices consécutives à des brûlures. Pendant la préparation, les chercheurs n'ont relevé aucune complication, telle qu'une hémorragie, à part un cas d'importante fibrose sous-cutanée dont l'hémorragie a été interrompue par une brève pression. Après l'opération, ils n'ont observé aucune complication chez 76 % des patients, mais 16,6 % ont présenté une infection au site chirurgical, liée à l'implantation de plusieurs expanseurs en une même intervention et traitée avec prudence. Un patient a présenté un hématome qui s'est résolu spontanément, et un autre, une extrusion de l'expanseur qu'il a fallu retirer. L'implantation simultanée d'au moins deux expanseurs s'associait statistiquement à un risque plus marqué de complication(s). Le taux de complications des auteurs était modéré et comparable à celui des chirurgies ouvertes ou des endoscopies. L'expansion était de plus courte durée que par chirurgie ouverte, grâce à l'incision à distance et à l'utilisabilité immédiate. Le rapport coût-efficacité semblait supérieur au moyen de pinces bon marché que de matériel endoscopique élaboré et coûteux.

Superficial Inferior Epigastric Artery: Learning Curve versus Reality.

BACKGROUND: Breast reconstruction with the superficial inferior epigastric artery (SIEA) free flap continues to gain popularity among reconstructive surgeons. The low risk for abdominal wall morbidity must be weighed against the higher concern for thrombotic events. The aim of this study was to review the authors' recent experience with the SIEA flap and investigate whether their previously published incidences of vessel thrombosis and flap loss were related to their own "learning curve" or whether these adverse events are attributable to inherent qualities of the SIEA flap. METHODS: The authors performed a retrospective chart review of all patients undergoing SIEA flap surgery between January 1, 2008, and July 1, 2014, at their institution. All included operations were performed by the senior author (J.M.S.). The main outcomes of interest included vessel thrombosis and partial/full flap loss. RESULTS: Forty-seven SIEA flaps were performed on 39 patients. Sixty-four percent (n = 30) were immediate reconstructions and 79 percent (n = 37) were bilateral. There were five intraoperative arterial thromboses (10.6 percent) and one intraoperative venous thrombosis (2.1 percent), with eight total thrombotic events (17.0 percent). One total flap loss (2.1 percent) and two partial flap losses (4.3 percent) were experienced. CONCLUSIONS: The authors' recent experience with SIEA-based breast reconstruction shows a similar incidence of thrombotic events and flap loss compared with the authors' early experience. These incidences remain greater than what is seen with other abdominally based autologous breast reconstruction techniques and do not appear to be attributable to an operator learning curve. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Modification of the Labbé Procedure: Integration of the Deep Temporalis Fascia Turnover Flap.

Modification of the lengthening temporalis myoplasty for reanimation of facial paralysis is presented. A patient experienced traumatic laceration of the left facial nerve resulting in left hemifacial paralysis. Multiple attempts at nerve repair were unsuccessful. For smile restoration, a Labbé procedure was performed. Because of inadequate length, the temporalis tendon could not be directly secured to the modiolus. Therefore, an inferiorly based temporalis fascia flap was recruited from the deep temporal fascia and reflected inferiorly to provide additional length by which the tendon could be secured to the modiolus. This technique provided immediate smile restoration and required no additional donor site.

Use of thoracodorsal artery perforator flaps to enhance outcomes in alloplastic breast reconstruction.

BACKGROUND: Use of the thoracodorsal artery perforator (TDAP) flap in combination with alloplastic devices has been proven to be a safe method of breast reconstruction. However, preoperative irradiation increases the complication rate and thus some consider preoperative radiotherapy a relative contraindication to alloplastic alone reconstruction. We evaluated the long-term outcomes of patients with preoperative radiotherapy who had delayed alloplastic reconstruction with a TDAP flap. METHODS: A retrospective analysis of a prospectively maintained database was performed to identify patients who had received a Latissimus Dorsi (LD), a Muscle Sparing Latissimus Dorsi (MSLD), or a TDAP flap plus a tissue expander or implant between 2005 and 2012. Information regarding patients' primary diagnosis, radiation history, prior breast reconstructions, and complications was collected and analyzed. RESULTS: Sixteen patients who had a total of 16 breast reconstructions with an LD (6) or TDAP/MSLD1 flap (10). Demographic data, device type, co-morbidities and complications were analyzed. The rate of capsular contracture and size asymmetry were higher in the LD group, but there was no difference noted for major complications. Minor complications were also similar between the 2 groups. CONCLUSIONS: Patients who underwent irradiation before TDAP flap did not have a higher complication rate when compared with patients who had a full LD flap following radiation. By integrating well-vascularized, nonradiated tissue of a TDAP flap in reconstruction, overall complication rate may be minimized and the results are comparable to the generally accepted method of utilizing the entire latissimus dorsi muscle.

Prelaminated fascia lata free flap for large nasal septal defect reconstruction.

Nasal septal defects can be challenging to repair, given their location, size, and the unique, tri-layered structure of the septum, which includes a thin piece of cartilage positioned between mucosal layers. The report herein presents a case of a 47 year-old woman with a large symptomatic nasal septal perforation, despite saline irrigations and ointment. Placement of a septal button or a traditional surgical approach was not considered because of the extremely large nature of the perforation. We describe the use of a tri-layered fascia lata flap prelaminated with buccal mucosa grafts to successfully repair this complicated defect. Subsequent follow-up visits showed complete repair of the defect and patent nasal passages, without the need for any debulking procedures. Based on these results, we conclude that a prelaminated fascia lata flap is a good reconstructive option for large, complex nasal septal defects, bringing thin, healthy mucosalized tissue to the defect and minimizing future surgical procedures.

Fat grafting to the hand in patients with Raynaud phenomenon: a novel therapeutic modality.

BACKGROUND: Raynaud phenomenon causes progressively decreasing blood flow to the extremities, resulting from an imbalance between vasoconstriction and vasodilation. Treatment options include biofeedback, phosphodiesterase inhibitors, calcium channel inhibitors, botulinum toxin injection, or surgical sympathectomy. The authors propose fat grafting to the hands as a method to delay progression of the disease. METHODS: Indications included symptomatic Raynaud phenomenon with failure of previous management. Fat is harvested from abdominal depots. Approximately 30 ml of decanted fat is injected by means of blunt cannulae: 10 to 15 ml in the dorsum of the hand, 2 to 3 ml in the snuffbox, 1 to 2 ml in each dorsal webspace, 3 to 4 ml along the superficial palmar arch, 1 to 2 ml in volar webspaces 2 to 4, and 2 to 3 ml in the first webspace. Patients underwent preoperative and postoperative laser speckle imaging study to assess changes in perfusion. RESULTS: A total of 13 patients were treated (21 hands). Twelve patients had undergone prior botulinum toxin injection, and 11 patients had prior sympathectomies. Findings included reduced pain (average reduction, 6.86 of 10 to 2.38 of 10), fewer cold attacks, improved skin and soft-tissue texture, decrease in ulcerations, and patient-reported improved function. Three patients had no changes. Increased blood flow per imaging was noted in five of 11 hands tested. Six patients had decreased readings on laser imaging. None of the laser speckle imaging changes were statistically significant, and they did not correlate clinically. There were no major complications. CONCLUSIONS: Preliminary results of fat grafting to the hands of patients with Raynaud phenomenon revealed improved symptomatology with evidence suggestive of measurably increased perfusion in some cases. Fat grafting may benefit the management of this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Treatment of wounds following breast reduction and mastopexy with subsequent wound dehiscence with charged polystyrene microspheres.

BACKGROUND: Lower T-junction wound dehiscence following breast reduction surgery or mastopexy constitutes a vexing and grievous complication both to the surgeon and the patient. Treatment modalities that can expedite wound healing and reepithelialization rates are highly craved. The objective of this study was to assess wound healing and epithelialization rates of open wounds following breast reduction and mastopexy wound dehiscence treated with charged polystyrene microspheres (CPM). MATERIALS AND METHODS: Five female patients with wound dehiscence and subsequent open wounds following breast reduction and mastopexy were treated with daily with CPMsoaked dressings. Wound closure rates were documented. RESULTS: The wounds showed both accelerated granulation tissue formation as well as swift epithelialization rates. No complications or side effects were encountered. CONCLUSIONS: Charged polystyrene microspheres may offer a new and efficacious way to heal open wounds due to wound dehiscence following aesthetic breast surgery. Further research with a larger patient population is still needed to verify these findings. .

Economic analysis and review of the literature on implant-based breast reconstruction with and without the use of the acellular dermal matrix.

BACKGROUND: Use of the acellular dermal matrix (ADM) in two-stage implant-based breast reconstruction has been widely adopted. Despite an increasing focus on health care costs, few reports have addressed the financial implications of ADM use. This study sought to examine the costs of the two-stage technique with and without ADM, concentrating on the direct variable costs of patient care during the expansion process. METHODS: A retrospective review of a prospectively maintained database was conducted. Data were collected on 132 cases resulting in a second-stage exchange for a permanent implant. The findings showed that AlloDerm was used in 61 reconstructions and Strattice in 23 reconstructions. The primary outcome was the number of fills required to achieve the final expander fill volume. The cost of subsequent patient encounters for expansion was estimated using institutional cost data. RESULTS: The number of fills required to achieve the final volume was higher in the non-ADM group (6.5 ± 1.7) than in the ADM group (3.6 ± 1.4) (p < 0.0001). No significant difference was found in the small fill volumes (<350 ml; 5.3 vs. 3.7; p > 0.05). The difference was significant in the larger fill volumes (>500 ml; 8.3 vs. 3.7; p < 0.05). Relative to non-ADM reconstruction, with AlloDerm at current prices, the cost increase ranged from $2,727.75 for large reconstructions to $3,290.25 for small reconstructions ($2,167.75-$2,739.25 with Strattice). CONCLUSION: The use of ADM in two-stage reconstruction reduces the number of visits required for reconstructions with 350 ml or more. However, at current pricings, the direct cost of ADM use does not offset the cost savings from the reduced number of visits. LEVEL OF EVIDENCE IV: 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 .