Dead Space - The Final Frontier in Rhinoplasty: Review and 10 Key Recommendations.

SUMMARY: Mitigating dead space has been recognized as an essential step towards ensuring a more predictable and aesthetically pleasing outcome in rhinoplasty. The current body of literature leaves a discernible gap in offering a unified, systematic approach to dead space management in rhinoplasty. The aim of our article is to bridge this gap by presenting an integrative approach to surgical and post-surgical techniques.

Isolated Fibrous Dysplasia of the Bilateral Nasal Bones: Complex Management of the Bony Vault.

Fibrous dysplasia is a benign fibro-osseous process affecting the skeletal system, with resulting cystic and fibrous tissue expansion. Craniofacial fibrous dysplasia represents a small subset of monostotic disease, accounting for approximately 10%-25% of all such cases. Involvement of the frontal, temporal, and sphenoid bones has most commonly been described, with a limited number of reported cases citing disease isolated to the nasal bones. The case reported here is differentiated by the degree of expansion of the bilateral nasal bones and the required clinical management of the bony vault in the setting of gross nasal asymmetry.

The emerging role of biostimulators as an adjunct in facial rejuvenation: A systematic review.

INTRODUCTION: Facial aging has long been an area of focus in esthetic surgery. It is the consequence of physiologic and environmental factors, with a trend toward non-surgical modalities. Although volume augmentation has long been a focus of non-surgical facial rejuvenation, there is emerging interest in the use of biostimulators to induce physiologic changes in the skin. This article aimed to provide an overview of this class of therapies. METHODS: A systematic review regarding the clinical use of biostimulatory agents including platelet-rich plasma (PRP), platelet-rich fibrin (PRF), poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA) in facial rejuvenation was performed using PubMed databases. The protocol was developed following the preferred reporting for items for systematic reviews-protocols guidelines. Included studies matched predetermined criteria according to the employed intervention and outcomes. RESULTS: The systematic review was performed in September 2023, with the primary search yielding 464 articles. Abstract review resulted in 73 articles of potential relevance. Comprehensive review of the articles and manual reference checks were performed, independently, by 2 authors. This yielded a total of 45 articles that met the inclusion criteria. CONCLUSIONS: There is an increasing role for non-surgical modalities in facial rejuvenation. Biostimulatory agents may be used as an alternative, or act as an adjunct, to other non-surgical modalities. These agents induce physiologic changes that mitigate facial aging. There is limited, quantifiable data, which fully illustrate the effect in these products. Although these agents are known to illicit inflammatory changes, more controlled studies are needed to better elucidate the biostimulatory capacity of such non-surgical treatments.

The Seven Step Neck Lift Z-Plasty.

Patients with large amounts of neck skin redundancy who do not desire or are not candidates for traditional face and neck lifts can be managed with direct neck lifts. There are many existing surgical techniques to address central neck laxity. In this article, we aim to clarify our surgical technique in a clear video format to showcase how to address central neck laxity in seven steps with neck lift Z-plasty.

Productivity and Efficiency of a Department Resident Aesthetic Plastic Surgery Clinic.

Background: There has been increasing demand for aesthetic surgery procedures in the United States, highlighting the critical importance of the competence of plastic surgery residents and rigorous methods of aesthetic surgery training. Objectives: The objective of this study was to review procedures and outcomes from our plastic surgery resident aesthetic clinic. Outcomes and costs were compared to national averages and reports from the literature. Methods: A retrospective chart review identified all adult patients who presented to the Resident Aesthetic Surgery Clinic at NYU Langone Health in 2021. Patient demographics, comorbidities, procedural data, postoperative complications, revisions, and surgeon fees were compiled. A brief confidence survey was distributed to participating residents before and after their clinic rotation. Data were analyzed using IBM SPSS software (Armonk, NY). Results: In 2021, 144/379 consultations led to an operation (38.0% conversion rate), resulting in 420 distinct surgical procedures. The majority (53.3%) of procedures involved the head and neck. Complication and revision rates were 5.5% and 1.0%, respectively, with surgeon fees consistently below the national average. Residents reported being significantly more confident performing face lifts, rhinoplasties, and aesthetic surgery in general following their clinic rotation. Conclusions: These data represent the largest annual reported study of plastic surgery resident aesthetic procedures and outcomes, demonstrating the high volume and productivity of the NYU Resident Aesthetic Surgery Clinic. These results further support resident aesthetic clinics as a robust training modality.

Does Laterality of Lower Extremity Donor Site Affect Outcomes in Microvascular Soft Tissue Lower Extremity Reconstruction?

BACKGROUND: There are many different variables to consider in lower extremity microvascular soft tissue reconstruction including flap choice. Our aim is to objectively evaluate recipient complications related to lower extremity donor flap laterality. METHODS: A total of 77 lower extremity soft tissue reconstructions utilizing microvascular free tissue transfers for Gustilo type III between 1979 and 2016 were collected. We compared complication rates between ipsilateral and contralateral donor sites relative to the injured leg. The following parameters were analyzed: overall complications, total flap failure, partial flap failure, major complications, operative takebacks, and salvage rates. RESULTS: In this study, 25 ipsilateral reconstructions were performed, while 52 cases utilized the contralateral leg. Overall complication rates were higher in the ipsilateral group (40.0%) compared with the contralateral side (23.1%) but were not statistically significant (p = 0.12). The ipsilateral group was four times as likely to experience vascular compromise (24.0 vs. 5.8%; p = 0.05). However, there were no significant differences in complications, flap failures or flap survival. Mean operative time was significantly greater in the same side group as compared with the contralateral group (11.3 vs. 7.5 hours; p = 0.006). CONCLUSION: Although there is a higher risk of anastomotic thrombosis, particularly venous thrombosis, associated with ipsilateral donor-site group, there were no significant differences in complications or flap survival. Flaps can be harvested from a traumatized leg with acceptable complication rates while avoiding the morbidity of operating on an uninjured limb.

Vascularized Composite Allotransplantation: Alternatives and Catch-22s.

Technical success has been achieved in several forms of vascularized composite allotransplantation, including hand, face, penis, and lower extremity. However, the risks of lifelong immunosuppression have limited these procedures to a select group of patients for whom nontransplant alternatives have resulted in unsatisfactory outcomes. Recent reports of facial allograft failure, and subsequent reconstruction using autologous tissues, have reinforced the idea that a surgical contingency plan must be in place in case this devastating complication occurs. Interestingly, backup plans in the setting of vascularized composite allotransplantation consist of the nontransplant alternatives that were deemed suboptimal in the first place. Moreover, these options may have been exhausted before transplantation, and may therefore be limited in the case of allograft loss or reamputation. In this article, the authors describe the surgical and nonsurgical alternatives to hand, face, penis, and lower extremity transplantation. In addition, the authors explore the ethical implications of approaching vascularized composite allotransplantation as a "last resort" or as a "high-risk, improved-outcome" procedure, focusing on whether nontransplant options eventually preclude vascularized composite allotransplantation, or whether vascularized composite allotransplantation limits future nontransplant reconstruction.

Topical inhibition of PUMA signaling mitigates radiation injury.

Radiation therapy is an effective treatment strategy for many types of cancer but is limited by its side effects on normal tissues, particularly the skin, where persistent and progressive fibrotic changes occur and can impair wound healing. In this study, we attempted to mitigate the effects of irradiation on skin using a novel transcutaneous topical delivery system to locally inhibit p53 up-regulated modulator of apoptosis (PUMA) gene expression with small interfering RNA (siRNA). In an isolated skin irradiation model, the dorsal skin of C57 wild-type mice was irradiated. Prior to irradiation, PUMA and nonsense siRNA were applied via a novel hydrogel formulation to dorsal skin and reapplied weekly. Skin was harvested at multiple time points to evaluate dermal siRNA penetration, mRNA expression, protein expression, dermal thickness, subcutaneous fat, stiffness, vascular hypertrophy, SCAR index, and reactive oxygen species (ROS) generation. Murine skin treated with topical PUMA siRNA via optimized hydrogel formulation demonstrated effective PUMA inhibition in irradiated tissue at 3-4 days. Tissue stiffness, dermal thickness, vascular hypertrophy, SCAR index, ROS levels, and mRNA levels of MnSOD and TGF-ß were all significantly reduced with siPUMA treatment compared to nonsense controls. Subcutaneous fat area was significantly increased, and levels of SMAD3 and Phospho-SMAD3 expression were unchanged. These results show that PUMA expression can be effectively silenced in vivo using a novel hydrogel lipoplex topical delivery system. Moreover, cutaneous PUMA inhibition mitigates radiation induced changes in tissue character, restoring a near-normal phenotype independent of SMAD3 signaling.

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review.

BACKGROUND: Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. METHODS: Retrospective review (1979-2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. RESULTS: More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. CONCLUSION: Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

Peri-Procedure Laser Scar Therapy Protocol: A Pilot Survey of Plastic Surgeons' Practices.

BACKGROUND: Scar management using laser phototherapy continues to evolve as it gains wide acceptance among patients and providers. Despite widespread use of laser therapy, there are no guidelines or consensus published regarding optimal pre- and post-procedure patient management. Our objective is to gain insight into the best laser practices; we decided to poll colleagues nationwide. METHODS: An online survey was distributed to members of the American Society of Plastic Surgeons. The survey consisted of 34 questions regarding pre- and post-procedure protocols related to laser scar therapy. RESULTS: Forty plastic surgeons responded to the survey. The survey demonstrated that ten types of lasers are currently used to treat scars. The most commonly used lasers are fractional Er:YAG (44.7%), pulsed dye (42.1%), and fractional CO2 (36.8%). On a Likert 3-point scale, providers favored the use of pre-procedural sunblock (2.12), topical analgesics (1.91), and oral antivirals (1.83). They also preferred the use of topical moisturizer (2.45), oral analgesics (2.29), and oral antivirals (1.97) as a part of the post-laser treatment regimen. CONCLUSION: The study verified there is no consensus regarding peri-procedure laser scar therapy regimens. As laser scar management continues to grow in popularity, this lack of consensus suggests the need for experts in the field to come together and propose agreeable protocols to be used as guidelines. LEVEL OF EVIDENCE V: 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 .

Use of Computerized Clinical Decision Support Systems to Prevent Venous Thromboembolism in Surgical Patients: A Systematic Review and Meta-analysis.

Importance: Health care professionals do not adequately stratify risk or provide prophylaxis for venous thromboembolism (VTE) among surgical patients. Computerized clinical decision support systems (CCDSSs) have been implemented to assist clinicians and improve prophylaxis for VTE. Objective: To evaluate the effect of implementing CCDSSs on the ordering of VTE prophylaxis and the rates of VTE. Data Sources: PubMed, MEDLINE via OVID, EMBASE via OVID, Scopus, Cochrane CENTRAL Register of Controlled Trials, and clinicaltrials.gov were searched in June 2016 for articles published in English from October 15, 1991, to February 16, 2016. A manual search of references from relevant articles was also performed. Study Selection: Clinical trials and observational studies among surgical patients comparing CCDSSs with VTE risk stratification and assistance in ordering prophylaxis vs routine care without decision support were included. Of the 188 articles screened, 11 (5.9%) were eligible for meta-analysis. Data Extraction and Synthesis: Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Two reviewers extracted data and assessed quality independently. Main Outcomes and Measures: Rates of prophylaxis for VTE and VTE events. Random- and fixed-effects models were used to summarize odds ratios and risk ratios. Results: Eleven articles (9 prospective cohort trials and 2 retrospective cohort trials) comprising 156 366 individuals (104 241 in the intervention group and 52 125 in the control group) were included. The use of CCDSSs was associated with a significant increase in the rate of appropriate ordering of prophylaxis for VTE (odds ratio, 2.35; 95% CI, 1.78-3.10; P < .001) and a significant decrease in the risk of VTE events (risk ratio, 0.78; 95% CI, 0.72-0.85; P < .001). Conclusions and Relevance: Use of CCDSSs increases the proportion of surgical patients who were prescribed adequate prophylaxis for VTE and correlates with a reduction in VTE events.

The effectiveness of negative pressure therapy on infected wounds: preliminary results.

Vacuum-assisted closure (VAC) therapy is a sophisticated system that maintains a closed, humid, sterile and isolated environment. Wound infection is considered a relative contraindication. The objective of this study is to extend the indications for VAC therapy to include infected wounds by demonstrating its ability to increase the antibiotic concentration in the damaged and infected tissues. Patients who presented with ulcers infected with daptomycin-sensitive bacteria were eligible to be enrolled in this prospective study. They were given antibiotic therapy with daptomycin with a specific protocol. A biopsy of the lesion was carried out to detect tissue concentration of the drug at time 0. Afterwards, the patients were subjected to VAC therapy. At the end of VAC therapy, a second lesion biopsy was performed and analysed to detect tissue concentration of the drug at time 1. A control group was enrolled in which patients followed the same protocol, but they were treated with traditional dressings. Fisher's exact test was used to compare the two groups. The results highlighted a significant increase in the concentration of antibiotics in the study group tissue; the improvement was sensibly lower in the control group. Statistical differences were not found between the two groups. The preliminary analysis of the data showed an important increase of antibiotic concentration in the tissue after VAC therapy. Despite the encouraging data, it is necessary to broaden the sample of patients and perform the same study with other antibiotics.

Systematic review of hyperbaric oxygen therapy for the treatment of radiation-induced skin necrosis.

Every year, 1.2 million cancer patients receive radiation therapy in the United States. Late radiation tissue injury occurs in an estimated 5-15% of these patients. Tissue injury can include skin necrosis, which can lead to chronic nonhealing wounds. Despite many treatments available to help heal skin necrosis such as hyperbaric oxygen therapy, no clinical guidelines exist and evidence is lacking. The purpose of this review is to identify and comprehensively summarize studies published to date to evaluate the effectiveness of hyperbaric oxygen therapy for the treatment of radiation-induced skin necrosis. Adhering to PRISMA guidelines, a systematic review of currently published articles was performed, evaluating the use of hyperbaric oxygen to treat skin necrosis. Eight articles were identified, including one observational cohort, five case series, and two case reports. The articles describe changes in symptoms and alteration in wound healing of radiation-induced skin necrosis after treatment with hyperbaric oxygen therapy. Hyperbaric oxygen therapy is a safe intervention with promising outcomes; however, additional evidence is needed to endorse its application as a relevant therapy in the treatment of radiation-induced skin necrosis.

Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional hernia? A systematic review and meta-analysis.

BACKGROUND: Operative intervention to correct incisional hernia affects 150,000 patients annually, with 1 in 3 repairs recurring within 9 years. The aim of this study was to compare the incidence of incisional hernia and postoperative complications in elective midline laparotomy patients after the use of prophylactic mesh placement and primary suture closure. METHODS: A systematic review was performed to identify studies comparing prophylactic mesh placement to primary suture closure in elective, midline laparotomy at index abdominal aponeurosis closure. The primary outcome was incisional hernia. Secondary outcomes included postoperative complications. RESULTS: Fourteen studies were included (2,114 patients), with 1,152 receiving prophylactic mesh placement. Prophylactic mesh placement decreased the risk of incisional hernia overall when compared to primary suture closure (relative risk = 0.15; P < .00001) and in trials using only polypropylene mesh versus 4:1 primary suture closure (relative risk = 0.15; P = .003). Prophylactic mesh placement reduced the risk of incisional hernia regardless of mesh location or composition: onlay (relative risk = 0.07; P < .0001), retrorectus (relative risk = 0.04; P = .002), and preperitoneal (relative risk = 0.18; P = .02). Prophylactic mesh placement increased risk of seroma overall (relative risk = 1.95; P < .0001), onlay (relative risk = 2.43; P = .01) and preperitoneal (relative risk = 1.47; P = .01) but not retrorectus plane (relative risk = 1.55; P = .26). Polypropylene mesh increased seroma risk only in the onlay position (relative risk = 2.77; P = .04). Prophylactic mesh placement patients are at increased risk for chronic wound pain compared to primary suture closure (relative risk = 1.70; P = .03). CONCLUSION: Prophylactic mesh placement is associated with an 85% postoperative incisional hernia risk reduction when compared to primary suture closure in at-risk patients undergoing elective, midline laparotomy closure. This technique appears to be safe with comparable complication profiles, barring an increased risk of seroma, especially with the onlay technique, and the possibility for an increased risk of chronic pain. Despite this verification, evidence from large domestic trials that sufficiently addresses major knowledge gaps is simply lacking.

Tissue Liquefaction Liposuction for Body Contouring and Autologous Fat Transfer: A Retrospective Review Over 3 Years.

Objective: Tissue liquefaction lipoplasty is a novel, low-energy method cleared for use in aesthetic body contouring and autologous fat transfer. This is a retrospective review of the clinical effectiveness and safety of a liquefaction lipoplasty system for liposuction and autologous fat transfer. Methods: A retrospective review was done evaluating all liquefaction lipoplasty procedures with or without autologous fat transfer performed by a single surgeon (March 2013 to June 2016). Patient demographics, operative details, and any complications were tabulated from patient charts. A typical case reported is presented with pre-/postoperative photographs. Results: Two hundred fifty-five consecutive liquefaction lipoplasty procedures were performed over 39 months. The average lipoaspirate volume was 1208 ± 991 mL and the average fat graft volume was 322 ± 277 mL. The overall complication rate was 9 of 255 (3.52%). There were 2 episodes of seroma (0.78%) that were aspirated and 2 episodes of cellulitis (0.78%) that responded to oral antibiotics. In the autologous fat transfer cohort, there were 5 of 103 (4.85%) cases of mild to moderate fat necrosis, with 1 patient requiring return to the operating room for removal of an oil cyst. No revisions of donor sites were required. Conclusions: Liquefaction lipoplasty appears safe for liposuction and autologous fat transfer, with a complication profile that is comparable with other widely used forms of suction-assisted liposuction. The liquefaction lipoplasty technology also provides potential time savings in the operating room that can minimize surgeon fatigue when harvesting large volumes of high-quality fat. Liquefaction lipoplasty appears to have advantages for both the patient and the surgeon, and further studies are underway.

A 5-year review of feedback on the Philadelphia-area mock ABS certifying examination.

OBJECTIVES: The American Board of Surgery Certifying Examination (ABSCE) is an oral examination designed to evaluate a resident׳s ability to apply their cognitive knowledge to manage a broad range of clinical problems. In this study, we analyze our 5-year experience with a Philadelphia-wide mock oral examination (PMOE). SETTING: The PMOE is organized by the Metropolitan Philadelphia Chapter of the American College of Surgeons and offered annually to all postgraduate year 4/5 residents from the 8 participating Philadelphia general surgery programs. Each examinee is scheduled for 3 consecutive 30-minute examinations given by 2 examiners per room. Overall performance is graded for each interaction using the ABSCE scoring method. Participants are given their "pass/fail" status, and they receive written examiner feedback. DESIGN: From 2008 to 2013, deidentified examinee scores from both the PMOE and the ABSCE were reviewed; overall pass/fail status was compared using the chi-square statistic for significance. Examinee feedback from 2009 to 2013 was reviewed by 3 independent raters and characterized as commenting upon cognitive knowledge, clinical management, or communication skills. This categorical data were then correlated with pass/fail status and examined using unpaired t tests for significance. RESULTS: From 2009 to 2013, 189 residents participated in the PMOE with an overall pass rate of 53%, compared with the ABSCE pass rate of 76% for 113 examinees from the Philadelphia area from 2008 to 2013 (χ(2) = 18.8, p < 0.01). A total of 2273 comments were reviewed and categorized from 2009 to 2013. Examinees who failed the PMOE received significantly more feedback pertaining to cognitive knowledge than examinees who passed the examination (p = 0.04). CONCLUSION: The PMOE provides residents an opportunity to receive feedback on their performance on a representation of the ABSCE that may be more rigorous than the actual certifying examination. Deficits in cognitive knowledge are a significant determinant of performance on a city-wide mock oral examination.