Co-surgeons in breast reconstructive microsurgery: What do they bring to the table?

INTRODUCTION: Current research within other surgical specialties suggests that a co-surgeon approach may reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved patient and surgical outcomes. We sought to evaluate the role of the co-surgery team and its development in free flap breast reconstruction. METHODS: A retrospective review of free-flap breast reconstruction by two surgeons from 2011 to 2016 was conducted. We analyzed 128 patients who underwent bilateral-DIEP breast. Surgical groups were: single-surgeon reconstruction (SSR; 35 patients), co-surgery where both surgeons are present for entire reconstruction (CSR-I; 69 patients), and co-surgery reconstruction where co-surgeons appropriately assist in two concurrent or staggered cases (CSR-II; 24 patients). Efficiency data collected was OR time and patient length-of-stay (LOS). The rate of flap-failure, return to OR, infection, wound breakdown, seroma, hematoma, and PE/DVT were compared. RESULTS: Single-surgeon reconstruction had significantly longer OR time (678 vs. 485 min, P < .0001), LOS (5 vs. 3.9 days, P < .001), higher wound occurrences of the umbilical site that required surgical correction [11.4 percent (n = 4) vs. 1.5% (n = 1); P < .043] compared to CSR-I. Similarly, SSR had significantly longer average OR time (678 vs. 527 min P < .0001), average LOS (5 vs. 4 days, P = .0005) when compared with CSR-II. There were no total increased patient related complications associated with co-surgery (CSR-I or II). CONCLUSION: The addition of a co-surgeon, even with concurrent surgery, reduces operative time, average patient LOS, and postoperative complications. This work lends a strong credence that co-surgery model is associated with increased operative efficiency.

The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction.

Although the medial femoral condyle has been used for reconstruction in various areas of the body, to the authors' knowledge it has not been used for frontal sinus reconstruction. The authors describe a novel approach to a complex patient using the medial femoral condyle cortiocoperiosteal free flap to reconstruct an anterior frontal sinus defect in conjunction with a recalcitrant mucocele.

Rationale and Argument for Subunit Mohs Excision in Nasal Reconstruction.

BACKGROUND: Optimal aesthetic results are achieved when nasal defects after Mohs micrographic surgery (MMS) are reconstructed as entire nasal subunits. OBJECTIVE: To illustrate the importance of reconstructing the nose in entire subunits and explore the possibilities of expanding the principles of subunit reconstruction to the concept of subunit Mohs excision. METHODS: An 83-year-old man presented for MMS to excise 3 lesions on the nasal ala. The surgeons elected to excise and reconstruct the entire subunit. RESULTS: Excellent aesthetic and functional results were obtained. CONCLUSION: When a defect greater than 50% of a nasal subunit is encountered during MMS, immediate marginal control excision of the entire subunit can be performed with subsequent reconstruction. This technique ultimately has the potential to deliver a more aesthetically pleasing outcome and should be, at the very least, considered by all Mohs surgeons.

Oral Antibiotics Are Effective for the Treatment of Hand Osteomyelitis in Children.

Background: Acute osteomyelitis of the hand is common in the pediatric population. Treatment with intravenous antibiotics is expensive and is associated with catheter-site infection and thrombosis. The purpose of this study is to investigate the efficacy of managing osteomyelitis of the hand in children with oral antibiotics. Methods: A retrospective review of cases of acute osteomyelitis of the hand at a single pediatric institution over a 4.5-year period was performed. Demographic and clinical data were reviewed, and treatment courses and outcomes were analyzed. Results: In total, 21 patients with acute osteomyelitis of the hand were included in the study. Of the 21 patients, 17 were initiated on a 6-week course of oral antibiotics upon diagnosis. Thirteen were successfully treated with oral antibiotics alone, 3 required subsequent surgical debridement, and 3 required conversion to intravenous antibiotics. Of the 21 patients, 4 were treated with surgical debridement upon diagnosis due to gross purulent drainage and then initiated on a 6-week course of oral antibiotics. All patients who underwent debridement were treated successfully with postoperative oral antibiotics. Conclusions: Most cases of osteomyelitis of the hand in children can be treated with oral antibiotics, either as the primary treatment or as postoperative therapy. Surgical debridement is indicated when purulence is present at the time of initial diagnosis or if the infection progresses during treatment with oral antibiotics. The use of oral antibiotics for treating acute osteomyelitis of the hand in children may result in decreased cost and fewer catheter-associated complications.

Arthroscopic Ganglionectomy in the Pediatric Population.

BACKGROUND: Arthroscopic dorsal wrist ganglionectomy is an established alternative to open excision in the adult population. The purpose of this study was to retrospectively compare outcomes of arthroscopic and open dorsal wrist ganglionectomy in the pediatric population. METHODS: All patients who underwent arthroscopic or open dorsal wrist ganglionectomy at a single pediatric institution between 2011 and 2014 were retrospectively evaluated by chart review and telephone interview. The primary outcome variable was whether or not the cyst had recurred. Other outcome measures included the incidence of complications, and patient-rated outcome measures such as satisfaction, pain, function, and aesthetics. RESULTS: There were eight cases of arthroscopic and 19 cases of open ganglionectomy, with a mean age of 14 years. At an average follow-up of 2 years, the recurrence rate was one of eight for the arthroscopic group and two of 19 for the open group. No patients in the arthroscopic group reported functional limitations, compared with three patients in the open group. On a 10-point scar appearance scale, with 1 being not satisfied at all and 10 being highly satisfied, the median score in the arthroscopic group was 9.5, compared with 8 in the open group. No patients in the arthroscopic group had residual pain at the surgical site, compared with nine patients in the open group, a finding that was statistically significant. All patients in the arthroscopic group reported that they would undergo surgery again, whereas two patients in the open group would not undergo surgery again. CONCLUSION: Arthroscopic dorsal wrist ganglionectomy compares favorably with open ganglionectomy in the pediatric population.

Accessory Nerves of the Forehead: A Newly Discovered Frontotemporal Neurovascular Bundle and Its Implications in the Treatment of Frontal Headache, Migraine Surgery, and Cosmetic Temple Filler Injection.

BACKGROUND: Surgical decompression of peripheral cranial and spinal nerves at several anatomically studied trigger sites has demonstrated significant efficacy in bringing permanent relief to migraine sufferers. In their experience performing frontal nerve decompression on migraine patients, the authors noticed a previously undescribed accessory nerve and vessel in the frontotemporal area, and report its implication in migraine surgery and cosmetic filler injection. METHODS: A retrospective review of 113 patients who underwent frontal migraine decompression surgery with the senior author at the University of Texas Southwestern Medical Center from July of 2012 to May of 2016 was performed. For the included 76 patients, measurements of this nerve had been taken intraoperatively using high-definition endoscopic assistance, and topographic measurements were correlated with endoscopic location of the nerve. RESULTS: This frontotemporal nerve (FTN) was present in 55 percent, and the bilateral incidence was 57 percent of those. An accompanying vessel was also present in 81 percent of nerve complexes. Both nerve and vessel varied in size. A large vessel was present in 8 percent of all patients, and a medium vessel was present in 20 percent. Consistently, the nerve exited a foramen in the frontal bone on average 3.4 ± 0.47 cm superior to the lateral canthus. CONCLUSIONS: The identification and proper avulsion neurectomy of this newly described sensory FTN may lead to better surgical response rate during migraine surgery. In addition, this nerve should be considered during nerve block and botulinum toxin injections in migraine treatment. The existence of the accompanying vessel could have significant implications in the safety of filler and fat injections to this area.

The Six-Step Lower Blepharoplasty: Using Fractionated Fat to Enhance Blending of the Lid-Cheek Junction.

Lower lid blepharoplasty is one of the most complex procedures performed by plastic surgeons and may cause significant long-term sequelae, including inadequate aesthetic outcomes if not performed with a thorough understanding of anatomy and proper technique. The authors' practice is consistently evolving to deliver the highest quality results for their patients. The purpose of this article is to introduce an additional sixth step to the lower lid blepharoplasty procedure involving the targeted injection of fractionated fat to better blend the lid-cheek junction. This added step will enhance overall facial rejuvenation, is reproducible, and will provide patients with exceptional outcomes.

Neck Rejuvenation through the Lateral Platysma Window: A Key Component of Face-Lift Surgery.

Rejuvenating an aged face relies on maintaining facial harmony to provide optimal aesthetic results. Restoration of more youthful facial contours is dependent on blending the aesthetic facial topographic units. Many authors continue to debate the best approach for neck rejuvenation through a medial approach, a lateral approach, or a combination of the two. The authors present their approach to neck rejuvenation through medial platysma plication, inferior release, and lateral platysma window.

Implications of Facial Asymmetry in Rhinoplasty.

Many rhinoplasty patients present with a chief complaint of nasal deviation and are unaware of any inherent facial asymmetries; however, recognizing and discussing the interrelation between the deviated nose and facial asymmetry is an important consideration in surgical planning. The objective of this study was to evaluate whether a surgeon's subjective assessment of facial analysis in the setting of nasal deviation correlates with objective anthropometric measurements. In addition, this study sought to further quantify the frequency of facial asymmetry associated with nasal deviation to highlight important anatomical trends for the rhinoplasty surgeon. Finally, this study presents the senior author's (R.J.R.) method of addressing a deviated nose on an asymmetric face. In this study, the authors demonstrated that nasal deviation is closely related to facial asymmetry. Furthermore, the authors demonstrated that objective facial analysis closely correlates to anthropometric facial measurements. In addition, the wide side of the face correlates to the short side of the face and the nose tends to deviate away from the wide side of the face. During surgical correction of the deviated nose in the setting of facial asymmetry, the surgeon's goal should be to obtain nasal symmetry and center the nose on a line between the mid glabella and the mid Cupid's bow. This may reduce the perception of a facial asymmetry, leading to increased patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

The Importance of the Anterior Septal Angle in the Open Dorsal Approach to Rhinoplasty.

Functional and aesthetic manipulation of the nose relies on a detailed understanding of nasal anatomy and a meticulous dissection. Maneuvers are performed in four regions of the nose: nasal tip, dorsum, posterior septum, and caudal septum. Positioned at the cornerstone of these regions, the anterior septal angle acts as a point of reference, especially in secondary rhinoplasty. Identification of the anterior septal angle early in the nasal dissection aids in reliable exposure, either wide or limited, and facilitates desired maneuvers. In addition, alteration of the position of the anterior septal angle can affect nasal tip projection, especially in cases such as the tension tip deformity. The authors emphasize the importance of the anterior septal angle in their simplified methodology for the open dorsal approach in rhinoplasty.

Facial Danger Zones: Techniques to Maximize Safety during Soft-Tissue Filler Injections.

Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.

Anatomy of the Facial Danger Zones: Maximizing Safety during Soft-Tissue Filler Injections.

With limited downtime and immediate results, facial filler injections are becoming an ever more popular alternative to surgical rejuvenation of the face. The results, and the complications, can be impressive. To maximize safety during injections, the authors have outlined general injection principles followed by pertinent anatomy within six different facial danger zones. Bearing in mind the depth and the location of the vasculature within each zone, practitioners can tailor their injection techniques to prevent vessel injury and avoid cannulation.

Preventing Soft-Tissue Triangle Collapse in Modern Rhinoplasty.

The unique anatomy of the soft-tissue triangle makes it prone to notching in primary, secondary, and reconstructive rhinoplasty. Understanding the anatomy of the region is critical to appropriate treatment. This article is meant to further clarify the anatomy of the soft-tissue triangle and to present the senior author's (R.J.R.) approach to proactive correction and prevention of soft-tissue triangle notching through five key steps: (1) precise dissection and incision placement, (2) providing internal support with cartilage grafting if needed, (3) closure of dead space, (4) avoiding undue tension during closure, and (5) providing external support postoperatively.

The Indian Nose.

Despite the growing number of rhinoplasty procedures being performed on Indian patients, there is a very limited body of literature regarding nuances of the Indian rhinoplasty. The authors review the spectrum of nasal phenotypes that fall under the category of the Indian nose; goals of rhinoplasty in these patients; operative techniques that can be used to address them; and, importantly, the specific pitfalls to be avoided in these groups.

Liposuction-Assisted Short-Scar Brachioplasty: Technical Highlights.

Upper arm contouring is based on the location and amount of excess skin and fat. The short-scar brachioplasty addresses minimal to moderate skin laxity and lipodystrophy in the proximal arm in patients with appropriate skin tone and quality. This article highlights technical refinements of the senior author's (R.J.R.) approach to short-scar medial liposuction-assisted brachioplasty to maximize results and minimize incision length. To highlight this simple and safe approach with high patient/surgeon satisfaction, the authors discuss the following in this Video Plus article: patient examination, preoperative assessment, surgical pearls, and postoperative outcomes.

Review of 3-dimensional Facial Anatomy: Injecting Fillers and Neuromodulators.

To achieve consistent results utilizing facial injectables, practitioners must understand the pertinent anatomy of the forehead, temple, cheek, nose, and perioral areas. A detailed understanding of facial blood vessels, nerves, and musculature is essential for safe and effective placement of fillers and neuromodulators.

The Importance of the Upper Lateral Cartilage in Rhinoplasty.

The upper lateral cartilages are instrumental in obtaining optimal outcomes in aesthetic and functional rhinoplasty. Knowledgeable manipulation of the upper lateral cartilages can take advantage of the crucial malleable parameters of projection, width, nasal dorsal shape, and tip rotation. A lucid understanding of the anatomical intricacies in this portion of the cartilaginous framework permits the surgeon to use their unique characteristics to consistently achieve the desired results.

Role of the Cephalic Trim in Modern Rhinoplasty.

There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.

Alar Contour Grafts in Rhinoplasty: A Safe and Reproducible Way to Refine Alar Contour Aesthetics.

BACKGROUND: Alar rim deformities such as retraction, notching, collapse, and asymmetry are common problems in rhinoplasty patients. Although alar rim deformities may be improved through rhinoplasty, this area is prone to late changes because of scarring of the soft triangles and a paucity of native structural support. The purpose of this study was to analyze the effect of alar contour grafts on primary rhinoplasty. METHODS: Fifty consecutive primary rhinoplasty patients with preoperative and postoperative photographs who received alar contour grafts were evaluated for alar aesthetics; 50 consecutive primary rhinoplasty patients without such grafts served as controls. Differences among alar retraction, notching, collapse, and asymmetry from anterior, lateral, and basal views were evaluated. Follow-up ranged from 1 to 4 years and was graded on a four-point scale. RESULTS: The average difference between the two groups' aggregate preoperative scores was 0.21 (p = 0.24). The average preoperative and postoperative scores in the nongraft group were significant for worsening retraction, notching, and collapse but insignificant for asymmetry. The preoperative and postoperative scores for the graft group were insignificant for retraction but improved significantly for notching, collapse, and asymmetry. Postoperatively, the aggregate average of the scores in the nongroup was 0.32 points worse (p < 0.01), whereas the graft group had a 0.33-point improvement (p < 0.01). CONCLUSIONS: Alar contour grafts have a clear and important impact on cosmetic results of primary rhinoplasty. Use of alar contour grafts has been shown to improve aesthetics, whereas there is a worsening of the measured parameters postoperatively without use of these grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.