Objective Effects of Breast Reduction Surgery on Physical Fitness.

BACKGROUND: Reduction mammaplasty is known for excellent outcomes and patient satisfaction. Although patients report improvements in pain, weight loss, and exercise levels, objective data on physical fitness benefits are limited. METHODS: Using the Stanford Military Data Repository, we identified 89 US Army active duty women with at least 1 pre- and postoperative Army Physical Fitness Test (APFT) who underwent reduction mammaplasty during 2011 to 2014. We used paired t tests to compare pre- and postoperative APFT score means and raw values for push-ups, sit-ups, and the 2-mile run. RESULTS: There were 56 subjects (62.9%) who improved in total APFT scores. Total score means increased from 235.9 preoperatively to 243.4 postoperatively (P = 0.0065). Of 28 subjects with at least 2 APFT scores before and after surgery, 20 (71.4%) improved in total scores. The subgroup's mean total score increased from 237.8 to 251.3 (P = 0.0009). Comparing individual pre- and postprocedure APFTs, all subjects demonstrated a mean 3.9% (SD, 0.1) improvement in total scores, and the subpopulation of 28 improved by 6.3% (SD, 0.1). In all events, mean performance values trended toward better postoperative scores. Differences were statistically significant for the total population for the number of sit-ups (P = 0.035), and, for the subgroup of 28, differences were statistically significant for the total score (P = 0.0009), sit-ups (P = 0.0002), and push-ups (P = 0.0134). CONCLUSIONS: Reduction mammaplasty was associated with postoperative physical fitness improvements among US Army active duty women. Soldier data are useful for objectively assessing physical fitness effects of breast reduction surgery.

Management of the Repeatedly Failed Cranioplasty Following Large Postdecompressive Craniectomy: Establishing the Efficacy of Staged Free Latissimus Dorsi Transfer/Tissue Expansion/Custom Polyetheretherketone Implant Reconstruction.

BACKGROUND: Postdecompressive craniotomy defect management following failed prior cranioplastyis challenging. The authors describe a staged technique utilizing free muscle transfer, tissue expansion, and custom polyetheretherketone (PEEK) implants for the management of previously failed cranioplasty sites in patients with complicating local factors. METHODS: Consecutive patients with previously failed cranioplasties following large decompressive craniectomies underwent reconstruction of skull and soft tissue defects with staged free latissimus muscle transfer, tissue expansion, and placement of custom computer-aided design and modeling PEEK implants with a 'temporalis-plus' modification to minimize temporal hollowing. Implants were placed in a vascularized pocket at the third stage by elevating a plane between the previously transferred latissimus superficial fascia (left on the skin) and muscle (left on the dura/bone). Patients were evaluated postoperatively for cranioplasty durability, aesthetic outcome, and complications. RESULTS: Six patients with an average of 1.6 previously failed cranioplasties underwent this staged technique. Average age was 33 years. Average defect size was 139 cm. Average time to procedure series completion was 14.9 months. There were no flap failures. One patient had early postoperative incisional dehiscence following PEEK implant placement that was managed by immediate scalp flap readvancement. At 21.9 month average follow-up, there were no cranioplasty failures. Three patients (50%) underwent 4 subsequent refining outpatient procedures. All patients achieved complete coverage of their craniectomy defect site with hear-bearing skin, acceptable head shape, and normalized head contour. CONCLUSIONS: The described technique resulted in aesthetic, durable craniectomy defect reconstruction with retention of native hear-bearing scalp skin in a challenging patient population.

Comparison of two-dimensional and three-dimensional images for phenotypic assessment of craniofacial microsomia.

Background and Purpose : Three-dimensional surface imaging is used in many craniofacial centers. However, few data exist to indicate whether such systems justify their cost. Craniofacial microsomia is associated with wide phenotypic variability and can affect most facial features. The purpose of this study is to compare three-dimensional versus two-dimensional images for classification of facial features in individuals with craniofacial microsomia. Methods : We obtained a series of two-dimensional and three-dimensional images of 50 participants, aged 0-20 years, diagnosed with craniofacial microsomia, microtia, or Goldenhar syndrome. Three clinicians classified the craniofacial features on each image, and ratings were compared by calculating kappa statistics. We also evaluated image quality using a 5-point Likert scale. Results : Reliability estimates were high for most features using both two-dimensional and three-dimensional image data. Our three-dimensional protocol did not allow for scoring of facial animation, occlusal cant, or tongue anomalies. Image quality scores for the mandible and soft tissue assessment were higher for three-dimensional images. Raters preferred two-dimensional photographs for assessment of the ear, ear canal, and eyes. Conclusions : Both three-dimensional and two-dimensional images provide useful data for objective characterization of the craniofacial features affected in craniofacial microsomia. A series of two-dimensional images has relative advantages for assessment of some specific features, such as the ear, though three-dimensional images may have advantages for quantitative analysis and qualitative assessment of deformities of the jaw and soft tissue. These results should apply to any assessment of these features with or without a craniofacial microsomia diagnosis.

The Power of Cooperation: A Quantitative Analysis of the Benefit of Civilian Partnerships on the Academic Output of Military Surgeons.

INTRODUCTION: Military-civilian partnerships are crucial to maintaining the skills of active duty surgeons and sustaining readiness. There have been no publications to date that report the quantitative effect of these partnerships on academic research. To address this question, the Hirsch indices (H-indices) of active duty surgeons with a civilian affiliation (CA) were compared to those without. As a secondary outcome, H-indices of military surgeons with and without an appointment to the Uniformed Services University (USU) were similarly compared. We hypothesized that military surgeons with a CA would have a higher H-index as compared to those without. MATERIALS AND METHODS: Rosters of active duty military surgeons were obtained confidentially through each branch consultant. H-indices were found on Scopus. Graduation dates and hospital affiliations were identified via public Doximity, LinkedIn profiles, and hospital biographies. Rosters were cross-referenced with USU appointments. Stata software was used for final analysis. RESULTS: Military surgeons without a civilian association have a median H-index of 2 versus 3 in those with such an affiliation (P = .0002). This pattern is also seen in average number of publications, at 3 and 5 articles (P < .0001). When further stratified by branch, Air Force surgeons have median H-indices of 2.5 and 1 with and without a CA, respectively (P = .0007). The Army surgeons follow a similar pattern, with median H-indices of 5 and 3 for those with and without affiliations, respectively (P = .0021). This significance does not hold in the Naval subgroup. Similar results are found for the secondary outcome of USU appointment, with median H-indices of 3 and 2 in those with and without CAs, respectively (P < .0001). In the multivariable negative binomial regression model, both CA and USU appointment significantly increased H-index in the overall cohort, with incidence rate ratios of 1.32 (95% CI = 1.08, 1.61) and 1.56 (95% CI = 1.28, 1.91), respectively. CONCLUSION: This article provides objective evidence that there is a benefit to military-civilian partnerships on the academic output of military surgeons. These relationships should continue to be fostered and expanded.

Lateral Canthotomy/Cantholysis Performance Gap Analysis and Training Recommendations for Expeditionary Physicians.

INTRODUCTION: Preservation of life, preservation of limb, and preservation of eyesight are the priorities for military medical personnel when attending to casualties. The incidences of eye injuries in modern warfare have increased significantly, despite personal eye equipment for service members. Serious eye injuries are often overlooked or discovered in a delayed fashion because they accompany other life- and limb-threatening injuries, which are assigned a higher priority. Prehospital military ocular trauma care is to shield the eye and evacuate the casualty to definitive ophthalmic care as soon as possible, with exceptions for treatment of ocular chemical injury and orbital compartment syndrome. Retrospective analysis of eye injuries in recent conflicts identified gaps in clinical capabilities with up to 96% of ocular injuries being suboptimally managed. Ocular compartment syndrome (OCS) is a complication associated with orbital hemorrhage, where significant morbidity occurs as a result of increasing intracompartment pressure. The ischemic tolerance of the retina and optic nerve is approximately 90 minutes, so OCS must be rapidly diagnosed and aggressively treated through lateral canthotomy/cantholysis (LC/C) to prevent permanent vision loss. LC/C procedures consist of using hemostats to crush the lateral canthal fold and cutting the lateral canthal tendon from the inferior crus to relieve increasing intracompartment pressure. The purpose of this study was to examine the baseline capabilities of military physicians and surgeons to accurately and independently perform the LC/C procedures and identify performance gaps that could be closed through focused professional development activities. MATERIALS AND METHODS: This study received institutional review board approval at our institution. A total of 60 subjects voluntarily participated in the study from emergency medicine (15), general surgery (28), and ophthalmology (17). All procedural assessments were performed 1:1 by expert faculty ocular trauma specialists using a high-reliability eye trauma simulator (Sonalysts, Inc.). The competency standard was set at independent and accurate completion of all procedural components and all critical procedural components. Analyses were performed using descriptive statistics and analysis of variance to examine between-group differences (P < 0.05). RESULTS: There was a significant difference between the total score performance and the critical score performance for the three groups (P < 0.001). Outcomes indicate a significant linear relationship between the expertise level of the clinical provider and the procedural performance of LC/C. Outcomes demonstrate the baseline surgical capabilities of the general surgeons transferred to LC/C performance; however, they were unfamiliar with the anatomy and the procedural techniques and requirements. The group of emergency medicine participants demonstrated performance gaps not only in the same areas as the general surgeons but also in their baseline surgical abilities. This suggests that different professional development activities are necessary for surgeons and physicians tasked with performing LC/V procedures. CONCLUSIONS: We identified significant performance gaps among emergency medicine physicians, general surgeons, and ophthalmologists in their abilities to recognize and treat OCS through LC/C procedures. These sight-saving procedures are a critical competency for forward-situated clinicians in expeditionary contexts. We identified the need for targeted approaches to professional development for closing the performance gaps for both emergency medicine physicians and general surgeons.

Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury.

Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.

Nasal lining mobilization for primary and secondary palatoplasty.

BACKGROUND: Repair of wide primary cleft palates and secondary cases are challenging. Much literature is dedicated to technique modifications and useful pearls for approaching these patients. Nasal lining is not often highlighted or addressed as a solution to these challenging cleft palate surgeries. The goal of this article was to describe and demonstrate through case examples the simple dissection and significant mobilization of nasal lining as a tool for cleft palate repair. METHODS: Retrospective case examples were selected to highlight the technique. RESULTS AND DISCUSSION: The surgical technique is standardly used by the senior author and has not been previously published. This technique for tension-free nasal lining closure is detailed, and case examples are provided. This technique for nasal lining mobilization is easily reproducible and is versatile. It can be used as an adjunct to any palatoplasty technique and is particularly useful in the treatment of wide clefts and revision cases.

Comparing fitness performance before and after breast reduction surgery.

BACKGROUND: Breast reduction is one of the most commonly performed surgeries by plastic surgeons. Patients may receive many benefits and overall complications are low allowing for breast reduction to be a popular procedure offered by plastic surgeons. Fitness improvement is a perceived benefit but has not been objectively demonstrated, which is the purpose of this study. METHODS: An IRB approved retrospective review of fitness performance scores before and after breast reduction for symptomatic macromastia in active duty women was performed. RESULTS: No improvement or statistically significant difference was demonstrate in overall fitness, push-ups, sit-ups, waist measurement, or 1.5-mile run time. All women reported relief of symptoms of macromastia and felt more comfortable exercising. CONCLUSIONS: Although comfort during exercise improves, actual fitness performance remains unchanged. Fitness requirements of active duty members allowed for this unique opportunity to study actual fitness performance in breast reduction patients.

The Air Force Visiting Surgeon Program: Development, Outcomes, and Future Application.

INTRODUCTION: Active duty service members and their families have limited access to subspecialty surgical care when assigned OCONUS. To address this issue, the Air Force Visiting Surgeon Program (VSP) was created to push subspecialty care to these locations. Visiting Surgeon Program was accomplished using temporary duty (TDY) orders. We conducted this 12-year review, 2009-2021, of the program to assess objective measures of impact, identify key lessons learned, and consider the program's future. MATERIALS AND METHODS: In 2009, the senior author, Col Latham, performed a cost analysis of plastic surgery care provided at OCONUS installations and found that TRICARE Overseas often paid rates substantially higher than a TDY assignment for a single procedure. To improve beneficiaries' access to care while providing a cost savings to the health care system, 2-week plastic surgery missions were proposed to interested OCONUS military treatment facilities (MTFs). Ultimately, four sites selected to host the program in Alaska, Italy, England, and Japan. These sites were selected based on patient volumes, operating room capacity, and local command and surgeon support. By 2015, the Air Force formalized the program via Air Force Instruction 44-102 which outlined roles and responsibilities of MTF Commanders; established points of contact; and instituted key safety measures. RESULTS: To date, 58 missions have been completed by 21 surgeons through the VSP at Aviano Air Base (Italy; 24.1%), Joint Base Elmendorf-Richardson (Alaska; 31.0%), Royal Air Force Lakenheath (England; 27.6%), and Yokota Air Base (Japan; 17.2%). While primarily an Air Force program, 17% (10/58) of missions were supported Army or Navy surgeons. Overall, 2,000 patient consultations and 865 surgical cases were performed avoiding $6.7 million in cost. In addition to direct beneficiary care, the VSP also contributed to the participating surgeon and host surgical teams mission readiness. CONCLUSIONS: The VSP provides a template to make select subspecialty surgical care available in a cost-effective manner across the military health system, while also providing a model for the forward deployment of military plastic surgeons and triservice collaboration.

Combating the "Peacetime Effect" in Military Plastic Surgery: Implications for Mission Readiness.

Military treatment facility-assigned surgeons face numerous challenges in maintaining critical wartime skills, including the "peacetime effect" and the "dual mission." Using the field of plastic surgery to illustrate these issues, we contrast plastic surgeons' contributions to combat casualty care with primary data describing plastic surgeons' clinical practice in many military hospitals. Then, we outline the current administrative mechanisms being promoted at the enterprise-level for surgeons to gain a more mission-focused, clinical practice, while also examining significant shortcomings in these policies. Finally, we conclude with a call to action for the military surgical community to accelerate change in the development of more robust clinical practices for our surgeons, or potentially lose our ability to field a ready surgical force.

Plastic Surgery at War: A Scoping Review of Current Conflicts.

INTRODUCTION: The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations. MATERIALS AND METHODS: Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered. RESULTS: The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain. CONCLUSIONS: Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.

Uniformed Services University Medical Student Mentorship Experiences and Gender From 2010 to 2017.

INTRODUCTION: Gender disparity in medicine has drawn increased attention in the form of root cause analysis and programmatic solutions with the goal of equity. Research indicates that mentoring, guidance, and support, which include the provision of social and academic guidance and support from more experienced practitioners, can mitigate challenges associated with gender disparity. The purpose of this study was to explore women medical students' self-reports of mentorship during their time at Uniformed Services University (USU), if women report similar levels of mentorship as compared to men, and if levels of characteristics associated with mentoring (eg, social support, academic guidance) changed over time. MATERIALS AND METHOD: Using data from the American Association of Medical College's Graduate Questionnaire, a survey sent to all medical students prior to graduation, items were coded as related to mentorship, guidance, and support and analyzed to compare responses of female and male students from graduating USU classes of 2010-2017. RESULTS: No significant difference was found between experiences of female and male survey respondents. Equitable experiences were consistent across time for the 8 years of the study. CONCLUSIONS: Although mentorship is cited as a key factor in mediating gender disparity in medicine, other STEM fields, and the military, the findings suggest that there is equity at the USU undergraduate medical education level. Further studies are needed to understand if disparities in mentorship experiences occur at other stages of a military physician's career, such as graduate medical education, faculty and academic promotion levels.

Military Medicine and the Academic Surgery Gender Gap.

INTRODUCTION: Gender disparity in academic medicine has been well described in the civilian sector. This has not yet been evaluated in the military health system where hundreds of female surgeons are practicing. Military service limits factors such as part time work and control over time spent away from family, which are often cited as contributors to the pay and promotion gap in civilian academic medicine. The military has explicit policies to limit discrimination based on gender. Pay between men and women is equal as it is based on rank and time in rank. One would expect to see less disparity in promotion through the academic ranks for military female surgeons given this otherwise equal treatment. This has not previously been objectively tracked or reported. It is beneficial to characterize the military academic medicine gender gap and benchmark against national data to define the academic gender gap and lay the groundwork for future work to identify factors contributing to the observed difference. MATERIAL AND METHODS: This study was granted exemption from the Walter Reed National Military Medical Center (WRNMMC) Internal Review Board (IRB). The Uniformed Services University (USU) Department of Surgery academic appointment list was reviewed to assess female representation in the categories of Instructor, Assistant Professor, Associate Professor, Professor, and Other. Defense Manpower Data Center (DMDC) and the US Navy Bureau of Medicine and Surgery (BUMED) were assessed for total numbers of female surgeons on active duty, and numbers were compared with nationally published Association of American Medical Colleges (AAMC) data using a logistic regression model. RESULTS: There was a higher proportion of women in academic positions in the civilian cohort than in the military cohort (OR: 1.84; CI: 1.53-2.21, p < .0001). This difference was observed at every level of academic achievement. A higher percentage of women were observed at lower levels of professorship than at higher levels; instructors were more likely to be women than assistant professor (OR: 1.44, CI:1.16-1.79), associate professor (OR: 2.24, CI: 1.77-2.84), or full professor (OR:4.61, CI: 3.57-5.94). CONCLUSIONS: Fewer female surgeons in military medicine hold academic appointment when compared with their counterparts in civilian medicine. Similar to the civilian sector, military academic surgery also demonstrates less likelihood of female representation in higher academic stations. This discrepancy in representation follows a linear trend over the different ranks. This discrepancy has not been previously documented. The military offers a unique opportunity to study the issue of gender imbalance in academic promotion practices given its otherwise equal treatment of males and females. Additional studies will be necessary to understand uniformed female surgeons' barriers to academic advancement.

Reconstructing the Face of War.

INTRODUCTION: Ongoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites. METHODS: A case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images. RESULTS: Four patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed. CONCLUSION: While the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.

Anthropometry of the external ear in children with cleft lip and palate in comparison to age-matched controls.

Comprehensive anthropometric measures in children with cleft lip (CL) and cleft palate (CP) have suggested that similar qualitative growth disturbances may be present in the auricle. We propose a study to evaluate and better understand auricular development in nonsyndromic children born with CL/CP. Our institution is a tertiary referral center for children with craniofacial anomalies. During a 4-year period, we randomly selected 50 nonsyndromic children, aged 5 to 18 years, with CL or CP. Fifty age-matched control children without craniofacial anomalies were selected as a control group. Anthropometric measurement analysis was conducted to compare auricular length (sa-sba), width (pra-pa), attachment to the cranium (obs-obi), and degree protrusion. Auricular index was also calculated for each group. Using a multivariate analysis of variance, statistical analysis with a P < 0.001 demonstrates group differences when comparing ear length and ear protrusion in nonsyndromic children with CL/CP to age-matched controls. Ear length was greater in the control group, whereas ear protrusion (distance from the mastoid process to helical rim) was found to be decreased in the experimental group. Age and sex did not demonstrate significant differences in ear protrusion or length between the control and experimental groups. In nonsyndromic children with CL/CP, greater sensitivity should be given to the timing of auricular surgery. Comparisons of age-matched auricular measurements suggest that ear development may be altered in children with CL or CP. Further research is needed to investigate anthropological differences between nonsyndromic children with cleft and the normal population.

Restoring full-thickness defects with spray skin in conjunction with dermal regenerate template and split-thickness skin grafting: a pilot study.

Complex, full-thickness soft tissue defects secondary to large burns, trauma and war-related injuries continue to challenge reconstructive surgeons. To achieve positive surgical outcomes in these patient populations, novel approaches are needed to restore the functional, protective and aesthetic properties of skin. Herein, we provide the first report describing the staged use of a dermal regenerate template (DRT) with a spray-on epidermal regenerative modality (spray skin) in addition to autologous split-thickness skin grafting (STSG) in non-burn trauma and compare these results with those of patients treated with DRT and STSG alone. A pilot study was performed to evaluate whether the use of spray skin technology (ReCell, Avita Medical) as an adjunct to DRT (Integra, Integra Lifesciences) and autologous skin grafting in the treatment of patients with large full-thickness soft tissue losses impacts donor site burden as well as recipient and donor site re-epithelialization. In this retrospective study, two patients who were treated with DRT and STSG alone (control group) were compared with two patients who were treated with DRT and spray skin/STSG in combination (experimental group). The mechanisms of injury, total defect and treatment sizes, time to complete re-epithelialization, lengths of follow-up, outcomes and complications were reviewed. Our group observed that using a DRT in conjunction with spray skin/STSG can reduce donor site burden and decrease time to complete healing. It can also permit greater or larger meshing ratios, while aiding in improved re-pigmentation when compared with similar wounds treated with a DRT and autologous skin grafting alone. Copyright © 2017 John Wiley & Sons, Ltd.

A Case Report of the First Nonburn-related Military Trauma Victim Treated with Spray Skin Regenerative Therapy in Combination with a Dermal Regenerate Template.

Massive soft tissue and skin loss secondary to war-related traumas are among the most frequently encountered challenges in the care of wounded warriors. This case report outlines the first military nonburn-related trauma patient treated by a combination of regenerative modalities. Our case employs spray skin technology to an established dermal regenerate matrix. Our patient, a 29-year-old active duty male, suffered a combat blast trauma in 2010 while deployed. The patient's treatment course was complicated by a severe necrotizing fasciitis infection requiring over 100 surgical procedures for disease control and reconstruction. In secondary delayed reconstruction procedures, this triple-limb amputee underwent successful staged ventral hernia repair via a component separation technique with biologic mesh underlay although this resulted in a skin deficit of more than 600 cm2. A dermal regenerate template was applied to the abdominal wound to aid in establishing a "neodermis." Three weeks after dermal regenerate application, spray skin was applied to the defect in conjunction with a 6:1 meshed split thickness skin graft. The dermal regenerate template allowed for optimization of the wound bed for skin grafting. The use of spray skin allowed for a 6:1 mesh ratio, thus minimizing the donor-site size and morbidity. Together, this approach resulted in complete healing of a large full-thickness wound. The patient is now able to perform activities of daily living, walk without a cane, and engage in various physical activities. Overall, our case highlights the potential that combining regenerative therapies can achieve in treating severe war-related and civilian traumatic injuries.

Neurofibromatosis of the head and neck: classification and surgical management.

BACKGROUND: Neurofibromatosis is common and presents with variable penetrance and manifestations in one in 2500 to one in 3000 live births. The management of these patients is often multidisciplinary because of the complexity of the disease. Plastic surgeons are frequently involved in the surgical management of patients with head and neck involvement. METHODS: A 20-year retrospective review of patients treated surgically for head and neck neurofibroma was performed. Patients were identified according to International Classification of Diseases, Ninth Revision codes for neurofibromatosis and from the senior author's database. RESULTS: A total of 59 patients with head and neck neurofibroma were identified. These patients were categorized into five distinct, but not exclusive, categories to assist with diagnosis and surgical management. These categories included plexiform, cranioorbital, facial, neck, and parotid/auricular neurofibromatosis. CONCLUSIONS: A surgical classification system and clinical characteristics of head and neck neurofibromatosis is presented to assist practitioners with diagnosis and surgical management of this complex disease. The surgical management of the cranioorbital type is discussed in detail in 24 patients. The importance and safety of facial nerve dissection and preservation using intraoperative nerve monitoring were validated in 16 dissections in 15 patients. Massive involvement of the neck extending from the skull base to the mediastinum, frequently considered inoperable, has been safely resected by the use of access osteotomies of the clavicle and sternum, muscle takedown, and brachial plexus dissection and preservation using intraoperative nerve monitoring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Subtotal Nasal Reconstruction: Military-civilian Collaboration in Care of an Afghan-American Woman's Plight.

Military plastic surgeons perform reconstructive surgeries for various congenital, oncologic, and traumatic craniofacial injuries or deformities. Recently, our Walter Reed National Military Medical Center Plastic Surgery team was tasked to care for a woman who bravely sought a new and better life in the United States after she suffered amputation of her nose and bilateral ears while in her home country of Afghanistan. A military-civilian team collaborated throughout her reconstructive planning, treatment, and postoperative course to create both an aesthetically acceptable and functional subtotal nasal reconstruction. This case report details the patient's unique journey, her reconstructive course, and highlights her reintegration into a new life and society.