Micro-Coring: A Novel Approach to Perioral Rejuvenation.

BACKGROUND: A long philtrum and poor perioral skin quality are stigmata of the aging face. Micro-coring is a novel technology that allows for scarless skin removal. OBJECTIVES: This study aimed to determine if micro-coring can shorten the philtrum and improve perioral skin quality. METHODS: A retrospective cohort study was performed on subjects who underwent facelift with perioral micro-coring and age/BMI-matched control patients who underwent facelift alone. Preoperative and postoperative three-dimensional facial imaging was performed. Standard perioral distances and percent change were calculated. Perioral skin quality was evaluated by blinded raters using the Scientific Assessment Scale of Skin Quality (SASSQ) and Global Aesthetic Improvement Scale (GAIS). RESULTS: Thirteen subjects and thirteen controls were included with a mean follow-up of 8.9 months (range 3.0-21.5). Subjects had significantly shorter mean philtral length postoperatively as compared to preoperatively, with an average decrease of 6.18% (±2.25%) (p<0.05). Controls did not experience significant changes in philtrum length (p>0.05). Postoperative philtrum length was significantly shorter in subjects as compared to controls (p<0.05). There were no significant changes in other perioral measurements. Perioral skin elasticity and wrinkles significantly improved in subjects as compared to controls and subjects had significantly greater GAIS scores (p<0.05). CONCLUSIONS: Micro-coring can achieve perioral rejuvenation through measurable shortening of the philtrum and observable improvement in skin quality. Non-surgical techniques continue to find new ways to achieve aesthetic goals without significant recovery or scarring and offer value to patients and clinicians.

A Relative Value Unit-Based Model for Targeted Nipple-Areola Complex Neurotization in Gender-Affirming Mastectomy.

Background: For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple-areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity. Methods: A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included. Results: A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2-111.5) without neurotization and 154.2 minutes (95% CI, 139.9-168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute. Conclusions: Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.

Prospective Sensory Outcomes for Targeted Nipple Areola Complex Reinnervation (TNR) in Gender-Affirming Double Incision Mastectomy with Free Nipple Grafting.

OBJECTIVE: This study analyses the anatomy and sensory outcomes of targeted nipple areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting (FNG). BACKGROUND: TNR is a novel technique to preserve and reconstruct intercostal nerves (ICN) to improve postoperative sensation. There is little evidence on relevant anatomy and outcomes. METHODS: 25 patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient reported questionnaires were completed preoperatively, and at one, three, six, nine and twelve months postoperatively. RESULTS: 50 mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P >0.05). BMI ≥30 kg/m 2 and mastectomy weight ≥800 g were associated with significantly worse preoperative sensation ( P <0.05). Compared to preoperative values, NAC sensation was worse at 1 month ( P <0.01), comparable at 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared to use of allograft only ( P <0.05), and with direct coaptation of ≥2 branches compared to direct coaptation of a single branch ( P <0.05). All patients reported return of nipple and chest sensation at one year postoperatively and 88% reported return of some degree of erogenous sensation. CONCLUSION: TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. Use of multiple ICN branches and direct coaptation led to the best sensory outcomes.

The Biomechanical Properties of Meshed versus Perforated Acellular Dermal Matrices (ADMs).

Acellular dermal matrices (ADMs) are used for soft tissue augmentation across surgical specialties. Since allograft incorporation depends on direct opposition between the ADM and a vascular bed, seroma formation can be detrimental to incorporation. Since most ADM products are available in many meshed and perforated forms, there is a lack of consistency between manufacture designs. We set out to determine the fluid egress properties and increase in surface area resulting from common cut patterns. METHODS: Three ADM cut patterns were studied: 1 meshed and 2 perforated. We calculated the surface area of these modified ADM samples. Fluid was passed through each ADM, and time required for fluid passage was recorded. An ANOVA (P < 0.05) was used to determine if there was a significant difference in egress properties across the 3 patterns. RESULTS: Meshing in a 1:1 pattern resulted in a 97.50% increase in surface area compared with the uncut product. In comparison, only a 0.30% increase resulted from Perforation Pattern #1 and a 0.59% increase resulted from Perforation Pattern #2. There was a significant difference in egress properties across the three cut patterns (P = 0.000). The average egress time of Mesh Pattern #1 was 1.974 seconds. The average egress time of Perforation Pattern #2 was 6.504 seconds, and of Perforation Pattern #1 was 10.369 seconds. CONCLUSIONS: Quantitative comparison revealed that meshing ADM significantly improves fluid egress and increases the surface area. Therefore, the use of meshed ADM tissue could improve the incorporation of ADM with the recipient, with improved patient outcomes.

Inpatient Flap Monitoring after Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: How Long Is Long Enough?

BACKGROUND: There is a growing trend across health care to perform increasingly complex procedures in less acute settings. This shift has been fueled, in part, by enhanced recovery protocols, which have shortened hospital stays after major surgeries. We set out to determine the timing of microvascular complications after deep inferior epigastric artery perforator (DIEP) free flap breast reconstruction in a high-volume practice using continuous flap monitoring technologies. METHODS: The medical charts of all patients who underwent breast reconstruction with DIEP flaps over 24 consecutive months were reviewed. Postoperatively, all flaps were monitored according to a protocol that included continuous tissue oximetry with near-infrared spectroscopy. The primary end points evaluated included any unplanned return to the operating room, time to takeback, and flap loss rate. RESULTS: A total of 196 patients underwent breast reconstruction with a total of 301 DIEP flaps. Five of the flaps (1.7%) were taken back to the operating room for microvascular issues, and nine (3.0%) were taken back for nonvascular issues. Of patients who were brought back for microvascular issues, all five (100.0%) were initially identified by continuous noninvasive monitoring and taken back to the operating room within the first 14 hours (range: 1.2-13.6 hours). In the series, the flap failure rate was 0.66% (n = 2). CONCLUSION: All of the microvascular issues were detected in the initial 23 hours after surgery, leading to prompt flap salvage. The results of this study bring into question the need for lengthy flap monitoring protocols and suggest that shorter inpatient, or even observation admissions, may be reasonable, particularly when flap monitoring protocols incorporating continuous noninvasive flap monitoring are used.

Gender Reassignment: Feminization and Masculinization of the Neck.

Facial stigmata associated with one's assigned gender can be very distressing for the gender dysphoric patient. The lower face and neck contain several structures that play a significant role in their ability to "pass" as their desired gender. Clinical recognition and modification of these structures will allow the patient to have facial and neck features that are consistent with their desired gender. This article reviews the techniques of mandibular angle contouring, genioplasty, chondrolaryngoplasty, facelift, and neck lift as they pertain to the feminization and masculinization of the face and neck of the patient with gender dysphoria.

Bilateral, Atraumatic Proximal Tibiofibular Joint Instability Treated With Suspensory Button Fixation.

Proximal tibiofibular joint (PTFJ) instability is a rare cause of lateral-sided knee pain. The authors present a case of bilateral, symptomatic PTFJ instability with peroneal nerve dysfunction in an active 16-year-old female athlete. This was addressed with peroneal nerve decompression and PTFJ stabilization using a suspensory button fixation system. This provides an alternative treatment from historical methods such as PTFJ fusion or re-approximation of the joint with tendon through bone tunnels. The surgical technique, as well as potential treatment challenges, is described in detail. The purpose of this report is to highlight PTFJ instability as a cause of lateral-sided knee pain to avoid misdiagnosis and delay in appropriate treatment. This patient had significant improvement in pain and decreased neurologic symptoms after the stabilization and nerve decompression. She was able to return to high-level activity. [Orthopedics. 2017; 40(6):e1107-e1111.].

Casting and Splinting Management for Hand Injuries in the In-Season Contact Sport Athlete.

CONTEXT: Upper extremity injuries are extremely common in contact sports such as football, soccer, and lacrosse. The culture of competitive athletics provides an environment where hand injuries are frequently downplayed in an effort to prevent loss of game time. However, studies have shown that many sport-induced hand injuries do not actually require immediate surgical attention and can be safely treated through immobilization so that the athlete may complete the athletic season. In these cases, appropriate casting and splinting measures should be taken to ensure protection of the injured player and the other competitors without causing loss of game time. EVIDENCE ACQUISITION: Articles published between 1976 and 2015 were reviewed to capture historical and current views on the treatment of hand injuries in the in-season athlete. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Although traditionally many sports-induced traumatic injuries to the hand held the potential to be season-ending injuries, experience has shown that in-season athletes do not necessarily need to lose game time to receive appropriate treatment. A thorough knowledge of converting everyday splints and casts into game day, sport-approved protective immobilization devices is key to safely allowing athletes with select injuries to play while injured. CONCLUSION: Protective techniques allow for maximum functionality during gameplay while safely and effectively protecting the injury from further trauma while bony healing takes place.

Completed Ulnar Shaft Stress Fracture in a Fast-Pitch Softball Pitcher.

Stress fractures of the upper extremity have been previously described in the literature, yet reports of isolated injury to the ulna diaphysis or olecranon are rare. The authors describe a case involving an 18-year-old fast-pitch softball pitcher. She presented with a long history of elbow and forearm pain, which was exacerbated during a long weekend of pitching. Her initial physician diagnosed her as having forearm tendinitis. She was treated with nonsurgical means including rest, anti-inflammatory medications, therapy, and kinesiology taping. She resumed pitching when allowed and subsequently had an acute event immediately ceasing pitching. She presented to an urgent care clinic that evening and was diagnosed as having a complete ulnar shaft fracture subsequently needing surgical management. This case illustrates the need for a high degree of suspicion for ulnar stress fractures in fast-pitch soft-ball pitchers with an insidious onset of unilateral forearm pain. Through early identification and intervention, physicians may be able to reduce the risk of injury progression and possibly eliminate the need for surgical management. [Orthopedics. 2017; 40(2):e360-e362.].

Jam Injuries of the Finger: Diagnosis and Management of Injuries to the Interphalangeal Joints Across Multiple Sports and Levels of Experience.

CONTEXT: Jam injuries of the finger are frequently encountered in general orthopaedic and sports medicine practice. The finger joints in particular are very susceptible to traumatic injury, but in the absence of severe deformity, digital trauma is often downplayed in the hopes of a more rapid return to game play. EVIDENCE ACQUISITION: Articles published from 1966 to 2015 were reviewed to capture historical and current views on the presentation, diagnosis, and treatment of jam injuries in athletes. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Although jam injuries are frequently grouped together, they represent a host of injuries that can be challenging to differentiate. A thorough knowledge of finger joint anatomy and injury mechanism is critical to perform an appropriate examination, establish an accurate diagnosis, and identify a treatment plan for each patient. CONCLUSION: Every member of the athletic care team must be aware of the spectrum of digital injuries, including the basic signs present on examination, which may indicate the need for more formal workup. Additionally, preventing injury through athlete education is paramount to athletic care.

A Therapeutic Role for Survivin in Mitigating the Harmful Effects of Ionizing Radiation.

Background. Radiation therapy is a form of adjuvant care used in many oncological treatment protocols. However, nonmalignant neighboring tissues are harmed as a result of this treatment. Therefore, the goal of this study was to induce the production of survivin, an antiapoptotic protein, to determine if this protein could provide protection to noncancerous cells during radiation exposure. Methods. Using a murine model, a recombinant adenoassociated virus (rAAV) was used to deliver survivin to the treatment group and yellow fluorescence protein (YFP) to the control group. Both groups received targeted radiation. Visual inspection, gait analysis, and tissue histology were used to determine the extent of damage caused by the radiation. Results. The YFP group demonstrated ulceration of the irradiated area while the survivin treated mice exhibited only hair loss. Histology showed that the YFP treated mice experienced dermal thickening, as well as an increase in collagen that was not present in the survivin treated mice. Gait analysis demonstrated a difference between the two groups, with the YFP mice averaging a lower speed. Conclusions. The use of gene-modification to induce survivin expression in normal tissues allows for the protection of nontarget areas from the negative side effects normally associated with ionizing radiation.

Patient attitudes toward resident participation in cosmetic vs reconstructive outpatient consultations.

OBJECTIVES: The goal of residency programs is to provide trainees with exposure to all aspects of their chosen field so that they exit the program ready to be independent practitioners. However, it is common in some plastic surgery residency training programs to exclude residents from participation in consultations with patients who are seeking cosmetic surgery. The purpose of this study was to determine whether cosmetic surgery patients had a different view about resident involvement than reconstructive surgery patients and to evaluate what factors might be linked to patient attitudes on this topic. PARTICIPANTS: All new patients older than 18 years presenting to either academic or nonacademic locations were asked to complete the voluntary survey at their initial consultation. SETTING: The study was conducted at both the Ohio State University (academic) and Advanced Aesthetic and Laser Surgery (private practice) in Columbus, Ohio. DESIGN: The survey asked patients to identify their surgical concern as either cosmetic or reconstructive and to indicate the location on their body where they were having surgery. Additionally, a series of statements regarding resident involvement was presented with a 5-point Likert-type rating system to assess each patient's attitudes about a range of factors, such as resident sex and seniority. RESULTS: In total, 119 patients participated in the study by completing the survey. Of this population, 59.7% (n = 71) were classified as reconstructive surgery patients and 40.3% (n = 48) were classified as cosmetic surgery patients. Based on responses, it was determined that reconstructive surgery patients were more approving of resident involvement in their care than cosmetic surgery patients were. When other factors were analyzed, the patients seeking breast surgery were found to be more apprehensive about resident participation than non-breast surgery patients were. CONCLUSION: Although there were some differences in the way resident participation was perceived by cosmetic and reconstructive surgery patient populations, neither group strongly believed that resident participation decreased the quality of patient care. Based on these findings, plastic surgery training programs should begin to allow residents to become more involved in the care of cosmetic surgery patients.

Improvement in stress urinary incontinence after abdominoplasty.

BACKGROUND: Abdominoplasty is indicated in cosmetic surgery to improve body contour. Results from several studies suggest that abdominoplasty also could be therapeutic for certain individuals with urinary incontinence. OBJECTIVES: The authors sought to determine the potential therapeutic effect of abdominoplasty on urinary incontinence in a large population to confirm the findings of smaller studies and to identify common characteristics of patients who experience the greatest improvement in these symptoms postoperatively. METHODS: Through a retrospective chart review, the authors identified 250 patients who underwent cosmetic abdominoplasty. These patients were invited to participate in a survey to ascertain changes in stress urinary incontinence (SUI) symptoms after abdominoplasty. Patients were subgrouped according to postoperative changes in their urinary incontinence symptoms, and the subgroups were evaluated for common within-group characteristics. RESULTS: Of the 250 patients who underwent abdominoplasty during the period of interest, 100 (40%) completed the survey, half of whom (n=50) reported incontinence preoperatively. After abdominoplasty, 30 (60%) of these 50 patients noted improvement in their symptoms, and the other 20 (40%) reported no improvement. Lack of previous cesarean section was a predictor of improvement in SUI symptoms after abdominoplasty. CONCLUSIONS: Abdominoplasty to improve body contour also may alleviate symptoms of SUI, especially among patients who have not undergone previous cesarean section. LEVEL OF EVIDENCE: 4.

Biologic matrices in oncologic breast reconstruction after mastectomy.

As the demand for post-mastectomy breast reconstruction has continued to rise, options for the implantable soft-tissue replacement products which enhance the aesthetic and reconstructive outcome of these procedures has grown as well. While the most common product used in an alloplastic breast reconstruction is an acellular dermal matrix derived from human sources, many other options are currently available, each offering their own unique properties and benefits. This review presents a concise description of each of the biologic matrices currently available and discusses their use in the context of one-stage and two-stage breast reconstructions.

Optimizing the closed suction surgical drainage system.

BACKGROUND: Closed suction drains are indicated in a wide array of postoperative settings, with many distinct drainage systems available to the surgeon. The purpose of this study was to compare the suction gradients achieved using 2 different sizes of suction reservoirs and 2 different techniques for generating negative pressure. MATERIALS AND METHODS: Drainage reservoirs of 100 and 400 ml were chosen to evaluate their ability to achieve suction. Suction was established in both sizes of drains by pressing the sides of the reservoir together or by pushing the bottom of the reservoir toward the top. Negative pressures were recorded with the reservoir empty, and after every 10-ml addition of saline. Averages were graphed to illustrate the applied suction over a range of drain volumes. RESULTS: The 100-ml drainage system reached a peak suction of -117.6 mmHg, while the 400-ml drainage system reached only a peak suction of -71.4 mmHg. Both of the maximum suction readings were achieved using the full-squeeze technique. The bottom-pushed-in technique did not result in any sustained measurable levels of suction using either of the reservoir volumes. CONCLUSIONS: Smaller drain reservoirs are more successful in generating a high initial suction than larger reservoirs, especially when the volume of fluid in the drain is relatively low. In all sizes of drains, compressing the sides of the reservoir is a far better technique for establishing negative pressure than pressing the bottom of the drain up toward the top.

Fat grafting as a vehicle for the delivery of recombinant adenoassociated viral vectors to achieve gene modification of muscle flaps.

BACKGROUND: The combination of gene therapy and plastic surgery may have the potential to improve the specificity that is needed to achieve clinically applicable treatment regimens. Our goal was to develop a method for gene modification that would yield sustainable production of gene products but would be less time consuming than existing protocols. METHODS: An adenoassociated virus was used to deliver gene products to pectoralis muscle flaps. Gene modification was accomplished via either direct injection or novel fat grafting techniques. RESULTS: The production of gene product was observable by both in vivo imaging and immunohistochemical staining. Gene products were not detected in tissues that were not in contact with the fat grafts that were incubated with the viral vector, indicating that the transduction stayed local to the flap. CONCLUSIONS: Using novel recombinant adenoassociated virus vectors, we have developed a method for gene delivery that is highly efficient and applicable to muscle flaps.

A reliable method for the preoperative estimation of tissue to be removed during reduction mammaplasty.

BACKGROUND: Insurance requirements for prior authorization of reduction mammaplasty are becoming increasingly stringent, with the sole criterion determined by the surgeon being the estimation of the amount of tissue to be removed. Previous formulas for predicting resected tissue weights have been inconsistent and particularly unreliable in smaller reductions. This study describes a dependable, surgeon-specific method based on two simple preoperative measurements to estimate tissue resection weights in patients undergoing reduction mammaplasty. METHODS: The medical charts of 72 consecutive patients who underwent reduction mammaplasty were reviewed. Preoperatively obtained measurements from the first 15 patients in the authors' series were plotted against the actual corresponding amount of breast tissue removed at the time of surgery. Linear regression of this plot was used to generate a mathematical formula that was then used to predict resection weights of the subsequent 57 patients. The results were compared with the actual weights recorded intraoperatively. RESULTS: Several measurements were evaluated and Pearson coefficients generated. The mathematical product of two unique breast-only surface measurements along horizontal and vertical planes generated the linear regression formula with the greatest accuracy (r = 0.95) for predicting the weight of tissue to be resected compared with either measurement alone or sternal notch-to-nipple distance. CONCLUSION: By using two simple preoperative measurements correlated with tissue resection weights in a small series of procedures, any reconstructive surgeon can create his or her own reliable formula for predicting breast tissue resection weights for reduction mammaplasty.