A systematic examination of the effect of tissue glues on rhytidectomy complications.

BACKGROUND: Fibrin glue has widespread use in multiple fields of surgery. There have been numerous studies on the use of fibrin glue in facelifts, with no consensus regarding differences in outcomes. OBJECTIVES: This study compared the risk of hematoma, seroma, and the 24-hour drainage volume in all published prospective controlled trials. METHODS: A MEDLINE search of English-language articles on fibrin glue and rhytidectomy published up to July 2013 yielded 49 citations. After screening, we examined 7 relevant controlled trials. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. RESULTS: Seven controlled trials measuring the outcomes of fibrin glue in facelifts were used to estimate the pooled relative risk of complications and confidence intervals. Hematoma formation was four times less likely with the use of fibrin glue (relative risk 0.25, P = .002). There was no significant reduction in seroma formation (relative risk 0.56, P = .19). There was not enough data to properly measure 24-hour drainage and ecchymoses. CONCLUSIONS: This analysis suggests that fibrin glue reduces the rates of hematoma formation, but does not significantly reduce the rates of seroma development. LEVEL OF EVIDENCE: 3 Therapeutic.

The ultra-thin, fascia-only anterolateral thigh flap.

BACKGROUND: While many potential donor sites have been described for fascial (fascia-only) flaps, a fascial flap harvested from the anterolateral thigh (ALT) donor site has not gained popularity, likely because of concerns regarding inadequate perfusion of the deep fascia. However, recent clinical experience demonstrates that the ALT fascia-only flap is a suitable option for reconstructions necessitating thin and pliable coverage. METHODS: In this study a retrospective chart review was performed examining the clinical experience of two plastic surgeons with the fascia-only ALT perforator flap from 2008 to 2012. Each flap was initially raised as a standard ALT flap, but all the overlying skin and adipose tissue was excised off the deep fascia before the inset, resulting in the creation of a fascia-only ALT flap. Immediate split- or full-thickness skin grafts were used to cover the flap. The results are reported in this article. RESULTS: Overall seven patients underwent reconstruction of wounds using either free (six) or pedicled (one) fascia-only ALT flaps (length, 10-20 cm, width, 5-10 cm). The following regions were successfully reconstructed using a fascia-only ALT flap: occipital scalp, lower extremity, upper extremity, and groin. All patients were followed for at least 6 months postoperatively. CONCLUSIONS: The fascia-only ALT flap was successfully used to reconstruct a variety of defects in seven patients. The authors experience demonstrates the viability of the fascia-only version of the ALT flap for reconstructions requiring thin coverage with good contour, and further adds to the versatility of the ALT as a donor site for flaps.

Contemporary techniques for the correction of temporal hollowing: augmentation temporoplasty with the classic dermal fat graft.

INTRODUCTION: Temporal hollowing is a depression within the soft tissues overlying the temporal fossa, sometimes seen after surgical dissection for access to the facial skeleton. Surgeons have successfully used bone grafts, hydroxyapatite, methyl methacrylate, and autogenous tissue to correct the deformity. A systematic review of the literature demonstrated that the most popular technique for the correction of temporal hollowing seems to be the use of nonbiologic materials. These materials have been used successfully but are associated with some complications. There has been a growing experience with augmentation of the soft tissues of the temporal fossa using dermal fat grafts at our institutions, and this article describes this experience. METHODS: Two senior surgeons' recent experience with the correction of temporal hollowing was reviewed and analyzed. RESULTS: The retrospective review revealed 5 cases of temporal hollowing treated with dermal fat graft placement. Follow-up at 1 year revealed aesthetically pleasing results. CONCLUSIONS: A thorough understanding of temporal anatomy and conscious effort to respect structural integrity during dissection are essential in avoiding temporal hollowing. Sometimes, however, this deformity is impossible to avoid. In these patients, there are a number of options for correction. Open placement of the classic dermal fat graft is a technique that seems to offer good long-term aesthetic results.

Optimizing pediatric interdental fixation by use of a paramedian palatal fixation site.

Condylar fractures are the most common injury seen in pediatric mandibular trauma. These injuries often cannot be adequately stabilized by conservative techniques such as splinting. The pediatric condyle fracture often requires a period of intermaxillary fixation. Because of the characteristics of the developing dentition, circumdental wiring is often not possible. Surgeons commonly achieve interdental stabilization by the connection of a circum-mandibular wire and a second wire placed through a drill hole in the piriform aperture. This method can be problematic in the young patient whose palatal suture is still patent. In this brief technical note, the use of a paramedian drill hole through the palate posterior to the maxillary incisors is described. It is believed that this method is superior to other techniques because it avoids injury to the deciduous tooth buds and allows for the maxillary wire to be seated in more structurally sound tissues.

A paradigm shift in correcting medial orbital fracture-related enophthalmos: volumetric augmentation through a lateral approach.

BACKGROUND: Posttraumatic enophthalmos resulting from medial orbital wall fractures presents a complex challenge. Access to this area through traditional incisions is limited, making visualization of the fracture site difficult. This can be ameliorated by the transcaruncular approach, but with the potential for complications both with access and with reconstructive materials. The authors sought a new technique where enophthalmos correction would be based on augmenting soft tissue volume, rather than reducing the volume of the bony orbital cone. This was successfully accomplished using porous high-density polyethylene wedges. In an effort to increase overall knowledge of this technique, a retrospective review was undertaken. METHODS: A retrospective chart review was undertaken to examine the senior authors' (J.F.T. and L.H.H.) experience using a lateral approach to address medial orbital fracture-related enophthalmos, aided by porous high-density polyethylene wedges to increase orbital volume. The relevant literature was reviewed and reported here. RESULTS: Three patients with post-medial orbital wall fracture enophthalmos were treated using a lateral approach to place porous high-density polyethylene wedges; this technique adequately corrected enophthalmos in these patients. CONCLUSIONS: Porous high-density polyethylene wedges can be placed into the orbit through a small lateral incision to reverse enophthalmos secondary to loss of volume after medial orbital wall fractures. Current techniques for orbital reconstruction typically focus on reduction of bony volume; this technique focuses on augmentation of soft tissue volume.

The variable position of the ear in lambdoid synostosis.

Isolated unilateral lambdoid craniosynostosis is often confused with posterior positional plagiocephaly because of a general overlap in their clinical presentations; however, distinction between these 2 entities is important because of the differences in appropriate management. Historical literature teaches that ear position is posterior in lambdoid synostosis, whereas it is anterior in positional plagiocephaly. Recently, several cases of anterior ear position in isolated unilateral lambdoid synostosis presented to the Texas Children's Hospital. A review of the cases and literature revealed that there are now 37 cases of unilateral lambdoid synostosis in the literature in which ipsilateral ear position is reported. Twelve cases (32%) had anteriorly displaced ears, 6 cases (16%) were nondisplaced, 7 cases (19%) were displaced posteriorly, 4 cases (11%) anteroinferiorly, 1 case (3%) inferiorly, and 7 cases (19%) posteroinferiorly. Based on this review, it seems that the diagnostic significance of the external ear position is unclear at this point.

Management of hypertension in the facelift patient: results of a national consensus survey.

INTRODUCTION: In the facelift patient, uncontrolled perioperative hypertension is a difficult, acute condition that can lead to significant complications. Although the treatment of hypertension in the ambulatory medical setting has been standardized, its management in the cosmetic surgery setting has been ambiguous. OBJECTIVES: The authors evaluate the results of a survey to assess current national trends in perioperative facelift hypertension management. METHODS: A 13-question survey regarding perioperative hypertension management was sent by postal mail to 1776 members of the American Society for Aesthetic Plastic Surgery (ASAPS). Respondents were queried about their geographic location, caseload volume, facelift method, and hematoma rate. RESULTS: A 35.4% response rate was attained (629 respondents). Superficial musculoaponeurotic system (SMAS) plication performed under general anesthesia as an outpatient procedure was the most common facelift technique. Perioperative blood pressure management was consistent among all respondents. Beta-blockers were commonly utilized throughout the preoperative period. Administration of alpha agonists was reported more frequently by surgeons with higher-volume caseloads and more years in practice. Reported hematoma rates did not vary with medication. Medical treatment at an intraoperative systolic blood pressure (SBP) threshold below 100 (p < .04) and a postoperative SBP of greater than 139 (p < .05) significantly increased reported hematoma rates. CONCLUSIONS: The data generated from the survey suggest that the timing of treating hypertension deserves more attention than the actual medication administered. Proper perioperative care of the facelift patient is paramount in the reduction of hematoma rates. Preexisting hypertension correlates with a higher hematoma rate, though this study also suggests that normotensive anesthesia, as well as strict postoperative blood pressure control did contribute to a reduction in hematoma rate.

Perioperative steroids for minimizing edema and ecchymosis after rhinoplasty: a meta-analysis.

BACKGROUND: Minimizing complications after rhinoplasty is a priority for every surgeon performing the procedure. Perioperative steroid administration has been shown to decrease postoperative edema and ecchymosis in a number of prospective randomized trials. OBJECTIVES: In an effort to further elucidate the significance of the data and develop an evidence-based algorithm for steroid administration, the authors offer a meta-analysis of the existing literature. METHODS: A systematic review of the literature was performed. All articles were reviewed for relevant data, which were extracted, pooled, and compared. Seven prospective randomized trials investigating perioperative steroid use in rhinoplasty have been conducted and reported. Four of these studies had the same method of patient edema and ecchymosis assessment, and their data were compared. RESULTS: Based on results from the four relevant studies, perioperative steroid use significantly reduces postoperative edema and ecchymosis of the upper and lower eyelids at one day and seven days postoperatively (P < .0001). Preoperative steroid administration decreases postoperative upper and lower eyelid edema at one day preoperatively, when compared to postoperative administration (P < .05). Extended dosing is superior to one-time dosing (P < .05). CONCLUSIONS: Perioperative steroid use decreases postoperative edema and ecchymosis associated with rhinoplasty. Preoperative administration is superior to postoperative, and extended dosing is superior to singular. Based on these results, evidence-based guidelines for perioperative steroid administration can be given.

Is primary thinning of the anterolateral thigh flap recommended?

BACKGROUND: Although primary thinning of the anterolateral thigh (ALT) flap has been successful in Asia, clinical and anatomic studies have demonstrated that this may be inadvisable in Western patients. Recent reports have demonstrated successful thinning of the ALT using smaller flaps. A systematic review was attempted, to assess whether ALT size affects the incidence of vascular compromise after primary thinning. METHODS: A systematic review was undertaken to examine the relevant literature. Student t-test was used to compare flaps that did and did not have complications. Fisher exact test was used to compare outcomes of flaps measuring less than and greater than 150 cm2. RESULTS: Eleven articles met the inclusion criteria. Eighty-eight ALT flaps were reported, and vascular compromise was seen in 11 (12.5%). The average size of flaps that demonstrated necrosis was 180.73 cm2; those without necrosis averaged 123.19 cm2 (P = 0.06). Flaps >150 cm2 had a significantly increased rate of compromise (25.93% vs. 6.56%; P < 0.05). CONCLUSIONS: A systematic literature review confirms that it is inadvisable to primarily thin large ALT flaps in the Western population. When large ALT flaps are required, primary thinning must be avoided to keep linking vessels intact.

Mechanotransduction: the missing link in the facial aging puzzle?

BACKGROUND: Craniofacial bony remodeling has been recognized as an important contributor to the facial aging process. Multiple studies have demonstrated significant craniofacial skeletal changes with age. However, no review has assembled this information in a concise, cogent fashion. Furthermore, the etiology of these skeletal changes has not been elucidated. This information is important for understanding the mechanisms of facial aging and for further development of facial rejuvenation. METHODS: A literature review of all articles discussing remodeling of the craniofacial skeleton with age was performed. Studies that used objective measurements of craniofacial skeletal parameters for different age groups were collected and analyzed. RESULTS: The studies demonstrated consistent morphologic changes in the craniofacial skeleton with age. These changes included trends toward increased facial bony width in women; contour changes of the orbit, anterior maxilla, and mandibular body; and decreased dimensions of the glabellar, pyriform, and maxillary angles. CONCLUSIONS: The craniofacial skeleton remodels with aging. Many of the observed changes in soft tissue contour and position reflect these skeletal changes. Changes in facial muscle function through the process of mechanotransduction may be responsible for these skeletal changes.

Facial attractiveness: is the whole more than the sum of its parts?

BACKGROUND: In order for aesthetic surgery to participate in the movement toward evidence-based medicine, a system that quantifies aesthetic outcomes must be developed based on reliable and reproducible data. Previous studies have investigated the attractiveness of averaged (or composite) faces. Data has shown that these faces are deemed more attractive than their constituent faces. OBJECTIVES: The authors seek to elucidate the mechanism behind the phenomenon in which more attractive faces included in a composite increase the overall attractiveness rating. METHODS: Ten composites, five male and five female, were generated with resources provided by the www.faceresearch.org research group. The five composites contained the top two, three, and five most attractive faces, a composite of all faces, and the five least attractive faces. An online survey was conducted in which participants were asked to rank each of the five faces in order of attractiveness. RESULTS: Analysis of variance (ANOVA) on ranks was performed on the data provided by the 245 participants. Attractiveness increased from the top two to the top three to the top five composite faces, and then decreased from the top five to all faces to the bottom five composite faces. This trend was present and statistically significant (with a P value <.05) across all genders, ages, and races. CONCLUSIONS: This study provides statistically significant evidence that averaging more attractive faces, specifically the top 10% of a population, renders a more attractive composite face. This optimal composite face could potentially be a standard to which aesthetic surgical outcomes could be objectively compared.

Contemporary techniques in inferior turbinate reduction: survey results of the American Society for Aesthetic Plastic Surgery.

BACKGROUND: Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management. OBJECTIVE: The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author's (SS) preferred technique. METHODS: A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy. RESULTS: One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%). CONCLUSIONS: Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon's skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.

A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy.

BACKGROUND: Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature. METHODS: A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed. RESULTS: Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery. CONCLUSIONS: Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.

Facial clefting and oroauditory pathway manifestations in ankyloblepharon-ectodermal defects-cleft lip/palate (AEC) syndrome.

Ankyloblepharon-ectodermal defects-cleft lip/palate (AEC) Syndrome is a rare disorder characterized by ectodermal dysplasia, along with other malformations such as cleft lip and palate, and various secondary issues such as chronic sinusitis, otitis media, and conductive hearing loss (CHL). The International Research Symposium for AEC Syndrome convened at Baylor College of Medicine in Houston, Texas. Patients with a suspected diagnosis of AEC syndrome attended, and members of the dental, dermatology, plastic surgery, otolaryngology, and audiology services examined each patient. Eighteen patients with a diagnosis of AEC were evaluated. Mean age was 7.5 years (range: 4 months-30 years). Fourteen of the 15 subjects tested (93.33%) demonstrated CHL, with seven showing moderate to severe hearing deficits (41-90 dB). Nine of 13 respondents reported hoarseness or voice problems; 8 were noted to display this on examination. Fourteen of 16 subjects reported speech was below average for age; 8 were in speech therapy. All 18 subjects reported a history of otitis externa or otitis media. Eleven of the subjects (61.11%) required myringotomy and pressure equalizing (PE) tubes. All patients demonstrated cleft palate defects. Of these, 16 (94.11%) presented with clefting of the soft palate, and 10 (58.82%) showed hard palate defects. Three subjects (16.67%) were noted to have submucous clefts. Our experience leads us to propose that while the oroauditory problems in those with AEC syndrome is likely multifactorial, many issues may stem from palatal clefting. Despite this, some abnormalities persist following surgical cleft closure, which indicates other complicating factors are also involved.

Prediction of post-operative necrosis after mastectomy: a pilot study utilizing optical diffusion imaging spectroscopy.

INTRODUCTION: Flap necrosis and epidermolysis occurs in 18-30% of all mastectomies. Complications may be prevented by intra-operative detection of ischemia. Currently, no technique enables quantitative valuation of mastectomy skin perfusion. Optical Diffusion Imaging Spectroscopy (ViOptix T.Ox Tissue Oximeter) measures the ratio of oxyhemoglobin to deoxyhemoglobin over a 1 x 1 cm area to obtain a non-invasive measurement of perfusion (StO2). METHODS: This study evaluates the ability of ViOptix T.Ox Tissue Oximeter to predict mastectomy flap necrosis. StO2 measurements were taken at five points before and at completion of dissection in 10 patients. Data collected included: demographics, tumor size, flap length/thickness, co-morbidities, procedure length, and wound complications. RESULTS: One patient experienced mastectomy skin flap necrosis. Five patients underwent immediate reconstruction, including the patient with necrosis. Statistically significant factors contributing to necrosis included reduction in medial flap StO2 (p = 0.0189), reduction in inferior flap StO2 (p = 0.003), and flap length (p = 0.009). CONCLUSION: StO2 reductions may be utilized to identify impaired perfusion in mastectomy skin flaps.

Popliteal pterygium: report of an anatomic variant.

The presence of a vertical fibrous cord along the posterior lower extremity is highly unusual. Because of its inflexible nature, cord structure may greatly limit leg extension, dorsiflexion, and general ambulation. Because of the paucity of such events, management strategies remain poorly defined. Although preoperative magnetic resonance imaging is useful in defining cord anatomy, a great deal of caution is critical during cord dissection. Not only have popliteal vessels been incorporated into such defects, but reports describe tibial nerve involvement as well. Although vertical fibrous cord presence is exceedingly rare in the lower extremity, fibrous cording is a frequent component of popliteal pterygia. However, the present malformation did not include soft tissue webbing, a critical portion of pterygial structure, and therefore cannot be considered a true pterygium. Although we suspect that the present cord defect may represent a relatively minor pterygial presentation, development of these unusual malformations remains enigmatic and confirmation is not currently possible. Here, we present an unusual case of vertical fibrous cord development in the lower extremity, and discuss relevant aspects of management.

Embryology of the hand and upper extremity.

As a universal means of communication and a critical tool for survival, the human hand is of extraordinary importance to our evolutionary survival. As the product of countless overlapping chemical signals, the upper extremity is highly dependent on a multifactoral web of genetic and environmental factors. At the molecular level, specialized signaling centers guide limb development along 3 spatial limb axes: (1) proximodistal, (2) anteroposterior, and (3) dorsoventral. Within the growing limb bud, the 3 main signaling centers are (1) the apical ectodermal ridge, (2) the zone of polarizing activity, and (3) the nonridge ectoderm. Cells within these signaling centers govern the process of limb differentiation via secretion of various chemical messengers. Although each aspect of extremity growth seems directly dependent on a process-specific mechanism, overall limb development relies on the proper interaction of these countless protein factors. Here, we review the macroscopic development of the upper limb and discuss the complex mechanisms underlying differentiation of the human hand.

Efficacy of lidocaine for pain control in subcutaneous infiltration during liposuction.

BACKGROUND: Liposuction remains the most commonly performed aesthetic surgical procedure in the United States. Preoperative infiltration of the subcutaneous tissues with a wetting solution has become standard. These solutions typically contain some amount of lidocaine for pain control. High doses of lidocaine have been demonstrated to be safe, but large amounts of this cardioactive agent during elective cosmetic procedures may be unnecessary. OBJECTIVE: A study was designed to examine the effects of wetting solutions with lower concentrations of lidocaine on perioperative pain. METHODS: Seventeen patients were prospectively randomized to subcutaneous infiltration with one of 3 different lidocaine concentrations: 10 mg/kg, 20 mg/kg, or 30 mg/kg. Intra- and postoperative lidocaine and monoethylglycinexylidide (MEGX) plasma concentrations were measured and the total intraoperative inhalation gas requirements and minimum alveolar concentrations were recorded. Postoperative pain medication requirements were recorded and morphine equivalents were calculated. Patient pain level was subjectively assessed by using a visual analog pain scale. RESULTS: There was no difference in the intraoperative lidocaine or MEGX concentrations between any of the 3 groups. There was also no statistical difference between the 3 groups when comparing intraoperative inhalational gas requirement, postoperative morphine equivalence requirements, or subjective pain using the visual analog scale. CONCLUSIONS: Decreasing concentrations of lidocaine in infiltrative wetting solutions did not significantly affect intraoperative anesthesia requirements or postoperative pain with liposuction. Lower concentrations of lidocaine can effectively be used, use of any lidocaine may be unnecessary. Future investigations may examine whether total elimination of lidocaine yields similar results in terms of anesthesia requirements and postoperative pain.