Free Tissue Transfer to the Knee for a Complex Wound Coverage When Good Recipient Vessels Are Not Available.

Free tissue transfer to the knee can be difficult due to limited options for reliable recipient vessels and vein grafts or arteriovenous loops may also be associated with an increased risk of flap failure. In this study, the authors describe our experience with creating proper recipient vessels for free flap reconstructions around the knee using the descending branch (DB) of the lateral circumflex femoral vessels (LCFV) or anterior tibial vessels (ATV). Three patients underwent free flap reconstruction of knee wounds secondary to trauma, prosthesis infection, and radiation therapy. The anterolateral thigh, rectus abdominis, and latissimus dorsi flaps were used to close the wounds, respectively. Dissection of the DB of LCFV was carried between the rectus femoris and vastus lateralis, and between the peroneus longus and brevis for the ATV. These recipient's vessels were created and placed in a more desirable location adjacent to the defect for microvascular anastomoses. The DB of LCFV and ATV were dissected successfully and both arterial and venous micro-anastomose were performed in an end-to-end manner with the recipient's vessels. All patients had successful free tissue reconstructions with uneventful postoperative courses. The flaps remained viable and reliable soft tissue coverage with acceptable contour had been accomplished during follow-up. Either DB of LCFV or ATV can serve as adequate recipient vessels after being placed adjacently to soft tissue defects for a straightforward free tissue transfer to the knee. The creation of such recipient vessels avoids vein grafts or arteriovenous loops and allows for a reliable free flap reconstruction of the knee.

Sensorimotor Outcomes of Upper Extremity End-to-Side Nerve Transfers: A Meta-analysis.

BACKGROUND: End-to-side nerve transfer (ETSNT) for treatment of peripheral nerve injuries is controversial given the myriad anatomic locations, injury types, and indications. Efficacy of ETSNT remains debated. We hypothesized differences in age, sex, transfer location, and time to surgery influence outcomes. METHODS: We performed a search of the PubMed database for ETSNT in the upper extremity from 1988 to 2018. Age, sex, transfer location, time to surgery, donor and recipient axons, and strength and sensation outcomes as measured by Medical Research Council scale were extracted from articles. Meaningful recovery was classified as Medical Research Council Grade 3 or greater. Association between meaningful recovery and younger (<25) and older (≥25) patients, injury mechanism, sex, transfer location, donor axons, and recipient axons were calculated using a χ 2 or Fisher exact test. A logistic mixed effect model was used with time to surgery, age (categorical), transfer location, and injury type as a fixed effect, and a random paper effect was included to account for correlation among patients from the same paper. RESULTS: One hundred fifteen patients from 11 studies were included. Neither age (continuous variable, P = 0.68) nor time to surgery ( P = 0.28) affected meaningful recovery. Injury mechanism, sex, and younger age (<25 vs ≥25 years) were not associated with meaningful recovery. Within the brachial plexus ETSNT demonstrated median M4 ± 1 postoperative strength, with trunks/cords as the primary axon donor ( P = 0.03). The musculocutaneous nerve demonstrated promising but variable results in 31 patients with median strength M3 ± 4. Digital nerves consistently demonstrated meaningful sensory recovery as both donor and recipient axons (15 of 15, 100%). Logistic regression analysis demonstrated that odds of meaningful recovery after ETSNT are significantly greater for transfers within the brachial plexus compared with the distal arm (odds ratio, 41.9; 95% CI, 1.1-1586.7, P = 0.04), but location does not significantly affect meaningful recovery ( P = 0.22). CONCLUSIONS: Patients undergoing ETSNT for digital nerve injury demonstrated meaningful recovery. End-to-side nerve transfer seems to be more efficacious when performed within the brachial plexus. This study did not find sex, injury mechanism, or time to surgery to significantly affect meaningful recovery. Additional study is needed to better evaluate the effectiveness of ETSNT in the upper extremity.

Substance Addiction and the Hand Surgery Patient: A Comprehensive Review.

Substance abuse is pervasive in the American society, with 10% of the United States population using marijuana, up to 17% of patients undergoing upper-extremity surgery reporting chronic opioid use, and up to 20% of acute hand infections occurring secondary to intravenous drug use. It is common, therefore, for a hand surgeon to take care of a patient under the influence of nonprescription drugs. The range of abused substances is diverse, and the implications are profound. As such, it is important for hand surgeons to understand the potential implications of drug use to best guide patient care and surgical decision-making. The abuse of opioids, amphetamines, marijuana, and other substances has an impact on treatment timing, adherence to postoperative hand therapy, and/or clinic follow ups. The physiologic effects of these drugs affect surgical risk, wound healing, and bone healing. Social factors associated with drug abuse can complicate the management of these patients. Collectively, all these factors substantially affect surgical outcomes. In this review, we provide an overview of commonly abused illicit and prescription drugs seen in hand surgery practice, tips to identify substance abuse, the drugs' implications for surgical risks, outcomes, and some recommendations for management.

The Biomechanical Effects of Augmentation With Flat Braided Suture on Dorsal Intercarpal Ligament Capsulodesis for Scapholunate Instability.

PURPOSE: Selecting treatment for scapholunate (SL) instability is notoriously difficult. Many methods of reconstruction have been described, but no procedure demonstrates clear superiority. New methods proposed use internal bracing (IB) with suture anchors and flat braided suture (FBS), alone or as an augmentation with tendon autograft for SL ligament injuries. Our goal was to use computed tomography (CT) to analyze alignment of the SL joint after 3 different modes of fixation of SL instability: after reconstruction with IB incorporating either tendon autograft or the dorsal intercarpal ligament (DICL), or DICL capsulodesis without FBS. METHODS: Ten fresh-frozen, matched-pair, forearm-to-hand specimens were used. Serial sectioning of the SL stabilizing ligaments was performed and the SL interval was measured with CT. We reconstructed the SL ligament with DICL capsulodesis alone (DICL) or with IB augmented with either tendon autograft (IB plus T) or DICL (DICL plus IB). The SL interval was measured with CT. Specimens underwent 500 weighted cycles on a jig and were reimaged. Differences in SL interval after repair and cycling were compared. RESULTS: Dorsal intercarpal ligament capsulodesis augmented with IB best maintained the SL interval before and after cycling. Dorsal intercarpal ligament capsulodesis alone was inferior to DICL plus IB and IB plus T both before and after cycling. CONCLUSIONS: Dorsal intercarpal ligament capsulodesis augmented with IB appears to maintain better SL joint reduction than IB with tendon autograft. CLINICAL RELEVANCE: This work serves as a necessary step for further study of the biomechanical strength and clinical application of FBS technology in the reconstruction of SL instability. Flat braided suture augmentation of DICL capsulodesis may provide another option to consider for reconstruction of SL instability.

Geriatric Patients Carry Increased Risk for Deep Venous Thrombosis and Pulmonary Embolism in Reduction Mammaplasty: An Analysis of 1897 Geriatric Patients Among 25,909 Cases From 2005 to 2017 National Surgical Quality Improvement Project Databases.

INTRODUCTION: Reduction mammaplasty is one of the most common plastic surgery procedures performed. No study has evaluated whether geriatric patients are at greater risk for developing postoperative complications relative to nongeriatric patients. METHODS: The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database was reviewed for reduction mammaplasty procedures from 2005 to 2017. Hypothesis testing for demographics, comorbidities, and postoperative complications between geriatric and nongeriatric patients was performed. Statistically significant differences were then evaluated with multivariate logistic regression analysis. RESULTS: A total of 25,909 reduction mammaplasties were collected by NSQIP from 2005 to 2017, with 1897 patients older than 64 years (8% of all cases). The average age for geriatric breast reduction patients was 69 years versus 41.5 years for nongeriatric patients. Rates of comorbidities including diabetes, smoking status, dyspnea status, and hypertension medication were statistically different between the groups. Rates of deep venous thrombosis (DVT) and pulmonary embolism (PE) were significantly higher in geriatric versus nongeriatric patients, respectively (0.32 vs 0.06, P < 0.001 and 0.37 vs 0.09, P < 0.001). Multivariate analysis demonstrated geriatric patients had a 4.2 and 3.9 times higher risk of developing a DVT and PE than nongeriatric patients (C.I. 1.5-11.6, P = 0.006 and C.I. 1.6-9.8, P = 0.004). DISCUSSION: This study represents the largest evaluation of geriatric reduction mammaplasties in the United States. Although rare, geriatric age confers a 4 times increased risk for developing DVT and PE relative to nongeriatric patients all while adjusting for preoperative risk factors in reduction mammaplasty. Plastic surgeons should consider counseling their geriatric patients regarding these increased risks.

Targeting of BRAF resistant melanoma via extracellular matrix metalloproteinase inducer receptor.

BACKGROUND: The BRAF inhibitor vemurafenib (PLX) has shown promise in treating metastatic melanoma, but most patients develop resistance to treatment after 6 mo. We identified a transmembrane protein, extracellular matrix metalloproteinase inducer (EMMPRIN) as a cell surface receptor highly expressed by PLX-resistant melanoma. Using an S100A9 ligand, we created an EMMPRIN targeted probe and liposome that binds to melanoma cells in vivo, thus designing a novel drug delivery vehicle. METHODS: PLX-resistant cells were established through continuous treatment with PLX-4032 over the course of 1 y. Both PLX-resistant and sensitive melanoma cell lines were evaluated for the expression of unique cell surface proteins, which identified EMMPRIN as an overexpressed protein in PLX0-resistant cells and S100A9 is a ligand for EMMPRIN. To design a probe for EMMPRIN, S100A9 ligand was conjugated to a CF-750 near-infrared (NIR) dye. EMMPRIN targeted liposomes were created to encapsulate CF-750 NIR dye. Liposomes were characterized by scanning electron microscopy, flow cytometry, and in vivo analysis. A2058PLX and A2058 cells were subcutaneously injected into athymic mice. S100A9 liposomes were intravenously injected and tumor accumulation was evaluated using NIR fluorescent imaging. RESULTS: Western blot and flow cytometry demonstrated that PLX sensitive and resistant A2058 and A375 melanoma cells highly express EMMPRIN. S100A9 liposomes were 200 nm diameter and uniformly sized. Flow cytometry demonstrated 100X more intracellular dye uptake by A2058 cells treated with S100A9 liposomes compared with untargeted liposomes. In vivo accumulation of S100A9 liposomes within subcutaneous A2058 and A2058PLX tumors was observed from 6-48 h, with A2058PLX accumulating significantly higher levels (P = 0.001626). CONCLUSIONS: EMMPRIN-targeted liposomes via an S100A9 ligand are a novel, targeted delivery system which could provide improved EMMPRIN specific drug delivery to a tumor.

Modification of the Zancolli Lasso Procedure for Simultaneous Correction of Wartenberg's Sign.

Ulnar nerve injury initiates an imbalance between the intrinsic muscles and extrinsic extensors of the ring and small fingers, which leads to the characteristic hyperextension of the metacarpophalangeal (MP) joints and flexion of the proximal interphalangeal joints of these 2 digits-commonly referred to as the ulnar claw hand. In addition to these changes in the static posture of the hand, ulnar nerve palsy severely impairs grasp due to deficient active MP joint flexion. In most cases, motor balance can be restored by preventing MP joint hyperextension and augmenting MP joint flexion using the Zancolli lasso procedure (ZLP). Ulnar neuropathy can cause a second motor imbalance between the ulnar intrinsics and the extensor digit minimi leading to an abduction deformity of the small finger known as Wartenberg's sign. The inability to adduct the small finger can be a great source of frustration to patients. Using a cadaveric biomechanical model, we have developed a simple modification of the Zancolli lasso procedure that simultaneously corrects claw deformity and Wartenberg's sign and we report its efficacy in 2 clinical cases.

Correlation of Time to Soft Tissue Coverage With Clinical Outcome in Lower Extremity Trauma in the Modern Era: A Single-Center Retrospective Review.

Background: Lower extremity salvage in the setting of severe trauma requires the consideration of multiple surgical specialties and treatment algorithms. We hypothesized that time to first ambulation, ambulation without an assistive device, chronic osteomyelitis, and delayed amputation were not affected by the time to soft tissue coverage in Gustilo IIIB and IIIC fractures at our institution. Methods: We evaluated all patients treated for open tibia fractures at our institution from 2007 to 2017. Patients requiring any form of soft tissue coverage to the lower extremity during their initial hospitalization and who had at least 30 days of follow-up from time of hospital discharge were included. Univariable and multivariable analysis was performed for all variables and outcomes of interest. Results: Of 575 patients included, 89 required soft tissue coverage. On multivariable analysis, the time to soft tissue coverage, length of negative pressure wound therapy treatment, and number of wound washouts were not found to be associated with development of chronic osteomyelitis, decreased 90-day return to any ambulation, decreased 180-day return to ambulation without assistive device, or delayed amputation. Conclusions: Time to soft tissue coverage in open tibia fractures did not affect time to first ambulation, ambulation without an assistive device, chronic osteomyelitis, or delayed amputation in this cohort. It remains difficult to definitively prove that time to soft tissue coverage meaningfully impacts lower extremity outcomes.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma.

The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon's armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.

Free-Style Free Perforator Flaps in Lower Extremity Reconstruction.

Improved knowledge of vascular anatomy has enabled surgeons to preoperatively identify perforators and design free-style flaps based on that perforator. Options for choosing the optimal donor site tissues are increased with the free-style technique. This reduces donor site morbidity while providing the same reconstructive success as traditional free skin flaps. The free-style technique allows the surgeon to successfully complete reconstruction when aberrant anatomy is encountered. With the necessary skills in perforator flap dissection and supermicrosurgery, the armamentarium of the reconstructive microsurgeon has been expanded with the introduction of free-style perforator free flaps.

Trends in flap reconstruction of pelvic oncologic defects: Analysis of the national inpatient sample.

BACKGROUND: Flap reconstruction of radiated pelvic oncologic defects decreases perineal wound-healing complications. How widely and how often reconstructions are performed, and how technical mastery and improved perioperative care has affected outcomes, is unknown. Our objective is to 1) provide a comprehensive evaluation of national trends in flap reconstruction of pelvic oncologic defects and 2) compare complications and length of stay (LOS) in patients with/without reconstruction. METHODS: The National Inpatient Sample (NIS) database was queried (1998-2014) for patients diagnosed with cancer, primarily of the rectum and anus, who underwent abdominoperineal resection (APR) or pelvic exenteration (PE). Differences in complications and LOS were compared between patients with flap reconstruction versus primary closure. Regional and hospital outcomes were also analyzed. RESULTS: The cohort included 117,923 adult patients; 3,673 (3.1%) underwent flap reconstruction. Flap reconstruction rates increased from 0.8% in 1998 to 9.8% in 2014. Extirpative procedures decreased 37.4% from 1998 to 2014. Flap reconstruction decreased risk of wound breakdown (OR 0.87; p = 0.0029) and need for secondary closure of dehiscence (OR 0.82; p = 0.0023) between periods 1998-2009 and 2010-2014. Median LOS was higher for flap patients (median [IQR] of 9.8 [7.2,14.8] vs. 7.9 [6.1-11.0; p < 0.0001) and decreased over time. CONCLUSIONS: The use of flap reconstruction for pelvic oncologic defects increased from 1998 to 2014, with a reduction in LOS. Following flap reconstruction, overall complications are higher, but wound breakdown and dehiscence requiring reclosure are decreasing, suggesting technique maturation. We anticipate flap reconstruction rates will increase with further improvement in patient outcomes.

The neutral red assay can be used to evaluate cell viability during autophagy or in an acidic microenvironment in vitro.

Harsh conditions within the tumor microenvironment, such as hypoxia and extracellular acidic pH (pHe), inactivate some chemotherapies, which results in limited or no cytotoxicity. Standard MTT, ATPlite and protease assays that are used to determine the potency of newly developed drugs often give erroneous results when applied under hypoxic or acidic conditions. Therefore, development of a cytotoxicity assay that does not yield false positive or false negative results under circumstances of both hypoxia and acidic pHe is needed. We evaluated currently used cell viability assays as well as neutral red staining to assess viability of ovarian and pancreatic cancer cells grown in an acidic pHe microenvironment after treatment with carboplatin, gemcitabine or chloroquine. We validated cell viability using western blotting of pro-caspase-9 and cleaved-caspase-9, and LC3-I and - II. Standard cell viability assays indicated cell viability accurately at pHe 7.4, but was not correlated with induction of apoptosis or autophagy at acidic pHe. By contrast, our modified neutral red assay detected cell viability accurately over a range of pHe as demonstrated by its correlation with induction of apoptosis and autophagy. Neutral red staining is effective for evaluating the effect of chemotherapeutic agents on cell viability under acidic pHe or hypoxic conditions.

Contemporary reconstruction after complex facial trauma.

Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient's reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author's broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.

Should We Consider Preparing Patients for Future Face Transplant when Managing Complex Facial Trauma?

With advancements in microsurgical technique and experience, face transplantation is becoming a clinical reality and acceptable procedure. Preparation of the maxillofacial skeleton and initial soft-tissue coverage for face transplant candidates is essential for optimizing the ultimate outcome by providing immediate coverage of vital structures, functionality, and a stable skeletal framework. We present our experience of preparing such a patient who underwent a successful face transplant, with an excellent outcome. A 24-year-old man sustained a self-inflicted ballistic injury to his face. Composite tissue deficits included significant soft-tissue loss in the central lower and midface, comminuted fractures of midface, and large bone gaps of the maxilla and mandible. He underwent open reduction internal fixation of bilateral LeFort III, zygomaticomaxillary complex, and complex maxillary and mandibular fractures with titanium plates and a free anterolateral thigh perforator flap to the midface with concomitant pedicled left supraclavicular artery fasciocutaneous flap to the lower face. He subsequently underwent a second free anterolateral thigh perforator for the exposed mandibular hardware due to partial necrosis of the supraclavicular artery fasciocutaneous flap. The patient achieved stable bone reconstruction and soft-tissue coverage and was discharged home. He was placed on the waiting list for a face transplant by another center in the country and eventually underwent a successful face transplant. We believe that the preparation of the patient with complex craniomaxillofacial trauma for face transplant should be considered when the extent of injury exceeds conventional reconstructive limits. Our approach provides the best opportunity for an optimal face transplant outcome while minimizing flap donor site morbidity.

Facial Fracture Patterns Associated with Traumatic Optic Neuropathy.

Traumatic optic neuropathy (TON) is rare. The heterogeneity of injury patterns and patient condition on presentation makes diagnosis difficult. Fracture patterns associated with TON have never been evaluated. Retrospective review of 42 patients diagnosed with TON at the R. Adams Cowley Shock Trauma Center from May 1998 to August 2010 was performed. Thirty-three patients met criteria for study inclusion of fracture patterns. Additional variables measured included patient demographics and mechanism. Cluster analysis was used to form homogenous groups of patients based on different fracture patterns. Fracture frequency was analyzed by group and study population. Visual depiction of fracture patterns was created for each group. Cluster analysis of fracture patterns yielded five common "groups" or fracture patterns among the study population. Group 1 ( n = 3, 9%) revealed contralateral lateral orbital wall (100%), zygoma (67%), and nasal bone (67%) fractures. Group 2 ( n = 7, 21%) demonstrated fractures of the frontal bone (86%), nasal bones (71%), and ipsilateral orbital roof (57%). Group 3 ( n = 14, 43%) involved fractures of the ipsilateral zygoma (100%), lateral orbital wall (29%), as well as frontal and nasal bones (21% each). Group 4 ( n = 5, 15%) consisted of mid- and upper-face fractures; 100% fractured the ipsilateral orbital floor, medial and lateral walls, maxilla, and zygoma; 80% fractured the orbital roof and bilateral zygoma. Group 5 ( n = 4, 12%) was characterized by fractures of the ipsilateral orbital floor, medial and lateral orbital walls (75% each), and orbital roof (50%). A notably high 15 of 33 patients (45%) sustained penetrating trauma. Our study demonstrates five fracture pattern groups associated with TON. Zygomatic, frontal, nasal, and orbital fractures were the most common. Fractures with a combination of frontal, nasal, and orbital fractures are particularly concerning and warrant close attention to the eye.

Vapocoolant Anesthesia for Cosmetic Facial Rejuvenation Injections: A Randomized, Prospective, Split-Face Trial.

Background: Minimally invasive cosmetic procedures are the most commonly performed aesthetic techniques by plastic surgeons. Patients are interested in a pain-free experience. Surgeons desire patient satisfaction and time-efficient utilization of office staff and resources. Clinical evidence exists for use of vapocoolant technology to reduce pain associated with intravenous cannulation in the pediatric population and in hemodialysis patients. Applying vapocoolant technology to facial rejuvenation is a novel approach to decrease pain associated with neurotoxin or filler injection. Methods: A randomized, prospective study was conducted, testing 15 subjects receiving filler injections and another 15 patients receiving neurotoxin injections using a split-face model. The vapocoolant spray used was composed of a 95:5 ratio of 1,1,1,3,3-pentafluoropropane and 1,1,1,2-tetrafluoroethane. Within each group, individual patients randomly received injection (filler or neurotoxin) alone versus injection (filler or neurotoxin) plus vapocoolant on an equivalent half of his or her face. An independent examiner recorded from each patient on a scale of 1 to 10 perceived pain for injection alone versus injection plus vapocoolant spray. Results were calculated as a percentage change of pain scores experienced after injection for each person between the control (nonvapocoolant) and treatment (vapocoolant) sides of the face. Results: Vapocoolant spray at the time of cosmetic facial injections leads to a 59% decrease in perceived pain score with neurotoxin injections (range, 0%-100% change) and 64% decrease in perceived pain score with filler injections (range, 0%-100% change). These results were statistically significant with P < .05. Conclusion: Vapocoolant spray reduces pain associated with facial rejuvenation procedures.

Reduction Mammoplasty: Intraoperative Weight Versus Pathology Weight and Its Implications.

Background: Despite the efficacy of reduction mammoplasty and demonstration that resection weight does not predict symptomatic relief of macromastia, many insurers still rely on the Schnur scale or predetermined resection weight for reimbursement. Insurers review pathology reports to determine reimbursement. Tissue desiccation and handling decrease specimen weight prior to pathology evaluation. Surgeons often make judgments based on intraoperative weight. Our goal was to determine whether (1) discrepancies exist between intraoperative and pathology weights, and (2) how differences may impact reimbursement and medical practice. Methods: Medical records review was performed on 25 reduction mammoplasty cases performed between 2007 and 2010, yielding 48 specimens. Tumescent was never used. Weight of each specimen from operative and pathology reports was reviewed and compared. The 2-sample Kolmogorov-Smirnov test was used to compare sample weights. Results: Comparison of intraoperative versus pathology specimen weights revealed an average 7% weight decrease (range, +11% to -45%). Average and median specimen weight decrease from intraoperative to pathology weights was 48 g (SD = 71 g) and 31 g (interquartile range = 6.6-58 g), respectively. Average intraoperative specimen weight was 780.7 g (SD = 375.3 g; range, 290-2238 g). Average pathology specimen weight was 732.3 g (SD = 358.4 g; range, 265-2053.6 g) (P < .001) All but 2 samples weighed less in pathology. Conclusion: Desiccation and handling between intraoperative and pathology weighing decrease specimen weight. Weight discrepancies may have implications on coverage and reimbursement by insurers. Awareness of such discrepancies can help plastic surgeons and patients avoid unexpected coverage and reimbursement complications.

Safe Plastic Surgery of the Breast II: Saving Nipple Sensation.

Background: Since its inception, reduction mammoplasty has matured considerably. Primary evolution in clinical research and practice initially focused on developing techniques to preserve tissue viability; breast parenchyma, skin, and nipple tissue that has expanded to include sensation and erectile function play a large role in the physical intimacy of women. Studies regarding primary innervation to the nipple are few and often contradictory. Our past anatomical study demonstrated that primary innervation to the nipple to come from the lateral branch of the fourth intercostal nerve. We propose an unsafe zone in which dissection during reduction mammoplasty ought to be avoided to preserve nipple sensation. Objective: To identify the trajectory of innervation to the nipple and translate these findings to the clinical setting so as to preserve nipple sensation. Methods: Eighty-six patients underwent reduction mammoplasty using the Wise pattern inferior pedicle (n = 72), vertical Hall-Findlay superomedial pedicle (n = 11), and Drape pattern inferior pedicle (n = 3). Aggressive dissection in the most superficial and deep tissue in the inferolateral quadrant of the breast was avoided. Results: All 86 patients reported having the same normal sensation to the breast at postoperative evaluation. Conclusions: The fourth intercostal nerve provides the major innervation to the nipple-areola complex. Avoiding dissection in inferolateral quadrant "unsafe zone" of the breast during reduction mammoplasty can reliably spare nipple sensation and maximize patient outcomes.