Reducing margins of wide local excision in head and neck melanoma for function and cosmesis: 5-year local recurrence-free survival.

BACKGROUND: The proximity of head and neck (H&N) melanomas to critical anatomical structures requires that surgeons achieve a balance between adequate margins of excision and the functional and cosmetic needs of patients. This study sought to determine the risk associated with reducing margins of wide local excision (WLE) in H&N melanoma and to identify risk factors of recurrence. METHODS: Seventy-nine cases of primary, invasive H&N melanoma were treated by WLE and followed prospectively for local recurrence. Forty-two WLEs were performed according to current practice guidelines (1cm for lesions<1.0 mm thick, 1-2 cm for lesions 1.01-2.0 mm thick, and 2 cm for lesions >2.0 mm thick). Reduced margins (0.5 cm for lesions ≤1.0 mm thick, 0.5-1.0 cm for lesions 1.01-2.0 mm thick, and 1.0 cm for lesion >2.0 mm thick) were utilized in 37 cases to preserve critical anatomical structures such as the eyelid, nose, mouth and auricle. RESULTS: Overall local recurrence rate was 8.9% over a mean follow-up period of 71.3 months and a minimum of 60 months. Reducing margins of WLE did not increase local recurrence rates as demonstrated by local recurrence-free survival (90.4% vs. 91.9%, P = 0.806). CONCLUSION: Margins of WLE may be safely reduced in melanomas in close proximity to structures of the H&N without affecting local recurrence rates.

Multidisciplinary approach to the management of dermatofibrosarcoma protuberans.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is the most common cutaneous sarcoma. Tentacle-like extensions of neoplastic cells create a high incidence of local recurrence and pose challenges to resection and reconstruction. OBJECTIVE: Here we present a multidisciplinary approach to the management of DFSP incorporating the expertise of a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic surgeon. METHODS: This was a single-institution, retrospective review of a prospectively maintained database of 19 consecutive patients who underwent resection and reconstruction of a DFSP from 1998 to 2010. All patients underwent Mohs micrographic surgery for mapping of peripheral margins (stage I excision), followed by wide local excision for delineation of the deep margin (stage II excision). Procedures were performed in consultation with a dermatopathologist who confirmed tumor-free margins, and a plastic surgeon who performed immediate reconstruction after the wide local excision (stage II reconstruction). RESULTS: Nineteen patients were included in this study. The average number of Mohs stages required for clearance of peripheral margins was 2.7 ± 0.7. The mean time between stage I and II procedures was 16 ± 11 days. The average defect size after the stage II operation was 87.3 cm(2) (range, 9-300 cm(2)). There were no cases of tumor recurrence. Mean follow-up time was 17 months (range, 1-53 months). LIMITATIONS: This is a retrospective review of a single-institution experience. CONCLUSION: A multidisciplinary approach to the management of DFSP optimizes both oncologic and reconstructive outcomes, minimizing the risk for local recurrence and limiting the functional and cosmetic morbidity associated with surgical resection.

A novel prospective three-dimensional analysis of nasolabial fold augmentation.

BACKGROUND: There are many products approved for aesthetic soft tissue augmentation. Despite this abundance, there is limited objective data regarding safety, longevity, and complication rates. Instead, most reports rely on subjective measures to report volume changes and outcomes, making product comparison difficult. OBJECTIVES: The authors developed and validated a mathematical model to prospectively calculate and analyze three-dimensional (3D) volumetric changes associated with nasolabial fold augmentation based on human acellular dermis. METHODS: Seven consecutive patients were included in this prospective review. The patients underwent nasolabial fold treatment with BellaDerm (Musculoskeletal Transplant Foundation, Edison, NJ), administered by a single surgeon. 3D photographs were obtained and analyzed with a novel mathematical model to determine absolute volumetric changes and objective longevity. RESULTS: Mean preoperative nasolabial fold volume was 0.17 mL. The mean one-, three-, and six-month postoperative fill volumes were 0.35, 0.19, and 0.07 mL, respectively. Fill volumes and contour changes returned to baseline by 24 weeks postoperatively in the majority of patients. CONCLUSIONS: The mathematical model utilized in this study provided prospective and objective data regarding longevity and volumetric changes associated with nasolabial fold augmentation. The analysis demonstrated minimal objective filler permanence beyond six months, with peak volume enhancement between one and three months. Adoption of objective 3D mathematical metrics into the assessment of soft tissue filler outcomes is critical to obtaining more accurate product-to-product comparisons.

Tissue expander breast reconstruction using prehydrated human acellular dermis.

INTRODUCTION: Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction. METHODS: The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated. RESULTS: Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749). CONCLUSIONS: The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.

Oblique pedicled paraumbilical perforator-based flap for reconstruction of complex proximal and mid-forearm defects: a report of two cases.

Reconstruction of complex proximal and mid-forearm wounds can be challenging. Free tissue transfer might not be feasible in certain patients or at institutions lacking microsurgical expertise and equipment. Traditional pedicled flaps are either insufficient in length to reach more proximal forearm defects or are used sparingly due to donor site complications and extremity stiffness. We present a novel technique to reconstruct forearm defects using the oblique pedicled paraumbilical perforator (PUP) based flap. This flap is simple to harvest, has low donor site morbidity, and allows elbow and shoulder range of motion during the interval between flap transfer and pedicle division.

Volumetric Changes of the Mid and Lower Face with Animation and the Standardization of Three-Dimensional Facial Imaging.

BACKGROUND: The objective of this study was to quantify volumetric changes of the mid and lower face caused by facial expression to understand how procedural results measured by three-dimensional imaging can be influenced by lack of standardization. Secondarily, the study identified soft-tissue surface landmarks that can be used to ensure the standardization of three-dimensional images. METHODS: Three-dimensional facial images of subjects performing 22 facial expressions or changes in head position were captured. Variable degrees of animation during smiling and frowning were also evaluated. Volumetric changes of the malar and jowl regions were quantified using a three-dimensional superimposed image subtraction technique. The translation of 14 standard soft-tissue surface landmarks was assessed during various facial animations to determine which three-dimensional landmarks can be used to standardize three-dimensional images. RESULTS: Twenty subjects participated in the study. Sixteen of the 22 facial expression studies had a significant effect on malar and/or jowl volume. Significant volume changes were noted with subtle animation during smiling and frowning. A combination of five landmarks (i.e., glabella, bilateral cheilion, pogonion, and laryngeal prominence) can be used to standardize three-dimensional images for evaluation of mid and lower facial volume changes. CONCLUSIONS: Subtle facial expressions may cause significant volumetric changes in the mid and lower face that can mimic the desired outcomes of surgical and nonsurgical facial rejuvenation procedures. The five-point referencing system allows one to identify subtle changes in head position and facial expression and may aid in the standardization of three-dimensional images.

Adenovirally delivered tumor necrosis factor-alpha improves the antiglioma efficacy of concomitant radiation and temozolomide therapy.

PURPOSE: Treatment of malignant glioma involves concomitant temozolomide and ionizing radiation (IR). Nevertheless, overall patient survival remains poor. This study was designed to evaluate if addition of Ad.Egr-tumor necrosis factor (TNF), a replication defective adenovector encoding a cDNA for TNF-alpha, to temozolomide and IR can improve overall antiglioma effect. EXPERIMENTAL DESIGN: The efficacy of combination treatment with Ad.Egr-TNF, IR, and temozolomide was assessed in two glioma xenograft models. Animal toxicity and brain histopathology after treatment were also examined. In addition, in an attempt to explain the antitumor interaction between these treatments, the activation status of the transcription factor nuclear factor-kappaB was examined. RESULTS: Triple therapy (Ad.Egr-TNF, IR, and temozolomide) leads to significantly increased survival in mice bearing glioma xenografts compared with dual treatment. Fifty percent of animals treated with the triple regimen survive for >130 days. Pathologic examination shows that triple therapy leads to a complete response with formation of a collagenous scar. No significant change in myelination pattern is noted after triple therapy, compared with any double treatment. Treatment of intracranial glioma bearing mice with Ad.Egr-TNF and IR leads to cachexia and poor feeding that does not improve, whereas triple therapy results in less toxicity, which improves over 21 days. Both Ad.Egr-TNF and IR activate nuclear factor-kappaB, and temozolomide inhibits this activity in an inhibitor of kappaBalpha (IkappaBalpha)-independent manner. CONCLUSION: This work shows that the addition of adenoviral TNF-alpha gene delivery to temozolomide and IR significantly improves antiglioma efficacy and illustrates a potential new treatment regimen for use in patients with malignant glioma.

Decreased postoperative pain, narcotic, and antiemetic use after breast reduction using a local anesthetic pain pump.

The purpose of this study was to conduct a prospective trial evaluating the efficacy of a local anesthetic pain pump in breast reduction surgery. Ninety-eight women undergoing bilateral breast reduction were enrolled. Thirty-seven patients received a pain pump containing 0.25% bupivicaine, and 61 patients received no pain pump. Parameters measured included subjective pain, episodes of postoperative nausea and vomiting (PONV), and the amount of narcotics and antiemetics used. Patients receiving a pain pump reported significantly lower pain scores on the day of surgery, as well as on the first and second postoperative days when compared with patients who did not (P < 0.01). The amount of intravenous and oral narcotics used paralleled the reduction in pain (P < 0.01), and there were fewer episodes of PONV and antiemetics used in the patients receiving a pain pump (P < 0.01). A postoperative local anesthetic pain pump can reduce pain, narcotic use, and PONV in women undergoing breast reduction.

Lipoic acid decreases exhaled nitric oxide concentrations in anesthetized endotoxemic rats.

We recently demonstrated that lipoic acid suppresses endotoxin-stimulated expression of inducible nitric oxide synthase and nitric oxide production in mouse macrophages. In this study, we tested whether lipoic acid suppresses these inflammatory mediators in the lungs of rats. Rats were assigned to receive either no special treatment, endotoxin alone, or pretreatment with lipoic acid followed by endotoxin. After anesthetizing the rats and injecting them intraperitoneally with lipoic acid (100 mg/kg) at 4 h and again at 1 h before treatment, the rats then received either endotoxin (0.01 mg/kg) or its vehicle solution. Exhaled gas was sampled every 15 min and concentrations of nitric oxide in the samples were measured using a chemiluminescence analyzer. After 150 min of exposure to endotoxin, the lungs were harvested and snap-frozen in liquid nitrogen for subsequent analysis. Lipoic acid attenuated endotoxin-induced increases in exhaled nitric oxide concentrations (P<0.001) and iNOS (P<0.05). These findings support the hypothesis that lipoic acid inhibits endotoxin-stimulated formation of intrapulmonary nitric oxide.

Effectiveness of conservative therapy and helmet therapy for positional cranial deformation.

BACKGROUND: The authors investigated the effectiveness of conservative (repositioning therapy with or without physical therapy) and helmet therapy, and identified factors associated with treatment failure. METHODS: A total of 4378 patients evaluated for deformational plagiocephaly and/or deformational brachycephaly were assigned to conservative (repositioning therapy, n = 383; repositioning therapy plus physical therapy, n = 2998) or helmet therapy (n = 997). Patients were followed until complete correction (diagonal difference <5 mm and/or cranial ratio <0.85) or 18 months. Rates of correction were calculated, and independent risk factors for failure were identified by multivariate analysis. RESULTS: Complete correction was achieved in 77.1 percent of conservative treatment patients; 15.8 percent required transition to helmet therapy (n = 534), and 7.1 percent ultimately had incomplete correction. Risk factors for failure included poor compliance (relative risk, 2.40; p = 0.009), advanced age (relative risk, 1.20 to 2.08; p = 0.008), prolonged torticollis (relative risk, 1.12 to 1.74; p = 0.002), developmental delay (relative risk, 1.44; p = 0.042), and severity of the initial cranial ratio (relative risk, 1.41 to 1.64; p = 0.044) and diagonal difference (relative risk, 1.31 to 1.48; p = 0.027). Complete correction was achieved in 94.4 percent of patients treated with helmet therapy as first-line therapy and in 96.1 percent of infants who received helmets after failed conservative therapy (p = 0.375). Risk factors for helmet failure included poor compliance (relative risk, 2.42; p = 0.025) and advanced age (relative risk, 1.13 to 3.08; p = 0.011). CONCLUSIONS: Conservative therapy and helmet therapy are effective for positional cranial deformation. Treatment may be guided by patient-specific risk factors. In most infants, delaying helmet therapy for a trial of conservative treatment does not preclude complete correction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Burnout phenomenon in U.S. plastic surgeons: risk factors and impact on quality of life.

BACKGROUND: Recent studies by the American College of Surgeons reveal that nearly 40 percent of U.S. surgeons exhibit signs of burnout. The authors endeavored to quantify the incidence of burnout among U.S. plastic surgeons, determine identifiable risk factors, and evaluate its impact on quality of life. METHODS: All U.S. residing members of the American Society of Plastic Surgeons were invited to complete an anonymous survey between September of 2010 and August of 2011. The survey contained a validated measure of burnout (Maslach Burnout Inventory) and evaluated surgeon demographics, professional and personal risk factors, career satisfaction, self-perceived medical errors, professional impairment, and family-home conflicts. RESULTS: Of the 5942 surgeons invited, 1691 actively practicing U.S. plastic surgeons (28.5 percent) completed the survey. The validated rate of burnout was 29.7 percent. Significant risk factors for burnout included subspecialty, number of hours worked and night calls per week, annual income, practice setting, and academic rank. Approximately one-fourth of plastic surgeons had significantly lower quality-of-life scores than the U.S. population norm, and this risk increases in burned out surgeons. In addition to having lower career satisfaction and more work-home conflicts, plastic surgeons with burnout also had a nearly two-fold increased risk of self-reported medical errors and self-reported impairment. CONCLUSIONS: Over one-fourth of plastic surgeons in the United States experience validated burnout, with concomitant attenuated career satisfaction and quality of life. Multivariate analysis identified predisposing factors that may aid in better understanding risk profiles that lead to burnout; therefore, efforts to understand and thereby avoid this burnout phenomenon are warranted.

Use of the tabbed expander in latissimus dorsi breast reconstruction.

Latissimus dorsi (LD) myocutaneous flap breast reconstruction with a tissue expander/implant is a post-mastectomy option often used as a salvage procedure for a failed tissue expander (TE). The patient is traditionally placed in the lateral decubitus position for flap dissection and is re-prepped and re-draped in the supine position for placement of the tissue expander. A new generation of anatomically-shaped, tabbed tissue expanders are increasingly being used in place of traditional untabbed expanders. The innovative suture tabs allow for more predictable and controlled expander placement while the patient is in the lateral decubitus position, eliminating the need to reposition the patient intraoperatively. The objective of this study was to evaluate the use of tabbed tissue expanders in latissimus dorsi breast reconstruction, with respect to total operative time, complication rates, and aesthetic outcomes. The outcomes of 34 LD breast reconstruction procedures with tissue expanders were evaluated. Eight patients received tabbed tissue expanders with no position change, while 26 patients underwent an intraoperative position change. Demographic information, total operative time, and follow-up complication data were collected. Aesthetic outcomes were evaluated by three blinded individuals using a validated scoring scale. The mean operative time for procedures with no position change was 107 minutes. The mean operative time for position change cohort was 207 minutes. There was no statistical difference in complication rates or aesthetic outcomes between the two groups. In conclusion, tabbed tissue expanders decrease operative time by eliminating the need for an intraoperative position change without influencing complication rates while maintaining equivalent aesthetic outcomes.

The staged face lift: addressing the biomechanical limitations of the primary rhytidectomy.

BACKGROUND: Although early secondary face lift is a highly scrutinized procedure, it is beneficial for a select group of patients. Justification for performing the early secondary face lift or staged face lift is more apparent when considering the biomechanical limitations of the primary face lift. METHODS: All patients undergoing primary face-lift procedures performed by the senior author (T.A.M.) between 1998 and 2008 were followed for 2 years to determine which patients would benefit from an early secondary rhytidectomy. Early secondary face lifts were performed in the same sub-superficial musculoaponeurotic system plane as the primary procedure and entailed full undermining. RESULTS: Forty-seven of 742 patients (6.3 percent) undergoing a primary face-lift procedure underwent an early secondary rhytidectomy. Identified limiting factors of the primary face lift included suture-tearing force, viscoelastic properties (tissue creep and stress relaxation), blood supply, and an attempt to avoid an overly pulled appearance. Indications for early secondary rhytidectomy included early symptoms of recurrence or residual age-related changes in patients with severe preoperative laxity or poor soft-tissue elasticity and mainly involved the perioral region. There were no significant complications and there was high patient satisfaction in all cases. CONCLUSION: With thorough understanding of the viscoelastic properties of facial tissues and proper consultation with patients, the early secondary face lift can be used as a safe and effective option with which to address the limitations of a primary face lift. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cosmetic outcomes following head and neck melanoma reconstruction: The patient's perspective.

BACKGROUND: While studies have compared aesthetic outcomes following wide local excision of head and neck melanoma, none have evaluated this important outcome from the patient's perspective. Indeed, one could argue that the psychosocial impact of head and neck melanoma excision and reconstruction is more accurately assessed by deriving patient-based as opposed to surgeon-based outcome measures. OBJECTIVE: To evaluate aesthetic outcomes following wide local excision of head and neck melanoma from the patient's perspective. METHODS: Fifty-one patients who underwent excision of 57 head and neck melanomas followed by immediate closure by primary repair, skin grafting, local flap coverage or free tissue transfer were asked to complete a written survey at least six months after their surgery. A visual analogue scale (VAS) was used to assess the patient's perception of appearance alteration, satisfaction with his or her appearance, and emotional impairment. An ordinal scale was used to evaluate several criteria of the reconstructive outcome (pain, itching, colour, scarring, stiffness, thickness and irregularity). RESULTS: Forty-two patients (82.4%) completed the survey. There were significant correlations between VAS scores reported for appearance alteration, satisfaction with outcome and emotional impairment (P=0.001). Patients who received skin grafts reported significantly unfavourable VAS scores compared with other methods of reconstruction (P=0.046). Moreover, skin grafts received significantly worse ordinal scale ratings for itching (P=0.043), colour (P=0.047), scarring (P=0.003) and stiffness (P=0.041) compared with other methods of reconstruction. Both skin grafts and free flaps were reported to have significantly less favourable thickness (P=0.012) and irregularity (P=0.036) than primary closure or local tissue transfer. There was no significant difference between patients undergoing primary closure with local tissue transfer (P>0.413). Other factors related to the patient's VAS scores included location of the melanoma (P=0.033), size of defect (P=0.037) and recurrence of melanoma (P=0.042). CONCLUSION: The degree of emotional impairment following reconstruction of head and neck melanoma excision defects was correlated with the patient's perception of appearance alteration. From the patient's perspective, primary closure and local tissue transfer appeared to result in the highest aesthetic satisfaction.

HISTORIQUE: Des études ont comparé les résultats esthétiques après une importante excision locale d'un mélanome de la tête et du cou, mais aucune ne s'est attardée sur ce résultat important selon le point de vue du patient. Pourtant, on peut faire valoir que les répercussions psychosociales de l'excision d'un mélanome de la tête et du cou seront évaluées de manière plus exacte d'après les mesures de résultats du patient que du chirurgien. OBJECTIF: Évaluer les résultats esthétiques après l'excision importante d'un mélanome de la tête et du cou selon le point de vue du patient. MÉTHODOLOGIE: Cinquante et un patients qui ont subi une excision de 57 mélanomes de la tête et du cou suivie d'une fermeture immédiate par réparation primaire, par greffe cutanée, par recouvrement par un lambeau local ou par transfert de tissus libres ont été invités à répondre à un sondage écrit au moins six mois après l'opération. Une échelle analogique visuelle (ÉAV) a permis d'évaluer le point de vue du patient pour ce qui est de la modification de l'apparence, de la satisfaction envers l'apparence et de l'atteinte affective. Une échelle ordinale a servi à évaluer plusieurs critères des résultats de la reconstruction (douleur, démangeaison, couleur, cicatrice, épaisseur et irrégularité). RÉSULTATS: Quarante-deux patients (82,4 %) ont répondu au sondage. Il y avait une importante corrélation entre les indices de l'ÉAV relatifs à la modification de l'apparence et à la satisfaction des résultats et celui de l'atteinte affective (P=0,001). Les patients qui avaient subi une greffe de la peau ont déclaré des indices d'ÉAV particulièrement défavorables par rapport à d'autres modes de reconstruction (P=0,046). De plus, les greffes cutanées ont reçu des résultats beaucoup plus négatifs à l'échelle ordinale relativement aux démangeaisons (P=0,043), à la couleur (P=0,047), aux cicatrices (P=0,003) et à la raideur (P=0,041) par rapport à d'autres modes de reconstruction. Tant les greffes cutanées que les lambeaux libres donnaient des résultats considérablement moins favorables sur le plan de l'épaisseur (P=0,012) et de l'irrégularité (P=0,036) que la fermeture primaire ou le transfert local de tissus. Il n'y avait pas de différence significative entre les patients qui subissaient une fermeture primaire par transfert local de tissus (P>0,413). D'autres facteurs liés aux indices d'ÉAV des patients incluaient l'emplacement du mélanome (P=0,033), la dimension de l'anomalie (P=0,037) et la récurrence du mélanome (P=0,042). CONCLUSION: Le degré d'atteinte affective après la reconstruction d'anomalies causées par l'excision du mélanome de la tête et du cou était corrélé avec la perception qu'avait le patient des modifications à son apparence. Selon le point de vue du patient, la fermeture primaire et le transfert local de tissus semblaient s'associer à la plus grande satisfaction esthétique.

A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction.

BACKGROUND: Human acellular dermal matrix has become an increasingly used adjunct to traditional submuscular tissue expander/implant breast reconstruction, but there is no strong consensus regarding complication outcomes. This study stratified outcomes based on a meta-analysis of complications. METHODS: A query of the MEDLINE database for articles on human acellular dermal matrix and submuscular tissue expander breast reconstruction yielded 901 citations. Two levels of screening identified 48 relevant studies. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. Risk ratios and pooled complication rates were calculated for each outcome of interest. RESULTS: Nineteen studies reporting human acellular dermal matrix (n = 2037) and 35 reporting submuscular outcomes (n = 12,847) were used to estimate complication rates. Rates were generally higher in acellular dermis patients: total complications, 15.4 versus 14.0 percent; seroma, 4.8 versus 3.5 percent; infection, 5.3 versus 4.7 percent; and flap necrosis, 6.9 versus 4.9 percent. Six studies reporting both acellular dermis and submuscular outcomes were used to estimate relative risks. There was an increased risk of total complications (relative risk, 2.05; 95 percent CI, 1.55 to 2.70), seroma (relative risk, 2.73; 95 percent CI, 1.67 to 4.46), infection (relative risk, 2.47; 95 percent CI, 1.71 to 3.57), and reconstructive failure (relative risk, 2.80; 95 percent CI, 1.76 to 4.45) in acellular dermis patients. CONCLUSIONS: The meta-analysis suggests that the use of human acellular dermal matrix increases complication rates vis-à-vis submuscular expander/implant reconstruction. This must be weighed against its reported advantages in enhancing cosmesis and ameliorating contracture. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, III.

Modified deep plane rhytidectomy with a lateral approach to the neck: an alternative to submental incision and dissection.

BACKGROUND: A "composite" type subplatysmal dissection with lateral advancement of the platysma-skin flap to lift the neck during rhytidectomy has been advocated by several authors. However, the limited subplatysmal dissection described in these techniques restricts the degree of mobilization of the flap. Therefore, most investigators rely on supraplatysmal dissection and medial plication of the platysma to achieve satisfactory cervical contours, especially in patients with difficult necks. METHODS: To allow for greater mobilization of composite neck flaps, the senior author (T.A.M.) extends the subplatysmal dissection to incorporate release of cervical retaining ligaments. The dissection is carried medially to just beyond the region defined by the inferomedial portion of the parotid gland, and inferiorly to where the superficial musculoaponeurotic system-platysma layer and greater auricular nerve cross the posterior border of the sternocleidomastoid muscle. Dissection of the composite flap is followed by use of fine cannula submental liposuction. RESULTS: Experience with 742 rhytidectomies performed over a 10-year period indicates that this operation can be completed safely with satisfactory results and a low incidence of complications. The use of a submental incision and medial platysma plication can be avoided almost entirely. CONCLUSIONS: Identification and release of the cervical retaining ligaments permits significant platysma-skin flap mobilization. When complemented with submental liposuction, complete cervical rejuvenation can be achieved without need for medial platysma plication. The full integration of the neck and facial plane of dissection results in a very even tension and a natural appearance, even in repeated face lifts.

A geometric analysis of mastectomy incisions: Optimizing intraoperative breast volume.

INTRODUCTION: The advent of acellular dermis-based tissue expander breast reconstruction has placed an increased emphasis on optimizing intraoperative volume. Because skin preservation is a critical determinant of intraoperative volume expansion, a mathematical model was developed to capture the influence of incision dimension on subsequent tissue expander volumes. METHODS: A mathematical equation was developed to calculate breast volume via integration of a geometrically modelled breast cross-section. The equation calculates volume changes associated with excised skin during the mastectomy incision by reducing the arc length of the cross-section. The degree of volume loss is subsequently calculated based on excision dimensions ranging from 35 mm to 60 mm. RESULTS: A quadratic relationship between breast volume and the vertical dimension of the mastectomy incision exists, such that incrementally larger incisions lead to a disproportionally greater amount of volume loss. The vertical dimension of the mastectomy incision - more so than the horizontal dimension - is of critical importance to maintain breast volume. Moreover, the predicted volume loss is more profound in smaller breasts and primarily occurs in areas that affect breast projection on ptosis. CONCLUSIONS: The present study is the first to model the relationship between the vertical dimensions of the mastectomy incision and subsequent volume loss. These geometric principles will aid in optimizing intra-operative volume expansion during expander-based breast reconstruction.

The effect of incision choice on outcomes of nipple-sparing mastectomy reconstruction.

INTRODUCTION: The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis. METHODS: A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis. RESULTS: Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis. CONCLUSION: The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.

Improving outcomes of the distally based hemisoleus flap: principles of angiosomes in flap design.

BACKGROUND: The reliability of the distally based pedicled hemisoleus flap for coverage of relatively small medial distal third leg wounds has been continuously debated among reconstructive surgeons. Whereas some authors report that the distally based hemisoleus can be elevated safely, other authors argue that the flap's retrograde blood supply is problematic. The authors believe that application of angiosome principles may help surgeons to better design the distally based hemisoleus flap such that outcomes are optimized. METHODS: Seventeen patients received a distally based hemisoleus flap for coverage of a small distal third leg wound. Flaps were designed to capture one full angiosome and only a portion of the adjacent angiosome. RESULTS: Reliable soft-tissue coverage and wound healing were achieved in all patients. Mean operative time of 130 minutes reflected the relative technical ease and efficiency of the surgery. Only one patient suffered distal tip flap necrosis, which did not compromise soft-tissue coverage and ultimately resulted in a healed wound and fracture. CONCLUSIONS: The distally based hemisoleus flap is an efficacious method of treating small distal third medial tibial wounds. Flap design based on vascular perforator angiosome principles may help surgeons improve the reliability of this flap.

A local anesthetic pump reduces postoperative pain and narcotic and antiemetic use in breast reconstruction surgery: a randomized controlled trial.

BACKGROUND: The purpose of this study was to conduct a double-blind, randomized, prospective trial evaluating the efficacy of a local anesthetic pain pump in reducing postoperative pain, narcotic use, and the incidence of postoperative nausea and vomiting in breast reduction surgery. METHODS: Thirty-one patients undergoing bilateral breast reduction using a single technique (inferior pedicle, Wise pattern with supplemental liposuction) were enrolled. The patients were randomized to receive either 0.25% bupivacaine (n = 16) or 0.9% saline (n = 15) delivered over a period of 48 to 55 hours. All patients were monitored postoperatively and completed a written survey and telephone interview. Parameters measured over a period of 48 hours included subjective pain, episodes of postoperative nausea and vomiting, and the amount of narcotics and antiemetics used. RESULTS: There were no statistically significant differences between the two groups regarding patient age, body mass index, weight of the breast reduction, complication rate, and standardized subjective pain perception. Patients randomized to bupivacaine reported significantly lower pain scores on the day of surgery and on the first and second postoperative days when compared with patients receiving placebo (p < 0.01). The amount of intravenous and oral narcotics used paralleled the reduction in pain (p < 0.01), and there were fewer episodes of postoperative nausea and vomiting and antiemetics used in the patients randomized to the bupivacaine group (p < 0.01). CONCLUSION: The results of this study support the efficacy of a postoperative local anesthetic pain pump in reducing pain, narcotic use, and postoperative nausea and vomiting in women undergoing breast reduction.