Effect of pedicle type on breast reduction: Clinical and patient-reported outcomes.

PURPOSE: The choice of pedicle in reduction mammaplasty is highly variable with prior studies demonstrating high patient satisfaction in most cases. This study aimed to examine the impact of pedicle type on clinical and patient-reported outcomes in patients undergoing reduction mammaplasty. METHODS: A total of 588 patients underwent bilateral reduction mammaplasty with Wise pattern or modified Robertson incision by 13 surgeons at a single institution. Clinical outcomes were compared according to the pedicle type in all patients and BREAST-Q responders (32% response rate). Survey respondents were sub-grouped by resection volume, and the BREAST-Q satisfaction scores were compared. RESULTS: Among all included reduction mammoplasties, 439 (75%) were performed using inferior pedicles, and 149 (25%) using superior or superomedial pedicles. Responders and non-responders were similar in preoperative characteristics including age, body measurements, and comorbidities. Although a higher incidence of infection occurred among the responders, clinical outcomes were comparable across all pedicle types. A total of 187 patients completed the BREAST-Q. Compared to the superior pedicle group, respondents in the inferior pedicle group reported higher nipple satisfaction, even when adjusted for resection weight over 500 g. In contrast, the superior pedicle group had better sexual well-being scores, which persisted in resection weight less than 500 g (all p values <0.05). CONCLUSION: Inferior pedicles were associated with greater nipple satisfaction and superior pedicles were associated with greater sexual satisfaction. Our findings suggest that those with resections less than 500 g were more satisfied with superior pedicles whereas those with greater resections were more satisfied with inferior pedicles.

Histological Assessment of the Effectiveness of Microneedling Device-Assisted Filler Delivery.

BACKGROUND: Microneedling is used to enhance transcutaneous drug delivery. However, the extent to which microneedling devices impact filler delivery and whether this varies by filler type, microneedling device type, and treatment sequence is not known. OBJECTIVE: To histologically assess and quantify the delivery of commonly used fillers through microneedling, using both a microneedling pen and a microneedling roller. In addition, the authors investigated whether there is a variation in filler delivery based on the sequence of microneedling in relation to topical filler application. METHODS: Ex vivo human abdominal skin samples were subjected to microneedling pen or microneedling roller treatment. Black tissue marking ink, hyaluronic acid, poly-l-lactic acid, or undiluted calcium hydroxyapatite was topically applied before or immediately after microneedling treatment. RESULTS: Histological evaluation revealed a notable presence of black ink within channels formed by both microneedling treatments (15.5%-98.1%), whereas there was limited presence of the various filler types tested (0%-6.6%) in all settings. Topical application before microneedling treatment led to relatively higher filler/ink deposition within the channels formed by the microneedling treatments compared with topical application after microneedling. CONCLUSION: Transcutaneous delivery of fillers was not significantly helped by microneedling treatment, whereas the microneedling devices demonstrated effective delivery of an aqueous solution.

Development of "Explore Plastic Surgery": An Educational Program for Medical Students Without Home Residency Programs.

BACKGROUND: Medical students who attend institutions without plastic surgery residency programs are at a disadvantage in the plastic surgery match. We developed an educational program for medical students without home programs called Explore Plastic Surgery to provide an overview of the steps toward a career in plastic surgery. The purpose of this study was to assess the impact, utility, and success of the novel program. METHODS: Pre- and postevent surveys were distributed to participants. Survey data were analyzed including participant demographics, perceptions of barriers unique to those without home programs, and the overall event utility. RESULTS: Two hundred seventeen students registered for the program. Ninety-five participants completed the pre-event survey (44%), and of those, 57 participants completed the post-event survey (60%). There was an increase in understanding of the steps toward a career in plastic surgery ( P < 0.001), confidence in overcoming barriers ( P = 0.005), and level of comfort in reaching out to faculty for opportunities ( P = 0.01). There was a decrease in the perceived negative impact that attending medical schools without a home program will have on their abilities to pursue careers in plastic surgery ( P = 0.006). CONCLUSIONS: After the event, participants demonstrated an increase in their confidence in overcoming barriers and a decrease in their perceptions that attending an institution without a home program would negatively impact their ability to pursue plastic surgery. Initiatives focused on early exposure and recruitment of medical students may be important to promote accessibility and diversity within plastic surgery.

Women in Plastic Surgery Innovation: A 10-Year Review of Gender Representation in Mammary Device Patents.

BACKGROUND: This study aims to pioneer in evaluating women's representation in plastic surgery innovations, focusing on mammary prosthesis devices' inventorship. Despite growing gender parity in the field, women's involvement in innovation remains underexplored. This is especially crucial, as the predominant recipients of these innovative technologies are women, urging a necessity for broader female engagement in pioneering surgical advancements. METHOD: Patents under the "A61F2/12: Mammary prostheses and implants" classification between the dates January 1, 2011, to December 31, 2020, were identified using Google Patents Advanced. Inclusion criteria included patents (not designs) in English and applications (not grants), with no litigation limitations. Data collected included ID, title, assignee (categorized as industry, academic, private, individual), inventors, and dates (priority, filing, and publication). Sex of inventors was identified with the literature validated gender API, with manual resolution of unresolved genders or with ga_accuracy scores of less than 75%. Data were analyzed using 2-tailed Student t tests, χ2 analysis, and Pearson correlation coefficient (significance set at P ≤ 0.05). RESULTS: Of the more than 130,000 plastic surgery patents in English identified between the 10-year period, 1355 were classified as A61F2/12. A total of 374 unique patents were included for analysis (841 duplicates were removed, and 140 patents were excluded because of non-English character author names). There was a significant increase in patents over the decade (from 15 in 2011 to 88 in 2020, R2 = 0.74, P < 0.05), with a decrease in number of inventors per patent (R2 = 0.12, P < 0.05). Of the 1102 total inventors, 138 were female (11.2%), with a 4-fold increase in representation over the decade (R2 = 0.58, P < 0.05), including increase in patents filed with a woman first inventor (0%-14.8%). Women were equally likely to be first 3 inventors versus middle to last inventors (12.8% vs 11.1%, respectively). CONCLUSIONS: Over a decade, mammary device innovations rose significantly. Although women inventors' representation improved, it remains disproportionate compared with women in residency/practice. Hence, interventions should aim to align inventor representation with training ratios, through institutional optimization, reducing gender segmentation, and enhancing funding opportunities.

Acute Diplopia Following Rhinoplasty: Clearing the Air.

Diplopia after rhinoplasty is a rare complication that requires immediate medical attention. Workup should include a complete history and physical examination, appropriate imaging, and consultation with ophthalmology. Diagnosis may be challenging due to the wide differential ranging from dry eyes to orbital emphysema to an acute stroke. Patient evaluation should be expedient, though thorough to facilitate time-sensitive therapeutic interventions. Here, we present a case of transient binocular diplopia presenting 2 days after closed septorhinoplasty. The visual symptoms were attributed to either intra-orbital emphysema or a decompensated exophoria. This is the second documented case of orbital emphysema after rhinoplasty presenting with diplopia. It is the only case with a delayed presentation as well as the only case that resolved after positional maneuvers.

La diplopie après la rhinoplastie est une complication rare qui exige des soins médicaux. Le bilan inclut une histoire complète et un examen physique, une imagerie appropriée et une consultation en ophtalmologie. Le diagnostic peut être difficile à poser en raison du vaste diagnostic différentiel, qui va de la sécheresse oculaire à l'emphysème orbitaire, en passant par l'accident vasculaire cérébral aigu. L'évaluation des patients doit être rapide, mais approfondie, pour favoriser des interventions opportunes. Les auteurs présentent un cas de diplopie binoculaire transitoire s'étant manifestée deux jours après une septorhinoplastie fermée. Les symptômes visuels étaient attribués à un emphysème intraorbitaire ou une exophorie décompensée. Il s'agit du deuxième cas répertorié d'emphysème orbitaire après une rhinoplastie démontrée par une diplopie. C'est le seul cas aux manifestations tardives, de même que le seul à s'être résorbé après des manœuvres positionnelles.

Cosmetic Rhinoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Perform a systematic nasofacial analysis. 2. Identify the underlying anatomical cause of specific external nasal findings. 3. Recognize the interrelated effects of operative maneuvers. 4. Develop an appropriate operative plan to address patient concerns. SUMMARY: The rhinoplasty operation is one of the most challenging procedures in plastic surgery, and requires a combination of surgical judgment, knowledge of anatomy, technical skill, and lifelong study. A foundation must be built on clearly defined patient goals and an accurate diagnosis, based on known ideals and their anatomical correlation. It is important to recognize the definitive impact of each operative maneuver to achieve predictable outcomes. This article provides a problem-based approach to common cosmetic nasal deformities.

Outpatient Prosthetic-Based Reconstruction during COVID-19 Pandemic Possible in Selected Patients without Increased Complications.

BACKGROUND: Following the reopening of elective surgery, the authors' division transitioned from inpatient admission to same-day discharge for immediate prosthetic breast reconstruction in an effort to decrease the hospital's clinical burden and minimize potential coronavirus disease of 2019 exposure. This study aims to compare complication rates following this acute transition for patients who had inpatient and outpatient mastectomy with immediate alloplastic reconstruction. METHODS: A retrospective chart review was performed on patients who underwent mastectomy with immediate prosthetic reconstruction. The outcome of interest was 30-day morbidity. Descriptive statistics were compared for patients with outpatient and inpatient operations. Odds ratios were calculated to determine whether any preoperative factors increased odds of 30-day complications. RESULTS: A total of 115 patients were included in this study. Twenty-six patients had outpatient surgery and 89 stayed inpatient postoperatively. Same-day discharge did not significantly impact the odds of having one or more 30-day complications (OR, 0.275; 95% CI, 0.047 to 1.618; P = 0.153). Patients with complications had significantly longer median operating times [5.0 hours (interquartile range, 4.0 to 6.0 hours) versus 4.0 hours (interquartile range, 3.0 to 5.0 hours; P = 0.05), and there was a statistically significant association between length of surgery and odds of complication (OR, 1.596; 95% CI, 1.039 to 2.451; P = 0.033). Age was independently associated with increased risk of 30-day complication (OR, 1.062; 95% CI, 1.010 to 1.117; P = 0.020). CONCLUSION: The authors' findings support a continuation of same-day discharge strategy, which could decrease costs for patients and hospitals without increasing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Public Confidence for Undergoing Elective Plastic Surgery Procedures during the COVID-19 Pandemic.

Background: The COVID-19 vaccine rollout has since been followed by a gradual resumption of elective surgery. Many individuals remain cautious about visiting a hospital or clinic to undergo surgery. As plastic surgeons are starting to resume elective surgery at this time, it is important to understand the perspectives of potential patients and the concerns they may have. Methods: A survey was distributed to participants in the United States through Amazon's Mechanical Turk (mTurk) during March of 2021. Participants were surveyed regarding their views on the severity of COVID-19, vaccination status, and how much COVID-19 has affected their interest in undergoing surgery. Results: Thirty-nine percent of respondents were either no longer willing or less willing to undergo elective plastic surgery. Seventy-three percent of respondents felt comfortable going to an office for a consultation. With regards to feeling comfortable visiting a hospital, 43.4% reported they would feel safe, 36% felt they would feel safe only if they could be discharged on the same day, and 30.6% reported not feeling safe. Fifty-two percent of respondents reported feeling comfortable undergoing surgery now or within the next year. Respondents who do not think COVID-19 is still a major health issue were more likely to still want plastic surgery. Conclusion: The results of this study highlight that the majority of patients, regardless of vaccination status, currently feel comfortable undergoing elective plastic surgery, particularly in an office setting. Plastic surgeons may expect to see a return in demand for elective procedures in the coming months.

Special Considerations for Chin Augmentation in the Professional Violinist.

ABSTRACT: The extensive training and unique positioning of a stringed instrument (eg, professional violinist) may subject the mandible to compressive forces that may lead to asymmetric micrognathia. Prior cephalometric studies have shown a right-sided facial dominance with an underdeveloped left mandible. Surgical correction must account for occupational demands, as the chin is uniquely load-bearing in violinists. The use of three-dimensional planning with a customized implant facilitates the correction of asymmetries and allows shared decision-making for optimal implant fit. Our case outlines important considerations for alloplastic chin augmentation in violinists.

Cleft Rhinoplasty Study and Evolution.

BACKGROUND: Most patients with a cleft lip will have a cleft lip nasal deformity. The nasal deformities are complex and are difficult to surgically correct as a result of the anatomical issues and deficiencies. In this study, the authors analyzed and reviewed nasal pathology and surgical maneuvers in patients with cleft lip nasal deformity treated by the senior author over the past 15 years. METHODS: A retrospective review was performed on patients who underwent a rhinoplasty for a cleft nasal deformity from the years of 2002 to 2017. Patients were stratified by unilateral and bilateral cleft lip. For each variable, comparisons were made between unilateral and bilateral cases. RESULTS: 39 patients had a unilateral cleft lip nasal deformity, while 17 had a bilateral cleft lip nasal deformity. Patients with a unilateral cleft nasal deformity had a significantly higher incidence of vestibular stenosis and septal deviation. Regarding surgical maneuvers, unilateral cleft lip patients had a relatively higher utilization of septoplasty, spreader grafts, and alar grafts compared to bilateral cleft lip patients. Bilateral cleft lip patients had a relatively higher utilization of dorsal hump reduction, columella strut grafts, and nasal tip grafts. These differences were not statistically significant. Unilateral cleft lip patients had a statistically significant higher use of alveolar support at the time of rhinoplasty. CONCLUSIONS: The rhinoplasty operation in patients with cleft lip nasal deformity is uniquely challenging and rewarding. This operation has undergone an evolution in our own practice and has led to improved outcomes for these patients.

Anatomic Implants in Breast Reconstruction: A Comparison of Outcomes and Aesthetic Results Compared to Smooth Round Silicone Implants.

BACKGROUND: Direct comparison studies of outcomes and aesthetic satisfaction of anatomic implants compared to other implants are scarce in the literature. OBJECTIVES: The objective of this study was to compare outcomes and aesthetic satisfaction of patients who underwent breast reconstruction with anatomic implants vs other implants (smooth round silicone). METHODS: A retrospective chart review was performed of patients who underwent implant-based breast reconstruction over 3 years. Outcomes including complications, number of surgeries, need for revisions, and aesthetic satisfaction of patients were tracked and compared. RESULTS: A total of 156 patients met inclusion criteria for this study. A total of 123 underwent reconstruction with a round implant, and 33 underwent reconstruction with an anatomic implant. Of the 156 patients, 38 underwent a 1-stage direct-to-implant reconstruction and the remainder underwent a 2-stage implant reconstruction. The round and anatomic implant groups did not differ with regards to number of surgeries, revisions, utilization of contralateral symmetry procedures, implant-related reoperations, complications, implant loss, infection, capsular contracture, and seroma. The Breast Q survey had a response rate of 27%. On all parameters, the round and anatomic implant groups did not significantly differ. CONCLUSIONS: There were no significant differences among round and shaped implants in regards to complications, revision surgeries, and overall outcomes. Furthermore, patients showed no differences regarding satisfaction and well-being when surveyed on the Breast Q survey. The decision of implant choice in breast reconstruction should be based on surgeon comfort and the patient's needs/body type.Level of Evidence: 4.

A breast prosthesis infection update: Two-year incidence, risk factors and management at single institution.

BACKGROUND: Infection following augmentation and prosthetic-based breast reconstruction can cause significant physical and psychological distress for patients. It may delay adjuvant therapies and compromise aesthetic outcomes. The aim of this study is to identify modifiable risk factors for infection and identify common bacterial isolates to achieve optimal outcomes for patients. METHODS: A retrospective cohort study was performed for patients undergoing implant-based breast reconstruction over a 2-year period. In each case, we documented demographics, co-morbidities, complications and antibiotic use. We reviewed treatments, infectious species cultured where applicable and all outcomes. RESULTS: A total of 292 patients met the inclusion criteria. Fifty-five patients (19%) developed an infection. Univariate analysis showed a significantly increased infection rate with longer operative times (P = 0.001) and use of tissue expanders (P = 0.001). Multiple logistic regression analysis confirmed drain use and elevated body mass index (BMI) as risk factors (odds ratio [OR] 2.427 and 1.061, respectively). After controlling for BMI, smoking status and radiation, we found an increased odd of infection with allograft use (OR 1.838) and a decreased odd with skin preparation using 2% chlorhexidine gluconate in 70% isopropyl (OR 0.554), though not statistically significant. Forty of 55 patients with infections had cultures, with 62.5% of isolates being Gram-positive species and 30% Gram-negative species. The median time to clinical infection was 25 days. Implant salvage with surgical interventions was achieved in 61.5% of patients. CONCLUSIONS: This study identified judicious use of drains and efficiency in the operating room as modifiable risk factors for infections following implant-based breast reconstruction. Prospective trials to analyse techniques for infection prevention are warranted. Implant salvage following infection is a possible end-point in the appropriate patient.

Biomechanical analysis of the FlatWire Figure 8 sternal fixation device.

OBJECTIVE: To determine whether the FlatWire Figure 8 sternal fixation device (Penn United, USA) is mechanically superior to the current standard in sternotomy closure. DESCRIPTION: Unstable sternal closure using traditional steel-wire cerclage can increase postoperative pain, bony cut-through and wound dehiscence. The authors present the Figure 8 sternal fixation device to minimize these complications. Biomechanical properties of the device were compared with conventional steel wire sternal repair. EVALUATION: Using two constructs of both FlatWire and steel wire, pull-to-failure, Hertzian contact and cut-through were compared. Samples were tested to 500,000 cycles or failure. Cyclic comparisons were performed using log-rank t tests and Student's t tests for cut-through analysis. FlatWires were found to have superior biomechanical properties in all categories tested. CONCLUSION: The FlatWire provides superior biomechanical properties compared with conventional steel wire, which may lead to reduced sternal wound complications.

OBJECTIF: Déterminer si le dispositif de fixation du sternum FlatWire Figure 8 (Penn United, États-Unis) est mécaniquement supérieur à la norme actuelle pour la fermeture des sternotomies. DESCRIPTION: La fermeture du sternum au moyen du cerclage classique en fil d'acier peut accroître la douleur postopératoire, l'insertion osseuse et la déhiscence de la plaie. Les auteurs présentent le dispositif de fixation du sternum Figure 8 pour réduire ces complications au minimum. Les auteurs ont comparé les propriétés biomécaniques du dispositif à la réparation sternale classique à l'aide d'un fil d'acier. ÉVALUATION: Les auteurs ont comparé le test de tension, le contact hertzien et l'insertion du modèle FlatWire à celui du fil d'acier. Ils ont comparé les échantillons jusqu'à 500 000 cycles ou jusqu'à l'échec. Les comparaisons cycliques ont été effectuées au moyen de tests t de Mantel-Haenzel et de tests t pour l'analyse de tension. Le modèle FlatWire avait des propriétés biomécaniques supérieures dans toutes les catégories mises à l'essai. CONCLUSION: Le FlatWire a des propriétés biomécaniques supérieures à celles du fil d'acier classique, lesquelles peuvent réduire les complications de la plaie du sternum.

Prospective, randomized, single blinded pilot study of a new FlatWire based sternal closure system.

BACKGROUND: Unstable steel wire cerclage following open heart surgery may result in increased pain, sternal cut-through, non-union, or dehiscence. These complications lead to longer hospital stays, increased cost, higher morbidity, and patient dissatisfaction. The Figure 8 FlatWire Sternal Closure System is a new construct which is a simple, intuitive, and inexpensive alternative for primary sternal repair following open heart surgery. Prior bench-top testing of FlatWire has demonstrated superior strength and stiffness compared to traditional steel wire. We present our initial experience in a prospective, randomized, single blinded pilot study utilizing this FDA approved system. METHODS: Sixty-three patients undergoing elective complete sternotomies at a single institution were randomly assigned to receive either the Figure 8 FlatWire or standard steel wire cerclage. All surgeries were performed by a single board certified cardiothoracic surgeon. Data collected included: Age, BMI, pump time, off pump to surgical stop time, length of hospital stay after surgery, cost from time of surgery to discharge, and pain on a visual analog pain scale on the day of discharge, day 30, and day 60. RESULTS: The groups were well matched. Patients receiving the Figure 8 FlatWire (33) had a reduction in length of stay compared to patients receiving steel wire circlage (30), but it was not statistically significant (6.8 vs. 7.8 days respectively, p < 0.093). Additionally those with the FlatWire reported significantly decreased pain at day of discharge (3.07 vs. 4.92 points on pain scale, p < 0.0066), with similar pain scores at 30 and 60 days. Off pump to surgery stop time was increased by 15.9 minutes in patients receiving the FlatWire vs. steel wires (55.7 vs. 71.6 minutes, p = 0.00025). Mean cost from surgery until discharge was $87,820.98 in the FlatWire group vs. $91,930.29 in the steel wire group (p < 0.3082). CONCLUSION: Early clinical results suggest that Figure 8 FlatWire provides excellent stability, which resulted in significantly diminished postoperative pain at discharge. Although not significant there was a trend toward decreased length of stay, and reduced cost. Further clinical research is warranted to expand upon these initial trends and validate long term outcomes.

Schwannoma of the ulnar nerve: a case report and review of the literature.

We report a case of a large ulnar nerve schwannoma, a rare type of soft tissue neoplasm. Diagnostic pearls are described to facilitate a more accurate and timely diagnosis. These characteristics include mobility, Tinel's sign, MRI target sign, S100 histological staining, Antoni patterns, and others. With a correct diagnosis, the tumor can be extirpated with preservation of nerve function and a low risk of recurrence.

Forehead reconstruction using a modified dual-plane A to T flap.

Forehead defects often present myriad challenges for the reconstructive surgeon. Many options exist for forehead reconstruction, from primary closure to free flaps. To optimally match colour, contour and texture, the best approach replaces 'like with like'. When primary closure is not possible due to size limitations, and colour or depth is not suitable for grafts, then locoregional flaps become the mainstay of repair. The authors present three cases in which a dual-plane modified A to T flap is used to reconstruct central and lateral forehead defects up to 8 cm in size with excellent aesthetic results. This technique applies principles of the periglabellar flap, with modifications designed to encompass larger defects as well as defects of the lateral forehead.

Les anomalies du front comportent de multiples défis pour le plasticien. Il existe de nombreuses possibilités pour reconstruire le front, de la fermeture primaire aux lambeaux libres. Pour optimiser l'agencement de couleur, de contour et de texture, la meilleure démarche consiste à utiliser des structures similaires. Lorsqu'il est impossible de procéder à une fermeture primaire en raison des dimensions, et que la couleur ou la profondeur ne se prêtent pas à une greffe, les lambeaux locorégionaux deviennent le pilier de la reconstruction. Les auteurs présentent trois cas dans lesquels un lambeau en A modifié en lambeau en T en deux plans est utilisé pour reconstruire les anomalies centrales et latérales du front d'une dimension pouvant atteindre 8 cm et ainsi obtenir d'excellents résultats esthétiques. Cette technique met en application les principes du lambeau périglabellaire, et les modifications sont conçues pour englober des anomalies plus importantes et les anomalies de la partie latérale du front.