Optimizing aesthetic results in autologous breast reconstruction.

Advances in breast cancer management have provided most patients with the hope for cure or avoidance of cancer altogether. Such advances have made quality of life much more important after treatment and have led to equally incredible advances in breast reconstruction, to the point where reconstructive goals have altered the way mastectomies are now performed. As experience and expertise in microsurgery has grown, the surgical feat of successfully transferring tissue to restore breast volume is no longer considered an adequate endpoint for aesthetic breast reconstruction. A shift towards patient-centered care has motivated plastic surgeons to adapt their approaches to reconstruction integrating aesthetic principles to the process of recreating a breast mound in order to provide patients with a long-term, natural, and optimal result. Vital to restoring a shapely breast is a thorough preoperative assessment and the understanding of the breast footprint, breast conus, skin envelope and nipple-areolar complex (NAC) position. These aesthetic goals should also extend to the donor site, where adequate contour improvement is sought to offset the price of the donor site scar and the morbidity is minimized. By utilizing strategies for optimizing the NAC position, incorporating novel techniques to ensure core projection, and paying attention to the donor site, the skilled microsurgeon can elevate breast reconstruction to the level of true aesthetic surgery where the reconstructed appearance is superior to the presurgical one.

Financial Implications of Enhanced Recovery After Surgery Protocols in Microsurgical Breast Reconstruction.

INTRODUCTION: Surgical advancements in breast reconstruction have allowed a shift toward optimizing patient-reported outcomes and efficiency measures. The enhanced recovery after surgery (ERAS) protocol has been instrumental in improving outcomes, but the effect of these protocols on health care spending has not been examined. This study aims to assess the effect of ERAS protocols on the length of hospital stay and costs associated with microsurgical breast reconstruction. METHODS: In 2018, the authors implemented an ERAS protocol for patients undergoing microsurgical breast reconstruction that included perioperative procedures involving patient education and care. Subjects included patients who underwent deep inferior epigastric perforator flap breast reconstruction at the authors' institution between 2016 and 2019. Data were gathered from the electronic medical record and the hospital system's finance department, and patients were divided into pre-ERAS and ERAS cohorts. A 2-sample t test was used for statistical analysis. RESULTS: The study included 269 patients with no statistically significant differences in demographic data between the cohorts. The average length of hospitalization was 3.46 days for the pre-ERAS group and 2.45 days for the ERAS group ( P = 0.000). In a linear regression, the ERAS protocol predicted a 1.04-day decrease in the length of stay ( P = 0.000). Overall, total direct cost decreased by 7.5% with the ERAS protocol. CONCLUSION: The rising cost of health care presents a challenge for providers to reduce the cost burden placed on our health system while providing the highest-quality care. This study demonstrates that the use of standardized ERAS protocols can achieve this 2-fold goal.

Inferiorly Directed Posterior Cranial Vault Distraction for Treatment of Chiari Malformations.

OBJECTIVE: The authors present a case series of patients with Chiari I malformations treated with distraction osteogenesis of the posterior cranial vault, utilizing a vertical distraction vector for appropriate cranial vault expansion while mitigating the risks of scaphocephaly and cerebellar ptosis. PATIENTS AND METHODS: Patients with syndromic and nonsyndromic Chiari I malformations treated with vertical-vector distraction osteogenesis of the posterior cranial vault were identified from 2008 to 2014. Demographics, preoperative and postoperative clinical symptoms, and perioperative details were assessed. Long-term esthetic outcomes, complications, and symptomatic improvement were evaluated in conjunction with neurosurgery. RESULTS: Nine patients were identified. Five had known syndromes, 2 likely had unidentified syndromes, and 2 were nonsyndromic. Seven had prior Chiari-related surgeries. Most presented with hydrocephalus, motor symptoms, and developmental delay. Operatively, 2 to 3 internal distraction fixators were applied such that the vector of distraction was along a cephalad-caudad axis. Devices were activated on postoperative day 5 and distracted 1 mm per day. Three postoperative complications were found within the first 3 months which included a dislodged distraction arm, a device extrusion, and a local cellulitis. No complications affected the clinical outcome. Radiographic follow-up showed good bone formation, decompression of the posterior fossa, improved cerebrospinal fluid flow, and no cerebellar ptosis. Neurological surveillance showed improvement in intracranial pressure, hydrocephalus, motor symptoms, and behavioral problems. CONCLUSION: The authors have presented 9 patients with Chiari I malformations treated with distraction osteogenesis, along with a novel technique to safely and effectively expand the posterior fossa while minimizing the risk of cerebellar ptosis. LEVEL OF EVIDENCE: Level II (prognostic/risk studies).

The Use of the Three-Dimensional Printed Polyether Ether Ketone Implant in Secondary Craniosynostosis Revision.

BACKGROUND: Skull deformities may be seen in patients years after craniosynostosis correction. These deformities cause psychosocial distress in affected patients. In this series, the authors describe the use of patient specific polyether ether ketone (PEEK) implants for correction of skull deformities after cranial vault remodeling for craniosynostosis. METHODS: A chart review was conducted for 3 revision procedures performed by 1 plastic surgeon in collaboration with 1 neurosurgeon, both affiliated with Northwell Health. Preoperative computed tomography scans were used to design three-dimensional (3D) printed PEEK implants manufactured by KLS Martin. Implants were used to correct frontal and orbital asymmetry and skull deformities in each patient. Outcomes were assessed at 1 week, 1 month, and 3 months post-operation. RESULTS: Two males and 1 female, ages 13, 17, and 19, underwent revision cranioplasty or orbital rim reconstruction using a custom, single piece 3D printed PEEK implant. All 3 patients underwent cranial vault remodeling in infancy; 1 was treated for coronal craniosynostosis and 2 were treated for metopic craniosynostosis. Revision cranioplasty operative times were 90, 105, and 147 minutes, with estimated blood loss of 45 mL, 75 mL, and 150 mL, respectively. One patient went home on post op day 1 and 2 patients went home on post op day 2. All patients had an immediate improvement in structural integrity and cranial contour, and all patients were pleased with their aesthetic results. CONCLUSIONS: Custom 3D printed PEEK implants offer a single piece solution in revision cranioplasty surgery to correct skull deformities after cranial vault remodeling for craniosynostosis.

Cryptocurrency: The Future of Plastic Surgery Payments?

Cryptocurrencies are digital currencies that allow for peer-to-peer transactions, maintained by a decentralized, secure, and trust-based system. Similar to the patient-centered care approach, cryptocurrency empowers the individual to transact, without a third-party, in a safe, largely transparent, and fast way. Awareness of the current economic state and the ongoing growth of cryptocurrency can place plastic surgeons in a unique and opportune position to broaden payment acceptance methods and create a more effective business model. By first creating a digital wallet for storage, and then employing a payment processing tool, transacting with cryptocurrency becomes practical and convenient. This paper explores the advantages and limitations of cryptocurrency and provides a high-level breakdown of the basics of accepting and transacting with cryptocurrency within a successful plastic surgery practice.

Use of the Vertical Profunda Artery Perforator Flap to Capture the Dominant Perforator: A Cadaver Dissection and Imaging Study.

BACKGROUND: While the originally described transverse profunda artery perforator (tPAP) flap is designed to capture the first profunda perforator, our group hypothesized the dominant perforator may not always be captured in this configuration. This study maps the location of dominant profunda perforators using imaging and cadaveric dissections to determine the probability of capturing dominant perforators with the transverse flap design versus the vertical PAP (vPAP) variant. METHODS: Fifty preoperative magnetic resonance angiogram or computed tomographic angiogram scans (100 total extremities) were examined from autologous breast reconstruction patients between 2015 and 2019. Profunda perforator characteristics that were examined included the distance from the pubic tubercle to the infragluteal fold (IGF), the distance of the perforators from the IGF, distance posterior to the gracilis, the diameter of the perforator at fascial exit, and total number of perforators present. Profunda perforator dissection was performed in 18 cadaveric extremities. Analysis included mean distance from pubic tubercle, distance posterior to the gracilis, diameter at fascial exit, and total number of perforators. RESULTS: In imaging analysis, the mean distance from the IGF to the fascial exit of all dominant perforators was 7.04 cm. The mean diameter of the dominant perforator at the fascial exit was 2.61 mm. Twenty-six thighs (26%) demonstrated dominant perforators that exited the fascia greater than 8 cm below the IGF. In cadaver dissections, the mean distance from the pubic tubercle to the fascial exit of all the dominant perforators was 10.17 cm. Nine cadaver specimens (50%) demonstrated perforators that exited the fascia greater than 8 cm below the estimated IGF. CONCLUSION: The dominant perforator can often be missed in the traditional tPAP design. The vPAP incorporates multiple perforators with a long pedicle, excellent vessel diameter, and favorable donor-site.

Thermal Imaging Facilitates Design of a Keystone Perforator Island Flap for a Myxofibrosarcoma Resection Reconstruction: Case Report.

Lower extremity defects are challenging to reconstruct. The keystone perforator island flap proves useful in difficult cases. Traditionally, a handheld Doppler is used to confirm perforator vessel(s) within the flap but has disadvantages including low sensitivity/specificity. Surgeons can use thermal imaging to localize "hot spots" on the skin, corresponding to perforators. FLIR ONE (FLIR Systems Inc., Wilsonville, OR) is a portable thermal camera with high concordance with computed tomographic angiography. In this case, when faced with handheld Doppler failure, we used intraoperative thermal imaging to continue planning and raising of a complex lower extremity keystone perforator island flap.

Perceived Esthetic Outcomes of Face Transplantation: A Survey of the General Public.

Facial transplantation (FT) has attracted the interest of individuals with facial disfigurement as a path to social reintegration. The perception among face transplant recipients and the reconstructive surgery community appears to be that superior functional and esthetic outcomes can be obtained with FT compared to autologous reconstruction (AR). Although lifelong immunosuppression adds well-known risks to FT, its benefits have proven difficult to quantify, especially because of its non-life-saving nature. Evidence that the general public perceives facial allograft recipients as less disfigured than AR patients may dramatically alter the currently accepted risk/benefit ratio of this novel procedure. A survey containing independent images of individuals in nondisfigured (ND), autologous facial reconstruction, and FT groups was administered to the general public in an urban environment. Participants assigned a disfigurement score to each photograph using the Observer-Rated Facial Disfigurement Scale, a validated instrument used to rate facial disfigurement among head and neck cancer patients. One-way analysis of variance was used to calculate differences in mean level of perceived facial disfigurement among the 3 groups. A total of 250 participants completed the survey. Mean perceived disfigurement scores assigned to the ND, FT, and AR groups were 1.2 ±â€Š0.4, 4.9 ±â€Š1.3, and 8.5 ±â€Š0.6, respectively. A significant difference in disfigurement score was observed between all 3 groups (P < 0.001). This pilot study suggests that the general public perceives the esthetic outcome of FT to be superior to those obtained with AR in patients with severe facial defects.