Facial Feminization: Perioperative Care and Surgical Approaches.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the regional anatomy involved in facial feminization surgery, the key differences between the male and female face, and surgical approaches for modification. 2. Appreciate the integration of preoperative virtual planning and nonoperative approaches for facial feminization care. 3. Understand the perioperative process and potential complications and sequela. 4. Understand the importance of transgender care acceptance as it pertains to clinical outcomes. SUMMARY: Facial feminization surgery (FFS) is composed of a broad spectrum of gender-affirming surgical procedures with the goal of modifying specific facial features to create a more feminine appearance. As FFS continues to evolve as a subspecialty of transgender care, it is important to consider the psychosocial evaluation, evolving aesthetic tastes, nonoperative facial feminization care, preoperative virtual planning, specialized instrumentation, and potential complications/sequelae when performing these procedures. Computed tomographic imaging and virtual preoperative planning may be used to assist the surgeon with morphologic typing of the brow, supraorbital rim, chin, and lateral mandible regions and aid in performing safer, more efficient procedures. The increasing number of FFS procedures performed on transwomen annually has been supported by objective outcome studies that demonstrate progress in minimizing both misgendering in social environments and reducing dysphoric feelings.

A Comparative Analysis of Online Reporting of Possible Complications for Minimally Invasive Cosmetic Procedures.

Background: The rise in Botox, fillers, and chemical peel procedures demands transparent online information that discloses all relevant risks and complications. This study assesses the quality of complication disclosure on the most popular cosmetic sites. Methods: The top 50 Google search results for "Botox," "fillers," and "chemical peel" were analyzed for their reporting on relevant complications. Websites were categorized based on their origin. An overall complication, prevention, management, prevalence, and disclaimer score were assigned to each site. Results: A total of 136 websites were analyzed. Of these websites, 31 (22.7%) did not mention any complications or risks associated with the treatment. The most commonly reported complications were bruising (67.0%) for Botox, swelling (79.0%) for fillers, and redness (58%) for chemical peels. The least-reported serious complications were toxin spread effects (31.0%) for Botox, vision loss (23.0%) for fillers, and allergic reaction for chemical peel (18.0%). Reports of serious and rare side effects were significantly lower than those of common side effects (Botox, P = .001; fillers, P = .004; chemical peels, P < .001). The overall mean (standard deviation) complication score across all websites was 2.81/5 (1.31). Online health reference and academic/hospital sites disclosed complications better than sources in most other categories (P < .001). Conclusions: The reporting of online complications for the top 3 cosmetic procedures performed in the US is highly variable, biased, and at times, completely absent. Patients pursuing cosmetic surgery are heavily influenced by the internet and vulnerable to misinformation. Cosmetic procedure websites are in need of drastic improvement to ensure the health and safety of all patients.

Trends in Medicare Reimbursement for the Top 20 Surgical Procedures in Craniofacial Trauma.

BACKGROUND: Research regarding financial trends in craniofacial trauma surgery is limited. Understanding these trends is important to the evolvement of suitable reimbursement models in craniofacial plastic surgery. The purpose of this study was to evaluate the trends in Medicare reimbursement rates for the top 20 most utilized surgical procedures for facial trauma. METHODS: The 20 most commonly utilized Current Procedural Terminology (CPT) codes for facial trauma repairs in 2018 were queried from The National Summary Data File from the Centers for Medicare & Medicaid Services (CMS). Reimbursement data for each procedure was then extracted from The Physician Fee Schedule Lookup Tool. Changes to the United States consumer price index (CPI) were used to adjust all gathered data for inflation to 2021 US dollars (USD). The average annual and the total percent change in reimbursement were calculated for the included procedures based on the adjusted trends from the years 2000 to 2021. RESULTS: From 2000 to 2021, the average reimbursement for all procedures decreased by 16.6% after adjusting for inflation. Closed treatment of temporomandibular joint dislocation and closed treatment of nasal bone fractures without manipulation demonstrated the greatest decrease in mean adjusted reimbursement at -48.7% and -48.3%, respectively, while closed treatment of nasal bone fractures without stabilization demonstrated the smallest mean decrease at -1.4% during the study period. Open treatment of nasal septal fractures with or without stabilization demonstrated the greatest increase in mean adjusted reimbursement at 18.9%, while closed treatment of nasal septal fractures with or without stabilization demonstrated the smallest increase at 1.2%. The average reimbursement for all closed procedures in the top 20 decreased by 19.3%, while that for all open procedures decreased by 15.5%. The adjusted reimbursement rate for all top 20 procedures decreased by an average of 0.8% each year. CONCLUSIONS: To the best of our knowledge, this is the first study to comprehensively evaluate trends in Medicare reimbursement for facial trauma surgical repairs. Adjusting for inflation, Medicare reimbursement for the top 20 most commonly utilized procedures has largely decreased from 2000 to 2021. Consideration of these trends by surgeons, hospital systems, and policymakers will be important to assure continued access to meaningful surgical facial trauma care in the United States.

Patient-reported Outcomes of Scar Impact: Comparing of Abdominoplasty, Breast Surgery, and Facial Surgery Patients.

Scarring negatively impacts patient mental health, causing worsened self-confidence, body image, and social interactions, as well as anxiety and depression. The objective of this study is to evaluate the scarring impact after facial surgery, breast surgery, and full abdominoplasty for symptoms, appearance, psychosocial health, career, and sexual well-being using validated patient-reported outcome measures. Method: A total of 901 patients from five providers completed the SCAR-Q (covering symptoms, appearance, and psychosocial) and Career/Sexual Well-being assessments via phone or email where a higher score indicated a more positive scar perception. Results: Of the 901 patients, 38.1% had abdominoplasty surgery, 38.1% breast reduction, 15.3% facial surgery, 4.7% breast lift, and 3.9% breast augmentation. The differences in SCAR-Q, appearance, and symptom scores between the five procedures were statistically significant. Breast augmentation SCAR-Q scores (median = 256) and facial surgery (median = 242) were significantly higher than those of abdominoplasty patients (median = 219; P = 0.003 and P = 0.001, respectively). Duration after surgery was positively correlated with improved symptom scale scores for abdominoplasty (r = 0.24, P < 0.001), breast augmentation (r = 0.71, P = 0.015), and facial surgery patients (r = 0.28, P = 0.001), but not for other procedures. Conclusions: This study is the first to show that breast augmentation and facial surgery patients have a more positive perception of their scars in terms of appearance, symptoms, psychosocial, career, and sexual well-being impact than abdominoplasty patients. Furthermore, the data suggest that symptoms may improve over time for abdominoplasty, breast augmentation, and facial surgery patients. This study highlights the need for further follow-up, counseling, or other improvements to postoperative scar care.

Microvascular Reconstruction of the Anterior Skull Base.

Anterior skull base defects present a unique reconstructive challenge. Risk factors such as previous operation, radiation and infection require a multidisciplinary approach to create a stable wound. Reconstructive microsurgery serves an important role when attempts with pericranial flap placement and nonvascularized graft obliteration fail. Our series analyzes the outcomes of 5 patients who underwent vascularized reconstruction of craniofacial defects at Northwestern Memorial Hospital from 2014-2021. Each patient presented with a complex, hostile scalp and bony wound. Common risk factors included previous craniotomy, failed obliteration, chemoradiation, osteomyelitis and epidural abscess. Patients underwent multi-stage procedures to obtain wound source control, reconstruct the frontal sinus and skull base, and frontal bone cranioplasty. Each patient underwent successful free flap reconstruction without flap loss or donor site complications. No patients suffered ongoing symptomatic CSF leak or pneumocephalus. However, only two patients have had sustained success with their alloplastic cranioplasty. A perfect, watertight seal is required to prevent seeding the implant and avoiding infection. Overall, free flap reconstruction of the skull base and frontal sinus is a necessary solution when patients fail more conservative locoregional options. Close collaboration with neurosurgery can help with diagnosis and establish the optimal timing for surgical care.

The Asian Eye: Anthropometric Eye Measurements of Attractiveness in Young East Asian Women.

BACKGROUND: Because of the high volume of Asian eyelid operations performed and the complexity of the Asian eye, there is a need to define exactly what anthropometric measurements determine attractiveness. METHODS: Eye photographs of young East Asian women were collected from publicly available sources online. Photographs were evaluated on a Likert scale ranging from 1 to 5 for attractiveness. Thirty-seven anthropometric measurements were collected using ImageJ from the most attractive and least attractive eyes to discover which features play the most important role in attractiveness. RESULTS: A total of 322 right eye photographs were evaluated for attractiveness. Sixty-six eyes received a median score of greater than or equal to 4.0 and were included in the attractive cohort. Forty-three eyes received a score of less than or equal to 2.0 and were included in the unattractive cohort. The superior brow peak was more lateralized compared to the upper lid crease and upper lash line peaks in attractive eyes. A greater palpebral aperture height-to-upper lid show ratio was found to be more associated with attractive eyes than with unattractive eyes. At the midpupillary line, the ratio was on average 1.58 ± 0.32 in attractive eyes and 1.22 ± 0.43 in unattractive eyes ( p < 0.001). Eyes with convergence of the upper lid crease with the upper lash line were more likely to be deemed unattractive ( p < 0.001). CONCLUSIONS: East Asian eyes have specific anthropometric measurements that are more associated with attractiveness. These ideal measurements are different from those in Caucasians, suggesting ethnic variability in features defining attractiveness and a need to tailor surgical care appropriately.

National Trends in Gender-Affirming Surgical Procedures: A Google Trends Analysis.

BACKGROUND: There has been a significant increase in the volume of gender-affirming surgical (GAS) procedures over the past decade. The objective of this paper is to use online search data from Google Trends (GT) to describe national search trends for GAS procedures. METHODS: GT was queried for search terms relating to GAS from January 2004 to February 2021. The 19 selected keywords covered a broad range of GAS topics. United States (US) search interest was collected as relative search volumes (RSVs) and then analyzed by geographic region. The number of plastic surgery providers offering GAS and academic surgery centers was collected from the World Professional Association for Transgender Health (WPATH) and Trans-health.com. RSVs were analyzed by metro area to determine the relationship between search demand and personal income. State Medicaid policies for transgender health services were also collected. RESULTS: All search terms demonstrated a positive increase in RSVs over time except "sex reassignment surgery" and "penectomy". The Mountain/Pacific and East South Central/West South Central had the greatest search volume for GAS and most providers offering care. The East South Central/West South Central region​​ ranked last for providers offering care, despite the relatively high search interest. This region also had no states with explicit Medicaid policies covering gender-affirming care. Metro areas in the top five for RSV but bottom quartile for per capita personal income were identified. CONCLUSIONS: Online search interest for GAS-related terms has increased. Search interest for GAS has regional variation and did not show a specific pattern with provider availability.

A Comparison of Outcomes of Proximal and Distal Anastomosis Sites of the Facial Artery in Head and Neck Reconstruction.

ABSTRACT: Recipient vessel selection in head and neck reconstruction is based on multiple factors, including defect size and location, patient history, and vessel location, diameter, and length. The authors present a comparison of proximal and distal anastomotic sites of the facial artery. A chart review of head and neck reconstructions using the facial artery as a recipient vessel over a 7-year period was conducted. The anastomosis site was identified as distal (at the inferior mandible border) or proximal (at the origin of the artery). The distal site was utilized for both defects of the midface/ scalp and of the mandible/neck, while the proximal site was exclusively used for mandible/neck defects. The following complications were included in the analysis: facial nerve injury, surgical site infection, thrombosis, flap congestion, flap loss, hardware failure, malunion/nonunion, osteomyelitis, sinus/fistula, hematoma, seroma, reoperation, and 90-day mortality. Fifty-four free tissue transfers were performed. The overall complication rate (including major and minor complications) was 53.7%. Anastomosis level did not have a significant impact on complication rate. In addition, there were no significant differences in complication rates for the distal anastomosis site when stratified by defect location. However, obese patients were more likely to have a complication than nonobese patients. This conclusion may reassure surgeons that factors related to anastomosis level, such as vessel diameter and proximity to the zone of injury, have less impact on outcomes than factors like obesity, which may inform preoperative planning, intraoperative decision-making, and postoperative monitoring.

Scar Perception: A Comparison of African American and White Self-identified Patients.

Scars can have significant morbidity and negatively impact psychological, functional, and cosmetic outcomes as well as the overall quality-of-life, especially among ethnic minorities. The objective of this study was to evaluate African American and White patients' perception of their scars' impact on symptoms, appearance, psychosocial health, career, and sexual well-being, using validated assessment tools. Method: A total of 675 abdominoplasty and breast surgery patients from four providers completed the SCAR-Q, and Career/Sexual Well-Being scales via phone or email. A higher score on both assessments indicates a more positive patient perception. Results: Of the 675 respondents, 77.0% were White, and 23.0% were African American. White patients scored significantly higher on the SCAR-Q (232 ± 79 versus 203 ± 116), appearance (66 ± 26 versus 55 ± 29), and Career/Sexual Well-Being (16 ± 2 versus 15 ± 5) scales than African American patients (P < 0.001, P < 0.001, P < 0.001, respectively). There was no significant correlation between duration after surgery and symptoms or appearance scores for African American patients (P = 0.11, P = 0.37). There was no significant correlation between patient age and SCAR-Q score or time after surgery and psychosocial scores. Conclusions: African American patients are more likely to have lower perceptions of their scarring appearance, symptoms, psychosocial impact, career impact, and sexual well-being impact than White patients. Scar appearance and symptoms are less likely to improve over time for African American patients. This study highlights the need to address patient ethnicity when considering further follow-up, counseling, or other measures to enhance scar perception.

"Post Mastectomy Pain Syndrome: A Systematic Review of Prevention Modalities".

BACKGROUND: Post-mastectomy pain syndrome (PMPS) is a surgical complication of breast surgery characterized by chronic neuropathic pain. The development of PMPS is multifactorial and research on its prevention is limited. The objective of this systematic review is to synthesize the existing evidence on interventions for lowering the incidence of persistent neuropathic pain after breast surgery. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we performed a comprehensive search of the electronic databases of MEDLINE, Cochrane Library, Embase, CINAHL, PsycINFO, Web of Science, and ClinicalTrials.gov using a combination of database-specific controlled vocabulary and keyword searches. Two reviewers independently screened all unique records. Publications on chronic (>3-month duration) pain after breast cancer-related surgery were included. Studies were classified by modality. RESULTS: Our literature search yielded 7092 articles after deduplication. We identified 45 studies that met final inclusion criteria for analysis, including 37 randomized-controlled trials. These studies revealed seven major intervention modalities for prevention of PMPS: physical therapy, mindfulness-based cognitive therapy, oral medications, surgical intervention, anesthesia, nerve blocks, and topical medication therapy. CONCLUSION: High-quality data on preventative techniques for PMPS are required to inform decisions for breast cancer survivors. We present a comprehensive assessment of the modalities available that can help guide breast and reconstructive surgeons employ effective strategies to lower the incidence and severity of PMPS. Our review supports the use of multimodal care involving both a peripherally targeted treatment and centrally acting medication to prevent the development of PMPS.

Evaluation of a Novel Absorbable Mesh in a Porcine Model of Abdominal Wall Repair.

Bioabsorbable meshes have seen increasing clinical use to reinforce soft tissue, and exist on a spectrum of strength loss versus absorption: several retain their strength for months, but remain in situ for years. Others lose strength fully by 6 weeks. An intermediate profile, with some strength for 3 -4 months, but consistent absorption in less than a year, may be an optimal balance of near-term support and long-term safety. In this large animal study, we evaluate such a mesh (DuraSorb, SIA), assessing its utility in a porcine model of abdominal wall repair. METHODS: Two full-thickness defects were created in the abdominal walls of nine Yucatan swine via midline approach and repaired preperitoneally with either DuraSorb or long-lasting control mesh (TIGR, Novus Scientific). At 30 days, 3 months, and 1 year, the implantations were assessed by clinical pathology, post-necropsy histopathology, and burst strength testing. RESULTS: No device-associated complications were found in vivo, at necropsy, or histologically. DuraSorb was well-integrated and vascularized by 30 days. DuraSorb demonstrated minimal/mild inflammation and fibroplasia, and lower inflammatory scores when compared with TIGR at all time points (P < 0.05). Burst strength of the repair sites was higher than adjacent abdominal wall at all time points (P < 0.05). CONCLUSIONS: DuraSorb provided durable long-term support, minimal inflammation, and consistent absorption in this porcine model of abdominal wall repair, as compared to a long-term control. Clinical data is needed, but these results suggest that this mesh provides adequate structural support while potentially reducing long-term device reactions.

Representation of African American Patients in Social Media for Breast Reconstruction.

BACKGROUND: Social media use by plastic surgeons may contribute to the overall increase in breast reconstruction in the United States. However, recent data show a concerning decrease in breast reconstruction in African American women. The purpose of this study was to analyze the inclusion of African American women in social media posts for breast reconstruction, with the premise that this may be a possible contributing factor to decreasing rates of breast reconstruction in this population. METHODS: Data from several social media platforms were obtained manually on December 1, 2019. Each image was analyzed using the Fitzpatrick scale as a guide. RESULTS: A total of 2580 photographs were included that met the authors' criteria. Only 172 photographs (6.7 percent) were nonwhite. This study surveyed 543 surgeons, 5 percent of whom were nonwhite. The analysis of the results from the random sample of the top plastic surgery social media influencers showed that only 22 (5 percent) of the photographs uploaded were nonwhite patients. Furthermore, 30 percent of surgeons did not have any photographs of nonwhite patients uploaded. CONCLUSIONS: Numerous factors can contribute to the disparity between the growing trend of white patients seeking reconstructive surgery compared to the decreasing trend of African American patients, one of which may be the disparity in their representation in social media, particularly among common platforms and social media influencers. This study highlights the evolving factors that may impair African American breast cancer patients' access to safe, effective breast reconstruction, which must be identified and resolved.

Post-Mastectomy Pain Syndrome: An Up-to-Date Review of Treatment Outcomes.

BACKGROUND: Post-mastectomy pain syndrome (PMPS) is a known debilitating surgical complication. While research on prevention, risk factors, and treatments have been conducted, there remains no cohesive treatment paradigm. The aim of our study is to synthesize the existing evidence on PMPS treatment, which may facilitate the implementation of standardized, effective management strategies. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a comprehensive search was developed and translated for MEDLINE, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and ClinicalTrials.gov. The databases were searched using a combination of free terms, phrase searching, and database-specific controlled vocabulary related to PMPS. All unique records were by two independent reviewers. Publications on chronic (>3 months duration) pain after breast cancer-related surgery were included. Limited case series, case reports, and editorials were not included. RESULTS: A total of 3402 articles from the years 1946-2019 resulted from the literature search after deduplication. Twenty-seven articles met final inclusion criteria for analysis, which revealed 10 major treatment modalities: fat grafting, neuroma surgery, lymphedema surgery, nerve blocks and neurolysis, laser, antidepressants, neuromodulators, physical therapy, mindfulness-based cognitive therapy, and capsaicin. CONCLUSIONS: In this review, we present a comprehensive assessment of the treatments available for PMPS that may help guide breast surgeons and reconstructive surgeons to employ the most effective treatment strategies for these patients. This review supports the importance of multimodal, multidisciplinary care in improving the management of PMPS.

Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication.

Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication. METHODS: Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last set of office photographs. RESULTS: Surgical site occurrence rate was 0% of the 40 patients in the mesh group and 19% of the 37 patients in the standard group (P = 0.005); rates of soft-tissue revision were 23% in the mesh group and 27% in the standard group (P = 0.84). As to aesthetics, the mesh abdominoplasty patients had mean statistically lower preoperative scores in comparison with the standard plication group (65.8 ± 11.6 versus 70.3 ± 11.4, P = 0.0013). The mesh group had a statistical improvement to 75.9 ± 12.6 (P < 0.0001), whereas the standard plication group improved to 82.5 ± 11.4 (P < 0.0001). CONCLUSIONS: Retrorectus mesh placement in a cohort of patients with severe rectus diastasis had a complication rate lower than that seen in a cohort of patients with less severe rectus diastasis, therefore negating our original hypothesis. This was done without compromising aesthetic improvement.

The Use of Botulinum Toxin to Prevent Anastomotic Thrombosis and Promote Flap Survival: A Bridge to Developing Clinical Studies.

BACKGROUND: Despite the possibility of using botulinum toxin to improve perfusion and prevent vasospasm, only a few studies have examined the use of botulinum toxin in the setting of flap surgery and thrombosis, and the mechanisms have not been fully explained. OBJECTIVE: The primary objective of this study was to provide a comprehensive review of the effectiveness of botulinum toxin in anastomotic thrombosis prevention and surgical flap survival to determine the value of conducting large-scale human trials. METHODS: Using the SYRCLE and CAMRADES criteria, a systematic review was performed. PubMed, Medline, EmBase, and the Cochrane Library were searched for studies that met our eligibility criteria. RESULTS: Twenty studies were included in the final selection. A total of 397 subjects were included. Eighteen studies used botulinum toxin type A alone, one used botulinum toxin type B alone, and only one used both botulinum toxin type A and botulinum toxin type B. The most commonly used injection technique was a preoperative intradermal injection. The most common procedure performed was a pedicled flap with random pattern skin flaps (65%). The mean injection dose was 28.17 ± 49.21 IU, whereas the mean reported injection time for studies using animal models was 7.4 ± 6.84 days. CONCLUSIONS: Similar mechanisms demonstrated in animal models may be replicable in humans, allowing botulinum toxin to be used to prolong flap survival. However, many factors, such as optimal injection techniques, dosages, and long-term outcomes of botulinum use in flap surgery, need to be further assessed before applying this to clinical practice.

Post-Mastectomy Pain Syndrome: Defining Perioperative Etiologies to Guide New Methods of Prevention for Plastic Surgeons.

From discussing the etiologies of post-mastectomy pain syndrome and potential methods of prevention, the next step is to create specific methods of prevention and to identify ways to measure their effects. With the increase in breast cancer related surgeries and increased survival after breast cancer patients, efforts must be made to prevent chronic pain and improve quality of life for these patients after surgery. The plastic surgeon, skilled in breast reconstruction and peripheral nerve reconstruction, may play a significant role in eliminating chronic pain after breast cancer related surgery.

Rethinking Upper Blepharoplasty: The Impact of Pretarsal Show.

BACKGROUND: Conventional upper blepharoplasty relies on skin, muscle, and fat excision to restore ideal pretarsal space-to-upper lid fold ratios. The purpose of this study was to identify presenting topographic features of upper blepharoplasty patients and their effect on cosmetic outcomes. METHODS: This is a retrospective review of patients who underwent upper blepharoplasty at the authors' institution from 1997 to 2017. Preoperative and postoperative photographs were standardized using Adobe Illustrator to an iris diameter of 11.5 mm. Pretarsal and upper lid fold heights were measured at five locations. Patients were classified into three groups based on preoperative pretarsal show: none, partial, or complete. Photographs were randomized in PowerPoint and given a cosmetic score of 0 to 5 by four independent reviewers. RESULTS: Three hundred sixteen patients were included, 42 men (13 percent) and 274 women (87 percent). Group 1 included 101 eyes (16 percent), group 2 had 159 eyes (25 percent), and group 3 had 372 eyes (59 percent). Mean cosmetic score increased from 1.75 to 2.38 postoperatively (p < 0.001), with a significantly lower improvement in scores in group 3 compared to groups 2 and 1 for both sexes (p < 0.01). For group 3, those with midpupil pretarsal heights greater than 4 mm had a significantly lower postoperative aesthetic score (1.95) compared with those less than or equal to 4 mm (2.50) (p < 0.001). CONCLUSIONS: Many patients presenting for upper blepharoplasty have complete pretarsal show and are at risk for worse cosmetic outcomes using conventional skin excision techniques. Adjunctive procedures such as fat grafting and ptosis repair should be considered in this group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Hostile Scalp Wound Reconstruction Using Acellular Dermal Matrix for Soft Tissue Augmentation.

The use of acellular dermal matrix (ADM) is well established in scalp burn reconstruction. However, its application in at-risk patients and hostile scalp wounds remains controversial and only described in the pediatric setting. This study aims to describe the pre-operative factors leading to the decision to use ADM in adult patients undergoing complex scalp reconstruction, and to describe the postoperative outcomes including wound breakdown and need for reoperation. This is a retrospective case series of patients undergoing scalp reconstruction with use of ADM. Data was collected from operations performed by a single surgeon over a period from January 2017 to October 2018. Nine patients underwent scalp reconstruction including placement of ADM during the study period. Seven patients were female, and median age was 64 years. Six patients had undergone prior craniotomies and three had undergone prior craniectomies for a variety of etiologies including neoplastic disease (n = 4), aneurysmal disease (n = 2), and trauma (n = 3). Wound breakdown or delayed wound healing necessitated reconstructive operations in all patients, 4 of whom had exposed/infected hardware that required removal. The median area of soft tissue defects was 30 cm. Two of the 4 patients with both benign and malignant tumors had been treated with radiation therapy, compromising the quality of the remaining adjacent scalp. Acellular dermal matrix was used in each setting to augment or buttress thin scalp. In 4 patients cranioplasty implants, hardware, or mesh were replaced concurrently. Two patients proceeded onto staged alloplastic cranioplasty without complication. Median follow up was 115 days. During follow up, only 1 patient suffered a major complication requiring reoperation to explant an osteomyelitic bone flap. Acellular dermal matrix can serve as an adjunct in hostile scalp reconstruction. Augmenting the areas of compromised scalp, especially over alloplastic cranioplasty material, can minimize the likelihood of future hardware exposure. Our study demonstrates its use in high-risk scalp wounds defined by frequent operation, chronic infection, and radiation.

Utilization of Intraparotid Segments of Superficial Temporal Vessels for Head and Scalp Free Flap Microanastomosis: A Clinical, Histological, and Cadaveric Study.

BACKGROUND: The superficial temporal vessels (STV) are an underutilized target for head and neck microvascular reconstruction. Most surgeons regard the dissection as difficult, unreliable, and the anastomosis prone to vasospasm. The intraparotid course of the STV may provide more reliable flow without accompanying morbidity. METHODS: A retrospective review of patients who underwent head and scalp free flap reconstruction utilizing STV intraparotid segment was performed. Demographic factors such as intraoperative and postoperative complications are reported. Five bilateral cadaver heads were dissected to describe the relationship to the facial nerve. STV histology was performed on four of the cadavers, noting intraluminal diameter and vessel wall thickness. RESULTS: Thirty-nine patients underwent free flap reconstruction with anastomosis to intraparotid STVs. Defect etiology included tumor resection (71.8%), traumatic brain injury (10.3%), intracranial bleed (12.8%), and acute trauma (5.1%). Flaps transferred included anterolateral thigh (51.3%), latissimus (33.3%), thoracodorsal artery perforator (7.7%), radial forearm (2.8%), and vastus lateralis (5.1%). Two flaps (5.1%) required takeback for arterial thrombosis, with one incidence of total flap loss (2.8%). There were no instances of transient or permanent facial nerve damage nor sialocele. On cadaver dissection, three distinct vessel segments were identified. Segments 1 and 2 represented the STVs superior to the upper tragal border. Segment 3 (intraparotid segment) began at the upper tragal border and STVs enlarged with a targeted anastomosis point at an average of 16.3 mm medial and 4.5 mm inferior to the upper border of the tragus. The frontal branch coursed 11.7 mm inferior and 11.5 mm anterior to this point. On histology, the intraluminal diameter of segment 3 was significantly larger than segment 2 (1.2 vs. 0.9 mm, p = 0.007). CONCLUSION: Head and neck free flap reconstruction with microanastomosis to the intraparotid segment of STVs can be safely and reliably performed.