Assessing the Effect of Time from Injection of Collagenase to Manipulation on Success Rates in Dupuytren Disease.

PURPOSE: Dupuytren disease can be managed with an injection of collagenase Clostridium histolyticum enzyme followed by manual manipulation. Although the recommended time from injection to manipulation is 24-72 hours, patient and physician schedules may not accommodate this time frame. Therefore, we sought to study the impact of time from injection to manipulation on outcomes and complications of collagenase injection. METHODS: We performed a review of 309 patients who underwent an injection of collagenase Clostridium histolyticum for Dupuytren disease with manipulation at two, five, or seven days after injection. We compared preinjection and postinjection contracture angles as well as frequency of skin tears and tendon ruptures. RESULTS: Of the 309 patients, 207 underwent manipulation at two days, 32 at five days, and 70 at seven days. Patients had similar preinjection contracture angles. All patients demonstrated improvement in contracture after manipulation. Rates of skin tears and tendon ruptures were similar in all three groups. Significant predictors of complications included number of cords injected and history of previous collagenase injection, but not history of previous Dupuytren diagnosis. CONCLUSIONS: Although collagenase injection for Dupuytren disease is typically performed with plans for manipulation at 24-72 hours, postinjection manipulation could be performed as late as seven days without adversely affecting the frequency of skin and tendon complications. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Initial Assessment of VECTRA Three-Dimensional Imaging to Accurately Simulate Breast Volume Changes in Transfeminine Patients: A Mannequin Study.

Background: Methods that aim to accurately measure and predict breast development can be utilized in gender-affirming treatment planning, patient education, and research. Objectives: The authors sought to evaluate whether three-dimensional (3D) stereophotogrammetry accurately measures transfeminine breast volume changes on a masculine frame when simulating anticipated changes in soft tissue after gender-affirming surgical therapy. Then, we describe the innovative application of this imaging modality in a transgender patient to illustrate the potential role of 3D imaging in gender-affirming surgical care. Methods: A 3D VECTRA scanner (Canfield, Fairfield, NJ) was used to measure anthropometric breast measurements. Postoperative changes in breast volume were simulated on a cardiopulmonary resuscitation mannequin using 450 cc MENTOR breast implants (Mentor Worldwide LLC, Irvine, CA). To demonstrate the ability of the VECTRA to accurately simulate transfeminizing augmentation in practice, we describe its use in a 30-year-old transgender female with a 2-year history of gender-affirming hormone therapy, presenting for gender-affirming surgical care. Results: In the mannequin, mean breast volumes were 382 cc on the right (range 375-388 cc), and 360 cc on the left (range 351-366 cc). The average calculated difference in volume between the 2 sides was 22 cc (range 17-31 cc). There were no instances where the left side was calculated to be larger than the right or where the calculated size was smaller than the actual implant size. Conclusions: The VECTRA 3D camera is a reliable and reproducible tool for preoperative assessment, surgical planning, and simulating breast volume changes after gender-affirming surgery.

Rating the Rater: A Technique for Minimizing Leniency Bias in Residency Applications.

Each program in the highly competitive match for a surgical residency needs a way to review applicants effectively. Often this task is undertaken by individual faculty members, reviewing an applicant's file and assigning a score. Despite being asked to rate on a standardized scale, our program found that ratings of the same applicants varied dramatically, with certain faculty consistently scoring higher or lower than others. This is termed leniency bias, or the Hawk-Dove effect, and can affect who is invited to interview depending on which faculty are assigned to review an applicant's file. Methods: A technique to minimize leniency bias was developed and applied to this year's 222 applicants for our plastic surgery residency. The effect of the technique was evaluated by comparing variance between ratings of the same applicants by different faculty before and after our technique. Results: The median variance of ratings of the same applicants reduced from 0.68 before correction to 0.18 after correction, demonstrating better agreement between raters of the applicants' scores after our technique had been applied. This year, applying our technique affected whether or not 16 applicants (36% of interviewees) were invited for interview, including one applicant who matched to our program but who otherwise would not have been offered an interview. Conclusions: We present a simple but effective technique to minimize the leniency bias between raters of residency applicants. Our experience with this technique is presented together with instructions and Excel formulae for other programs to use.

Airway Edema after Keloid Resection and Superficial Radiation: Unexpected Event in an Unusual Location.

Postoperative radiation therapy has been shown to significantly reduce recurrence rates of keloids after surgical excision. Adverse effects of radiation therapy in this setting are generally minimal because the radiation utilized quickly dissipates below the skin, and the radiation effects on the internal organs are usually negligible. This case report describes a patient who underwent excision of a wide anterior neck keloid and received postoperative external beam radiation therapy of the incision. She presented with extensive upper airway edema, dyspnea, and dysphagia requiring readmission and steroids. Re-evaluation of the radiation protocol revealed an inadvertent intersection of the multiple abutting radiation fields at the supraglottic region, resulting in tripling of the dose in the area, and likely leading to her complication. She did well with conservative management with IV steroids, and did not require intubation. She has had no long-term sequelae and no recurrence at 6 months postoperative.

Personal Safety of the Plastic Surgeon: Keeping Yourself Healthy While You Work.

LEARNING OBJECTIVES: After reading this study, the participant should be able to: 1. Recognize the primary physical and mental risks faced by the practicing plastic surgeon. 2. State the primary risk factors for cervical spine disease and back pain. 3. State the critical steps for protection from ionizing and nonionizing radiation. 4. List the characteristics of a surgeon exhibiting signs of burnout. 5. Develop a plan for mitigating personal risk of musculoskeletal, exposure, and other injuries. SUMMARY: Health care workers are exposed to significant occupational hazards, and have a risk of injury similar to that of construction, mining, and manufacturing employees. Plastic surgeons must have a clear understanding of the types of risks they face and the techniques for mitigating them. Exposure to some risks is attributable to unavoidable occupational conditions, but others can be avoided completely. The sources of injury risk from musculoskeletal, exposure, and other causes are discussed in this article, and evidence-based recommendations to ameliorate these risks are presented.

Eliminating Geographic Bias Improves Match Results: An Analysis of Program Preferences and Their Impact on Rank Lists and Results.

BACKGROUND: Previous studies have demonstrated that programs emphasize United States Medical Licensing Examination scores, publications, and geography in creating rank lists. The authors aimed to quantify the importance of geography and to determine how eliminating geographic preferences would affect Match outcomes. METHODS: The Match algorithm was implemented and validated on 6 years of deidentified data from the San Francisco Match (2009 to 2014). A "consensus" ranking was generated for each year-all applicants were ordered into a single list using Markov chain rank aggregation. Each program's rank list was reordered using the consensus list, and a new Match result was simulated. Statistical analysis was carried out with Microsoft Excel. RESULTS: Variation of program rank lists from the consensus rank list was driven by geography (training in the same medical center or state as the ranking program), "pedigree" (top 25 ranking of applicants' prior training), and foreign medical graduation status. Step 1 scores, publications, and medical school or residency region were not factors. The simulated Match resulted in a slight increase in the match rate. The median normalized number needed to match decreased from 6.7 to 6.5, and 80 percent of applicants had an unchanged or better result compared to the actual Match. CONCLUSIONS: Geography is the primary driver of variation between program rank lists. Removing this variation would result in fewer unfilled positions, no significant change in the average number needed to match, and improved Match outcomes for most applicants. Programs should critically evaluate whether their geographic biases reflect underlying information about applicant quality.

Defining Temporal Hairline Landmarks.

Brow dermoids are benign pediatric neoplasms. Endoscopic resection requires incisions placed within the temporal hairline, which is often difficult to reliably locate in infants. The authors studied adult and pediatric patients to define the location of the hairline in relationship to simple facial landmarks. Adult and pediatric patients who were seen in preoperative consultation for facial surgical procedures were identified and included in the study. Patients with a history of facial trauma, surgery, or congenital anomalies were excluded. Digital photographs were analyzed to measure corneal white-to-white diameter. Lines were drawn connecting the tragus to the lateral canthus and from the inferiormost aspect of the earlobe bisecting the first line (line A). The maximal distance between line A and the temporal hairline was recorded. One hundred sixteen patients met the inclusion criteria, 81 adults and 35 pediatric patients. Average age was 55.9 years in adults and 3.2 years in the pediatric group. Measurements were normalized to the corneal diameter. Average temporal hairline distance from line A was 25.0 mm in adults and 21.8 mm in the pediatric group. Hairline position was not correlated with age or sex. The temporal hairline can be reliably located relative to a line drawn from the inferior aspect of the earlobe to the midpoint of the line connecting the lateral canthus and tragus. The temporal hairline is within 30 mm of this line. When designing a temporal hairline incision in infants, it can be safely placed 30 mm or more posterior to this line to ensure a well-hidden scar.

Correlation between Facial Nerve Axonal Load and Age and Its Relevance to Facial Reanimation.

BACKGROUND: Two-stage facial reanimation procedures with a cross-facial nerve graft often have unsatisfactory results in the older patient. Although the cause of result variability is likely multifactorial, some studies suggest that increased donor nerve axonal load improves function of a free muscle transfer after a cross-facial nerve graft. This study attempts to characterize the relationship between age and facial nerve axonal load. METHODS: Sixty-three fresh cadaveric heads were dissected to expose the facial nerve. For each hemiface, two facial nerve samples were taken: one proximal as the nerve exits the stylomastoid foramen, and one distal at the buccal branch (at a point 1 cm proximal to the anterior parotid border). Nerve samples were stained and quantified. Correlation analysis was completed using a Pearson correlation coefficient. RESULTS: Thirty-six female and 27 male cadavers were dissected; their average age was 71 years (range, 22 to 97 years). At the proximal (r = -0.26; p < 0.01; n = 104) and distal (r = -0.45; p < 0.0001; n = 114) sampling points, there was a significant negative correlation between age and axonal load. CONCLUSIONS: As age increases, the axonal load of the facial nerve decreases at the buccal and zygomatic branches approximately 1 cm proximal to the anterior parotid border. The authors previously suggested this location as significant for cross-facial nerve coaptation. These results propose that decreasing axonal load can be a factor in the unsatisfactory outcomes of cross-facial grafting in the aging population. Moreover, this underscores the importance of recruiting more donor axons in attempting to improve facial reanimation in the older patient.

Versatility of the Profunda Artery Perforator Flap: Creative Uses in Breast Reconstruction.

BACKGROUND: Flaps based on the profunda artery perforators were first used for reconstruction of pressure sores, burn contractures, and extremity wounds. Recently, a revised profunda artery perforator flap was introduced for breast reconstruction. However, the flap is rarely used despite interesting reports on its use. The authors present their experience with the profunda artery perforator flap, describing its versatile applications in breast reconstruction. METHODS: The authors conducted a retrospective review of all patients of the lead author who underwent breast reconstruction with profunda artery perforator flaps before January of 2015. Patient demographics, perioperative data, and postoperative complications were recorded and analyzed. RESULTS: Seventy-three consecutive profunda artery perforator flaps were used to reconstruct 71 breasts. In 21 breasts, a profunda artery perforator flap was used in conjunction with another flap-with a deep inferior epigastric perforator flap (n = 18), a superior gluteal artery perforator flap (n = 1), or as stacked profunda artery perforator flaps (n = 2). The flap failure rate was 2.7 percent. There was one case of clinically apparent fat necrosis. There were no other major flap complications. Donor-site complications included cellulitis in two thighs (2.7 percent) and minor wound dehiscence in six thighs (8.2 percent). All donor-site complications healed satisfactorily by secondary intention without any additional procedures. CONCLUSIONS: The profunda artery perforator flap is a safe and versatile option for breast reconstruction. It can be combined with other flaps when additional volume or skin requirements are present. Flap and donor-site complications are comparable to other free tissue breast reconstruction options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facial Nerve Axonal Analysis and Anatomical Localization in Donor Nerve: Optimizing Axonal Load for Cross-Facial Nerve Grafting in Facial Reanimation.

BACKGROUND: Donor nerve axonal count over 900 in two-stage reconstructions using cross-facial nerve grafts is possibly associated with improved outcomes in facial reanimation. Facial nerve axonal analysis was performed to determine the ideal location for optimizing axonal load. Correlation of axonal number, branch diameter, and age was also assessed. METHODS: Twenty-eight fresh unpreserved cadaveric hemifaces were dissected exposing the extracranial facial nerve branches. Axonal counts at 2-cm intervals from the pes anserinus along branches inserting into the zygomaticus major muscle were taken, noting position relative to the zygomatic arch, posterior ramus border, lateral border of the zygomaticus muscle, and anterior parotid gland border. Nerves were fixed, sectioned, and stained with SMI-31 antineurofilament stain for digital axonal analysis. RESULTS: All specimens had one or more intraparotid zygomatic branches with over 900 axons, and 96 percent had an extraparotid branch with over 900 axons. The likelihood that a zygomatic branch would have over 900 axons at its last intraparotid point (mean, 6 mm posterior to the parotid border) was 92 percent (range, 67 to 100 percent) in contrast to 61 percent (range, 25 to 100 percent) when sampled at the first extraparotid point (mean, 14 mm anterior to the parotid border). Nerve cross-sectional area was positively correlated to its axonal count (R° = 78 percent; p < 0.0001), with nerve diameter over 0.6 mm predicting over 900 axons. Age did not correlate with axonal counts. CONCLUSIONS: Branches with adequate axonal load were found in all specimens. The likelihood of adequate branch selection improved from 61 percent to 92 percent with short retrograde intraparotid dissection. Nerve diameter correlated with axonal load.

Neurectomy for the Treatment of Chronic Postoperative Pain after Surgery of the Trunk.

BACKGROUND: Incidence of chronic postoperative neurogenic pain after open and laparoscopic trunk operations is reported between 1 and 20 percent, rendering a large population in the United States and worldwide. One possible treatment is selective surgical neurectomy. METHODS: All patients who underwent neurectomy for chronic trunk or groin postoperative neurogenic pain were identified. Based on individual history and examination, patients underwent neurectomies of the ilioinguinal, iliohypogastric, genitofemoral, lateral-femoral cutaneous, or intercostal nerves. Recorded preoperative pain levels (Likert score ranging from 0 to 10) were compared to postoperative pain levels and quality-of-life indices were assessed. RESULTS: Fifty-six patients (32 men and 24 women) were included. Mean age was 49 years. All patients underwent preoperative nerve blocks by either surgeon, radiologist, or referring physician, and had either complete or significant response defined as over 50 percent relief. Forty-five patients completed the survey. Median follow-up was 2.8 years (range, 1.0 to 5.7 years). Average pain level was 9.0 preoperatively and 3.5 postoperatively. Quality-of-life impairment improved from 8.3 preoperatively to 3.5 postoperatively. A subset of patients (n = 12) had minimal improvement, reporting a decrease in pain from 8.5 to 7.2 and quality-of-life improvement from 8.5 to 7.1. CONCLUSIONS: Complete avoidance of nerve injury during all trunk and groin operations is likely unattainable. When chronic postoperative neurogenic pain develops, neurectomy can be an effective means of treatment, significantly improving pain and quality of life in most patients. Better insight is necessary into a patient subset responding to nerve blocks yet experiencing minimal postoperative improvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Indian Nose.

Despite the growing number of rhinoplasty procedures being performed on Indian patients, there is a very limited body of literature regarding nuances of the Indian rhinoplasty. The authors review the spectrum of nasal phenotypes that fall under the category of the Indian nose; goals of rhinoplasty in these patients; operative techniques that can be used to address them; and, importantly, the specific pitfalls to be avoided in these groups.

Varied Definitions of Nasolabial Angle: Searching for Consensus Among Rhinoplasty Surgeons and an Algorithm for Selecting the Ideal Method.

BACKGROUND: The nasolabial angle (NLA) is an important aesthetic metric for nasal assessment and correction. Although the literature offers many definitions, none has garnered universal acceptance. METHODS: To gauge the consensus level among practitioners, surveys were administered to a convenience sample of rhinoplasty surgeons soliciting practice characteristics, self-assessment of rhinoplasty experience and expertise, and preferred NLA definition. Choices of NLA definition included the angle between: (A) columella and line intersecting subnasale and labrale superius; (B) columella and line tangent to philtrum; (C) nostril long axis and Frankfort perpendicular; and (D) nostril long axis and vertical facial plane. RESULTS: Of the 82 total respondents, mean age was 50 years (range, 30-80years), and mean professional experience was 17 years (range, 0-67 years). Nineteen described themselves as novice rhinoplasty surgeons, 27 as intermediates, and 36 as experts. Mean number of lifetime rhinoplasties performed was 966 (range, 0-10,000). Twenty respondents (24%) agreed with definition A, 27 (33%) with B, 16 (20%) with C, and 13 (16%) with D. Six chose "other," offering their own explanations of NLA. Self-identified novices were more likely to prefer definition D than were experts (P = 0.009). CONCLUSIONS: No majority consensus was reached regarding the definition of NLA. Each method has its benefits and drawbacks, and establishing a single one may be unnecessary and even counterproductive in some cases. Having options available means that surgeons can tailor to each encounter, as long as they adopt a systematic methodology. We submit an algorithm to facilitate this effort.

No-drain DIEP Flap Donor-site Closure Using Barbed Progressive Tension Sutures.

BACKGROUND: The use of progressive tension sutures has been shown to be comparable to the use of abdominal drains in abdominoplasty. However, the use of barbed progressive tension sutures (B-PTSs) in deep inferior epigastric artery perforator (DIEP) flap donor-site closure has not been investigated. METHODS: A retrospective chart review was performed on patients with DIEP flap reconstruction in a 3-year period at 2 institutions by 2 surgeons. Patients were compared by method of DIEP donor-site closure. Group 1 had barbed running progressive tension sutures without drain placement. Group 2 had interrupted progressive tension closure with abdominal drain placement (PTS-AD). Group 3 had closure with only abdominal drain placement (AD). Data collected included demographics, perioperative data, and postoperative outcomes. RESULTS: Seventy-five patients underwent DIEP reconstruction (25 B-PTS, 25 PTS-AD, and 25 AD). Patient characteristics-age, body mass index, comorbidities, smoking status, and chemotherapy-were not significantly different between groups. Rate of seroma was 1.3% (B-PTS = 0%, PTS-AD = 4%, AD = 0%), wound dehiscence 16% (B-PTS = 8%, PTS-AD = 16%, AD = 24%), and umbilical necrosis 5.3% (B-PTS = 0%, PTS-AD = 0%, AD = 16%). No hematomas were observed in any patients. No statistically significant difference was found between complication rates across groups. CONCLUSIONS: Use of B-PTSs for abdominal closure after DIEP flap harvest can obviate the need for abdominal drains. Complication rates following this technique are not significantly different from closure using progressive tension suture and abdominal drain placement. This practice can prevent the use of abdominal drains, which can promote patient mobility, increase independence upon discharge, and contribute to patient satisfaction.

Allergan Style 410 Implants for Breast Reconstruction: A Prospective Study in Efficacy, Safety, and Symmetry.

BACKGROUND: Implant-based breast reconstruction is performed with both saline and silicone. In 2001, a study was conducted in which a novel implant made of highly cohesive silicone gel in anatomical shape was used. It differs from others because it holds its anatomical shape and forces tissue to conform to the implant. METHODS: Two hundred twelve consecutive patients who underwent reconstruction with Allergan 410 cohesive gel anatomical implants were enrolled prospectively over a 12-year period. Complications and satisfaction rates were recorded. RESULTS: Average age of the patients was 48.5 years and average body mass index was 24.1 kg/m. Bilateral reconstruction was performed in 83 percent of patients. Long-term follow-up was achieved in all patients and averaged 3.3 years (range, 0.5 to 10.2 years). The overall complication rate was 19.8 percent; most were minor complications, such as rippling (9.4 percent) and asymmetry (4.2 percent). Major complications included infection (2.4 percent), malposition (1.4 percent), capsular contracture (0.9 percent), seroma (0.5 percent), extrusion (0.5 percent), and implant rupture (0.5 percent). The rate of implant-related reoperation, excluding cancer recurrence, was 9.0 percent, consisting of implant replacement (5.7 percent), implant removal (1.9 percent), and implant repositioning (1.4 percent). Patient satisfaction averaged 4.83 (range, 2 to 5) on a five-point scale. Surgeon satisfaction averaged 4.9 (range, 2 to 5). CONCLUSIONS: Allergan 410 cohesive gel anatomical implants have a favorable risk profile in reconstruction, with excellent patient and surgeon satisfaction. This novel implant allows for a paradigm shift in implant-based breast reconstruction. Surgeons can now use an implant to help shape the final contour of the breast mound rather than rely on mastectomy flaps and suture techniques to create aesthetic contours needed to create an attractive breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Role of the Cephalic Trim in Modern Rhinoplasty.

There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.

The Profunda Artery Perforator Flap: Investigating the Perforasome Using Three-Dimensional Computed Tomographic Angiography.

BACKGROUND: The profunda artery perforator flap has been emerging as an alternative method of autologous breast reconstruction. This flap uses upper posterior thigh tissue. The profunda artery perforator perforasome is investigated using three-dimensional computed tomographic angiography. METHODS: Ten cadaveric thighs were dissected centered over the profunda artery perforator. The perforator was injected with contrast medium and the flap was then subjected to computed tomographic scanning using a GE Lightspeed 16-slice scanner. The three-dimensional images were viewed, and measurements were obtained using Aquarius software, including horizontal and vertical extensions of the flap and areas of perfusion. Clinical examples are presented. RESULTS: A profunda artery perforator (occasionally two) was consistently found in the upper medial thigh region, posterior to the gracilis muscle. The area of vascularity shown by the spread of contrast extends inferiorly beyond the usual lower border of the profunda artery perforator flap, which is usually 7 cm wide. In injected cadaveric flaps, the mean horizontal dimension was 16.7 cm and the mean vertical dimension was 16.5 cm. The mean area perfused was 8812 cm. CONCLUSIONS: The profunda artery perforator flap is a vascularly sound flap, and is a good option for autologous breast reconstruction. Advantages include a reliable pedicle, no position changes required, and possibly an improved donor-site contour from a thigh lift. It is an excellent alternative to abdominally based free flaps and can also be used in conjunction with other flaps for further volume enhancement.