Optimizing the Use of Autografts, Allografts, and Alloplastic Materials in Rhinoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the autologous graft options available to the rhinoplasty surgeon, including septal cartilage, auricular cartilage, costal cartilage, and bone. 2. Understand the autograft and allograft options available to the rhinoplasty surgeon, including cadaveric costal cartilage, silicone, Medpor, and Gore-Tex. 3. Identify the ideal situations to use each of these implant materials. 4. Understand the advantages and disadvantages of the different autografts, allografts, and implants in rhinoplasty. SUMMARY: This review focuses on the graft options available to the modern rhinoplasty surgeon. Autologous options are varied in the quality of cartilage harvested and the morbidity of the donor site. In addition, surgeons should understand the allograft options should autologous grafting be unfeasible or undesirable. New technological advances in processing of allograft cartilage makes this an attractive secondary option.

Internal Mammary Lymph Node Biopsy during Microsurgical Breast Reconstruction: A Prospective Study.

BACKGROUND: Accurate assessment of regional lymph node basins is critical for oncological management of breast cancer. The internal mammary lymph node (IMLN) basin directly drains the medial pole of the breast, but biopsy is not commonly performed. While the axillary sentinel lymph node sample remains the standard of care, the majority of patients who have been found to have a positive IMLN biopsy have simultaneously had negative axillary sentinel lymph nodes. This study prospectively examines routine IMLN biopsy during microsurgical breast reconstruction. METHODS: An IRB-approved study of routine IMLN biopsies in 270 consecutive patients who underwent microsurgical breast reconstruction was performed from July 1, 2018, to June 1, 2021. Recorded data included unilateral or bilateral breast reconstruction, unilateral or bilateral IMLN sampling, patient demographics, disease stage, and pathologic findings of IMLN. RESULTS: The majority of patients, 240 of 270 patients (88.9%), had bilateral reconstruction. Overall, 5 out of 270 (1.9%) patients had positive IMLN; one of these patients had positive axillary sentinel lymph nodes. The IMLN biopsy results in two of the five patients affected the clinical course as they were upstaged and required chemoradiation. CONCLUSION: Direct visualization of the internal mammary lymph nodes during dissection of the recipient vessels for microsurgical breast reconstruction allows for convenient sampling, with minimal donor site morbidity and enhances the therapeutic management of patients in whom nodal involvement is present. As such, the authors recommend IMLN sampling.

Is There Gender Inequality in Plastic Surgery? Evaluation of Society Leadership and Composition of Editorial Boards.

BACKGROUND: Women now constitute 40.5 percent of integrated plastic surgery residents; however, in 2007, women represented only 11.3 percent of the leadership positions in plastic surgery societies and journal editorial boards. The authors analyzed female representation in these societies and editorial boards over the past 10 years. METHODS: Names of board members from the major plastic surgery societies (American Society of Plastic Surgeons, The Plastic Surgery Foundation, and American Society for Aesthetic Plastic Surgery, among others) for the past 10 years and the major plastic journals (Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and so on) from the past 5 years were extracted from their websites. The yearly percentage of female plastic surgery residents was obtained from Accreditation Council for Graduate Medical Education published data. The proportions of women in society leadership, editorial boards, and residency were compared with data analyses of time series trend and linear and Auto Regressive Integrated Moving Average time series modeling. RESULTS: Over the past 10 years, the percentage of female residents has grown steadily, from 21.84 percent to 37.31 percent. Similarly, female representation in society leadership has grown from 6.78 percent to 20.29 percent. Both growth coefficients were statistically significant and showed no statistical difference between the two. In contrast, editorial board leadership over the past 5 years showed statistically insignificant growth and showed a statistically significant difference when compared to the growth of the percentage of female residents and female representation in society leadership. CONCLUSION: Female representation in plastic surgery society leadership shows promising growth, whereas their representation on editorial boards showed significantly less growth, which may reflect the slower turnover on these boards.

Does Fracture Pattern Influence Functional Outcomes in the Management of Bilateral Mandibular Condylar Injuries?

The purpose of this study was to compare the functional outcomes of different types of bilateral mandibular condylar fractures. This was a retrospective study of patients with bilateral mandibular condylar fractures at a level-1 trauma center over a 15-year period. The primary predictor variable was fracture pattern, classified as type I (bilateral condylar), type II (condylar-subcondylar), or type III (bilateral subcondylar). Secondary predictor variables were demographic, injury-related, and treatment factors. Bivariate associations between the predictors and complication rates were computed; a multiple logistic regression model was utilized to adjust for confounders and effect modifiers. Thirty-eight subjects with bilateral condylar injuries met the inclusion criteria. The sample's mean age was 37.6 + 18.2 years, and 16% were female. The most common mechanisms of injury were motor vehicle collisions (53%) and falls (29%). Seventy-four percent had associated noncondylar mandibular fractures, and 32% of cases had concomitant midface fractures. Fifty-three percent of cases were classified as type I, 21% as type II, and 26% as type III. Ten subjects (26%) were managed with open reduction and internal fixation. The average length of follow-up was 4.5 + 6.3 months. After adjusting for confounders and effect modifiers, the type of fracture was a significant predictor of functional complications with type II injuries having the highest likelihood of a poor functional outcome (odds ratio: 7.77, 95% confidence interval: 1.45-41.53, p = 0.02). Asymmetric bilateral mandibular condylar fractures may be associated with an increased risk of poor functional outcomes.

Risk-to-Benefit Relationship of Contralateral Prophylactic Mastectomy: The Argument for Bilateral Mastectomies with Immediate Reconstruction.

BACKGROUND: The increasing trend of women with unilateral breast cancer to electively undergo contralateral prophylactic mastectomy in addition to treatment of the index breast has been controversial. The authors set out to better frame the risks and benefits of contralateral prophylactic mastectomy in the treatment of unilateral breast cancer by evaluating outcomes of a large, consecutive cohort of patients. METHODS: An institutional review board-approved review of a single-surgeon (N.T.) experience (2013 to 2018) was conducted of all consecutive patients with unilateral breast cancer treated with mastectomy and immediate reconstruction. Patient characteristics, surgical pathologic results, and 30-day complications were assessed. Outcomes of patients with unilateral cancer who underwent unilateral mastectomy versus bilateral mastectomy (with one breast being contralateral prophylactic mastectomy) were compared. Logistic regression models evaluated various risk factors for potential associations with positive pathologic findings in the contralateral prophylactic mastectomy specimen and/or postoperative complications. RESULTS: Of 244 patients, 68 (27.9 percent) underwent unilateral mastectomy and 176 (72.1 percent) underwent contralateral prophylactic mastectomy. Surgical pathologic results of the prophylactic breast revealed occult ductal carcinoma in situ or invasive cancer in 13 patients (7.3 percent) and lobular carcinoma in situ in eight patients (4.6 percent). Incidence of complications was similar between groups [unilateral mastectomy, 19.12 percent (n = 13); contralateral prophylactic mastectomy, 13.07 percent (n = 23); p = 0.234]. CONCLUSIONS: Immediate reconstruction for unilateral mastectomy and contralateral prophylactic mastectomy have similar complication risk profiles, among patients as a whole and between individual breasts. These findings contribute to our understanding of the clinical impact prophylactic mastectomy and reconstruction may have on optimizing the counseling among extirpative surgeons, reconstructive surgeons, and patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Minimally Invasive Approach for Resection of Masseteric Vascular Malformations.

OBJECTIVE: Vascular malformations (VMs) in the head and neck region often cause esthetic as well as functional problems for patients. Intramuscular VMs (IVM), such as those in the masseter, can cause severe facial asymmetry and typically are excised transcutaneously to facilitate wide exposure and safe dissection from the facial nerve. This requires extensive dissection, prolonged healing, and can lead to suboptimal facial scarring. METHODS: We describe the technique of resecting large IVMs of the masseter muscle in 3 patients using an entirely intraoral approach with continuous nerve monitoring and without visible facial scarring or secondary deformity. Preoperative injection of sclerotherapy was performed to reduce intra-operative bleeding and optimize resection. RESULTS: Successful excision was performed without complication in 3 patients to date. Total average operating room time was 120 minutes (range 95-145 minutes). Estimated blood loss was 213 mL (range 180-240 mL). The patients were discharged home either post-operative day (POD) 1 or 2, with 1 returning to work POD 4. Facial nerve function was normal postoperatively and no hematomas developed. Subjective masticatory function was equivalent to preoperative levels in all patients. CONCLUSIONS: Intraoral excision of VMs of the masseter muscle can be safely performed without added risk or complication. Continuous facial nerve monitoring allows minimally invasive approaches to be considered with less risk of iatrogenic facial nerve injury. We purport that this is a safe and effective method with substantially better esthetic outcomes compared with traditional transcutaneous approaches.

Which Factors Are Associated with Open Reduction of Adult Mandibular Condylar Injuries?

BACKGROUND: The purpose of this study was to identify factors associated with the decision to perform open reduction and internal fixation of mandibular condylar fractures. METHODS: This was a retrospective cohort study of patients with mandibular condylar fractures managed by the plastic and reconstructive surgery, oral and maxillofacial surgery, and otorhinolaryngology services over a 15-year period. Bivariate associations and a multiple logistic regression model were computed for injury characteristics that were associated with open reduction and internal fixation. For all analyses, a value of p ≤ 0.05 was considered significant. RESULTS: Six hundred fifty-four condylar injuries were identified in 547 patients. The sample's mean age was 36.0 ± 16.5 years, 20.5 percent were women, and 63 percent were Caucasian. The most common mechanisms of injury were motor vehicle collisions (49 percent), 53.4 percent involved the subcondylar region and 20 percent were bilateral injuries. Associated noncondylar mandibular fractures were present in 60 percent of cases; 20.7 percent were managed with open reduction and internal fixation. The overall complication rate was 21.6 percent. In a multiple logistic regression model, factors associated with an increased likelihood of open reduction and internal fixation were the presence of extracondylar mandibular injuries, condylar neck or subcondylar region injuries, increasing dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery (p ≤ 0.04). CONCLUSIONS: Increasing severity of mandibular injury, lower level of fracture, joint dislocation, and treatment by plastic and reconstructive surgery/oral and maxillofacial surgery are associated with open reduction and internal fixation of mandibular condylar injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Extracapsular Mandibular Condyle Fractures Are Associated with Severe Blunt Internal Carotid Artery Injury: Analysis of 605 Patients.

BACKGROUND: Mandibular condyle fractures are common following facial trauma and carry an increased risk for concomitant blunt carotid artery injuries. Further elucidation of this relationship may improve vascular injury screening and management. METHODS: A retrospective cohort study was performed for all patients sustaining condylar fractures presenting to a large trauma center over twelve years. Fracture locations were classified according to the Strasbourg Osteosynthesis Research Group (1, condylar head; 2, condylar neck; and 3, extracapsular condylar base). Carotid artery injury severity was based on the Biffl scale. Severe vascular injury was defined as a Biffl score greater than I. RESULTS: 605 patients were identified with mandibular condyle fractures consisting of 21.0 percent (n = 127) condylar head; 26.8 percent (n = 162) condylar neck; and 52.2 percent (n = 316) extracapsular condylar base. The incidence of vascular injuries in this population was 5.5 percent (n = 33), of which 75.8 percent (n = 25) were severe. Severe vascular injuries occurred in 1.6 percent (n = 2) of condylar head, 2.5 percent (n = 4) of condylar neck, and 6.0 percent (n = 19) of extracapsular condylar base fractures (p < 0.05). Extracapsular condylar base fractures were independently associated with a 2.94-fold increased risk of a severe blunt carotid artery injury compared with other condyle fractures on multivariable analysis (p < 0.05). CONCLUSIONS: Extracapsular subcondylar fractures should heighten suspicion for concomitant blunt carotid artery injury. The data support a force transmission mechanism of injury in addition to direct injury from bony fragments. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Risk, II.

Classification of mandible defects and algorithm for microvascular reconstruction.

BACKGROUND: Composite mandibular tissue loss results in significant functional impairment and cosmetic deformity. This study classifies patterns of mandibular composite tissue loss and describes a microvascular treatment algorithm. METHODS: A retrospective review of microvascular composite mandibular reconstruction from July of 2005 to April of 2013 by the senior surgeon at the R Adams Cowley Shock Trauma Center and at The Johns Hopkins Hospital yielded 24 patients with a mean follow-up of 17.9 months. Causes of composite mandibular defects included tumors, osteoradionecrosis, trauma, infection, and congenital deformity. Patients with composite tissue loss were classified according to missing subunits. RESULTS: A treatment algorithm based on composite mandibular defects and microvascular reconstruction was developed and used to treat 24 patients. A type 1 defect is a unilateral dentoalveolar defect not crossing the midline and not extending into the angle of the mandible. A type 2 defect is a unilateral defect extending beyond the angle. A type 3 defect is a bilateral defect not involving the angles. A type 4 defect is a bilateral defect with extension into at least one angle. Type 2 defects were the predominant group. Patients had microvascular reconstruction using either fibula flaps (n = 19) or iliac crest flaps (n = 5). Complications included infection, partial necrosis, plate fracture, dehiscence, and microvascular thrombosis. CONCLUSION: This novel classification system and treatment algorithm allows for a consistent and reliable method of addressing composite mandibular defects and focuses on recipient vasculature and donor free flap characteristics.

Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the current data.

BACKGROUND: Microvascular reconstruction is the mainstay of treatment in complex scalp defects. The rate of elderly patients requiring scalp reconstruction is increasing, but outcomes in elderly patients are unclear. The purpose of this study was to systematically review the literature pertaining to free tissue transfer for scalp reconstruction in patients older than 65 years to compare outcomes among different free flaps and determine the safety profile of treatment. METHODS: A systematic review of the available literature of patients undergoing microvascular scalp reconstruction was completed. Details for patients 65 years and older were extracted and reviewed for data analysis. RESULTS: A total of 45 articles (112 patients) were included for analysis. Mean age of the patients was 73.3 ± 6.3 years (men, 69.4 percent; women, 23.4 percent; not reported, 7.2 percent). Mean flap size was 598 cm2 (range, 81 to 2500 cm2). The mean age of patients developing a complication was 72.8 ± 6.4 years and patients that did not develop a complication was 73.4 ± 5.5 years (p = 0.684). Overall, periprocedural mortality was 0.9 percent. Flap failures occurred in two cases (1.8 percent). The overall complication rate was 22.3 percent (n = 25). Complications by flap type varied without reaching statistical significance. CONCLUSIONS: Microvascular reconstruction in complex scalp defects is associated with successful outcomes, and chronologic age does not increase mortality or catastrophic flap complications. The most common flaps used to repair scalp defects are anterolateral thigh and latissimus dorsi, but a superior flap type could not be identified.

Chest wall, thymus, and heart vascularized composite allograft proof of concept cadaveric model for heart transplantation.

The use of vascularized composite allografts allows for the reconstruction of complex scenarios that previously have required multistaged operations. Heart transplantation often follows a series of previous operations leading to chest wall deformities and significant mediastinal adhesions that can limit the use of larger hearts, making it difficult to find a suitable donor. Further, research has shown that the use of vascularized bone marrow and vascularized thymus in transplantation potentially prolongs graft survival with decreased immunosuppression requirements. The authors propose using a vascularized composite allograft of the chest wall consisting of sternum and thymus in conjunction with the heart for cardiac transplantation to allow for more flexibility from the donor pool, maintain chest wall integrity and physiology, and potentially immunoregulate the concomitant solid organ transplant.