Preventing Hump Recurrence in Dorsal Preservation Rhinoplasty: The Five Key Tenets.

SUMMARY: Preservation rhinoplasty has re-emerged over the past decade and continues to gain traction in the rhinoplasty community. Dorsal preservation rhinoplasty (DPR), one of the tenets of preservation rhinoplasty, centers on preservation of the native osseocartilaginous joint of the dorsum, with changes instead achieved through modification of the underlying septal cartilage and surrounding bony nasal pyramid. However, one complication unique to DPR is the phenomenon of hump recurrence, where tensile forces or memory lead to a recurrent convexity of the dorsal hump. Hump recurrence is the most common complication after DPR and often requires revisionary surgery. Accordingly, strategies to reduce the incidence of hump recurrence are highly sought after. In this article, we describe the senior author's main tenets of preventing hump recurrence in DPR, focusing on 1. Appropriate patient selection; 2. Addressing anatomic blocking points; 3. Adding mechanical fixation of the cartilaginous vault with suture techniques depending on the level of septal manipulation; 4. Applying a graduated approach to DPR procedural selection; and 5. Ancillary measures to control the shape of the nasal dorsum. Implementation of each of these five tenets is critical for modern rhinoplasty surgeons to reduce the incidence of hump recurrence in their preservation rhinoplasty practices.

Machine learning analysis of online patient questions regarding breast reconstruction.

BACKGROUND: Social media has become a dominant educational resource for breast reconstruction patients. Rather than passively consuming information, patients interact directly with other users and healthcare professionals. While online information for breast reconstruction has been analyzed previously, a robust analysis of patient questions on online forums has not been conducted. In this study, the authors used a machine learning approach to analyze and categorize online patient questions regarding breast reconstruction. METHODS: Realself.com was accessed and questions pertaining to breast reconstruction were extracted. Data collected included the date of question, poster's location, question header, question text, and available tags. Questions were analyzed and categorized by two independent reviewers. RESULTS: 522 preoperative questions were analyzed. Geographic analysis is displayed in Figure 1. Questions were often asked in the pre-mastectomy period (38.3%); however, patients with tissue expanders currently in place made up 28.5%. Questions were often related to reconstructive methods (23.2%), implant selection (19.5%), and tissue expander concerns (16.7%). Questions asked in the post-lumpectomy period were significantly more likely to be related to insurance/cost and reconstructive candidacy (p < 0.01). The "Top 6″ patient questions were determined by machine learning analysis, and the most common of which was "Can I get good results going direct to implant after mastectomy?" CONCLUSIONS: Analysis of online questions provides valuable insights and may help inform our educational approach toward our breast reconstruction patients. Our findings suggest that questions are common throughout the reconstructive process and do not end after the initial consultation. Patients most often want more information on the reconstructive options, implant selection, and the tissue expansion process.

Refinements in Extended Alar Contour Grafts: Retrograde Approach in Conjunction with Alar Base Surgery.

SUMMARY: Alar contour grafts are an excellent adjunct in both primary and revision rhinoplasty for correction and prevention of alar rim irregularities. They are traditionally placed at the conclusion of a rhinoplasty through a vestibular incision along the underside of the alar rim. Alternatively, alar base resection provides an opportunity for precise retrograde placement of alar contour grafts. The purpose of this article is to describe an efficient, five-step technique for retrograde placement of alar contour grafts in the setting of concomitant alar base surgery.

The Blocking Points: The Keys to Consistent Success in Preservation Rhinoplasty.

SUMMARY: Preservation rhinoplasty is a growing area of interest amongst rhinoplasty surgeons. Dorsal preservation-a tenet of preservation rhinoplasty-is predicated on maintaining the integrity of the nasal midvault and effecting aesthetic change through alterations to the bony nasal pyramid and underlying septum. A challenge that is unique to dorsal preservation is the phenomenon of hump recurrence, owing to the existence of anatomical blocking points. Blocking points are resistant tensile forces that either impede dorsal lowering intraoperatively or push the dorsum back to its native convexity over time. Five anatomical blocking points have previously been described, which the authors expand upon and include an additional two. The seven anatomical blocking points are: the cartilaginous septum, perpendicular plate of the ethmoid, lateral osteotomy site, Webster's triangle, internal mucoperiosteum of the maxillary bone, medial canthal ligament, and the lateral keystone area. It is critical that the surgeon be aware of the particular blocking points relevant to his or her chosen technique, and to appropriately and methodically address them to ensure consistent long-term results.

An Evidence-Based and Case-Based Comparison of Modern Face Lift Techniques.

BACKGROUND: Facial aging is a multifactorial process that affects each component of facial anatomy. The two general groups of face lift techniques are superficial musculoaponeurotic system (SMAS) elevation and SMAS manipulation. The purpose of this article is to describe and compare the advantages, disadvantages, and limitations of face lift techniques. METHODS: A systematic review was performed to describe current outcomes evidence for face lift techniques. A subcohort of articles was selected for case-based analysis based on designated facial assessment criteria. Analysis was performed to determine the advantages, disadvantages, and limitations of each respective technique. RESULTS: A total of 65 articles were selected for systematic review, of which 15 met criteria for case-based review. Patient satisfaction was found to be equivocal for various face lift techniques. Specific advantages and disadvantages for each face lift technique were dependent on the techniques' approach to skin shift vector along with its degree of mobilizing superficial facial fat. Facial fat grafting was universally applicable for restoration of deep malar volume. Facial fat grafting was also used differently depending on the SMAS technique to address its specific limitations. CONCLUSIONS: The authors' review confirms that there are many methods to obtain excellent outcomes in facial rejuvenation. Experienced surgeons are able to obtain consistent results through a variety of techniques based on understanding the aesthetic needs of the individual patient, the quality of the soft tissues being manipulated, and how to vary a specific technique to reach desired aesthetic end points.

Defining Our Terms: Are Postoperative Complications Adequately Defined in the Rhinoplasty Literature?

BACKGROUND: Rhinoplasty is one of the most common aesthetic surgical procedures, and yet its postoperative complication profile remains somewhat ill-defined and underreported. The purpose of this study was to examine the quality of complication reporting in the rhinoplasty literature and provide a framework for future complication classification. METHODS: Studies were identified from a previously published 2019 systematic review conducted at Duke University Medical Center. Each included study was again reviewed to determine the reported complications and definitions. Reported complications were analyzed to determine occurrence rate, definition presence/absence, definition location, subjectivity/objectivity, and presence of severity grading system. RESULTS: A total of 30 studies were included. Overall, 63% (n = 19) of studies failed to provide a single definition for any reported complications. The remaining 11 studies (37%) provided at least one definition for their reported complications. Grading/severity scales were included by 8 studies. A specific complication was identified as a "primary outcome" in 15 cases. Definitions were included for 11 (73%) of these 15 complications. Complications denoted as "primary outcomes" were significantly more likely to have an included definition (p <0.01). CONCLUSIONS: Postoperative complications following rhinoplasty are inadequately defined in the available literature, with over sixty percent of studies failing to define a single-reported complication. When complication definitions are included, they are often subjective in nature and rarely include a grading or severity scale. In the absence of standardized rhinoplasty complication definitions, comparing complication rates across studies is exceedingly difficult, and the ability to conduct high-quality meta-analyses is limited. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Primary Targeted Muscle Reinnervation after Below-Knee Amputation Is Not Associated with an Increased Risk of Major or Minor Surgical Complications: A Multi-Institutional, Propensity Score-Matched Analysis.

BACKGROUND: Targeted muscle reinnervation has emerged as a technique to reduce neuroma and phantom limb pain after below-knee amputation; however, the incidence of postoperative complications remains unknown. This multi-institutional study assessed the risk of postoperative complications among patients who underwent targeted muscle reinnervation at the time of below-knee amputation. METHODS: Patients who underwent below-knee amputation with targeted muscle reinnervation were propensity score-matched 1:3 to patients who underwent below-knee amputation alone. Study outcomes included the incidence of major or minor complications within 60 days. Regression models were used to estimate the relative risk of major and minor complications. RESULTS: Overall, 96 patients were matched, including 31 patients who had below-knee amputation with targeted muscle reinnervation and 65 who had below-knee amputation alone. In the matched sample, a higher incidence of major complications (29 percent versus 24.6 percent), readmission (25.8 percent versus 18.5 percent), and reoperation (19.4 percent versus 10.8 percent) was seen after both procedures compared with below-knee amputation alone. Patients who underwent both procedures displayed a higher incidence of minor complications (25.8 percent versus 20.0 percent), blood transfusion (22.6 percent versus 18.5 percent), and wound healing complications (45.2 percent versus 33.8 percent) and longer operative time (mean ± SD, 188.5 ± 63.6 minutes versus 88 ± 28.2 minutes). There was no statistically significant difference in the risk of major (relative risk, 1.20; 90 percent CI, 0.68, 2.11) or minor (relative risk, 1.21; 90 percent CI, 0.61, 2.41) complications between the two cohorts. CONCLUSIONS: Despite an increased incidence of postoperative complications, undergoing below-knee amputation with targeted muscle reinnervation does not confer a statistically significant increased risk of major or minor complications. Future studies are needed to delineate patient selection criteria when assessing the suitability of targeted muscle reinnervation at the time of major limb amputation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Leadership and Advanced Degrees: Evaluating the Association Between Dual Degrees and Leadership Roles in Academic Plastic Surgery.

BACKGROUND: There are increasingly prevalent formal educational programs for physicians who seek to be better trained to advance their fields. Although higher education and advanced degrees are not necessarily linked to leadership, we hypothesize that leaders in plastic surgery commonly have dual degrees. We sought to evaluate the prevalence of and association between additional advanced degrees in academic plastic surgery and plastic surgery leadership. METHODS: Plastic surgery faculty from 96 academic training programs and all executive committee and board of directors' members from national, regional, and local plastic surgery societies were evaluated. Surgeons' institutional online profile pages, personal web pages, societal websites, and LinkedIn profiles were all evaluated for current/past leadership roles, as well as for advanced degree. Odds ratios (ORs) were used to determine if the presence of extra degrees increased their likelihood of leadership roles. RESULTS: A total of 1036 plastic surgeons were evaluated. Sixteen percent of academic faculty have a dual degree. Furthermore, 25.5% of plastic surgeons holding formal academic leadership roles have a dual degree (OR, 2.15; P = 0.043), as do 34.4% of those serving on the executive committee or board of directors in national plastic surgery societies (OR, 2.23; P = 0.026) and 29.2% of those serving in local/regional societal leadership roles (OR, 1.96; P = 0.043). Among all dual degrees, Masters in Business Administration has the highest association with leadership roles (OR, 3.45; P = 0.002). CONCLUSIONS: Academic plastic surgeons with dual degrees are approximately twice as likely to hold a formal academic or societal leadership role. Additional studies are needed to determine if causative relationships exist.

Cutaneous Reconstruction of the Nasal Distal Third: Alternative Local Flaps for a Complex Region.

Small-to-medium cutaneous defects of the distal nose pose a significant challenge to reconstructive surgeons, and commonly described reconstructive techniques have their limitations. As the skin of this region is characteristically rigid and sebaceous, care must be taken to avoid introducing unfavorable tension vectors that can result in functional or anatomic distortion of the nasal free margins. With this in mind, the authors discuss 3 alternative reconstructive options, the East-West, nasalis sling, and trilobed flaps, which have wide utility in the repair of distal nasal cutaneous defects and can result in excellent cosmesis. The indications, surgical technique, and limitations of each are discussed in detail, and are compared with several of the more commonly described options in the context of distal nasal reconstruction.

Two or Three? Approaches to Staging of the Paramedian Forehead Flap for Nasal Reconstruction.

The paramedian forehead flap is a historic cornerstone of plastic surgery and a mainstay of complex nasal reconstruction. Although initially described as a 2-stage procedure, several procedural advancements and modifications have been proposed, with the most notable being the addition of a third, intermediate stage. Proponents of this 3-stage approach argue that the addition of an intermediate stage improves flap perfusion, expands lining and structural support options, and provides superior aesthetic outcomes. Although this technique has grown in popularity, studies comparing the 2- versus 3-stage approach are relatively scarce in the literature. Existing comparative studies seem to suggest that the 3-stage paramedian forehead flap may have advantages in large, complex nasal defects and patients at high risk for vascular compromise. Additionally, comparative analyses with respect to aesthetic outcome were found to be largely equivocal, suggesting that surgeon comfort and preference should guide flap selection.

A Comparison of Surgical Complications in Patients Undergoing Delayed versus Staged Tissue-Expander and Free-Flap Breast Reconstruction.

BACKGROUND: Patients undergoing mastectomy may not be candidates for immediate free-flap breast reconstruction because of medical comorbidities or postmastectomy radiation therapy. In this setting, flap reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" reconstruction). The optimal reconstructive choice and incidence of complications for these approaches remain unclear. METHODS: The authors retrospectively identified patients who underwent delayed [n = 140 (72 percent)] or staged [n = 54 (28 percent)] abdominal free-flap breast reconstruction between 2010 and 2018 and compared the incidence of postoperative complications. RESULTS: Patients undergoing staged reconstruction had a higher overall incidence of perioperative complications, including surgical-site infection (40.7 percent versus 6.5 percent; p < 0.001), wound healing complications (29.6 percent versus 12.3 percent; p = 0.004), hematoma (11.1 percent versus 0.7 percent; p < 0.001), and return to the operating room (27.8 percent versus 4.4 percent; p < 0.0001). These complications occurred predominately during the expansion stage, resulting in an 18.5 percent (n = 10) rate of tissue expander failure. Mean time from mastectomy to flap reconstruction was 476.8 days (delayed, 536.4 days; staged, 322.4 days; p < 0.001). At the time of flap reconstruction, there was no significant difference in the incidence of complications between the staged cohort versus the delayed cohort, including microsurgical complications (1.9 percent versus 4.3 percent; p = 0.415), total flap loss (0 percent versus 2.1 percent; p = 0.278), or fat necrosis (5.6 percent versus 5.0 percent; p = 0.875). CONCLUSIONS: The aesthetic and psychosocial benefits of staged free-flap breast reconstruction should be balanced with the increased risk of perioperative complications as compared to a delayed approach. Complications related to definitive flap reconstruction do not appear to be affected by the approach taken at the time of mastectomy. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

An Assessment of Patient Satisfaction and Decisional Regret in Patients Undergoing Staged Free-Flap Breast Reconstruction.

BACKGROUND: In the setting of radiation therapy or significant medical comorbidities, free-flap breast reconstruction may be intentionally delayed or staged with tissue expander placement ("delayed-immediate" approach). The effect of a staged approach on patient satisfaction and decisional regret remains unclear. METHODS: All patients undergoing free-flap breast reconstruction (n = 334) between 2014 and 2019 were identified. Complication rates, patient satisfaction using the BREAST-Q, and decisional regret using the Decision Regret Scale were compared between patients undergoing immediate, delayed, and staged approaches. RESULTS: Overall, 100 patients completed the BREAST-Q and Decision Regret Scale. BREAST-Q scores for psychosocial well-being (P = 0.19), sexual well-being (P = 0.26), satisfaction with breast (P = 0.28), physical well-being (chest, P = 0.49), and physical well-being (abdomen, P = 0.42) did not significantly vary between patients undergoing delayed, staged, or immediate reconstruction. Overall, patients experienced low regret after reconstruction (mean score, 11.5 ± 17.1), and there was no significant difference in regret scores by reconstruction timing (P = 0.09). Compared with normative BREAST-Q data, unlike immediate and delayed approaches, staged reconstruction was associated with lower sexual well-being (P = 0.006). Furthermore, a significantly higher infection rate was seen among staged patients (immediate 0%, delayed 5%, staged 20%, P = 0.01). CONCLUSIONS: Staged free-flap breast reconstruction confers similar long-term satisfaction and decisional regret as immediate and delayed reconstruction but may be associated with worsened sexual well-being, when compared with normative data, and an increased risk of surgical site infection. When counseling patients regarding the timing of reconstruction, it is important to weigh these risks in the context of equivalent long-term satisfaction and decisional regret between immediate, delayed, and staged approaches.

Perioperative Approach to Reducing Hematoma during Rhytidectomy: What Does the Evidence Show?

BACKGROUND: Postoperative hematoma remains the most common complication in rhytidectomy, prompting surgeons to use a multitude of adjunctive measures to prevent its occurrence. The goal of this systematic review was to determine which of these measures are supported by strong evidence, and to highlight those that remain unsubstantiated and require further investigation. METHODS: A systematic search was performed of the PubMed and Embase databases for English literature from 1975 to March of 2020 containing designated keywords, and focusing specifically on adjunctive measures aimed at preventing hematoma in rhytidectomy. The resultant articles were then systematically screened according to predefined inclusion and exclusion criteria to determine eligibility for inclusion in the study. RESULTS: The keyword search yielded a total of 2391 articles. Title and abstract screening resulted in 103 articles that were eligible for full-text review. Ultimately, 48 articles met final inclusion criteria. The articles were categorized into their particular mode of intervention: fibrin tissue sealants, perioperative medications (anesthetics, antihypertensives, miscellaneous medications), and intraoperative maneuvers (hemostatic agents, preinfiltration, intraoperative maneuvers, and drains). Nine studies were indexed as evidence Level II and 24 as evidence Level III. The remainder of studies constituted Level IV evidence. CONCLUSIONS: Adjunctive interventions have been borne out of necessity in efforts to reduce postoperative hematoma after rhytidectomy. Although many of these interventions have promising results, the current literature supports the senior author's (R.J.R.) experience that an evidence-based, multimodal approach is ideal to minimize the rates of hematoma after rhytidectomy.

Location, Location, Location: The Geographic Impact of Medical School on the Plastic Surgery Match.

BACKGROUND: This resident application cycle posed academic leadership and applicants with an unprecedented challenge: how to virtually match applicants to mutually beneficial programs. The authors sought to refer to previous years' data, specifically geographic trends, to better inform both program directors and applicants. The authors hypothesized that geography, as it pertains to the transition from medical school to residency, impacts match patterns. METHODS: The study was designed as a cross-sectional analysis including all current integrated plastic surgery residents. The independent websites of all accredited integrated plastic surgery programs were then queried for the desired demographic resident information. Additionally, as an illustrative endpoint, geospatial heat maps were generated to better understand geographic trends. RESULTS: All (n = 78) integrated plastic surgery programs and 953 residents were included in the study. Nearly half (47.2%) of current residents remain in the same geographic region in which they obtained their medical degree, with 26% and 17% remaining in the same state and institution, respectively. Students within all regions (North, South, Midwest, West) were more likely to stay within that region for residency (OR 2.59, 2.39, 2.09, 3.80, respectively). Students attending medical schools with affiliated integrated plastic surgery residencies have matched to programs with significantly higher Doximity rankings (p < 0.0001). CONCLUSIONS: Matched integrated plastic surgery applicants are more likely to continue their training at institutions in closer geographic proximity to their medical schools. Students graduating from medical schools without affiliated integrated plastic surgery programs appear to be at a disadvantage during the match process.

The Effect of Lavender Oil on Perioperative Pain, Anxiety, Depression, and Sleep after Microvascular Breast Reconstruction: A Prospective, Single-Blinded, Randomized, Controlled Trial.

BACKGROUND: Psychosocial distress, depression, or anxiety can occur in up to 50% of women after a breast cancer diagnosis and mastectomy. The purpose of this study was to assess the potential benefit of lavender oil as a perioperative adjunct to improve anxiety, depression, pain, and sleep in women undergoing microvascular breast reconstruction. METHODS: This was a prospective, single-blinded, randomized, controlled trial of 49 patients undergoing microvascular breast reconstruction. Patients were randomized to receive lavender oil or placebo (coconut oil) throughout their hospitalization. The effect of lavender oil on perioperative stress, anxiety, depression, sleep, and pain was measured using the hospital anxiety and depression scale, Richards-Campbell Sleep Questionnaire, and the visual analogue scale. RESULTS: Twenty-seven patients were assigned to the lavender group and 22 patients were assigned to the control group. No significant differences were seen in the perioperative setting between the groups with regard to anxiety (p = 0.82), depression (p = 0.21), sleep (p = 0.86), or pain (p = 0.30) scores. No adverse events (i.e., allergic reaction) were captured, and no significant differences in surgery-related complications were observed. When evaluating the entire cohort, postoperative anxiety scores were significantly lower than preoperative scores (p < 0.001), while depression scores were significantly higher postoperatively as compared with preoperatively (p = 0.005). CONCLUSION: In the setting of microvascular breast reconstruction, lavender oil and aromatherapy had no significant adverse events or complications; however, there were no measurable advantages pertaining to metrics of depression, anxiety, sleep, or pain as compared with the control group.

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis.

BACKGROUND: Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction. METHODS: Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model. RESULTS: A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival. CONCLUSIONS: Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.