The Dieffenbach Flap for Reconstruction of Auricular Defects After Mohs Micrographic Surgery.

Auricle reconstruction is a challenging problem in plastic surgery due to the ear's prominent location, complex anatomy, and limited local tissue availability. The Dieffenbach flap, a folded postauricular flap, offers a viable flap for reconstruction of larger ear defects. Although the technique has been well defined in previous literature, there are few studies evaluating its outcomes and complications. The authors conducted a retrospective review of patients who underwent auricle reconstruction with the Dieffenbach flap by a single surgeon between 2016 and 2022. Data collection included demographics, medical history, cancer type, defect characteristics, postoperative care, outcomes, and complications. Univariable analyses using the Fischer exact test assessed the association between risk factors (smoking, anticoagulation use, and age) and complication rates, with P ≤ 0.05 considered statistically significant. A total of 40 patients were included in this study, with a mean age of 67.6 and a male prevalence of 77.5%. The mean defect size was 6.5 cm2, with most defects located on the superior helix. The most common complication was postoperative cellulitis (3 patients, 7.5%), followed by contour abnormality that required revision surgery (2 patients, 5.0%). History of smoking had a statistically significant association with complications (P = 0.013). Use of anticoagulants, or older age (defined as >70 years), had no significant association with complication risk. The Dieffenbach flap remains a reliable method for reconstruction of various auricle defects. It is low maintenance, well tolerated by patients, and involves minimal donor site morbidity without the need for cartilage.

Aesthetic Auricle Reconstruction with the Dieffenbach Flap: A Retrospective Case Review.

The Dieffenbach flap is often used for post-Mohs reconstruction of auricle defects, effectively restoring the auricle rim. However, its impact on auricle projection and length after division and inset is not well-documented. This study evaluates auricle projection and length following defect repair with the Dieffenbach flap, comparing results to the nonoperative ear. We conducted a retrospective review of patients who underwent a Dieffenbach flap repair surgery at a single institution from 2016 to 2023. Auricle projection and length of the reconstructed ear were measured within the first month following division and inset of the flap and compared with the contralateral ear. A subset of patients had additional measurements > 1 month following division and inset, and these measurements were compared with the contralateral ear. Our study included 23 patients with an average age 67.4 years and 78.3% male. Within 1 month following division and inset, the Dieffenbach flap resulted in a significant decrease in auricle projection (16.5 vs. 18.6 mm, p < 0.05) and length (67.0 vs. 69.7 mm, p < 0.05) compared with the contralateral ear. Subsequent follow-up showed no significant differences in projection (18.5 vs. 18.5 mm, p = 0.98) or length (68.0 vs. 68.7 mm, p = 0.54). Following division and inset of the Dieffenbach flap, auricle projection and length experience initial reduction but subsequently self-correct to match the contralateral ear.

Current and Future Photography Techniques in Aesthetic Surgery.

BACKGROUND: The rapidly increasing modalities and mediums of clinical photography, use of 3-dimensional (3D) and 4-dimensional (4D) patient modeling, and widening implementation of cloud-based storage and artificial intelligence (AI) call for an overview of various methods currently in use as well as future considerations in the field. OBJECTIVES: Through a close look at the methods used in aesthetic surgery photography, clinicians will be able to select the modality best suited to their practice and goals. METHODS: Review and discussion of current data pertaining to: 2-dimensional (2D) and 3D clinical photography, current photography software, augmented reality reconstruction, AI photography, and cloud-based storage. RESULTS: Important considerations for current image capture include a device with a gridded viewing screen and high megapixel resolution, a tripod with leveling base, studio lighting with dual-sourced light, standardized matte finish background, and consistency in patient orientation. Currently, 3D and 4D photography devices offer advantages such as improved communication to the patient on outcome expectation and better quality of patient service and safety. AI may contribute to post-capture processing and 3D printing of postoperative outcomes. Current smartphones distort patient perceptions about their appearance and should be used cautiously in an aesthetic surgery setting. Cloud-based storage provides flexibility, cost, and ease of service while remaining vulnerable to data breaches. CONCLUSIONS: While there are advancements to be made in the physical equipment and preparation for the photograph, the future of clinical photography will be heavily influenced by innovations in software and 3D and 4D modeling of outcomes.

A Novel Sand Dollar and Staves Technique for Unilateral Lambdoid Craniosynostosis.

BACKGROUND: Unilateral lambdoid synostosis (ULS) is the rarest form of craniosynostosis. Due to the associated cranio-caudal shift seen in ULS, surgical correction is technically challenging from a morphological standpoint. Herein, the authors present a novel "Sand-Dollar and Staves" technique for the repair of ULS. METHODS: A zigzag coronal incision is performed, and an anteriorly-based pericranial flaps are elevated. Prefabricated cutting guides are placed and the calvarium is marked. To treat the flattening on the ipsilateral side, a wedged suturectomy is performed with additional barrel staves. A large circle centered over the bulging on the contralateral side is cut out above the open lambdoid suture. This piece is barrel staved in a radial fashion, leaving the center intact and creating a Sand-Dollar appearance. This disk is then flattened and trimmed. The modified Sand-Dollar is fixed using an absorbable plating system. While gentle pressure is applied to the Sand-Dollar piece as it is being secured, the ipsilateral side demonstrates compensatory filling. Results are evaluated using the Whitaker Classification. RESULTS: Four patients underwent surgical correction with this technique. The procedure was performed at mean age of 11.7 months. The mean operative time was 2.5 hours. Intraoperative blood loss was 50 to 100 ml. Total hospitalization time was 2 to 3 days. No post-operative complications were encountered. Whitaker scores ranged from 1 to 1.5. The mean follow-up was 10 months. CONCLUSION: The Sand-Dollar and Staves procedure is a novel, single-stage approach for the management of ULS with decreased operative time, blood loss, and hospital stay with satisfactory aesthetic outcomes.

Plastic Surgeons as Institutional Leaders.

BACKGROUND: Physicians, especially plastic surgeons, are underrepresented in hospital leadership. As such, the steps an aspiring plastic surgeon should take toward assuming a high-level administrative role remain unclear. The authors aim to profile the chief executive officers and surgeons-in-chief at top-ranked U.S. hospitals with the goal of better characterizing the attributes of institutional leaders. METHODS: Chief executive officers and surgeons-in-chief at top-ranking hospitals in the 2019 to 2020 U.S. News and World Report "Best Hospitals Honor Roll" were included in this study. For each leader, sex, title, degrees, years of experience, total number of publications, practice specialty (for physician leaders), and previous leadership roles in national societies were reviewed. Descriptive statistical analyses were performed. RESULTS: A total of 99 leadership positions at 66 institutions were included. Of these, 67 were chief executive officers and 32 were surgeons-in-chief. Overall, 28 of 67 chief executive officers (42 percent) were physicians-23 nonsurgeons and five surgeons. Of all surgeon executives, only two were plastic surgeons, and both were surgeons-in-chief. The "average" physician-chief executive officer had 24 years of experience, no M.B.A., over 100 publications, zero to one fellowship, and was involved in national leadership. There was no difference in professional qualifications (defined as years of experience, business training, number of publications and fellowships, and leadership positions) between nonsurgeon- and surgeon-chief executive officers, or between plastic surgeons and other surgeons in leadership positions. CONCLUSIONS: Despite possessing adequate qualifications, plastic surgeons are underrepresented in American health care institutional leadership roles. Aspiring plastic surgeon leaders should lean on their peer credibility and experience delivering patient-centered care to succeed in leadership roles.

Chicken or the Egg: A Case Report of Endoscopic-Assisted Treatment of Concomitant Sagittal Craniosynostosis With Calcified Cephalohematoma.

Nonsyndromic craniosynostosis results in premature fusion of cranial sutures and is rarely found in the context of other craniofacial abnormalities. Here the authors present the case of a 3-month-old male infant with a rare presentation of sagittal craniosynostosis and concomitant calcified cephalohematoma repaired by endoscopic-assisted sagittal strip craniectomy with good cosmetic and functional outcomes. The authors discuss the advantages of endoscopic repair of craniosynostosis when found in the presence of a cephalohematoma and the need for further research to investigate a possible causal relationship between these 2 pathologies.

Oculocardiac Reflex as a Late Presentation of Orbital Floor Fracture.

Delayed repair of orbital trapdoor fractures can jeopardize the viability of entrapped contents and prolong recovery. Variation in presentations, both clinically and radiographically, complicate prompt diagnosis. The oculocardiac reflex may be the only indication of fracture with entrapped orbital contents, but, unfortunately, the reflex has variable onset patterns and can mimic common diagnoses. Therefore, the authors present the case of a 14-year-old male with a right orbital floor fracture, who presented with delayed symptoms secondary to an oculocardiac reflex. The vagal sequelae of the reflex, including gastric hyperactivity and headache, were experienced approximately 1 week after the injury and caused the patient to be misdiagnosed with gastroenteritis and status migrainosus, on 2 separate hospital visits. After admission to the hospital due to progressive symptoms, a CT scan showed concerns for a subacute orbital blowout fracture. The patient underwent orbital floor exploration with findings of scarred orbital fat herniating into a healing fracture site. Repositioning of the fat into the orbit resulted in immediate resolution of the patient's symptoms. Awareness of the presenting characteristics of the oculocardiac reflex can lead to prompt diagnosis and maximize clinical outcomes.

Approach to Reconstruction of Nasal Defects.

The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well-organized repair minimizes the occurrence of progressive necrosis and severe late-stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

Approach to Reconstruction of Cheek Defects.

The cheek is the largest facial unit with a prominent position on the face. Trauma, burns, and the resection of skin cancers constitute common sources of injury, potentially resulting in defects that, through natural healing, produce noticeable scarring. Surgical repair focuses on the reformation of three-dimensional geometries, proper establishment of symmetry, and the minimization of color and texture discrepancies to the surrounding. Defects located in this region may extend to the orbital, nasal, or buccal units and cause unique structural and functional disturbances. Furthermore, without appropriate repair, full-thickness defects involving the buccal mucosa may result in oral dysfunction. In this article, the authors provide a framework to approach various cheek defects and provide a review of the host of ideologies and techniques.