Current Fat Grafting Practices and Preferences: A Survey from Members of ISPRES.

Fat grafting has established its niche in a wide spectrum of aesthetic and reconstructive procedures. A consensus-based method of harvest, processing, enrichment, injection, and assessment is lacking, despite the rising trends in its application. We conducted a survey among plastic surgeons to evaluate and identify trends of fat grafting practices. Methods: We conducted an electronic survey with a 30-item questionnaire of 62 members of the International Society of Plastic Regenerative Surgeons. We collected demographic information, techniques, and experiences related to large volume (100-200 ml) and small-volume (<100 ml) fat grafting. Results: The majority of the respondents worked predominantly as aesthetic surgeons. The donor area selection was based on the patient's fat availability (59.7%). For fat enrichment, platelet-rich-plasma and adipose stem cells were routinely used by 12.9% and 9.7% of respondents, respectively. A 3- to 4-mm cannula with three holes was the most preferred instrument for large-volume fat harvesting (69.5%). For small-volume fat grafting, 2-mm cannulas (75.8%) with Mercedes tip (27.3%) were used most commonly. For processing, decantation of fat was performed by 56.5% of respondents (without exclusivity). For handheld injections (without exclusivity), respondents preferred a 1- to 2-mm cannula with a 1 cm3 syringe. The most popular method of outcome assessment was photographic evaluation. Conclusions: The respondents' tendencies were similar to those reported in the previous literature, with some exceptions, such as the technique for preparing fat and enrichment. A wider cross-sectional survey, involving national delegates and global representatives of plastic surgeons, is anticipated.

Free Tissue Transfer to the Knee for a Complex Wound Coverage When Good Recipient Vessels Are Not Available.

Free tissue transfer to the knee can be difficult due to limited options for reliable recipient vessels and vein grafts or arteriovenous loops may also be associated with an increased risk of flap failure. In this study, the authors describe our experience with creating proper recipient vessels for free flap reconstructions around the knee using the descending branch (DB) of the lateral circumflex femoral vessels (LCFV) or anterior tibial vessels (ATV). Three patients underwent free flap reconstruction of knee wounds secondary to trauma, prosthesis infection, and radiation therapy. The anterolateral thigh, rectus abdominis, and latissimus dorsi flaps were used to close the wounds, respectively. Dissection of the DB of LCFV was carried between the rectus femoris and vastus lateralis, and between the peroneus longus and brevis for the ATV. These recipient's vessels were created and placed in a more desirable location adjacent to the defect for microvascular anastomoses. The DB of LCFV and ATV were dissected successfully and both arterial and venous micro-anastomose were performed in an end-to-end manner with the recipient's vessels. All patients had successful free tissue reconstructions with uneventful postoperative courses. The flaps remained viable and reliable soft tissue coverage with acceptable contour had been accomplished during follow-up. Either DB of LCFV or ATV can serve as adequate recipient vessels after being placed adjacently to soft tissue defects for a straightforward free tissue transfer to the knee. The creation of such recipient vessels avoids vein grafts or arteriovenous loops and allows for a reliable free flap reconstruction of the knee.

A Simple and Effective Intraoperative Technique for Correction of Severe Congenital Breast Asymmetry.

BACKGROUND: One severe type of congenital breast asymmetry, with a hypoplastic breast on one side and a hyperplastic breast on the other side, has been recognized in the author's practice. Although breast augmentation, mastopexy, and breast reduction used separately or in combination are the most common procedures performed to correct congenital asymmetrical breasts, an effective approach for the correction of such a congenital breast asymmetry has not been established in the literature. In this article, a simple and effective intraoperative approach is described for correction of severe congenital breast asymmetry. METHOD: Breast augmentation with an implant for the hypoplastic side and mastopexy or small breast reduction for the hyperplastic side were performed. Symmetry was achieved intraoperatively by an implant for breast augmentation on the hypoplastic side and mastopexy or small reduction, determined by a tailor-tacking technique, on the hyperplastic side. RESULTS: In the past 2 years, a total of 4 patients with severe congenital breast asymmetry was operated on by the author with this established approach. All patients were pleased about their symmetry and cosmetic outcome without any surgical complications. The resulted breast scars are minimal and well tolerated by patients. No revision or subsequent surgery has even been needed during follow-op. CONCLUSION: Correction of severe congenital breast asymmetry is not an easy task and can be difficult. This simple and effective intraoperative approach provides a relatively easy and logical way as a 1-stage procedure for this subgroup of patients with symmetrical and cosmetically pleasing outcome.

Reoperative Microsurgical Free Flap Surgery: Lessons Learned.

ABSTRACT: Microsurgical free flap surgery has revolutionized reconstructive surgery at most academic centers worldwide. However, free flap failures still occur even in the hands of the most experienced microsurgeon. Although we have achieved a great deal of success performing microsurgical free flap reconstruction for various indications, complications from initial free flap surgery that result in reoperation remain a small, but steady percentage. Venous flap congestion is one of the most challenging conditions that result in free flap failure if not resolved promptly. It can be caused by several conditions, and salvage for venous congestion is often difficult and time consuming. Over 20 years, the senior author has encountered 2 unique situations that resulted in venous congestion of the flap requiring reoperative surgery for flap salvage or a second free flap. Several medical conditions can compromise free flap surgery and result in total flap loss. The senior author has also encountered 2 medical conditions resulting in total flap loss. However, both patients received successful second free tissue transfers when combined with unique perioperative management strategies. It is our hope that this review will highlight some unique management strategies for reoperative microsurgical free tissue transfer and serve as "lessons learned" for initial salvage procedures and a second free tissue transfer. We also hope our reoperative approach demonstrated in this review will help the future generation of microsurgeons to avoid such complications altogether so that overall outcome after microsurgical free flap surgery can further be improved.

Hyaluronidase Availability in Emergency Rooms: A Statewide Analysis.

Objective: Authors sought to determine the immediate availability of hyaluronidase (HYAL) among emergency rooms (ERs) in California. Background: Hyaluronic acid (HA) fillers are regarded as a safe procedure; however, major ischemic complications do exist, notably blindness and tissue necrosis. The successful management of these vascular events relies on an injector's immediate HYAL, the enzymatic reversal agent for HA. Unfortunately, many barriers exist for injector sites to stock HYAL. As a result, ERs serve as unofficial safety nets in cases when providers encounter an ischemic complication and do not have HYAL in supply. Materials and Methods: Telephone survey inquiring about HYAL availability in all California ERs. Results: This study included 330 California ERs and achieved an 89.7% response rate (n = 296). 45.6% of the surveyed ERs did not have immediate access to HYAL. HYAL availability was positively associated with level I-III adult trauma center status, pediatric trauma center status, children's hospital status, higher bed counts, and regional geography (p < 0.05, all). Conclusions: HYAL availability is unreliable among Californian ERs, posing a potential risk to patient safety.

Asian Upper Blepharoplasty: A Comprehensive Approach.

Asian upper blepharoplasty is one of the most popular cosmetic procedures for Asians, but less optimal result is still common. The authors' comprehensive approach to Asian upper blepharoplasty includes (1) to determine both the height and length of the upper skin crease; (2) to create more ideal anatomy of the upper eyelid; (3) to reconstruct the desirable anatomic structure of the upper eyelid skin crease; and (4) to add a medial epicanthoplasty if needed to enhance cosmetic results.

An Updated Definition of Plastic Surgery.

ABSTRACT: Modern medicine tends to provide comprehensive medical services based on disease or pathological features. As a result, the overlap between plastic surgery and other surgical departments greatly deepened. What was exclusively done by plastic surgeons are nowadays frequently practiced by other surgeons as well. Thus, generating confusion as to whether plastic surgery is an independent subject or a tool. Therefore, in this new era of modern medicine, it is necessary to reconsider the definition of plastic surgery.

Fat Grafting as Regenerative Surgery: A Current Review.

SUMMARY: Autologous fat grafting has long been regarded as an ideal filler, lauded for its ability to restore soft-tissue contour. In recent times, fat grafting has exhibited regenerative capacity, largely secondary to the action of adipose-derived stem cells and preadipocytes in the stromal vascular fraction of adipose tissue. This has birthed a new field of regenerative surgery with benefits germane to scarring, fibrosis, atrophy, burns, neuropathic pain, and autoimmune disease. The broad clinical applications of regenerative fat grafting have the potential to improve quality of life through functional and aesthetic improvement. Fat grafting has the potential to serve as a regenerative option for difficult clinical problems that cannot be treated effectively at the present time. Fat grafting also exhibits angiogenic and immunomodulatory properties in the context of autoimmune disease. The broad clinical applications of regenerative fat grafting have the potential to improve quality of life both functionally and aesthetically. It may present a less invasive avenue for clinical issues that today necessitate conventional surgical techniques. However, regenerative fat grafting is still in its infancy; further research is required to ascertain evidence-based protocols for the various clinical indications and better understand the precise regenerative mechanisms after fat grafting.

The Second Free Tissue Transfer After the First Free Flap Loss for a Complex Scalp Reconstruction: Our Strategy to Success With a Staged Approach.

ABSTRACT: Scalp reconstruction for a critical neurosurgical patient, as lifesaving efforts continued, can be challenging and a free tissue transfer is often needed to achieve reliable soft tissue coverage. However, the patient's labile perioperative condition may compromise successful reconstruction and perioperative hypotension is one of the major known factors for the failure of free tissue transfer. In this report, the authors encountered such an instance, and present our strategy in overcoming this hurdle toward obtaining successful scalp reconstruction with second free tissue transfer after the first free flap loss. After optimizing the patient's medical condition, the second free tissue transfer was performed in 2 stages with recipient vessel dissection during the first stage and the flap harvest and microvascular anastomoses during the second stage. Our staged approach is warranted to ensure the patient can tolerate the stressor of general anesthesia and to precondition the patient for ultimate successful second free tissue transfer.

Microsurgical Scalp Reconstruction: An Overview of the Contemporary Approach.

BACKGROUND: Microsurgical scalp reconstruction has evolved immensely in the last half-century. The core concepts of microsurgical scalp reconstruction have always been to transfer soft tissue of a sufficient quality to within the defect while minimizing donor site morbidity. Refinements in scalp reconstruction consist of both improvement in reducing donor site morbidity and enhancing recipient site contour and balance. Furthermore, technical advancements and the vast experience within our field have allowed for preoperative evaluation of recipient vessels that are more favorable in proximity to the scalp. METHODS: In this review, we aim to describe the contemporary approach to microsurgical scalp reconstruction. This is to include the indications of choosing free flaps as well as how to select the ideal flap based on patient-oriented factors. The need for cranioplasty, recipient vessel selection, operative technique, and reoperations is also reviewed. In addition, our considerations and the nuances within each category are also described. SUMMARY: Scalp reconstructions involve the fundamental tenants of plastic surgery and demand application of these principles to each case on an individual basis and a successful reconstruction must consider all aspects, with backup options at the ready. Two workhorse free flaps, the anterolateral thigh perforator and latissimus dorsi muscles flaps, serve a primary role in the contemporary approach to microsurgical scalp reconstruction. CONCLUSION: We hope this review can lay the foundation for which future plastic surgeons may continue to build and advance the approach to complex microsurgical scalp reconstruction.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma.

The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon's armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.

The Modified Skate Flap: A New Technique for Nipple-Areola Complex Reconstruction in Implant-Based Breast Reconstruction.

Nipple-areola complex (NAC) reconstruction is an important part of breast reconstruction. Although several techniques for NAC reconstruction have been described in the literature, the long-term outcomes after NAC reconstruction remain less satisfactory, especially following implant-based breast reconstruction. The authors reported their newly developed technique for NAC reconstruction in implant-based breast reconstruction. The authors describe their modified skate flap, by preserving more dermal tissues from the skate flap, for NAC reconstruction, following implant-based breast reconstruction. Additional derma-fat grafts, harvested from the full-thickness skin graft site, are also added to the reconstructed nipple to ensure long-term shape, size, and projection of the reconstructed nipple. A total of 30 patients underwent such a NAC reconstruction after successful implant-based breast reconstruction by the senior author. The minimum follow-up time was 1 year. No significant surgical complications have been observed in their series of 30 patients, and only a minor office procedure was performed subsequently in 6 patients (4 unilateral and 2 bilateral) to improve the shape of the reconstructed nipple. During a minimum of a 1-year follow-up period, outcomes with the authors' technique in 30 patients are satisfactory; good size, shape, and projection of the reconstructed nipple are maintained. The long-term outcome of NAC reconstruction after implant-based breast reconstruction can be optimized with their modified skate flap by using all available flap tissue and with the addition of derma-fat grafts. The authors' technique can be used safely for NAC reconstruction after implant-based breast reconstruction with good outcome and high patient satisfaction.