Single Staged Mastopexy With Autologous Fat Grafting: An Alternative to Augmentation Mastopexy With Implants.

BACKGROUND: Improving the ptotic breast with mastopexy and restoring upper pole fullness with augmentation continues to be a challenging issue for plastic surgeons. Autologous fat grating (AFG) for shaping and contouring of implant augmented breasts has shown positive outcomes with few complications. OBJECTIVES: The objective of this study was to evaluate our experience with combined mastopexy and fat grafting for women with existing breast ptosis who prefer not to receive prosthetic breast implants but do desire volume enhancement. METHODS: A retrospective review of patients undergoing a single staged mastopexy with AFG, from 2006 to 2017, was performed. Inclusion criteria were women with breast ptosis or tuberous breasts desiring improved breast shape and volume. Patients were excluded if they were undergoing implant removal before the procedure. Clinical aesthetic outcomes were assessed by fellow plastic surgeons according to the Telemark Breast Scoring system. RESULTS: A total of 284 breasts, in 140 women, underwent a single staged mastopexy with AFG. The mean amount of fat grafted per breast was 299.4 mL (range, 50-710 mL). There were no surgical site infections, hematomas, or seromas. There were 3 major and 8 minor (0.06%) postoperative breast complications. A total of 13 plastic surgeons, of the 183 invited (7.1%), completed the breast outcomes survey. Regarding each category, there was significant improvement (P ≤ 0.0001) in upper pole fullness, ptosis, overall aesthetics, and symmetry postoperatively. CONCLUSIONS: AFG combined with mastopexy is not associated with significant postoperative complications and results in excellent breast aesthetic outcomes.

Population-Based Health Utility Assessment of Migraine Headache Symptoms before and after Surgical Intervention.

BACKGROUND: Approximately 30 million Americans suffer from migraine headaches. The primary goals of this study are to (1) use Migraine-Specific Symptoms and Disability criteria and Migraine Headache Index to describe the symptomatic improvement following decompressive surgery for refractory migraines, and (2) use the average Migraine Headache Index preoperatively and postoperatively for health utility assessment from a healthy patient's perspective. METHODS: The Migraine-Specific Symptoms and Disability criteria and the Migraine Headache Index were used to characterize migraine symptoms in the authors' patient population before and after decompressive surgery. Healthy individuals were randomized to a scenario in which they assumed either the preoperative or postoperative average patient symptom profile described by the authors' migraine patients. Health utility assessments were used to quantify the evaluation of health states the authors' patients experienced before and after surgical migraine therapy. RESULTS: Twenty-five patients underwent surgery for migraine headaches. The Migraine-Specific Symptoms and Disability questionnaire showed a significant decrease in both frequency of headaches per month (p < 0.0001) and overall pain score (p = 0.007). The Migraine Headache Index demonstrated a statistically significant improvement (p = 0.03). Healthy individuals in the preoperative group had significantly lower utility scores compared with the postoperative group in all of the health utility assessments completed for migraine symptoms. CONCLUSION: This is the first study to use health utility assessments to attest the efficacy of decompressive therapy by demonstrating the population perspective, which perceived a significant improvement in quality of life following the surgical treatment of migraines in the authors' patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

American Society of Plastic Surgeons Member Post-Operative Opioid Prescribing Patterns.

INTRODUCTION: Despite the widespread use of opioids in pain management, there are currently no evidence-based guidelines for the treatment of postoperative pain with opioids. Although other surgical specialties have begun researching their pain prescribing patterns, there has yet to be an investigation to unravel opioid prescribing patterns among plastic surgeons. METHODS: Survey Monkey was used to sample the American Society of Plastic Surgeons (ASPS) members regarding their opioid prescribing practice patterns. The survey was sent randomly to 50% of ASPS members. Respondents were randomized to 1 of 3 different common elective procedures in plastic surgery: breast augmentation, breast reduction, and abdominoplasty. RESULTS: Of the 5,770 overall active ASPS members, 298 responses (12% response rate) were received with the following procedure randomization results: 106 for breast augmentation, 99 for breast reduction, and 95 for abdominoplasty. Overall, 80% (N = 240) of respondents used nonnarcotic adjuncts to manage postoperative pain, with 75.4% (N = 181) using nonnarcotics adjuncts >75% of the time. The most commonly prescribed narcotics were Hydrocodone with Acetaminophen (Lortab, Norco) and Oxycodone with Acetaminophen (Percocet, Oxycocet) at 42.5% (N = 116) and 38.1% (N = 104), respectively. The most common dosage was 5 mg (80.4%; N = 176), with 48.9% (N = 107) mostly dispensing 20-30 tablets, and the majority did not give refills (94.5%; N = 207). CONCLUSIONS: Overall, plastic surgeons seem to be in compliance with proposed American College of Surgeon's opioid prescription guidelines. However, there remains a lack of evidence regarding appropriate opioid prescribing patterns for plastic surgeons.

Mosaic Fleur-de-Profunda Artery Perforator Flap for Autologous Breast Reconstruction.

Perforator-free flaps, in autologous breast reconstruction, have expanded to exploit tissue available at smaller donor sites while retaining high success and low risk rates. Abdominal based flaps, such as the deep inferior epigastric perforator, remain the most common; however, when the abdomen is not an appropriate donor site, lower extremity flaps are options. The profunda artery perforator has the benefit of hiding unsightly scar in the gluteal crease but has the drawback of poor donor site volume. Our mosaic fleur-de-profunda artery perforator flap technique for breast reconstruction has shown to increase volume with the addition of a vertical limb, include full angiosome of perforators, and exhibit donor site morbidity equivalent to a medial thigh lift.

Peroneal Nerve Repair of a 9 Year Old: Return of Motor Function after 2 Years.

Major factors that influence functional nerve recovery, postrepair, are length of the nerve defect, type of injury, operative technique, time until treatment, and age of the patient. We present a severe motor nerve defect in a complicated peroneal nerve injury in a 9-year-old that showed functional return after a delayed period of 23 months with sural nerve cable grafting. This case revealed the increased resiliency and regenerative capacity of motor end plates in young patients. In conclusion, autograft for a deep peroneal nerve repair, by means of sural nerve graft, proved to be an acceptable option in children.

Neoumbilicoplasty with a Superiorly Based Abdominal Skin Flap.

We propose a neoumbilicoplasty technique that can be applied when the umbilical stalk becomes disrupted during an abdominoplasty. This case used surgical concepts that involved progressive thinning of the flap in a 3-cm radius around the neoumbilicus, with increased thinning toward the neoumbilical position. This was followed with suture tacking of the thinned abdominal flap to create a concavity around the neoumbilicus. A longer "U" shaped incision was created and also sutured down to abdominal wall to recreate an umbilical "floor" with the adjacent skin sutured to the superior-based flap to construct the walls of the neoumbilicus. An aesthetically pleasing umbilicus resulted with high patient satisfaction and a lack of postoperative complications. There were no additional scars extending beyond the umbilical region.

Cosmetic Surgeon Representation: Ensuring Board Certification Transparency and Patient Awareness.

BACKGROUND: Previous studies revealed that patients preferred plastic surgeons over cosmetic surgeons for surgical procedures, but few knew that any physician with a medical degree was legally qualified to perform cosmetic surgery. Results also indicated that a primary consideration for patients in selecting a surgeon was board certification. Although patient preferences concerning aesthetic surgery have previously been surveyed, no study examined a consumer's ability delineate between specialties based on Web sites. The purpose of this study was to investigate the responses of medical students to questions regarding a cosmetic and plastic surgeon's board certification. METHODS: A total of 4 cosmetic and 5 plastic surgeon Web sites were selected, in a single large city, from a Google search for the following procedures: liposuction, breast augmentation, blepharoplasty, rhytidectomy, and abdominoplasty. Screenshots of the Google search link, the page after clicking on the link, and the about the doctor page were collected to simulate an actual patient search experience. Four randomized surveys were created using screenshots and scenarios through Survey Monkey. Surveys were distributed and collected anonymously. Data analysis was accomplished using a chi-square test of independence (P < 0.05). RESULTS: A total of 474 medical students responded, and the difference between cosmetic and plastic surgeon variables was significant (P < 0.001). Upon comparison of different procedures, the cosmetic and plastic groups were found to be statistically different (P < 0.05), with some exceptions. On average, when presented with a plastic surgeon, 95.3% thought this was a board-certified plastic surgeon. When presented with a cosmetic surgeon, 54.3% also thought this was a board-certified plastic surgeon. The decline in responses regarding board certification, for the first and second cosmetic surgeons presented, was found to be statistically different (P < 0.0001). CONCLUSIONS: Over 50% of medical students had difficulty distinguishing between a cosmetic and plastic surgeon based on Web site advertisements; therefore, patients may have a more difficult experience. Results of this study prove the need for a universal definition, and patient education, relating to board certifications.