Progressive Contouring of the Platysma With Barbed Sutures.

BACKGROUND: As the prevalence of neck lift surgeries increases, the field is continually enriched by evolving techniques for enhancing neck aesthetics. While many recent publications focus on deep neck procedures, it is essential not to overlook the significance of platysmal contouring as an integral aspect of neck rejuvenation surgery. Accordingly, we would like to elucidate our unique approach to contouring the platysma. OBJECTIVES: This study was designed to assess the efficacy of the progressive contouring concept, a technique wherein the neck is reshaped using barbed sutures synergistically with other treatment strategies. METHODS: Our study encompassed 337 patients who received neck rejuvenation treatment using the progressive contouring concept from 2014 to 2021. We conducted a retrospective review to evaluate the change in cervicomental angle (CMA) using Mirror software during the preoperative and postoperative stages. RESULTS: The study sample predominantly comprised females (304 out of 337), with a median age of 61 years (24-88). Most patients (95%) underwent deep cervicoplasty, with a surgical net used in all cases for skin adaptation. After a median follow-up of 14 months, significant improvements were observed in CMA values (reducing from 149.8° to 106.7°). This demonstrated statistically significant differences when comparing preoperative and postoperative outcomes. CONCLUSIONS: Progressive shaping of the neck with barbed sutures is an effective technique in neck rejuvenation. It utilizes multipoint and multi-vector plication, particularly when integrated with other adjunctive surgical maneuvers.

Does Size Really Matter? A Review on How to Determine the Optimal Umbilical Size During an Abdominoplasty.

Background: The umbilicus has historical significance regarding health and beauty principles. The visually pleasing aesthetic of the umbilicus has become a vital standard for the perceived success of an abdominoplasty procedure. While the ideal position and shape of the umbilicus have been studied extensively in literature, less is known about the optimal size. Herein, the authors provide a comprehensive literature review to help determine the ideal umbilical size. Methods: A computerized search in the PubMed database was performed to identify articles that discussed ideal umbilical size. Results: The review was performed in July 2022. A total of 21 articles were initially identified, only 6 of which discussed umbilical size. References from the included articles were also evaluated for relevance and resulted in 10 additional articles in the final review. Most of the articles indicated that a smaller umbilicus was found to be aesthetically pleasing, but a numerical range of values were not specified. Conclusions: Although the literature on the ideal umbilical size is sparse, the consensus is toward a smaller, vertically oriented umbilicus.

The 5 D's to Dunk the Dog: A Retrospective Clinical Review to Prevent Dog-Ear Contour Abnormalities in Vertical Breast Reductions and Breast Lifts.

Background: In 2020, reduction mammoplasties and mastopexies comprised 34.2% of all breast surgeries performed by plastic surgeons. Various approaches for the skin incision of these procedures have been described. The vertical pattern has become an increasingly popular option due to its lower scar burden. However, it is prone to dog-ear formation along the caudal aspect of the incision. Herein, we describe 5 technical steps to eliminate the dog-ear in patients undergoing vertical mammoplasties. Methods: A retrospective chart review was performed on all patients who underwent vertical breast reduction and mastopexy between the years 2008 and 2020 performed by the senior author. The 5 steps employed in eliminating the dog-ear are delineated and depicted pictorially. Results: A total of 58 patients and 89 breasts were operated upon. A majority of 66.6% were Caucasian, 33.3% were African American, and 1 patient was of Hispanic descent. The mean age was 53.2 years (19-73 years), and average BMI was 31.5 kg/m2 (21.3-42.7 kg/m2). The average resection weights for reduction and mastopexy patients were 479 grams (100-1500 grams) and 58.1 grams (18-100 grams), respectively. Mean follow-up was 10.5 months (1-35 months). Only one patient developed a dog-ear (1.7%) in bilateral breasts (2.2%); however, the patient did not request a revision. Our revision rate over 13 years remained at 0%. Conclusions: Utilizing these 5 technical steps reduces the risk of dog-ear deformity and thereby diminishes the overall need for revisional surgery in patients undergoing short scar vertical mammoplasties.

Breast Implants Save Lives: Gunshot Wound to a Silicone Gel Implant.

What is the incidence of gunshot injuries involving breast implants?What are the considerations for managing a patient with a gunshot wound to a breast implant?Can a breast implant alter the trajectory of a bullet to the chest?What are the considerations for reconstructing a breast after a gunshot wound?

Establishment of Safety of Hemostatic Net Application Utilizing Laser-Assisted Fluorescence Angiography With SPY-Q Software Analysis.

BACKGROUND: The hemostatic net, which was initially described as a method to decrease hematoma rates in facelift and necklift procedures, has since increased in practice and applicability. However, despite its demonstrated safety and efficacy, there exists significant skepticism with regard to its necessity; in particular, there is concern that the transcutaneous sutures may restrict dermal perfusion. OBJECTIVES: The goal of this study was to assess flap perfusion, both before and after application of the hemostatic net, to determine if there was an objective decrease in tissue perfusion in relation to application of the hemostatic net, as measured by laser-assisted angiography (LAA). METHODS: Eight patients underwent cervicofacial flap reconstruction of cutaneous malignancy defects, after which a hemostatic net was applied. All patients underwent evaluation with LAA both before and after application of the net. The average relative and absolute perfusion of different zones of the flap were calculated. RESULTS: The average absolute change in relative perfusion was +6.41%, +0.31%, and +3.28% for zones 1, 2, and 3, respectively, after application of the hemostatic net. There was no statistical difference in relative tissue perfusion after application of the net. There were no instances of delayed healing, infections, ischemia, necrosis, or hematoma. One patient developed a seroma after the net was removed. No patients had scarring or residual track marks from the transcutaneous sutures. CONCLUSIONS: With LAA, we were able to objectively demonstrate no significant decrease in tissue perfusion after the application of the hemostatic net.

Red Breast Syndrome: Complete Resolution Following Replacement of Acellular Dermal Matrices With Acellular Collagen Matrices.

What is red breast syndrome (RBS)?What causes RBS?How often do patients present with RBS?What are effective treatments for RBS?

Complete Penile Amputation: An Anatomical Reference and Surgical Pearls to Ensure a Successful Replantation.

How common are penile amputations, and how are they treated?What key anatomic structures are involved?What are some technical pearls for a successful replantation?What are common complications, and how can they be prevented/treated?

Prevention of Implant Malposition in Latissimus Dorsi Myocutaneous Flap Breast Reconstruction Using an Acellular Dermal Matrix With Pectoralis Muscle Following Mastectomy for Breast Cancer: A Clinical Review.

Background: Latissimus dorsi myocutaneous (LDM) pedicled flaps are a well-established method for breast reconstruction in women with inadequate soft tissue coverage following mastectomy for breast cancer. The robust nature of the latissimus blood supply can accommodate immediate implant placement to increase breast volume; however, a known risk factor with this technique is implant malposition. By utilizing an acellular dermal matrix (ADM) in subpectoral implant-based LDM reconstruction, it is hypothesized that patients will experience a lower incidence of implant malposition. This 13-year retrospective review aims to evaluate the effectiveness of breast reconstruction using this technique. Methods: A retrospective review was conducted to identify all patients who underwent breast reconstruction following mastectomy with a LDM flap, subpectoral implant, and an ADM from 2007 to 2020 by a single surgeon at a single institution. Demographic and clinical data were collected and analyzed. Results: A total of 40 patients (LDM flaps, N = 51) were identified. Mean participant age was 50.25 ± 9.67 years and mean body mass index (BMI) was 30.85 ± 6.15 kg/m2. Comorbidities included hypertension (40.0%), diabetes mellitus (17.5%), and current smoking (25.0%). Mean follow-up was 31.52 ± 29.51 months. The most common complication was seroma formation (9.8%). No patients experienced implant malposition or flap necrosis. Conclusions: The use of a LDM flap and an ADM in implant-based breast reconstruction are each well described in the literature. This 13-year series supports the efficacy of these techniques utilized in combination to provide an aesthetic result while mitigating implant malposition during breast reconstruction of oncologic patients.

Functional Disability Associated With Proximal Clavicle Resection and Pectoralis Flap Transposition for Sternoclavicular Joint Infections.

Background: Sternoclavicular joint infections (SCJI) are increasing with the opioid crisis and increased intravenous drug abuse (IVDA). Proximal clavicle resection with subsequent pectoralis muscle transposition is part of the treatment of such infections, but the long-term effects on shoulder function are not clear. Methods: This report presents a consecutive series of 15 cases of SCJI treated with proximal clavicle resection and pectoralis muscle flap coverage. Patient-reported outcomes were recorded using the Shoulder Disability Questionnaire (SDQ) developed by van der Heijden et al. Results: The average age of patients was 50 years (range, 23-73 years), with nearly half being male (7/15). Of these patients, 3 were lost to follow-up, 1 was excluded due to subsequent shoulder surgery for an unrelated problem, and another was excluded due to subsequent medical issues that precluded a reliable history. Recurrence was noted in 1 patient with ongoing IVDA. Average length of follow-up was 12 months (range, 8-19 months). The long-term shoulder disability was minimal (mean score of 6 ± 9). Among patients with IVDA, however, the long-term shoulder disability was significantly higher (mean score of 33 ± 16, P < .05). Conclusions: In cases where the SCJI was attributed to IVDA, the long-term shoulder disability score was significantly higher, despite resolution of infection. Possible explanations include the self-reporting nature of the SDQ and the well-documented issues with chronic pain in patients with opioid dependency.  Of the patients lost to follow-up, 2 of 3 had infections attributed to IVDA, highlighting the difficulty of meaningful follow-up in this vulnerable patient population.

Restoring Breast Volume in High BMI Patients: A Single-Center Review of Breast Reconstruction Using Hyperinflated Saline Implants.

Background: Breast reconstruction in the obese patient is often fraught with poor patient satisfaction due to inadequate volume restoration. The off-label hyperinflation of saline implants is a direct yet controversial solution to this problem, with limited studies in the literature. This study sought to determine the safety and efficacy of this technique for breast reconstruction. Methods: A retrospective chart review was performed to identify all patients with a body mass index (BMI) greater than or equal to 30 kg/m2 who underwent breast reconstruction between the years 2013 to 2020 with saline implants filled beyond the manufacturer's maximum recommended volume. Results: The 21 patients identified had an average age of 49 years. The mean BMI was 39.5 kg/m2. A total of 42 implants were placed; 34 were 800 mL, 4 were 750 mL, and 4 were 700 mL. The average overfill volume was 302 mL (138%). Mean follow-up was 65.0 months. Of these, 1 (4.8%) patient with a history of chest wall radiotherapy underwent reoperation for unilateral implant exposure 27 days after the index procedure, no patient sustained spontaneous leak or rupture, and 1 patient had unilateral deflation following emergent central line and pacemaker placement 2 years after the implant was placed for an unrelated cardiovascular event. Conclusions: Hyperinflation of saline implants beyond the maximum recommended volume may be considered for volume replacement in obese patients undergoing implant-based breast reconstruction. This practice is well tolerated, has a complication rate comparable to using implants filled to the recommended volume, and has the potential to restore lost breast volume in the obese patient post mastectomy.

The Utilization of Poly-l-Lactic Acid as a Safe and Reliable Method for Volume Maintenance After Facelift Surgery With Fat Grafting.

Background: For age-related volume loss, fat grafting is now recognized as an integral adjunctive procedure with facelift surgery. However, when there is continued and unpredicted volume loss postoperatively, the surgeon has limited options for restoring this lost volume. Objectives: Poly-l-lactic acid (PLLA) is a proven biostimulator that creates volumetric enhancement. This study is undertaken to demonstrate that PLLA is a safe and efficacious option for maintenance of post-facelift volume loss. Methods: A retrospective review was conducted to identify all patients who underwent facelift surgery with fat grafting and postoperative PLLA injections from 2010 to 2018 by a single surgeon. Demographic and clinical data were collected and analyzed. Results: This review identified a total of 241 patients who had undergone a facelift with fat grafting and PLLA injections. Of these, 190 patients were treated with PLLA after facelift and fat grafting, while 51 patients received PLLA injections before their operation. We identified 5 common indications for use of PLLA after facelift surgery and fat grafting. These included unexplained early fat graft loss, significant weight loss in the postoperative period, normal aging process, and patients who had a high perioperative lean body mass. Additionally, PLLA was found to be an effective volumizer for site-specific areas that did not undergo fat grafting during the initial operation. There were no complications reported from the PLLA injections related to nodule formation, papules, or granulomas. Conclusions: The high degree of variability in the survival of fat grafts with facelift surgery is an accepted reality. PLLA represents a safe and highly effective solution to restore volume loss in patients who have undergone facelifts with fat grafting.

Posterior Interosseous Nerve Graft: Utilizing External Landmarks and Anthropometric Ratios to Predict Available Length for Digital Nerve Reconstruction in a Cadaveric Study.

Objective: In digital nerve defects that require grafting, autografts remain the efficacious option. The sensory posterior interosseous nerve (PIN) is an ideal choice as it is of similar caliber to digital nerves and leaves no donor morbidity upon resection. However, a finite length of harvestable PIN exists, and considerable variations of this length have been reported in the literature. There exists no predictive model to estimate this length. We sought to determine a method to accurately predict the available length of PIN based on individual patient anthropometry. Methods: A cadaveric dissection study was performed in a fresh tissue laboratory. The length of the sensory branch of the PIN and various anthropometric measurements were made in respect to surface anatomy of the ulna to develop a predictable ratio for available PIN donor graft. Results: A total of 16 specimens were obtained. On average the length of the PIN was 5.7 cm (range: 3.3-9. cm) and the length of the ulna was 25.7 cm (range: 23.5-30.6 cm). The ratio of PIN to ulnar length was 0.222 (r = 0.4651). Using one-fifth the length of the ulna, the mean predicted length of the PIN was 5.14 cm (range: 4.7-6.1 cm). On univariate analysis, there was no significant difference between the measured and predicted PIN length (P = .249). Conclusion: An anthropometric ratio predicated on reproducible surface anatomy of the ulna is a useful tool in predicting the sensory PIN length. Such a prediction may be a useful in guiding patient discussions concerning surgical options for digital nerve reconstruction.

Objectif: Dans les cas d'anomalies des nerfs digitaux qui exigent une greffe, les autogreffes sont les plus efficaces. Le nerf interosseux postérieur (NIP) sensitif est le choix idéal, car son calibre est semblable à celui des nerfs digitaux et qu'il ne provoque aucun problème de santé au site de résection. Cependant, la longueur du NIP pouvant être récolté est limitée, et d'énormes variations sont présentées dans les publications. Aucun modèle prédictif ne permet d'évaluer cette longueur. Les chercheurs ont entrepris d'établir une méthode pour prédire avec fiabilité la longueur disponible du NIP d'après les caractéristiques anthropométriques de chaque patient. Méthodologie: Les chercheurs ont procédé à une étude de dissection cadavérique dans un laboratoire de tissus frais. Ils ont mesuré le rameau sensitif du NIP et diverses dimensions anthropométriques d'après l'anatomie de surface de l'ulna pour établir un ratio prévisible de greffe du NIP disponible chez le donneur. Résultats: Les chercheurs ont obtenu 16 prélèvements et calculé une longueur moyenne du NIP de 5,7 cm (plage de 3,3 cm à 9,6 cm) et une longueur moyenne de l'ulna de 25,7 cm (plage de 23,5 cm à 30,6 cm). Ils ont calculé un ratio de 0,222 (r = 0,4651) entre la longueur du NIP et de l'ulna. D'après le cinquième de la longueur de l'ulna, ils ont prédit une longueur moyenne du NIP de 5,14 cm (plage de 4,7 cm à 6,1 cm). À l'analyse univariée, ils n'ont constaté aucune différence significative entre la longueur mesurée et prédite du NIP (P = 0,249). Conclusion: Le ratio anthropométrique établi d'après l'anatomie de la surface reproductive de l'ulna est un outil utile pour prédire la longueur du NIP sensitif. Une telle prédiction peut être utile pour orienter les échanges avec le patient au sujet des possibilités chirurgicales de la reconstruction du nerf digital.

Anatomic surface landmarks to guide injection for posterior interosseous nerve block.

Proper injection of the posterior interosseous nerve (PIN) is important for both the therapeutic and diagnostic management of wrist pain. However, no anatomical study exists describing the site of injection based on individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN. Fresh frozen cadaver forearms were dissected at the University of Louisville tissue lab. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. A total of 16 cadaver forearms of equal male to female ratio were obtained. On average, the male forearm had a greater mean wrist circumference obtained at the level of Lister's tubercle compared to female forearms, 17.1 cm vs. 13.5 cm. An injection given ulnar to proximal edge of Lister's tubercle at a length of one-fourth the distance between Lister's tubercle and radial aspect of ulnar styloid resulted in 100% accurate perineural injection without intraneural injection. An anthropometric ratio of one-fourth the distance from Lister's tubercle to the ulnar styloid was able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.

Surface Landmarks to Provide a Safe Ulnar Nerve Block in the Wrist: Anatomical Study and Literature Review.

Introduction: Use of local anesthesia in awake patients undergoing hand surgery has become increasingly popular. A thorough understanding of local anatomy, such as the distal wrist for ulnar nerve block, is required to provide safe blockade. We sought to conduct an anatomic study of the distal wrist and review cadaveric studies describing various techniques for ulnar nerve block. Methods: Dissection of fresh-frozen cadaver forearms at the University of Louisville Robert Acland Fresh Tissue Lab assessing relationships between the flexor carpi ulnaris tendon and the ulnar nerve and the ulnar artery was performed. Three cadaveric studies on ulnar nerve blockade using the ulnar, volar, and/or transtendinous technique were identified and reviewed. Results: A total of 16 cadaver forearms of equal male to female ratio were obtained. The ulnar nerve was noted to be directly posterior to the flexor carpi ulnaris tendon in 15 (93.8%) forearms, with 1 (6.3%) specimen having the nerve extend along the ulnar border of the flexor carpi ulnaris. The ulnar artery was radial to the ulnar nerve 1 cm proximal to the pisiform in all specimens. In all 3 cadaveric studies, only the ulnar technique was associated with no ulnar artery and/or ulnar nerve injury. Conclusion: Knowledge of distal wrist anatomy can help minimize risk of iatrogenic injury during local blockade. On review, the ulnar approach provides the safest method for ulnar nerve block.

Students teaching students: A survey of a medical student led surgical skills workshop - A prospective cohort study.

BACKGROUND: Surgical skills training is a recognized vital component of medical education, yet a standardized curriculum does not exist. Early opportunities for skills development and mentorship may increase student interest in pursuing surgery. We evaluated the effects of a student-led, faculty-supervised suture clinic on student comfort level with basic surgical skills and interest in surgery. METHODS: A cohort survey study of 103 second-year medical students participating in a surgical skills course was performed between the years 2016-2018. Upon completion of the course, we assessed their comfort level with performing six basic skills as well as their interest in pursuing surgery based on pre- and post-course surveys. RESULTS: Mean age was 25 years and 50.5% were female. Most students (61.2%) had no prior suturing experience. Upon completion of the course, there was a significant improvement (p = < 0.0001) in comfort level for each of the six skills. Most students (81%) reported an increased interest in surgery. CONCLUSIONS: Early implementation of a basic skills workshop can augment student comfort level and promote an interest in surgery. Peer student mentors can effectively lead the workshop and minimize the time commitment needed by surgical faculty. This can serve as a new direction in medical education and an avenue for further studies to analyze the longitudinal effects of the curriculum on career choice and success in surgical residency.

Telesurgical Assessment: Using Smartphone Messaging to Efficiently Manage Postoperative Wounds.

Background: Telemedicine is an evolving field of interactions between physicians and patients remotely. Health care delivery, patient satisfaction, adherence, earlier diagnosis, increased access, and cost reduction are all areas that telemedicine has potential influence. One focus involves the use of photos in wound assessment. Today, many patients' smartphones can capture high-quality digital photographs, which can easily be transmitted. Postoperative patients are an ideal population for this, as they have a certain level of uncertainty with regard to the healing course, which can often lead to patients seeking out care in unnecessarily costly settings. These visits can lead to inefficient use of health care resources, especially when a telesurgical assessment (TSA) could provide appropriate care more efficiently. Objective: We present data collected from a series of patients who received a TSA to demonstrate the potential benefits of incorporating TSA into postoperative wound care. Methods/Clinical Presentation: Patients who underwent a procedure and contacted their surgeon within 2 weeks with concerns received a TSA, which included a discussion as well as photographs through smartphone. Their surgeon then determined further treatment steps, if any. Results: We experienced that 85% of patients did not require emergent treatment for their concerns, 46% were prescribed medications, whereas 39% of patients did not require any intervention. Conclusion: Our results show that TSAs alleviated patient concerns and provide resolutions, while saving resources and increasing satisfaction. Incorporating aspects of telemedicine into outpatient practice could be valuable, especially with postoperative wound checks.

Basic suture technique: Instructional videos explaining suturing for medical students in a qualitative study.

BACKGROUND: Understanding basic surgical skills is important for medical students prior to entering residency regardless of future specialty. In these videos we provide instruction for suturing as it relates to skin closure. MATERIAL AND METHODS: Instructional videos were created by the senior faculty (R.A. and M.K.) to teach medical students at the University of Louisville suturing techniques. RESULTS: Entering and exiting the needle at an angle of 90° or greater allows for tissue eversion. Inadequate eversion of tissue or inadequate angling of the needle will lead to tissue inversion. When suturing uneven edges, a deep bite on the low side and a shallow bite on the high side will allow for appropriate tissue leveling. For buried sutures, skin eversion with substantial dermal bites and proper knot location is essential. CONCLUSION: Understanding the basics of skin apposition will provide students with knowledge about primary wound healing and prepare them for residency.

Incisional Hernia After Percutaneous Endoscopic Gastrostomy Tube Placement: Importance of Avoiding the Linea Alba.

A gastrostomy tube passes from a patient's stomach through the abdominal wall and allows for direct enteral access. An alternative to an open gastrostomy, a percutaneous endoscopic gastrostomy (PEG) is typically favored because it is a less invasive option. However, a thorough understanding of the anatomy involved is paramount to prevent complications, regardless of what technique is chosen for placement. We present a case of an incisional hernia, which developed after the removal of a PEG tube placed through the midline of an abdominal wall, which is both a rare and avoidable complication. Placement of a PEG tube lateral to midline and avoiding the linea alba, an inherent weak point, will decrease the incidence of incisional hernias.