Management of Maxillofacial Trauma in Pregnant Women.

INTRODUCTION: Trauma during pregnancy deserves special attention as management must be directed towards both the mother and the fetus. Management of maxillofacial fractures in pregnancy can adversely affect the well-being of the fetus by impinging on normal functions such as respiration, mastication, and nutrition. Pregnancy complicates the management of facial injury due to the maintenance of the patent airway, anesthesia considerations, and imaging restraints. The purpose of this study is to use three illustrative from our own institution to further elucidate education on the management of mandible fracture in pregnancy with a focus on multidisciplinary treatment and outcomes. METHODS: A retrospective chart review was performed for all cases of facial fractures admitted to Ryder Trauma Center from 2012 to 2022. During this time, 4,910 patients presented with facial fractures 1319 patients were female. Three of the patients were pregnant at the time of admission. Demographics, mechanism of injury, associated injuries, and management information were collected. RESULTS: Patient 1 was a 20-year-old female presented to Ryder Trauma Center following a motor vehicle collision. She was 17 weeks pregnant at the time of admission and was found to have a left mandibular angle fracture. Patient 2 was a 14-year-old female who presented to Ryder Trauma Center status post gunshot wound to the mandible after she and her brother were unknowingly playing with a loaded gun. She was 18 weeks pregnant at the time of admission, with a past medical history of domestic violence, suicidal ideation, and major depressive disorder. Patient 3 was a 20-year-old female 36 weeks pregnant at the time of admission. She presented with a right paraymphyseal fracture and left mandibular angle fracture as a result of falling on the stairs. Patients all underwent surgical repair of fractures.

Modified oncoplastic lift, lymphatic excision, and reconstruction: Introduction of a novel technique in oncoplastic breast surgery with simple surgical principles.

INTRODUCTION: Oncoplastic surgery is an important component of the management of breast cancer. As prognosis has improved, the need for proficient techniques to achieve disease eradication while maintaining cosmesis for naturally appearing breasts has gained importance. This study describes an easy-to-learn modified oncoplastic technique for patients undergoing breast-conserving treatment. DESCRIPTION OF THE TECHNIQUE: Tumor resection is performed through different peri-areolar, inframammary, or radial incisions. To reduce the size of the surgical defect created after tissue resection, an internal purse-string is performed parallel to the chest wall or base of the wound with subsequent staggering in three or more layers as needed, while maintaining the parallel orientation of the needle. This is followed by the creation and overlapping of internal breast tissue flaps that are rearranged to decrease the dead space with the aim of improving cosmesis. The redundant skin is removed for the skin envelope to maintain shape. The wound is closed in layers. We also describe steps in performing sentinel lymph node and tumor extraction through the same periareolar, inframammary, or radial incisions for tumors located in outer quadrants. Following closure, contour and projection of the breast were maintained without indentation or loss of projection, with a symmetrical appearance to the contralateral side. CONCLUSION: This simplified oncoplastic (MOLLER) technique can be easily learned and used by surgeons who treat cancer patients and have limited oncoplastic training. It uses basic known surgical principles to decrease the size of the defect created while minimizing the need for larger incisions/pedicles.

The Brazilian Butt Lift Remains the Deadliest Aesthetic Surgery Procedure: Are Plastic Surgeons Adjusting Their Surgical Practice to Promote Safety?

BACKGROUND: The number of Brazilian butt lift (BBL) fatalities remains high in the United States despite numerous practice advisories geared towards patient safety and reducing the incidence of fatal pulmonary fat emboli. OBJECTIVES: This study aimed to evaluate US board-certified plastic surgeons' opinions, understanding of BBL-related mortality, and current risk-reducing surgical practices for BBL procedures. METHODS: An online 18-question survey was distributed via email by the Aesthetic Surgery Education and Research Foundation to national board-certified plastic surgeon members of the The Aesthetic Society. Survey responses were collected over 21 days on the Qualtrics platform. RESULTS: The survey response rate was 10% (n = 178). Of the 77% who performed BBL procedures, 48% (n = 80) did not use ultrasound. Approximately 60% (n = 102) of all respondents disagreed with imposing regulations to require ultrasound, with the most frequent reason being that it was unnecessary with adequate surgeon experience (45%). Plastic surgeons thought that high-volume budget clinics (n = 64) and a lack of regulations imposed on individual surgeons by boards of medicine (n = 31) were the greatest contributors to BBL mortality. CONCLUSIONS: Most US plastic surgeons did not use ultrasound for BBL procedures and did not agree that ultrasound should be required, which may partially be the result of unsuccessful educational outreach for risk-reducing practices and training for ultrasound. Regulations by the boards of medicine imposed on individual surgeons, in combination with new legislation targeted at ownership of high-volume clinics, are strongly backed by surgeon respondents as measures that may improve patient safety.

Prepectoral Direct-to-Implant versus Staged Tissue Expander Breast Reconstruction: A Comparison of Complications.

BACKGROUND: Direct-to-implant (DTI) reconstruction has multiple advantages over a staged tissue expander (TE) approach. However, its use may be limited by concerns of increased complications. This study is the largest series to date comparing postoperative outcomes for DTI versus TE reconstruction in the prepectoral plane. METHODS: The authors retrospectively reviewed 348 patients that received 536 total immediate, prepectoral implant-based breast reconstructions between January 2018 and December 2021. The authors compared the presence of risk factors and the rate of six separate complications between patients that received DTI versus TE reconstruction up to one year after surgery. RESULTS: Of 348 patients, 147 (42%) and 201 (58%) underwent TE and DTI reconstruction (p=0.1813), respectively. Overall infection rate was 16.4% (n=57). DTI patients had a significantly greater incidence of wounds (p<0.0001), including minor (p<0.0011) and major wounds (p<0.0053). Significantly greater mastectomy resection weights were found for DTI patients that experienced any complication (p<0.0076), postoperative wounds (p<0.0001), and major wounds specifically (p<0.0035). Compared to medium thickness, extra-thick acellular dermal matrix (ADM) was associated with significantly increased rates of infection (p<0.0408) and wounds (p<0.0001). CONCLUSIONS: Prepectoral DTI reconstruction in patients with adequate flap perfusion may have comparable complication rates to staged TE reconstruction apart from a higher incidence of postoperative wounds. Greater mastectomy resection weights and thickness of ADM may specifically contribute to infectious and wound-healing complications. Prepectoral DTI reconstruction is encouraged in the patients with adequate flap perfusion and moderate to low mastectomy resection weights that desire comparable or smaller implant volumes.

Stalled at the intersection: insurance status and disparities in post-mastectomy breast reconstruction.

PURPOSE: Post-mastectomy breast reconstruction (PMBR) is an important component of breast cancer treatment, but disparities relative to insurance status persist despite legislation targeting the issue. We aimed to study this relationship in a large health system combining a safety-net hospital and a private academic center. METHODS: Data were collected on all patients who underwent mastectomy for breast cancer from 2011 to 2019 in a private academic center and an adjacent public safety-net hospital served by the same surgical teams. Multivariable logistic regression was used to assess the effect of insurance status on PMBR, controlling for covariates that included socioeconomic, demographic, and clinical factors. RESULTS: Of 1554 patients undergoing mastectomy for breast cancer, 753 (48.5%) underwent PMBR, of which 592 (79.9%) were privately insured, 50 (6.7%) Medicare, 68 (9.2%) Medicaid, and 31 (4.2%) uninsured. Multivariable logistic regression showed a significantly higher likelihood of not undergoing PMBR for uninsured (OR 6.0, 95% CI 3.7-9.8; p < 0.0001), Medicare (OR 1.9, (95% CI 1.2-3.0; p = 0.006), and Medicaid (OR 1.5, 95% CI 1.0-2.3; p = 0.04) patients compared with privately insured patients. Age, stage, race and ethnicity, and hospital type confounded this relationship. CONCLUSION: Patients without health insurance have dramatically reduced access to PMBR compared to those with private insurance. Expanding access to this important procedure is essential to achieve greater health equity for breast cancer patients.

Persistent and interdependent: Racial disparities and their mechanisms in postmastectomy breast reconstruction.

BACKGROUND: Racial disparities in accessing postmastectomy breast reconstruction persist despite expansion of insurance coverage. An updated examination with a broad assessment of mediating factors in a "majority minority" community is needed. METHODS: Data were collected on all patients undergoing mastectomy for breast cancer from 2011 to 2019 in a private academic center and adjacent safety-net hospital. Multivariable logistic regression was used to assess the effect of race on postmastectomy breast reconstruction, controlling for predetermined potentially mediating and confounding variables. RESULTS: Of 1,554 patients, 63.8% (n = 203) of non-Hispanic White, 33.4% (n = 102) of Black, and 47.9% (n = 438) of Hispanic patients underwent postmastectomy breast reconstruction. Multivariable logistic regression showed that Black patients (odds ratio [OR] 3.6, 95% confidence internal [CI]: 2.2-5.9; P < .0001) undergo significantly less postmastectomy breast reconstruction than White patients. Age, insurance status, stage, and hospital type mediated this relationship. CONCLUSION: Black patients have substantially reduced rates of postmastectomy breast reconstruction compared with White patients, which is mediated by socioeconomic factors.

Comparison of Immediate Breast Reconstruction Outcomes in Patients With and Without Prior Cosmetic Breast Surgery.

BACKGROUND: Skin-sparing (SSM) and nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR) have significantly increased. There is limited information on complications of IBR in patients with prior cosmetic breast surgery (CBS). We compare IBR outcomes in patients undergoing SSM and/or NSM with and without prior CBS. MATERIALS AND METHODS: Patients undergoing mastectomy from January 1, 2017 to December 31, 2019 were selected. Patient characteristics, surgical approach, and complications were compared between mastectomy and IBR cases for breasts with and without prior CBS. Binary logistic regression analysis was performed to identify predictors of complications and reconstruction loss. RESULTS: 956 mastectomies were performed in 697 patients, with IBR performed for 545 mastectomies in 356 patients. Median age was 51 (range 19-83), 45.8% of patients were age < 50, 62.6% of mastectomies were performed for breast cancer. 95 mastectomies (17.4%) were performed in breasts with prior CBS and 450 (82.6%) without. NSM was more frequently utilized for breasts with prior CBS (P < .001). Complications occurred in 80 mastectomies (14.7%); reconstruction loss in 30 (5.5%). On multivariable analysis, age ≥ 50 (OR 1.76, 95%CI 1.01-3.09, P = .047) and NSM (OR 2.11, 95%CI 1.17-3.79, P = .013) were associated with an increased risk of any complication. Prior CBS was not associated with an increased risk of complications (OR 1.11, 95%CI 0.58-2.14, P = .743) or reconstruction loss (OR 1.32, 95%CI 0.51-3.38, P = .567). CONCLUSION: In this analysis of mastectomy and IBR, prior CBS was not associated with an increased risk of complications or reconstruction loss. In patients with prior CBS undergoing mastectomy, IBR may be safely performed.

Operational and Financial Impact of COVID-19: A Survey of Plastic Surgeons in Miami.

BACKGROUND: In response to the COVID-19 pandemic, new guidelines were issued cautioning against performing elective procedures. We aimed to assess the impact of the COVID-19 pandemic on operational and financial aspects of plastic surgery in Miami. METHODS: A multiple-choice and short-answer survey regarding practice changes and financial impact was sent to all 67 members of the Miami Society of Plastic Surgeons. RESULTS: A 41.8% (n = 28) response rate was obtained, five responses did not meet the inclusion criteria, and statistical analysis was performed on 34.3% (n = 23) of responses. Of the plastic surgeons who responded, 21.74% operate in an academic setting, 60.87% are in a single practitioner private practice, and 17.39% are in a multi-practitioner private practice. An estimated 60% of academic plastic surgeons had 75% or more of their previously scheduled cases canceled, compared with 57.14% in single practitioner private practice and 100% in multi-practitioner private practice. In total, 64.29% of single practitioner private practices and 50% of multi-practitioner private practices have had to obtain a small business loan. Single practitioner private practice plastic surgeons reported having an average of 6.5 months until having to file for bankruptcy or permanently close their practices, and multi-practitioner private practice plastic surgeons reported an average of 6 months. CONCLUSIONS: Guidelines to support small business must be implemented in order to allow private practice surgeons to recover from the substantial economic impact caused by the pandemic because it is necessary to reestablish patient access and provide proper care to our patients.

BreastImplantAnalyzer: An easy-to-use, validated tool for calculating breast implant volume from MRI data.

BACKGROUND: Given the prevalence of breast augmentation and prosthetic-based breast reconstruction, it is common for the plastic surgeon to see patients presenting for revisional implant surgery. A frequent issue encountered in such procedures is uncertainty of implant size, which presents numerous challenges and may lead to undesired outcomes for both the patient and the surgeon. There is currently no tool available with the purpose of measuring implant volume from magnetic resonance imaging (MRI) data. In this study, such a program was designed and tested. METHODS: An open-source software was developed that provides volume measurement of a chosen breast implant with minimal interaction from the user, allowing for precision in the planning of breast implant revisional surgery. It was developed to be as easy to use as possible for clinicians who may not have experience with imaging analysis platforms. The program was tested on patients who underwent revisional implant surgery and had documented implant volumes and pre-operative breast MRIs. Twenty-two implants were tested in total, including saline and both smooth and textured silicone implants. RESULTS: The software has shown to be highly accurate with an average accuracy of 98.6%. A Spearman correlation coefficient of 0.967 was obtained. The software also performed faster than previously proposed methods. CONCLUSION: Plastic surgeons can easily calculate breast implant volume pre-operatively using BreastImplantAnalyzer, which is available to download for free from www.BreastImplantAnalyzer.com or as an extension for the popular medical imaging platform 3D Slicer.

Immediate application of vacuum assisted closure dressing over free muscle flaps in the lower extremity does not compromise flap survival and results in decreased flap thickness.

BACKGROUND: Free muscle flaps are a mainstay for reconstruction of distal third leg wounds and for large lower extremity wounds with exposed bone. However a major problem is the significant postoperative flap swelling, which may take months to resolve. We studied the efficacy and safety of immediate application of a vacuum assisted closure (VAC) dressing after a free muscle flap to the lower extremity. METHODS: Over a 19 months period, all consecutive free muscle flaps for lower extremity reconstruction at a Level I trauma center were evaluated prospectively for postoperative flap thickness, complications and flap survival. Immediate application of a VAC dressing was performed in 9 patients, while the flap was left exposed for monitoring in 8 patients. RESULTS: There was no statistically significant difference in flap survival between both cohorts. Mean flap thickness at postoperative day 5 for the VAC group was 6.4±6.4 mm, while flap thickness for the exposed flap group was 29.6±13.5 mm. Flap thickness was significantly decreased at postoperative day 5 for the VAC dressing group. CONCLUSIONS: Immediate application of VAC dressing following free muscle flaps to the lower extremity does not compromise flap survival or outcomes and results in decreased flap thickness and a better aesthetic outcome.

Pedicle De-epithelialization in Reduction Mammoplasty: A Systematic Review of the Literature.

BACKGROUND: Reduction mammoplasty is among the most commonly performed plastic surgery procedures. The reduction pedicle is traditionally de-epithelialized. Many practitioners propose that preservation of the subdermal blood supply results in improved circulation for the nipple-areolar complex. However, this is a time-consuming step of the procedure. Presumed benefits have not been definitively demonstrated. OBJECTIVE: To evaluate current evidence regarding pedicle de-epithelialization in inferior pedicle reduction mammoplasty. METHODS: The MEDLINE database was searched for studies evaluating pedicle de-epithelialization in reduction mammoplasty surgery. Studies reporting outcomes after reduction mammoplasty with pedicle de-epithelialization and deskinning were included. Additionally, reports detailing novel techniques or modification for pedicle de-epithelialization were evaluated and included. RESULTS: One hundred and thirty-eight articles were identified on a systematic review. Thirty-six articles met the study criteria. This includes 23 reporting outcomes after reduction mammoplasty procedures and 13 describing novel techniques for pedicle de-epithelialization. Of the 23 studies reporting outcomes, 6 studies evaluated deskinning of the pedicle. Two of the six studies directly compared deskinning and de-epithelialization. They reported no significant difference in outcomes. The remaining 17 articles described outcomes of inferior pedicle reduction mammoplasty with pedicle de-epithelialization. Studies evaluating deskinning reported ischemic nipple-areolar complex complication rates between 0 and 1.4%. Studies evaluating de-epithelialization reported ischemic nipple-areolar complex complication rates between 0 and 11.1%. CONCLUSIONS: Pedicle de-epithelialization is commonly performed despite limited definitive evidence evaluating its surgical necessity or benefits. Available evidence suggests deskinning may yield acceptable results; however, further investigation is necessary. 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 .

Treatment Options for Exposed Calvarium Due to Trauma and Burns.

Wounds involving the calvarium secondary to trauma or burns are rare. However, they can present with challenging potential clinical sequelae. A wide variety of reconstructive options have evolved over the last century. Technical aspects have progressively improved as well over time. For proper surgical restoration of function and cosmesis reconstructive surgeons must have a detailed understanding of both the scalp and skull anatomy. Several factors such as etiology of the injury, including whether or not calvarial bone defects exists or simply soft tissue loss, as well as size, local tissue environment and patient comorbidities play major roles in appropriate choice for reconstruction. Currently, there is no single treatment option for scalp or calvarial reconstruction after trauma or burns. However, reconstructive alternatives are constantly emerging with promising results.

Intraosseous venous malformations of the zygoma: clarification of misconceptions regarding diagnosis and management.

Primary intraosseous venous malformations affecting the zygoma are rare vascular lesions, with only 35 cases reported in the surgical literature. Despite the establishment of the binary classification system, which serves to distinguish vascular tumors from malformations, inappropriate use of the term "hemangioma" to describe a variety of distinct vascular anomalies remains widespread. The authors present 3 cases of zygomatic intraosseous venous malformations and summarize the clinical, radiographic, and immunohistochemical features of these lesions. In each case, an insidious clinical course, combined with the pathognomonic finding of radiating trabeculae on computed tomography, suggests the diagnosis of intraosseous venous malformation. Negative glucose transporter isoform 1 immunoreactivity and histopathological analysis were used to reinforce this diagnosis in 1 patient. Management was individualized in each case, based on symptom complex and aesthetic concern. Given that the therapeutic approach to vascular anomalies is dependent on accurate diagnosis, resolution of semantic matters will optimize the management of these lesions.

Overview of pediatric orbital fractures.

Orbital fractures in children are uncommon. The pattern of orbital fractures changes as children age. Although the management of pediatric orbital fractures is evolving, a thorough clinical assessment with computed tomographic scan imaging is essential. Urgent surgical intervention is indicated in cases of entrapment or acute enophthalmos. Entrapment with oculocardiac reflex is common in the white-eyed blow-out or trapdoor fractures. Otherwise, pediatric fractures may be treated conservatively with surveillance. A variety of autogenous and allogenic materials may be used to repair the fractured orbit. Resorbable plating systems are an alternative to rigid metallic fixation and may be used on the developing craniofacial skeleton.

Outpatient management of pediatric burns.

The leading etiologies of pediatric burns are scald, thermal, and electrical injuries. The initial management of burns involves assessment of burn depth and total body surface area (TBSA) affected, a history, and physical examination. Calculation of percent of TBSA affected is an important determinant of the necessity for hospitalization versus outpatient management. Only second- and third-degree burns are included in the calculation. The criteria for outpatient management vary based on the center experience and resources. One such set of criteria in an experienced burn center includes burn affecting less than 15% TBSA, therefore not requiring fluid resuscitation; the ability to take in oral fluids, excluding serious perioral burns; no airway involvement or aspiration of hot liquid; no abuse; and dependable family able to transport the patient for clinic appointments. Once the child is ready to reenter school, the physician must discuss with the family and school staff any needs and expectations for the child, including wound care. Social reintegration can be difficult. Educating the teachers and staff of the child's appearance may help prepare the students.

Perioperative considerations in the autologous breast reconstruction patient with systemic lupus erythematosus.

Following mastectomy, women with breast cancer are faced with choices for reconstruction. In women with systemic lupus erythematosus (SLE), with or without antiphospholipid syndrome (APS), concurrent morbidities are important considerations when deciding the method of reconstruction. The 2 cases we present represent the variable spectrum of SLE and/or APS and their potential complications. When deciding the best course of action, it is most important to consider each case on an individual basis, with important emphasis on preoperative disease status.