Clinical Outcomes of Acellular Dermal Matrix (SimpliDerm and AlloDerm Ready-to-Use) in Immediate Breast Reconstruction.

Background The use of acellular dermal matrix (ADM) for post-mastectomy reconstruction is considered by many surgeons to be an accepted component of surgical technique. Early clinical experience is described for SimpliDerm® - a novel human ADM (Aziyo Biologics, Silver Spring, USA), and AlloDerm® Ready-To-Use (RTU) - an established ADM (Allergan Medical, Irvine, USA). Methods Records were retrospectively reviewed from four sites between 2016 and 2021 of patients who underwent immediate, two-stage reconstruction with either SimpliDerm (n=38) or AlloDerm RTU (n=69) after mastectomy and were followed out to exchange to permanent implant(s), tissue expander(s) explant, or death. Results Immediate breast reconstruction with tissue expanders and ADM was performed on 107 patients (181 breasts). Overall mean patient age was 51.4 ± 12.4 years, and mean BMI was 28.0 ± 5.8 kg/m2. Significantly more patients in the SimpliDerm group were of Hispanic or Latino ethnicity (34.2% vs. 7.2%; P<.001). Reconstructions were predominantly prepectoral (82.3%). A total of 35 adverse events (AEs) occurred in 27 (25.2%) patients, with no difference in AE type, classification, or rates between ADM groups. No AEs were considered related to either ADM. The observed AE profiles and rates are similar to those published for other ADMs in immediate breast reconstruction. Conclusions There continues to be a need for additional clinically equivalent ADMs to provide physicians with more availability and options for their practice. This retrospective, multisite study describes comparable clinical outcomes with SimpliDerm and AlloDerm RTU through a median of 133.5 days (~four months) following immediate two-stage breast reconstruction.

Pyriform Costal Cartilage Graft Improves Cleft-Side Alar Asymmetry in Secondary Cleft Rhinoplasty.

OBJECTIVE: The asymmetry of a retrusive cleft-side ala positioned posterior, lateral, and inferior relative to the noncleft ala is exacerbated by ipsilateral deficiency of the pyriform aperture. We describe use of pyriform costal cartilage grafts for enhanced structural foundation and alar symmetry in secondary cleft rhinoplasty. DESIGN: Retrospective case series. PATIENTS: All pyriform aperture paranasal augmentation secondary cleft rhinoplasty cases performed between May 2013 and February 2018 were included. Clinical photos were analyzed, and these results are provided in addition to a detailed description of the augmentation technique. RESULTS: Twelve total cleft patients, 10 (83.3%) unilateral cleft lip and palate, 1 (8.3%) unilateral cleft lip, and 1 cleft palate (8.3%) were included. Age averaged 18.6 ± 6.0 years with 3 (25.0%) males and 9 (75.0%) females. Costal cartilage grafting to the pyriform aperture through the gingivobuccal sulcus was used to reposition the alar base and nasal sill to a more anatomic anterior position, thereby enhancing symmetry in secondary cleft rhinoplasty. Average rib graft donor site incision was 2.5 cm. Follow-up ranged from 3.2 to 48.2 months, average 15.3 ± 14.4 months. No complications related to the pyriform cartilage graft were observed, other than one minor intraoperative breach of parietal pleura. CONCLUSIONS: We observed improvement in the anatomic contour of the cleft-side ala with costal cartilage grafting to the pyriform rim. This resulted in improved cleft-side alar form and thus overall alar symmetry. These results were obtained consistently, without significant complications. This technique is safe and provides a powerful tool to reposition the ala in secondary cleft rhinoplasty. Further studies will quantify the enhancement in nasal base symmetry.

Propranolol for Preoperative Management of a Large Infantile Hemangioma.

Infantile hemangiomas (IHs) are common vascular tumors that typically follow a predictable pattern of rapid proliferation followed by gradual involution. Although most do not require treatment, some large or difficult IHs do, with medical and surgical options available. Prior reports indicate the success of using propranolol, a nonselective ß-blocker, to treat these lesions. This report will demonstrate the use of propranolol preoperatively to manage a large IH followed by surgical excision of the lesion in a collaborative medical and surgical approach.

Anterior-posterior dissociative slide facilitates the second stage of 3-stage forehead flap nasal reconstruction.

Pedicle-lining skin grafts contract between the first and second stage in a 3-stage forehead flap nasal reconstruction. The second stage involves an inherent reduction in vascularity due to the soft tissue thinning performed. The Anterior-Posterior Dissociative Slide restores first-stage pedicle length at the second stage. Incisions are made at the distal seam between the contracted graft and the pedicle tissue. The flap is then slid caudally relative to the fixed graft, thus relengthening the pedicle. This technique has been performed in 16 patients achieving an average length gain of 0.7 (+0.2) cm. The additional length created with the dissociative slide translates into reduced tension with flap reinset, thus increasing flap workability and overall artistry in the second stage.

The reliability and advantages of the sentinel vein as a microsurgical recipient vessel.

Free flaps to the scalp, calvaria, and anterior and middle cranial fossae are typically transferred to the superficial temporal artery and vein. Occasionally the superficial temporal vein is unsuitable for microvascular anastomosis. In such cases, we have had success using the sentinel vein, a perforating vein located in the anterior aspect of the deep temporal fat pad. This article describes the pertinent anatomy, our clinical experience, and the advantages of the sentinel vein as a microsurgical recipient vessel.

Stahl's ear correction: synergistic use of cartilage abrading, strategic Mustarde suture placement, and anterior anticonvexity suture.

Stahl ear deformity is characterized by a third auricular crus with a horizontal orientation. A diminutive superior crus and prominence of the upper pole of the ear are also generally present. Many acknowledge that Stahl ear is a challenging deformity to correct. In the present report, an effective technique is introduced that uses 3 different, yet synergistic, maneuvers to oblate the third crus, enhance the superior crus, and normalize superior pole projection. The maneuvers are posterior abrading of the third crus, strategic placement of a posterior Mustarde suture, and placement of an anterior anticonvexity suture. Postoperative care involves the use of a custom scaphoid fossa splint and headband.

External doppler monitoring of free flaps through negative pressure dressings.

The negative pressure dressing is a highly effective modality for coverage and bolstering of skin grafts in the early postoperative period. In the situation of a skin graft over a free flap, the surgeon might be inclined to avoid this modality out of concern that the dressing would deleteriously effect flap survival or impede flap monitoring. This case series supports the safety of the negative pressure dressing and demonstrates a technical modification that permits external Doppler monitoring of the flap through the dressing. Thus, this technique provides an ideal environment for skin graft healing while maintaining the ability to monitor the flap in a straightforward manner and also simplifies nursing care.

Chicken sternal cartilage for simulated septal cartilage graft carving: a rhinoplasty educational model.

BACKGROUND: In rhinoplasty, cartilage is often harvested from the nasal septum and meticulously carved into delicate grafts designed to reshape and strengthen the nasal osteocartilaginous framework. Proficiency at this task develops with experience in the clinical setting. OBJECTIVE: The author offers a simulated educational model designed to provide rhinoplasty surgeons with increased preclinical experience in cartilage graft carving. METHODS: This model relies on inexpensive, food-grade chickens, which may be purchased at any grocery store. Four whole chickens were dissected to expose and harvest the sternal (breast/keel) cartilage. A technique was developed for preparing the cartilage to approximate the shape and dimensions of human septal cartilage. Measurements were made to demonstrate similarities between the model material and the human septum. RESULTS: The average weight of the chickens was 4.27 lb. The average cartilage height, length, and thickness were 2.36 cm, 6.13 cm, and 3.4 mm, respectively. This size compared favorably with typical septal harvest pieces, which had both heights and lengths of 2.5 cm and thicknesses of 3.25 mm. The author found that one sternal cartilage piece could be employed to carve two spreader grafts, a columellar strut graft, a tip graft, and two alar rim cartilage grafts. The performance of the avian cartilage was subjectively very similar to that of septal cartilage. Furthermore, two pieces of the sternal cartilage could be glued together and fastened within a model of a human skull to replicate the cartilaginous septum in situ. This construct was employed for demonstrations of actual septal cartilage harvest. CONCLUSIONS: Carving septal cartilage into grafts is a difficult process. Precision and improved results increase with clinical experience on human patients, but this cadaveric avian (chicken) model provides an opportunity for simulated surgical training on a very similar tissue type at a very low cost. This model has the potential to improve human outcomes by providing increased practice opportunities in a procedure that requires precision and artistry for the formation of reproducible geometric graft shapes.

Factors contributing to the facial aging of identical twins.

BACKGROUND: The purpose of this study was to identify the environmental factors that contribute to facial aging in identical twins. METHODS: During the Twins Day Festival in Twinsburg, Ohio, 186 pairs of identical twins completed a comprehensive questionnaire, and digital images were obtained. A panel reviewed the images independently and recorded the differences in the perceived twins' ages and their facial features. The perceived age differences were then correlated with multiple factors. RESULTS: Four-point higher body mass index was associated with an older appearance in twins younger than age 40 but resulted in a younger appearance after age 40 (p = 0.0001). Eight-point higher body mass index was associated with an older appearance in twins younger than age 55 but was associated with a younger appearance after age 55 (p = 0.0001). The longer the twins smoked, the older they appeared (p < 0.0001). Increased sun exposure was associated with an older appearance and accelerated with age (p = 0.015), as was a history of outdoor activities and lack of sunscreen use. Twins who used hormone replacement had a younger appearance (p = 0.002). Facial rhytids were more evident in twins with a history of skin cancer (p = 0.05) and in those who smoked (p = 0.005). Dark and patchy skin discoloration was less prevalent in twins with a higher body mass index (p = 0.01) and more common in twins with a history of smoking (p = 0.005) and those with sun exposure (p = 0.005). Hair quantity was better with a higher body mass index (p = 0.01) although worse with a history of skin cancer (p = 0.005) and better with the use of hormones (p = 0.05). CONCLUSION: This study offers strong statistical evidence to support the role of some of the known factors that govern facial aging.

Purse-string nipple areolar reconstruction.

We present a surgical technique of nipple areolar reconstruction that uses a purse-string to increase areolar projection while reducing loss of nipple projection. A permanent purse-string is used around a modified CV flap to advance tissue centrally to the base of the nipple reconstruction. Two opposing hemiareolar island flaps are advanced toward the base of the nipple to add tissue volume. The resulting circumareolar full thickness skin is closed using a permanent purse-string suture. Synching the purse-string suture produces an effect similar to that of a periareolar mastopexy and enhances areolar projection. Eighty-two patients underwent 108 nipple areola reconstructions. Ninety-six percent of the patients achieved good results without any flap loss or suture infections. Revision surgery was necessary in 4 patients for minor problems including asymmetry or loss of projection. The purse-string nipple areolar reconstruction method described results in a high rate of maintenance of projection and patient satisfaction.

The comprehensive management of chemosis following cosmetic lower blepharoplasty.

BACKGROUND: Chemosis can cause persistent discomfort and aggravation in the postoperative period following surgery of the eyelids. This article focuses on chemosis associated with cosmetic lower blepharoplasty. The cause is multifactorial and includes exposure, periorbital edema, and postoperative lymphatic dysfunction. METHODS: A chart review of 312 primary bilateral lower transcutaneous blepharoplasties was performed. Data were collected to identify the incidence of chemosis, define associated etiologic factors, develop a chemosis classification system, and outline a successful treatment algorithm. RESULTS: The incidence of chemosis was 11.5 percent in this population of lower lid blepharoplasty patients. Chemosis presented intraoperatively or up to 1 week postoperatively. The median duration was 4 weeks, with a range from 1 to 12 weeks. Associated etiologic factors included conjunctival exposure, periorbital and facial edema, and lymphatic dysfunction. The four general patterns of presentation were classified as type 1, acute mild chemosis with complete lid closure; type 2, acute severe chemosis that prohibits complete lid closure (chemosis-induced lagophthalmos); type 3, subchronic chemosis that persists longer than 3 weeks; and type 4, chemosis associated with lower lid malposition. Successful treatment existed along a continuum from liberal lubrication to ophthalmic steroid preparations and ocular decongestants to eye-patching to minor surgical procedures such as drainage conjunctivotomy and temporary tarsorrhaphy. In all cases, chemosis ultimately resolved. CONCLUSIONS: Chemosis is a common complication of lower blepharoplasty. Pharmacologic, mechanical, and surgical therapies may be used alone or in combination for the successful management of chemosis. Prevention by minimization of triggering factors intraoperatively and immediately postoperatively is important.

"Universal" and ethnic ideals of beautiful buttocks are best obtained by autologous micro fat grafting and liposuction.

Recently there has been a dramatic increase in the number of patients seeking buttocks enhancement and in the degree of augmentation requested. To fulfill these requests,aesthetic plastic surgeons must understand the patient's personal requests and ethnic identity, as well as any universal ideal of proportions and contours that create the impression of beautiful buttocks. "Universally" perceived ideal buttocks are 1.4 times the circumference of the waist, which is consistent cross-culturally and throughout history. Beyond this are important ethnic differences in the image of perfect buttocks shape. The combination of autologous micro fat grafting and liposuction is the best and possibly only way to obtain various ideal shapes, and offers a lower incidence of complications compared with buttock implants.

Circumferential negative-pressure dressing (VAC) to bolster skin grafts in the reconstruction of the penile shaft and scrotum.

This paper presents 4 consecutive cases using negative-pressure dressings (VAC) to bolster skin grafts in male genital reconstruction. In this series reconstruction followed 1 case of tumor ablation and 3 cases of debridement of abscesses or Fornier's gangrene. The VAC was applied circumferentially to the penis to secure skin grafts either directly to the penile shaft or to facilitate skin grafting to the scrotum. Graft areas ranged from 75 to 250 cm. All cases resulted in successful genital wound coverage; minor complications are described. Three practical points are brought forth. First, the VAC facilitates skin grafting to the complex contour of male genitalia. Second, the VAC can be applied circumferentially to the penis without the need for perfusion monitoring or fears of avascular necrosis. Third, with the use of the VAC, bolster use can likely be discontinued as early as 72 hours with good graft adherence and survival.

International trends in the treatment of cleft lip and palate.

This article presents a contemporary (2004) survey of the methods and timing used in the care of cleft patients. The results are compared, when possible, with those of a similar study published by the lead author in 1998 and with those of the Eurocleft Project that took place from 1996 to 2000. Although very little uniformity is seen in the care of cleft patients, this comparison demonstrates a significant degree of agreement on many aspects of cleft care and a continuing process of adaptation and evolution in the field of cleft lip and palate surgery.

Topographic mapping of the superior transverse scapular ligament: a cadaver study to facilitate suprascapular nerve decompression.

Division of the superior transverse scapular ligament for decompression of suprascapular nerve entrapment can be curative. However, the superior transverse scapular ligament can be difficult to locate, and large incisions are often required. This study was designed to determine the topographic coordinates of the superior transverse scapular ligament to permit reproducible surgical localization and reduce incision size. In 20 cadavers, the superior transverse scapular ligament was identified through a superior approach. Measurements were obtained from the superior transverse scapular ligament to external landmarks. The superior transverse scapular ligament was located 1.3 +/- 0.3 cm (+/- SD) posterior to the posterior border of the clavicle and 2.9 +/- 0.8 cm from the acromioclavicular joint in a two-dimensional surface plane. The depth of the superior transverse scapular ligament from the skin surface was 3.9 +/- 0.7 cm. An incision (mean length, 6.3 +/- 0.7 cm) derived from a novel system of planning marks facilitated access to the superior transverse scapular ligament. The authors conclude that the superior transverse scapular ligament can be located consistently through an incision located on the superior aspect of the shoulder on the basis of palpable topographic landmarks. The superior approach permits small incision size and the maintenance of local muscle anatomic integrity.