Reverse Anterolateral Thigh Flap for Complex Scalp Reconstruction.

It is common for patients diagnosed with severe traumatic brain injury or intracranial tumors to undergo multiple craniotomy and cranioplasty procedures. In the setting of infection, these patients can develop scalp wounds with no local options. A reverse flow anterolateral thigh (ALT) flap for coverage of a complex multifocal scalp wound in a patient with exposed cranioplasty mesh and multiple prior operations without necessitating vein grafts was presented. This might be the first reverse flow free ALT flap to be reported in head and neck reconstruction.

How Big is Too Big: Pushing the Obesity Limits in Microsurgical Breast Reconstruction.

PURPOSE: Obesity is a major public health concern in the United States, affecting nearly 79 million people. There have been promising results performing microvascular breast reconstruction in patients with obesity; however, the definition of obesity is often poorly defined or does not extend above a body mass index (BMI) of 35. Our goal was to examine outcomes of microvascular breast reconstruction in this questionably more risky population. METHODS: A retrospective review from 2013 to 2016 was performed of 2 surgeons' experience with abdominally based microvascular breast reconstructions. Women were categorized by BMI into the following groups: normal (18.5-24.9 kg/m), overweight (25.1-29.0 kg/m), class I (30.0-34.9 kg/m), class II (35.0-39.9 kg/m), and class III (>40 kg/m). Demographics included history of tobacco use, breast cancer diagnosis, adjuvant care, and comorbidities. Complications evaluated included donor site (delayed wound healing, fat necrosis, dehiscence, infection, abdominal hernia/bulge, and seroma), recipient site (delayed wound healing and fat necrosis), and need for reoperation. Statistical analyses were performed using analysis of variance and χ test. RESULTS: A total of 90 women (117 breasts) underwent microsurgical breast reconstruction using abdominal tissue. Twenty-seven women (48 breasts) met criteria for class II and class III obesity (BMI 35-53). Mean follow-up was 24 months. No statistically significant difference was found in demographics among all groups. There was a trend toward variability in overall complications across the BMI groups (P = 0.149). Donor site complications had a significant variation across the different BMI groups (P = 0.016). The rate of donor site complications was similar in class II (8/14) and class III (7/13) obese women. Recipient site complications were similar across the BMI groups. CONCLUSIONS: We found obese women to have a higher rate of abdominal donor site complications; however, this risk seems to level off at class I or II obesity. We have modified our surgical technique of managing the abdominal donor site to optimize our outcomes in the morbidly obese patient population.

Decreasing ALT donor site morbidity with the keystone flap.

BACKGROUND: The anterolateral thigh (ALT) flap is a workhorse flap for a variety of wounds. The primary disadvantage of ALT flaps is donor site morbidity associated with large skin paddle defects. We present a strategy of managing the donor site with the Keystone flap to avoid skin grafts in cases where primary closure is not possible. METHODS: A retrospective, multi-institutional review from December 2015 to March 2017 based on a single surgeon's experience was performed. Inclusion criteria were harvest of an ALT flap and closure of the thigh donor site with a keystone flap. RESULTS: Six patients underwent reconstruction of the ALT donor site with a keystone flap. The average width of the ALT skin paddle was 7.8 cm (range 7-8 cm) and the defects could not be closed primarily or with wide undermining. Surface area of the ALT flaps averaged 96.8 cm2 (range 64-152 cm2 ). Mean patient BMI was 24.6 (range 16-37). Keystone flap dimensions averaged 9.5 × 17.8 cm. There were no major donor or recipient site complications, and one ×minor complication of delayed wound healing. No patients exhibited decreased range of motion at the hip or knee. CONCLUSIONS: Primary closure of the ALT donor site is preferred, but becomes difficult as skin paddle width approaches 8 cm. Managing the ALT flap donor site with a keystone flap is safe, does not appear to have significant morbidity, and can allow the surgeon to avoid the morbidity and secondary donor site associated with skin grafting.

The Visor Flap: A Novel Design for Scalp Wound Closure.

Full-thickness scalp defects pose a reconstructive problem in the setting of infection, radiation, and underlying calvarial defects. Current options include dermal matrices, skin grafts, and local fasciocutaneous flaps. Free tissue transfer is frequently required when scalp-based flaps fail or the wound is significantly large or complex. The authors present 7 patients of complex scalp defect reconstruction using the novel visor flap. The visor flap is a bipedicled advancement flap with a triangular posterior extension. The flap was designed to redistribute tension over a large surface area that prioritizes tension-free closure of the wound over a relatively small remote donor site. This method achieved complete primary healing of the recipient site in all patients. This flap design is a durable adjunct to minimize donor site morbidity and avoid microsurgical reconstruction of hostile scalp wounds.

A Review of Body Dysmorphic Disorder in Aesthetic Surgery Patients and the Legal Implications.

BACKGROUND: Body dysmorphic disorder (BDD) is an often under-recognized yet severe psychiatric illness. There is limited guidance for plastic surgeons in the USA in how to recognize and manage patients with BDD and protect themselves from potential litigation and harm. Therefore, in collaboration with legal counsel, we remind our profession of the serious nature of patients with BDD, provide warning signs for recognizing BDD, and critically evaluate the validity of informed consent and the legal ramifications of operating on such patients in the USA. METHODS: A literature review was performed to clearly define the psychopathology of BDD and identify cases of patients with BDD who underwent cosmetic surgery resulting in potential threats to the surgeon. An additional search of the legal literature was performed in collaboration with legal counsel to identify key cases of patients with BDD attempting litigation following cosmetic surgery procedures. RESULTS: The diagnostic criteria and psychopathology of BDD are presented. Warning signs are highlighted to alert the plastic surgeon to patients at high risk for BDD. Strategies for legal protection include a pre-procedure checklist for patients that are suspected of having a BDD diagnosis. CONCLUSION: Body dysmorphic disorder is prevalent in the cosmetic surgery population. Patients with BDD often have a poor outcome following aesthetic surgery, which can result in a dangerous or even deadly situation for the surgeon. We aim to remind aesthetic plastic surgeons of the psychopathology, severity, and specific risks associated with operating on patients with BDD while suggesting specific protective strategies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Targeted Muscle Reinnervation following Breast Surgery: A Novel Technique.

Post-mastectomy pain syndrome is a prevalent chronic pain condition that affects numerous patients following breast surgery. The mechanism of this pain has been proposed to be neurogenic in nature. As such, we propose a novel surgical method for the prophylactic management of postsurgical breast pain: targeted muscle reinnervation of the breast. This article serves to review the relevant current literature of post-mastectomy pain syndrome and targeted muscle reinnervation, describe our current surgical technique for this operation, and present an initial cohort of patients to undergo this procedure.