An Algorithmic Approach to the Management of Ballistic Facial Trauma in the Civilian Population.

Annual incidence of non-fatal ballistic civilian has been increasing for the last decade. The aim of the present study was to clarify the optimal reconstructive management of civilian ballistic facial injuries. A systematic review of PubMed was performed. Articles were evaluated for defect type and site, reconstructive modality, complications, and outcomes. A total of 30 articles were included. Most common region of injury was mandibular with a 46.6% incidence rate. All-cause complication rate after reconstruction was 31.0%. About 13.3% of patients developed a postoperative infection. Gunshot wounds had overall lower complication rates as compared with shotgun wounds at 9.0% and 17.0%. By region, complications for gunshot wounds were 35% and 34% for mandible and maxilla, respectively. Immediate surgical intervention with conservative serial debridement is recommended. However, for patients with pre-existing psychiatric disorders, secondary revisions should be delayed until proper psychiatric stabilization. When there is extensive loss of soft tissue in the midface, aesthetic outcomes are achieved with a latissimus dorsi or anterolateral thigh free flap. Radial forearm flap is favored for thin lining defects. Open reduction is suggested for bony-tissue stabilization. The fibula flap is recommended for bony defects >5 cm in both midface and mandible. For bony defects, <5 cm bone grafting was preferred. Delaying bone grafting does not worsen patient outcomes. Surgical treatment of ballistic facial trauma requires thorough preparation and precise planning. An algorithm that summarizes the approach to the main decision points of surgical management and reconstruction after ballistic facial trauma has been presented in this study.

Composite Volumization of the Aging Face: Supra-Periosteal Space as the Foundation for Optimal Facial Rejuvenation.

Current concepts of facial aging propose that volume losses of bone and fat in specific compartmentalized areas are the primary and the most important causes of the characteristic changes seen in the aging face. The authors propose that the use of Radiesse in the supra-periosteal space of the temple, zygomatic arch, anterior cheek, pyriform aperture, and pre-jowl sulcus most effectively and most efficiently corrects these volume losses, and therefore best helps to restore a youthful appearance. Placement of filler directly on bone produces a lifting effect on all of the overlying tissues as a single unit which the authors term "composite volumization".

J Drugs Dermatol. 2016;15(9):1136-1141.

Technique and outcomes of laparoscopic bulge repair after abdominal free flap reconstruction.

INTRODUCTION: Bulges and hernias after abdominal free flap surgery are uncommon with rates ranging from as low as 0-36%. In the free flap breast reconstruction population, there are no clear guidelines or optimal strategies to treating postoperative bulges. We describe our minimally invasive technique and outcomes in managing bulge complications in abdominal free flap breast reconstruction patients. METHODS: A retrospective review was performed on all abdominal free flap breast reconstruction patients at Albany Medical Center from 2011 to 2014. All patients with bulges on clinical exam underwent abdominal CT imaging prior to consultation with a minimally invasive surgeon. Confirmed symptomatic bulges were repaired laparoscopically and patients were monitored regularly in the outpatient setting. RESULTS: Sixty-two patients received a total of 80 abdominal free flap breast reconstructions. Flap types included 41 deep inferior epigastric perforator (DIEP), 36 muscle-sparing transverse rectus abdominus myocutaneous (msTRAM), 2 superficial inferior epigastric artery, and 1 transverse rectus abdominus myocutaneous flap. There were a total of 9 (14.5%) bulge complications, with the majority of patients having undergone msTRAM or DIEP reconstruction. There were no complications, revisions, or recurrences from laparoscopic bulge repair after an average follow-up of 181 days. CONCLUSION: Although uncommon, bulge formation after abdominal free flap reconstruction can create significant morbidity to patients. Laproscopic hernia repair using composite mesh underlay offers an alternative to traditional open hernia repair and can be successfully used to minimize scarring, infection, and pain to free flap patients who have already undergone significant reconstructive procedures. © 2016 Wiley Periodicals, Inc. Microsurgery 36:367-371, 2016.

The impact of a standardized consultation form for facial trauma on billing and evaluation and management levels.

BACKGROUND: Facial trauma is among the most frequent consultations encountered by plastic surgeons. Unfortunately, the reimbursement from these consultations can be low, and qualified plastic surgeons may exclude facial trauma from their practice. An audit of our records found insufficient documentation to justify higher evaluation and management (EM) levels of service resulting in lower reimbursement. Utilizing a standardized consultation form can improve documentation resulting in higher billing and EM levels. METHODS: A facial trauma consultation form was developed in conjunction with the billing department. Three plastic surgery residents completed 30 consultations without the aid of the consult form followed by 30 consultations with the aid of the form. The EM levels and billing data for each consultation were obtained from the billing department for analysis. The 2 groups were compared using χ2 analysis and t tests to determine statistical significance. RESULTS: Using our standardized consultation form, the mean EM level increased from 2.97 to 3.60 (P = 0.002). In addition, the mean billed amount increased from $391 to $501 per consult (P = 0.051) representing a 28% increase in billing. CONCLUSIONS: In our institution, the development and implementation of a facial trauma consultation form has resulted in more complete documentation and a subsequent increase in EM level and billed services.

Bilateral autologous breast reconstruction with deep inferior epigastric artery perforator flaps: Review of a single surgeon's early experience.

BACKGROUND: The purpose of this study is to describe the early experience of a single surgeon just out of training, including preoperative conditioning, surgical approach, and outcomes in bilateral deep inferior epigastric artery perforator (DIEP) flap breast reconstruction patients. METHODS: We retrospectively reviewed 54 consecutive patients who underwent 108 DIEP flap breast reconstructions performed by a single surgeon over an initial 2.5-year period. RESULTS: There was 100% overall flap survival. The unplanned reoperation rate was 7.6% (n = 4). Minor complications including nonoperative infection, minor wound dehiscence, and donor site seroma occurred in 26% of patients (n = 14). Significant late complications were abdominal wall bulge (n = 1) and fat necrosis < 10% of volume (n = 1). Tissue expander explantation due to infection occurred in 25% of attempted staged patients (two of eight); this did not seem to compromise their oncologic treatment or final reconstruction outcome. CONCLUSION: This study demonstrates the efficacy of the DIEP flap for bilateral autologous breast reconstruction in the immediate, staged, and delayed settings.

Anterolateral thigh flap for trauma reconstruction.

High velocity injuries have traditionally been covered with free muscle flaps. We sought to evaluate the utility of the anterolateral thigh flap (ALT) flap as a primary choice in reconstructing traumatic injuries in Western patients.A retrospective chart review was conducted of 122 patients treated at the R Adams Cowley Shock Trauma Center and at the Louisiana State University Trauma Center. Data collected included defect size, donor site location, flap composition and size, number of anastamoses, number of perforators, donor site closure, and complications.A total of 127 ALT flap reconstructions were performed. About 74% involved the lower extremity, 12% head and neck, 11% upper extremity, 2% abdomen, <1% chest, and <1% pelvis. The success rate was 96% with 3 total flap failures and 2 partial flap failures. Average follow-up was 9.3 months.The results of this review confirm that the ALT flap is a reliable, versatile tool for managing composite traumatic injuries.

An Algorithmic Approach to the Management of Infantile Digital Fibromatosis: Review of Literature and a Case Report.

Objective: Infantile digital fibromatosis is a rare benign childhood tumor, infrequently cited in the literature. Hallmarks include nodular growths exclusive to fingers and toes and the presence of eosinophilic cytoplasmic inclusions on histology. This article aims to exemplify diagnoses of infantile digital fibromatosis and possible treatment options. Methods: A computerized English literature search was performed in the PubMed/MEDLINE database using MeSH headings "infantile," "juvenile," "digital," and "fibromatosis." Twenty electronic publications were selected and their clinical and histological data recorded and used to compile a treatment algorithm. Results: A 9-month-old male child was referred for a persistent, symptomatic nodule on the third left toe. A direct excision with Brunner-type incisions was performed under general anesthesia. The procedure was successful without complications. The patient has no recurrence at 2 years postsurgery and continues to be followed. Histological examination revealed a proliferation of bland, uniformly plump spindle cells with elongated nuclei and small central nucleoli without paranuclear inclusions consistent with fibromatosis. Conclusions: Asymptomatic nodules should be observed for spontaneous regression or treated with nonsurgical techniques such as chemotherapeutic or steroid injection. Surgical removal should be reserved for cases with structural or functional compromise.

Synthetic Fillers for Facial Rejuvenation.

Soft tissue filler procedures have increased dramatically in popularity in the United States. Synthetic fillers such as calcium hydroxyapatite (CaHA), polymethyl methacrylate (PMMA), and poly-l-lactic acid (PLLA), and silicone provide initial volume replacement but have an additional biostimulatory effect to supplement facial volumization. Indications include human immunodeficiency virus lipoatrophy and nasolabial folds for CaHA and PLLA and atrophic acne scars for PMMA. Most clinical use of these synthetic fillers is in an off-label fashion. Beyond the proper choice of a synthetic filler, careful consideration of dilution, injection method, and postprocedural care allows for successful and consistent results.

Mesotherapy, Microneedling, and Chemical Peels.

Mesotherapy, microneedling, and chemical peels are minimally invasive techniques used to combat facial aging. Chemical peeling is one of the oldest methods of facial rejuvenation. By using different chemicals in various combinations, strengths, and application techniques, plastic surgeons can tailor a patient's treatment for optimal, safe, and consistent results. Mesotherapy and microneedling have emerged in the plastic surgery literature with increasingly complex indications. Both techniques have increased in popularity although research into efficacy and long-term results is lagging. With a thorough understanding of patients and the modalities available, plastic surgeons can use the appropriate minimally invasive technique to provide patients with desired skin changes.

The effect of fibrin sealant on the prevention of seroma formation after postbariatric abdominoplasty.

BACKGROUND: Seroma formation is one of the most common complications following abdominoplasty. Fibrin sealant/glue has shown mixed results in seroma prevention when used in a variety of procedures. Limited information is available on its effectiveness during postbariatric abdominoplasty. METHODS: A retrospective chart analysis of 65 consecutive patients who underwent postbariatric abdominoplasty over a course of 16 months by a single surgeon was performed. Two sequential groups either receiving or not receiving fibrin sealant treatment were defined. Seroma formation and initial 24 h drain output volumes were recorded. RESULTS: Three patients in group 1 (9.1%) receiving fibrin sealant developed seroma. Twelve patients in group 2 (28.1%) not receiving fibrin sealant developed seroma; this was statistically significant (P=0.006). Twenty-four hour drain output was also statistically different, with higher initial output in the fibrin sealant group (222.2 mL versus 140.0 mL; P=0.047). CONCLUSION: Fibrin sealant was a useful adjunct during surgical wound closure and significantly decreased seroma formation in patients undergoing postbariatric abdominoplasty.

HISTORIQUE: La formation de sérome est l'une des principales complications après une abdominoplastie. La colle de fibrine, utilisée dans diverses interventions, donne des résultats mitigés dans la prévention du sérome. L'information relative à son efficacité lors d'une abdominoplastie après une chirurgie bariatrique est limitée. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de 65 patients consécutifs qui, sur une période de 16 mois, ont subi une abdominoplastie après une chirurgie bariatrique. Ils ont défini deux groupes séquentiels, l'un recevant un traitement à la colle de fibrine et l'autre pas. Ils ont enregistré la formation de sérome et les volumes d'écoulement par le drain dans les 24 premières heures. RÉSULTATS: Trois patients du groupe 1 (9,1 %) qui ont reçu de la colle de fibrine ont développé un sérome. Douze patients du groupe 2 (28,1 %) qui n'en avaient pas reçu en ont également développé un, ce qui est statistiquement significatif (P=0,006). L'écoulement par le drain sur 24 heures était également différent sur le plan statistique, l'écoulement initial étant plus important dans le groupe ayant reçu de la colle de fibrine (222,2 mL par rapport à 140,0 mL; P=0,047). CONCLUSION: La colle de fibrine était un ajout utile pendant la fermeture chirurgicale de la plaie et réduisait considérablement la formation de sérome chez les patients qui subissaient une abdominoplastie après une chirurgie bariatrique.

Mobile robot navigation modulated by artificial emotions.

For artificial intelligence research to progress beyond the highly specialized task-dependent implementations achievable today, researchers may need to incorporate aspects of biological behavior that have not traditionally been associated with intelligence. Affective processes such as emotions may be crucial to the generalized intelligence possessed by humans and animals. A number of robots and autonomous agents have been created that can emulate human emotions, but the majority of this research focuses on the social domain. In contrast, we have developed a hybrid reactive/deliberative architecture that incorporates artificial emotions to improve the general adaptive performance of a mobile robot for a navigation task. Emotions are active on multiple architectural levels, modulating the robot's decisions and actions to suit the context of its situation. Reactive emotions interact with the robot's control system, altering its parameters in response to appraisals from short-term sensor data. Deliberative emotions are learned associations that bias path planning in response to eliciting objects or events. Quantitative results are presented that demonstrate situations in which each artificial emotion can be beneficial to performance.

Beyond wet-to-dry: a rational approach to treating chronic wounds.

OBJECTIVE: This article reviews the current recommendations for the classification and treatment of chronic wounds. With a rational approach and a thorough understanding of available treatment options, plastic surgeons can provide better-quality and more cost-effective wound care. METHODS: The authors reviewed the literature on the history of wound care and on recent advancements in wound care and also summarized the current clinical practices of the Johns Hopkins Wound Center. RESULTS: n/a. CONCLUSIONS: Optimized wound dressings decrease pain, diminish morbidity, and improve healing times.

An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration.

BACKGROUND: The authors' goal was to describe an algorithm for surgical reconstruction and prosthetic rehabilitation after orbital exenteration. METHODS: A review of 79 patients who underwent orbital exenteration between 1999 and 2007 was performed. Reconstructions were classified as resulting in an "open" cavity when a concave orbital socket facilitating prosthetic retention was created or a "closed" cavity when the orbit was filled with soft tissue to the level of the orbital rim. RESULTS: Reconstructive procedures included skin grafts (n = 18), regional flaps (n = 6), and microvascular free flaps (n = 55). Open cavities were created in 34 patients and closed cavities were created in 45 patients. Twenty-one patients (27 percent) experienced surgical complications. There were no significant differences in complication rates among various reconstructive techniques (skin graft versus regional flap versus free flap) or types of cavities created (open versus closed). Of the 17 patients who use prostheses, eight (47 percent) wear their prostheses regularly. Fourteen patients (82 percent) who received an orbital prosthesis had open cavities (p = 0.001). Thirty-nine percent of patients with a skin graft received orbital prostheses, and 17 percent with a regional flap and 15 percent with a free flap received orbital prostheses (p = 0.01). CONCLUSIONS: The reconstructive method should be tailored to the defect and the patient's needs. When a prosthetic is planned, the goal should be to create an open cavity with a skin graft, regional flap, or thin free flap. Bulky free flaps are indicated when a closed cavity is preferred, such as when no prosthetic is planned or the defect is extensive.