[show abstract][hide abstract] ABSTRACT: Beauty lies in the eyes of the beholder, but influenced by the individual's geographic, ethnic, and demographic background and characteristics. In plastic surgery, objective measurements are used as a foundation for aesthetic evaluations. This study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception.
Computerized images of a model's face were generated with the ability to alter nasal characteristics and the projection of the lips and chin. A survey containing these modifiable images was sent to more than 13,000 plastic surgeons and laypeople in 50 different countries, who were able to virtually create a face that they felt to be the aesthetically "ideal" and most pleasing. Demographic information about the interviewees was obtained.
Values of various aesthetic parameters of the nose were described along with their relationship to geography, demography, and occupation of the respondents. Interregional and ethnic comparison revealed that variables of country of residence, ethnicity, occupation (general public vs surgeon), and sex correlate along a 3-way dimension with the ideal projection of the lips and the chin. Significant interaction effects were found between variables of country of residence or ethnicity with occupation and sex of the respondents.
What are considered the "ideal" aesthetics of the face are highly dependent on the individual's cultural and ethnic background and cannot simply and solely be defined by numeric values and divine proportions. As confirmed with this study, ethnic, demographic, and occupational factors impact peoples' perception of beauty significantly.
The Journal of craniofacial surgery 03/2014; 25(2):e157-61. · 0.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: Autologous breast reconstruction offers higher rates of patient satisfaction, but not all patients are ideal candidates, often due to inadequate volume of donor sites. Although autologous fat grafting is frequently used to augment volume and contour abnormalities in implant-based breast reconstruction, its clear utility in microsurgical breast reconstruction has yet to be defined. Here, we examined patients undergoing autologous microsurgical breast reconstruction with and without the adjunct of autologous fat grafting to clearly define utility and indications for use.
A retrospective review of all patients undergoing autologous breast reconstruction with microvascular free flaps at a single institution between November 2007 and October 2011 was conducted. Patients were divided into 2 groups as follows: those requiring postoperative fat grafting and those not requiring fat grafting. Patient demographics, indications for surgery, history of radiation therapy, patient body mass index, mastectomy specimen weight, need for rib resection, flap weight, and complications were analyzed in comparison.
Two hundred twenty-eight patients underwent 374 microvascular free flaps for breast reconstruction. One hundred (26.7%) reconstructed breasts underwent postoperative fat grafting, with an average of 1.12 operative sessions. Fat was most commonly injected in the medial and superior medial poles of the breast and the average volume injected was 147.8 mL per breast (22-564 mL). The average ratio of fat injected to initial flap weight was 0.59 (0.07-1.39). Patients undergoing fat grafting were more likely to have had deep inferior epigastric perforator and profunda artery perforator flaps as compared to muscle-sparing transverse rectus abdominis myocutaneous. Patients additionally were more likely to have a prophylactic indication 58% (n = 58) versus 42% (n = 117) (P = 0.0087), rib resection 68% (n = 68) versus 54% (n = 148) (P < 0.0153), and acute postoperative complications requiring operative intervention 7% (n = 7) versus 2.1% (n = 8) (P < 0.0480). Additionally, patients undergoing autologous fat grafting had smaller body mass index, mastectomy weight, and flap weight.
Fat grafting is most commonly used in those breasts with rib harvest, deep inferior epigastric perforator flap reconstructions, and those with acute postoperative complications. It should be considered a powerful adjunct to improve aesthetic outcomes in volume-deficient autologous breast reconstructions and additionally optimize contour in volume-adequate breast reconstructions.
Annals of plastic surgery 07/2013; 71(1):24-30. · 1.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: There is no more important decision an academic Plastic Surgery Department or Division can make than naming a chair or chief. Externally recruited leadership brings fresh perspectives and connections. Critics, however, argue that they lack the in-depth knowledge of the institution's culture and history that may be needed to succeed. The ability and skill of an internal candidate is already known and can increase the odds of that person's success in the leadership position. Finally, external recruitment can be a more costly process. Ultimately, the decision is really a litmus test for a Plastic Surgery program. The authors aim to evaluate factors influencing ascent in Plastic Surgery leadership, including training history, internal promotion, and external recruiting.
All Plastic Surgery residency programs accredited by the Accreditation Council for Graduate Medical Education were noted (n = 71). Academic departmental chairs or divisional chiefs of these residency programs were identified at the time of study design (October 1, 2011). For each chair or chief, gender, training history, and faculty appointment immediately prior to the current leadership position was recorded.
There were 71 academic chairs or chiefs of Plastic Surgery residency programs at the time of data collection. The majority (62%) had done fellowship training following Plastic Surgery residency. Fellowships included hand (43%), craniofacial (29%), microsurgery (18%), and other types (10%). The majority (73%) of leaders were internal hires (P < 0.01), having faculty appointments at their institutions prior to promotion. However, only a fraction (22%) of these internal hires had done Plastic Surgery residency or fellowship training at that institution (P < 0.01). External recruits consisted of 27% of all 71 academic hires (P < 0.01).
Many factors influence the decision to recruit leadership from internally or to hire an external candidate. These include the time to fill the position, program culture, candidate experience, and cost. These results support that the insider/outsider hire decision is ultimately one of duality. That dichotomy is achieved with an emphasis on internal promotion, but always with an eye towards the advantages of bringing in external talent as a valuable contribution to increase organizational success.
The Journal of craniofacial surgery 07/2013; 24(4):1146-1148. · 0.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND:: Acellular dermal matrix (ADM) has become a commonly used adjunct in immediate implant based breast reconstruction. It was popularized for its proposed benefits, which include lower pole coverage and greater initial tissue expansion. Several recent studies have revealed increased perioperative complications associated with its use. As a result of these findings, our institution placed strict limitations regarding the use of ADM. Recently, sterile "ready to use"(RTU) ADM was introduced and utilized as an alternative to the aseptic predecessor. The purpose of this investigation is to compare the infectious complications of breasts undergoing reconstruction with aseptic ADM and sterile "ready to use" ADM. METHODS:: After obtaining IRB approval and instituting strict guidelines for ADM use, a review of all patients undergoing immediate implant based breast reconstruction at New York University Medical Center over a two-year period, November 2010-October 2012, was conducted. Alloderm (Life Cell. Branchburg, NJ) was used solely as the source of ADM and RTU alloderm was introduced into use one year after initiating guidelines. Breasts were divided into three cohorts: total submuscular coverage, aseptic ADM, and sterile RTU ADM. These were then analyzed in comparison based on age, specimen weight, body mass index (BMI), the need for lymph node dissection, medical history, indication for surgery, breast cancer stage, use adjuvant/neoadjuvant chemotherapy and radiation, history of recent and remote breast surgery, smoking history, tissue expander (TE) size, initial TE fill, percentage TE fill, and complications including mastectomy skin flap necrosis, infection and need for explantation. RESULTS:: 546 breasts underwent immediate implant based breast reconstruction, including tissue expanders and immediate permanent implants, during the study period. 64.2% (n=351) had reconstruction without ADM, 16.4% (n=90) had reconstruction with aseptic ADM and 19.2% (n=105) had reconstruction with RTU ADM. When comparing breasts reconstructed with aseptic ADM to those with RTU ADM patients were similar in age, BMI, incidence of TE and implant reconstructions, indication for surgery, TE size, fill, and percentage fill, medical comorbidities and smoking status. However, patients undergoing reconstruction with RTU ADM were found to have a significant decrease in overall infection (8.5% versus 20.0% (p=0.0088)), major infection requiring IV antibiotics (4.7% versus 12.2% p=0.069), and need for explantation (1.9% versus 6.6% (p=0.1470) when compared to the aseptic cohort. The incidence of seroma and mastectomy skin flap necrosis was similar in both cohorts. When comparing patients undergoing reconstruction with RTU ADM to those having total submuscular coverage patients had similar overall infectious complications at 8.5% versus 5.7% (p=0.3602) respectively. Diabetes mellitus, postoperative seroma, mastectomy skin flap necrosis, and reconstruction with aseptic ADM were found to be independent predictors of infectious complications. CONCLUSION:: While not indicated for all patients, the use of RTU ADM in immediate implant based breast reconstruction provides an acceptable and useful adjunct. Additionally, RTU ADM mitigates the risks of infectious complications in patients undergoing immediate implant based breast reconstruction when compared to aseptic ADM.
Plastic and reconstructive surgery 06/2013; · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Access to the frontal sinus remains a challenging problem for the craniofacial surgeon. A wide array of techniques including minimally invasive endoscopic approaches have been described. Here we present our technique using medical modeling to gain fast and safe access for multiple indications. METHODS: Computer-aided surgery involves several distinct phases: planning, modeling, surgery, and evaluation. Computer-aided, precise cutting guides are designed preoperatively and allowed to perfectly outline and then cut the anterior table of the frontal sinus at its junction to the surrounding frontal bone. The outcomes are evaluated by postoperative three-dimensional computed tomography scan. RESULTS: Eight patients sustaining frontal sinus fractures were treated with the aid of medical modeling. Three patients (37.5%) had isolated anterior table fractures, and 4 (50%) had combined anterior and posterior table fractures, whereas 1 patient (12.5%) sustained isolated posterior table fractures. Operative times were significantly shorter using the cutting guides, and fracture reduction was more precise. There was no statistically significant difference in complication rates or overall patient satisfaction. CONCLUSIONS: The surgical approach to the frontal sinus can be made more efficient, safe, and precise when using computer-aided medical modeling to create customized cutting guides.
The Journal of craniofacial surgery 05/2013; 24(3):992-995. · 0.81 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND: Infection requiring explantation remains the most devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in face of infection using both oral and intravenous antibiotics. In the absence of patient-specific culture data, antibiotic selection is generally directed toward broad-spectrum coverage based on historical data. We hypothesize that reviewing our institution's microbiology data obtained from explanted implant-based breast reconstructions would provide a rational basis for antibiotic selection in the future. METHODS: A retrospective review of 902 consecutive immediate implant-based breast reconstructions at a single institution from November 2007 to May 2011 was conducted. Implant reconstructions requiring explantation or drainage by interventional radiology were identified. Patient demographics, implant characteristics, presence of skin necrosis, microbiological data, and outcomes were reviewed. RESULTS: Forty-three (4.76%) implant reconstructions requiring explantation or drainage by interventional radiology met the inclusion criteria for this study. Five patients (11.6%) had round, smooth silicone implants, and 36 (88.4%) had textured tissue expanders. Twenty-six implants were explanted because of infection; 3, because of exposure from skin necrosis; and 11, because of the combination of flap necrosis and infection; and 1, secondarily because of cancer invasion into the skin. Reconstruction was salvaged in 21 breasts (51.2%): 12 (57.1%) by implant reconstruction, 5 (23.8%) by pedicled latissimus dorsi flaps, and 4 (19.1%) with a microvascular free flap. Thirty explants had microbiology data available. The most common organism isolated was Staphylococcus epidermidis (10), followed by methicillin-sensitive Staphylococcus aureus (5), Serratia marcescens (5), Pseudomonas aeruginosa (4), enterococcus (3), Escherichia coli (2), Enterobacter (2), group B streptococcus (1), and Morganella morganii (1). Forty percent of the organisms were resistant to cefazolin; however, 86% were sensitive to gentamicin, 80% were sensitive to Levaquin, and 63% were sensitive to ciprofloxacin. CONCLUSIONS: Infection associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiological data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first-line treatment. If this regimen fails, intravenous imipenem or gentamicin and vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance should play a role in decision making, but these data provide an evidence-based rationale for first-line oral antibiotic selection.
Annals of plastic surgery 03/2013; · 1.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: INTRODUCTION-: Prior breast irradiation increases the rate of post-operative complications including capsular contracture in tissue expander/implant (TE/I) reconstruction. Acellular dermal matrix (ADM) is heralded to decrease capsular contracture; however, recent evidence suggests a possible increase in the rate of postoperative complications. We evaluate outcomes in patients undergoing bilateral, TE/I reconstruction with ADM in the setting of prior unilateral irradiation. METHODS-: A case-control study was conducted on all patients undergoing bilateral, ADM-assisted, TE/I reconstruction with a history of previous unilateral irradiation, at Memorial Sloan Kettering Cancer Center. The rate of complications including, infection, mastectomy skin flap necrosis, hematoma, seroma and capsular, contracture were compared. RESULTS-: Twenty-three patients met inclusion criteria and had an average followup, of 19 months (range: 4-60 months). When comparing radiated breasts to control, breasts, the perioperative infection rate was 21.7% (n=5) versus 4.3% (n=1), (p=0.079). Rates of mastectomy skin flap necrosis, explantation, hematoma, and, seroma were also not significantly different between the groups. Sixty percent of, patients had a contracture in the irradiated breast that was one Baker grade greater, than the non-irradiated breast. BMI >25 and smoking history were significant, independent risk factors for early postoperative complications in univariate analysis, (p=0.01). CONCLUSIONS-: Previous radiation does not appear to increase the risk of early postoperative complications associated with ADM use in TE/I breast reconstruction. However, ADM should be used cautiously, in patients with a BMI >25 or a smoking history. Additionally, ADM does not appear to affect the degree of capsular contracture formation in the setting of prior irradiation. CLINICAL QUESTION-: Therapeutic LEVEL OF EVIDENCE-: Level III.
Plastic and reconstructive surgery 02/2013; · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: : Nipple-sparing mastectomy warrants thorough preoperative evaluation to effectively achieve risk reduction, high patient satisfaction, and improved aesthetic outcome. To the authors' knowledge, this review represents the largest series of microsurgical breast reconstructions following nipple-sparing mastectomies.
: All patients undergoing nipple-sparing mastectomy with microsurgical immediate breast reconstruction treated at New York University Medical Center (2007-2011) were identified. Patient demographics, breast cancer history, intraoperative details, complications, and revision operations were examined. Descriptive statistical analysis, including t test or regression analysis, was performed.
: In 51 patients, 85 free flap breast reconstructions (n = 85) were performed. The majority of flaps were performed for prophylactic indications [n = 55 (64.7 percent)], mostly through vertical incisions [n = 40 (47.0 percent)]. Donor sites included abdominally based [n = 66 (77.6 percent)], profunda artery perforator [n = 12 (14.1 percent)], transverse upper gracilis [n = 6 (7.0 percent)], and superior gluteal artery perforator [n = 1 (1.2 percent)] flaps. The most common complications were mastectomy skin flap necrosis [n = 11 (12.7 percent)] and nipple necrosis [n = 11 (12.7 percent)]. There was no correlation between mastectomy skin flap or nipple necrosis and choice of incision, mastectomy specimen weight, body mass index, or age (p > 0.05). However, smoking history was associated with nipple necrosis (p < 0.01).
: This series represents a high-volume experience with nipple-sparing mastectomy followed by immediate microsurgical reconstruction. When appropriately executed, it can deliver low complication rates.
: Therapeutic, IV.
Plastic and reconstructive surgery 02/2013; 131(2):139e-47e. · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: BACKGROUND:: Fingertip injuries are the most common hand injuries presenting for acute care. Treatment algorithms have been described based on defect size, bone exposure, and injury geometry. However, most of the outcomes data is associated with specific procedures and there is a dearth of comparative data across injury type. We hypothesized that despite accepted algorithms many fingertip injuries can be treated conservatively. METHODS:: A prospectively collected retrospective review of all fingertip injuries presenting to Bellevue Hospital between January 2011 and May 2011 was conducted. Patients were entered into an electronic database upon presentation. Follow-up care was tracked through the electronic medical record. Patients lost to follow-up were questioned via telephone. Patients were analyzed based on age, mechanism of injury, handedness, occupation, wound geometry, defect size, bone exposure, emergency room procedures performed, need for surgical intervention, and outcome. RESULTS:: 100 fingertips were injured. Injuries occurred by crush(46%), laceration(30%), and avulsion(24%). 64% of patients healed without surgery, 18% required operative intervention, and 18% were lost to follow up. Patients requiring operative intervention were more likely to have a larger defect, 3.28cm vs. 1.75 cm(p<0.005), volar oblique injury, 50% vs. 8.8%(p<0.005), exposed bone, 81.3% vs. 35.3%(p<0.005) and an associated distal phalanx fracture, 81.3% vs. 47.1%(p<0.05). Patients requiring surgical intervention had a longer average return to work time when compared to those not requiring surgical intervention, 4.33 vs. 2.98 weeks(p<0.001). CONCLUSION:: Despite current accepted algorithms, many fingertip injuries can be treated non-operatively to achieve optimal sensation, fine motor, and earlier return to work. LEVEL OF EVIDENCE:: Therapeutic Level 3.
Plastic and reconstructive surgery 09/2012; · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: Larger thoracic defects require stable yet flexible reconstruction to prevent flail chest and debilitating respiratory impairment. We present the use of locking rib-spanning plates as a chest salvage procedure.
A 30-year-old male presented with a massive desmoid tumor in the posterolateral aspect of the chest wall. The mass measured 22 by 14 by 6 cm and involved the posterior third through seventh ribs. The patient underwent wide excision and reconstruction in layers with a porcine dermal substitute for the pleura, locking rib-spanning plates for structural support, and coverage with ipsilateral latissimus dorsi.
The patient tolerated the procedure without complication. He was extubated on postoperative day zero and has had an uneventful course.
Chest wall reconstruction with rib-spanning plates is an alternative method of reconstruction for large chest wall defects. This method limits the foreign body burden while providing rigid structural support. This technique also makes chest wall reconstruction possible in situations that might previously have been treated with pneumonectomy.
Journal of Plastic Reconstructive & Aesthetic Surgery 06/2012; 65(9):e253-6. · 1.44 Impact Factor
[show abstract][hide abstract] ABSTRACT: Acellular dermal matrix is commonly used in implant-based breast reconstruction to allow for quicker tissue expansion with better coverage and definition of the lower pole of the breast. This study was performed to analyze complications associated with its use in immediate two-stage, implant-based breast reconstruction and to subsequently develop guidelines for its use.
A retrospective analysis of 628 consecutive immediate two-stage tissue expander breast reconstructions at a single institution over a 3-year period was conducted. The reconstructions were divided into two groups: reconstruction with acellular dermal matrix and reconstruction without it. Demographic information, patient characteristics, surface area of acellular dermal matrix, and complications were analyzed and compared.
A total of 407 patients underwent 628 immediate two-stage, implant-based breast reconstructions; 442 reconstructions (70.3 percent) used acellular dermal matrix and 186 (29.6 percent) did not. The groups had similar patient characteristics; however, major complications were significantly increased in the acellular dermal matrix group (15.3 versus 5.4 percent; p = 0.001). These complications included infection requiring intravenous antibiotics (8.6 versus 2.7 percent; p = 0.001), flap necrosis requiring excision (6.7 versus 2.7 percent; p = 0.015), and explantation of the tissue expander (7.7 versus 2.7 percent; p = 0.004).
Use of acellular dermal matrix in immediate two-stage, implant-based breast cancer reconstruction is associated with a significant increase in major complications. Therefore, it should only be used in specific patients and in minimal amounts. Indications for its use include single-stage permanent implant reconstruction and inadequate local muscle coverage of the tissue expander.
Plastic and reconstructive surgery 05/2012; 129(5):1049-58. · 2.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: Management of severe traumatic lower extremity injuries remains a considerable challenge. Free tissue transfer is now a standard part of reconstruction for Gustilo IIIB and IIIC injuries. There is limited information on arterial injury patterns in this population. We undertook a review of our experience to gain insight on vascular injury patterns and surgical outcomes.
A 26-year retrospective analysis was performed of all lower extremity Gustilo IIIB and IIIC injuries requiring microvascular reconstruction at New York University Medical Center. Patient demographics, Gustilo classification, angiographic findings (conventional/computed tomographic angiography/magnetic resonance angiography), recipient vessels, elapsed time from injury, flap choices, and outcomes were examined.
Two hundred twenty-two free flaps on 191 patients were performed from September 1982 until March 2008. There were 151 males and 40 females ranging in age from 4 to 83 years (median age 33 years). Patients sustained either Gustilo IIIB (170 patients) or IIIC (21 patients) open fractures. One hundred fifty-four patients had angiograms (78.2% IIIB, 100% IIIC). Sixty-six (42.9%) had normal 3-vessel runoff and 88 (57.1%) were abnormal. Sixty-one patients (31.9%) had anterior tibial injuries, 17 patients (8.9%) had posterior tibial injuries, and 30 (15.7%) had peroneal injuries. Sixty-three complications occurred (11 early thrombosis, 33 requiring secondary procedures, and 10 requiring amputation).
Angiography of severe lower extremity injuries requiring free flap reconstruction usually revealed arterial injury and is generally indicated. In our experience, the anterior tibial artery is most commonly injured and the posterior tibial artery is most likely to be spared and used as a recipient.
Journal of the American College of Surgeons 01/2010; 210(1):66-72. · 4.50 Impact Factor