Annals of Plastic Surgery

Published by Lippincott, Williams & Wilkins
Online ISSN: 1536-3708
Print ISSN: 0148-7043
A 55-year-old woman with recurrent glioblastoma multiforme on palliative chemotherapy including Avastin, an angiogenesis inhibitor, presents with several episodes of bacterial meningitis secondary to a persistent cerebrospinal fluid (CSF) leak. Anastomotic dehiscence of the dura mater in the region of the previous craniotomy sites was evident. Attempts to repair the cranial CSF leak with external ventricular drain and ventriculoperitoneal shunt were unsuccessful. This patient underwent repair of the dural defects with a radial forearm free fascial flap, with consequent resolution of the CSF leak.A literature search was performed, and the available data on angiogenesis inhibitors and anastomotic dehiscence was reviewed, specifically focusing on delayed anastomotic dehiscence in patients receiving Avastin (bevacizumab). Although the potential complications of anastomotic dehiscence in patients receiving angiogenesis inhibitors are well documented, there is comparatively little documentation in the literature regarding delayed wound or anastomotic dehiscence. Twenty such cases were found cited in the literature; however, only one study was found which specifically considered angiogenesis inhibitors within the context of central nervous system malignancies.
Anthropometry of the face has always been an interesting subject for artists and plastic surgeons. Since ancient times, many rules have been proposed for the ideal face. The authors measured directly vertical and horizontal proportions of the face and inclinations of the soft-tissue facial profile in 1050 young Turkish adults. Differences between the facial measurements of subjects from seven different geographic regions were analyzed. Some of the measurements were compared further with the measurements of other populations in the literature, and the validity of the neoclassical canons were tested. The special head height measure was shorter than the special face height in the majority of our study group (women/men: equal height, 13%/15%; longer special head height, 28%/30%; shorter special head height, 59%/55%). Faces with three equally high-profile sections were not seen in women or in men. When the forehead height was compared with the nose height, equality was present in a small percentage of the population (women/men: equal height, 17%/18%; longer forehead, 41%/ 42%; shorter forehead, 42%/40%). The nose height was equal to the lower face height in a minority of the population (women/men: equal height, 10%/11%; longer nose, 9%/11%; shorter nose (81%/78%). The forehead height was shorter than the lower face height in the majority of the population (women/ men: equal height, 8%/9%; longer forehead, 12%/13%; shorter forehead, 79%/78%). The intercanthal distance was shorter than the nose width in the majority of the population (women/men: equal width, 20%/19%; wider intercanthal distance, 35%/37%; narrower intercanthal width, 65%/68%). The population was distributed evenly in regard to the variations of the orbital proportion canon (women/men: equal intercanthal width and eye fissure length, 31%/36%; wider intercanthal distance, 34%/27%; narrower intercanthal width, 35%/37%). The mouth width was greater than 1.5 times the nose width in the majority of the population (women/men: equal width, 6%/5%; wider mouth, 53%/54%; narrower mouth, 41%/41%). The nose width was narrower than one quarter of the face width in the majority of the population (women/men: equal width, 4%/3%; wider nose, 30%/39%; narrower nose, 66%/58%). The nose inclination was equal to the ear inclination in a very small fraction of subjects (women/ men: equal inclination, 3%/3%; greater nose inclination, 88%/87%; less nose inclination, 9%/9%). To sketch an outline of the average facial profile in the population studied, a convex facial profile is revealed, with the forehead and the chin retrodisplaced minimally with respect to the midface. The neoclassical canons were found to be invalid for the majority of the population in this study, and different proportional analytic results were obtained.
Data are presented on 1,244 patients who had subcutaneous mastectomies during the past fourteen years with an average follow-up of seven years. Obscure lobular carcinoma in situ was found in 4.3% of patients and obscure ductal or intraductal carcinoma was found in 5.1%, for a total of 9.4%. Breast cancer developed in only 6 patients after subcutaneous mastectomy, an incidence of 0.5%, indicating that subcutaneous mastectomy is effective in preventing breast cancer. Where obscure breast cancer was found, the prevalent associated benign fibrocystic diseases were microcystic and macrocystic and lobular hyperplasia. Where obscure ductal or intraductal carcinoma was found, the prevalent associated benign diseases were microcysts, macrocysts, intraductal hyperplasia, and sclerosing adenosis.
In the Eugene H. Courtiss Memorial Lecture, Dr. May outlines the resident education program at the Massachusetts General Hospital.
A device that can both achieve and maintain wound closure by serial tightening of a loop suture was developed. The device consists of 3 components: a hollow plastic cylinder with a 1-way locking mechanism, a flat plastic strip passing though the cylinder, and a plastic cushion between the cylinder and the skin. The body of the device is composed of a soft cylinder and a hard strip. This difference in flexibility enables the device to absorb impacts of positional changes and daily activities, while the device preserves tension of loop suture and wound closure (Fig. 1).
There are different methods described until now for immediate breast reconstruction. Despite the use of autologous flaps considered by many authors, implants are considered as an option by others. A prospective study of 102 clinical cases was designed, including a 1-year follow-up in which glands were reconstructed by immediate breast reconstruction (IBR) with direct, extra projection, anatomic prostheses located in a submuscular pocket after a skin-sparing mastectomy. The prosthesis coverage was made by the muscle in its upper two thirds and by using the skin from the mastectomy in its lower third. The cosmetic results obtained were evaluated according to the volume, form, and symmetry achieved using a linear numeric analogical score. This evaluation had an averaged value of 2.79 +/- 0.8 in our scale from poor (0) to excellent result (4). The overall rate of complications was 15.7% of the cases, with seroma being the most frequent. In conclusion, this preliminary study demonstrates that immediate breast reconstruction with a direct, extra projection, anatomic prosthesis is a good alternative. Nevertheless, more long-term studies with a higher number of patients and using an SF-36 for patient satisfaction are needed to confirm these results.
Replantation has become the state of the art reconstruction for an amputated thumb. The aim of our study was to review our series of thumb replantations over a period of 12 years at the Bellevue Hospital Center in New York City. The mechanism of injury, level of amputation, and use of vein grafts was reviewed and correlated with survival rates of the replanted thumbs. The overall survival rate was 91.3%. Of the 12 thumbs that were re-explored for vascular compromise, 75% were successfully salvaged. Our study also indicates that there is no statistical difference in survival of thumb replants when comparing the mechanism of injury, the level of amputation, and the use of vein grafts. However, the use of vein grafting seemed to be beneficial in the successful outcome of replantation in severe crush and avulsion injuries, even though the values did not reach statistical significance. We conclude that thumb replantation is associated with very high survival rate, regardless of the mechanism of injury or level of amputation, and should be attempted in all cases. An early reexploration for vascular problems yields a high salvage rate and should be performed in all cases. We also recommend the use of vein grafts in severe crush and avulsion injuries.
Reconstruction of abdominal wall defects is a challenging problem. Often, the surgeon is presented with a patient having multiple comorbidities, who has already endured numerous unsuccessful operations, leaving skin and fascia that are attenuated and unreliable. Our study investigated preoperative, intraoperative, and postoperative factors and techniques during abdominal wall reconstruction to determine which variables were associated with poor outcomes. Data were collected on all patients who underwent ventral abdominal hernia repair by 3 senior-level surgeons at our institution during an 8-year period. In all cases, placement of either a synthetic or a biologic mesh was used to provide additional reinforcement of the repair. A total of 106 patients were included. Seventy-nine patients (75%) had preoperative comorbid conditions. Sixty-seven patients developed a postoperative complication (63%). Skin necrosis was the most common complication (n = 21, 19.8%). Other complications included seroma (n = 19, 17.9%), cellulitis (n = 19, 17.9%), abscess (n = 14 13.2%), pulmonary embolus/deep vein thrombosis (n = 3, 2.8%), small bowel obstruction (n = 2, 1.9%), and fistula (n = 8, 7.5%). Factors that significantly contributed to postoperative complications (P < 0.05) included obesity, diabetes, hypertension, fistula at the time of the operation, a history of >2 prior hernia repairs, a history of >3 prior abdominal operations, hospital stay for >14 days, defect size > 300 square cm, and the use of human-derived mesh allograft. Factors that significantly increased the likelihood of a hernia recurrence (P < 0.05) included a history of >2 prior hernia repairs, the use of human-derived allograft, using an overlay-only mesh placement, and the presence of a postoperative complication, particularly infection. Hernia recurrences were significantly reduced (P < 0.05) by using a "sandwich" repair with both a mesh overlay and underlay and by using component separation. A history of multiple abdominal operations is a major predictor of complications and recurrences. If needed, component separation should be used to achieve primary tension-free closure, which helps to reduce the likelihood of hernia recurrences. Our data suggest that mesh reinforcement used concomitantly in a "sandwich" repair with component separation release may lead to reduced recurrence rates and may provide the optimal repair in complex hernia defects.
One hundred and eleven breast reconstructions after a mastectomy for carcinoma in 109 patients are reported. Depending on the quality of muscle and skin coverage, reconstructions were performed either with a latissimus dorsi musculocutaneous flap or a subpectoral prosthesis (including expander prosthesis). The follow-up involved 90 patients. The purely aesthetic results as well as the very positive result of reconstruction with regard to appearance in clothing, participation in sports, and self-esteem were of great importance to the patients. The difference in ptosis, the most obvious shortcoming in our reconstructions, is discussed. Attention is given to the importance of flap planning and the restoration of the anterior axillary fold in the latissimus dorsi flap reconstructions. The disappointing results of tissue expansion and the shortcomings of the nipple-areola reconstructions are discussed.
Management of recurrent soft tissue sarcomas often involves surgical resection and adjuvant brachytherapy. This study reviews our experience in the management of these patients and proposes a logical approach toward reconstruction. All patients who underwent soft tissue sarcoma resection, adjuvant brachytherapy, and soft tissue flap reconstruction (pedicled or free) during the 10-year period from 1991 to 2000 were included in this study. There were 17 patients (14 male, 3 female) with a mean age of 51 years (range, 16-80 years). Soft tissue sarcomas were distributed in the lower extremity (n = 9), upper extremity (n = 5), and trunk (n = 3). Reconstruction was accomplished by regional transposition flaps (n = 10) and free tissue transfer (n = 7). The average defect size was 143 cm. Patients received 5 to 12 (mean, 8) brachytherapy catheters. The brachytherapy dose delivered ranged from 1600 to 4500 cGy (mean, 3773 cGy). Brachytherapy catheters were loaded with radioactive sources between 5 and 7 days postoperatively. All flaps in this series survived. One patient required return to the operating room for revision of a venous thrombosis with flap salvage. Closed suction drainage tubes were left in place until after the brachytherapy catheters were removed to avoid dislodging the catheters. Two patients developed postradiation partial-thickness skin necrosis with delayed secondary wound healing. This study demonstrates that soft tissue reconstruction in the setting of sarcoma resection and brachytherapy catheter placement is safe and efficacious. Postoperative wound healing complications can be minimized through coordination among the ablative surgeon, reconstructive surgeon, and radiation oncologist. Specifically, placement of microvascular anastomoses well away from the radiation target area is indicated whenever possible. Finally, removal of closed suction drainage tubes should be deferred until after the brachytherapy catheters are removed to minimize complications resulting from catheter dislodgement.
Patients with psychologic diagnosis such as eating disorders have been automatically disqualified as candidates for plastic surgery. We have previously reported on a cohort of women with bulimia nervosa who presented with symptomatic macromastia. All patients reported that dysfunctional eating habits where in part the result of breast enlargement. Five patients underwent reduction mammaplasty and postoperatively reported relief of physical symptoms and improvement in psychologic well-being. Symptoms of eating disorders were completely eliminated or greatly reduced. The aim of the current study is to evaluate the degree of long-term postoperative satisfaction and recovery from eating disorders. Patients participating in the original study were contacted for long-term follow-up telephone survey. Data regarding current physical symptoms, body dissatisfaction, and eating attitudes measured by the Eating Attitude Test-26 (EAT-26) questionnaire was obtained. A statistical analysis was performed. Data was obtained from 4 patients. All patients maintained consistent recovery from their eating disorder. A statistically significant improvement in eating attitudes was found when comparing pre- and postoperative data obtained from the EAT-26. Comparing body dissatisfaction, pain, and physical symptoms, we found an overall consistent improvement in subjective scoring. Macromastia can produce a distortion of body image and become a secondary cause of eating disorders. Surgical correction of macromastia can correct physical symptoms, improve body image, and lead to permanent amelioration of associated eating disorders. This could, in part, represent a surgical treatment of a psychologic abnormality. Consequently, the presence of an eating disorder should not automatically exclude a woman from surgical consideration.
Clinical appearance of cobblestone pattern in CM. 
Clinical Characteristics of 11 Patients With CM and Hypertrophy of the Lip
Clinical appearance of 2 patients with facial CM with hypertrophy involving the lip. 
Hypertrophy in capillary malformation (CM) may be present at birth or manifest itself later in life. To gain insight into the pathology of hypertrophic CM, we investigated a series of 11 excisional biopsies of hypertrophic lips.All biopsies showed dilated thin-walled microvessels in the superficial dermis without a neural component. However, large multinodular conglomerates of thick-walled vessels with a substantial increase in nerve fibers were found in the deeper parts of the lesions. These veins extended deep into the facial musculature. Hypertrophy in CM is caused by venous malformation underlying the CM. So CM associated with hypertrophy should be considered as Capillary Venous malformations.
Background: Systematic reporting of mortality data is lacking in many surgical fields including plastic surgery. Current plastic surgery literature is largely limited to adverse events associated with specific procedures. Without mortality data, it is unclear how the recent growth of patient safety initiatives can rationally impact outcomes. Methods: We evaluated 11 years of patient outcome data collected prospectively and updated monthly by our department. Paper records were entered into a Health Insurance Portability and Accountability Act-compliant digital database capable of prospectively maintaining future data. Data were reviewed for 5 surgical services in 4 different hospitals that comprise our department's activity. Results: Between 2000 and 2011, a total of 60,834 cases were performed. In this time, a total of 829 (1.4%) negative outcome reports were identified. Of these, a total of 25 (0.04%) cases had an outcome of death (24) or brain death (1). Deaths were either directly or indirectly associated with cardiopulmonary causes, multisystem organ failure, sepsis, massive bleeding, CVA, saddle embolism, or unknown causes. Conclusions: This study is the largest reported series of cases performed by a single academic plastic surgery service to report overall mortality data.
Background: In the last decade, perforator flaps have been introduced for the treatment of pressure ulcers as alternative to the more popular myocutaneous local flaps. We reviewed our single-team 11-year experience in order to define whether real advantages could be achieved. Methods: We analyzed 143 patients undergoing perforator flap surgery for a single late-stage pressure sore. All patients underwent the same protocol treatment. Data regarding associated pathologies, demographics, complications, healing, and hospitalization times were collected. Results: Ninety-three percent of 143 patients were white Caucasian, and 61% were men, with median age of 51 years. Of 143 stage 4 ulcers, 46.2% were ischial, 42.7% sacral, and 11.2% trochanteric. The most common diagnosis was traumatic paraplegia/tetraplegia (74.9%); no significant difference was found in diagnosis distribution and in ulcer location between recurrent and nonrecurrent patients. We performed 44 S-GAP, 78 I-GAP, 3 PFAP-am, and 18 PFAP-1 flaps. At 2 years' follow-up, the overall recurrence was 22.4% and new ulcer occurrence was 4.2%. Mean hospital stay was 16 days. The overall complication percentage was 22.4%, mostly due to suture-line dehiscence (14%) and distal flap necrosis (6.3%). PFAP flaps had a significant higher risk of developing recurrence than I-GAP flaps. The recurrence risk was significantly higher for subjects suffering from coronary artery disease. Conclusions: Late-stage pressure sore treatment with local perforator flaps can achieve reliable long-term outcomes in terms of recurrences and complications. When compared to previously published data, perforator flaps surgery decreased postoperative hospital stay (by an average of nearly 1 week), reoperations (5.6%), and occurrences.
Reconstruction of multilayer defects of the lower nose, using composite grafts from the ear is a widespread technique. Little information exists about important aspects of managing the ear as a donor site for composite grafts. In a retrospective study, patient data were worked up concerning special preoperative planning features (donor site, recipient site), defect closure techniques, donor site morbidity, and esthetic and functional long-term results. One hundred ten composite grafts from the auricle were harvested for different defects at the lower nose. Skin and soft-tissue defect reconstruction at the auricle was carried out by tissue advancement in 43 cases or local flaps in 66 cases. Donor site morbidity was low (5 cases of delayed wound healing, 1 abscess). No flap necrosis occurred. Long-term follow-up (2-5 years) revealed no esthetic or functional impairments. Composite graft harvesting from the auricle is safe with minimal donor site morbidity, proper implementation assumed.
Diagnosing osteomyelitis in patients with pressure ulcers is complicated by overlying soft-tissue inflammation and reactive bone formation. We set out to evaluate the efficacy of indium scanning in the diagnosis of chronic osteomyelitis in spinal-cord-injury patients with grade IV pressure ulcers. The goal was to estimate the sensitivity and specificity of indium scanning as compared with diagnostic modalities previously evaluated by the principal investigator. Our method was a retrospective chart review of cases at a university hospital. Eleven patients with pressure sores and suspected chronic osteomyelitis underwent indium scanning. The results were compared with ostectomy specimens taken at the time of reconstructive surgery and/or bone biopsy. The sensitivity and specificity were 100% and 50%, respectively. Indium scanning appears to be more sensitive than specific. These data suggest that the value of indium scanning may primarily be to rule out osteomyelitis and not as a primary diagnostic modality.
The authors have used a posterior interosseous flap for resurfacing in 113 cases of hand injury during the past 13 years. Its main indications were complex hand trauma or burn injuries with large skin loss, either acute or postprimary. Flaps survived completely in 98 patients. Twelve patients had superficial necrosis of the distal part of the flap, which did not require additional surgical procedures. Three flaps were lost and alternative coverage was used. Six patients demonstrated paralysis of the motor branch to the extensor muscles of the wrist or fingers (generally to the extensor carpi ulnaris, the extensor digiti quinti, or the extensor pollicis longus). All recovered completely within 6 months. The donor area was closed directly in 3 to 4-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. Donor site morbidity was minimal. Major anatomic variations precluding the use of the flap were encountered twice in this series.
In this current study, the clinical data and postoperative follow-up findings of 118 patients with a primary lower lip carcinoma who were treated between 1983 and 1999 in the Department of Plastic and Reconstructive Surgery are presented. Medical records were reviewed retrospectively and data were collected concerning age, gender, followup period, location of lesion on the lip, cervical metastasis at presentation, preoperative biopsy results, histological grade, initial treatment, reconstruction type, pathological outcome, local recurrence, regional lymph node metastasis, treatment of local recurrence and regional lymph node metastasis, and postoperative treatment. The prognostic value of clinical stages in relation with recurrence and mortality from disease was investigated. The overall rate of recurrence was calculated as being 39.8%, and the determinate survival rate was found to be 72.9% at 5-year follow-up. The data concerning the above-mentioned parameters, together with risk factors that might play a role in the development of lip cancer, are discussed in light of the current literature.
We present a review of international literature on the topic of nasal dorsum reconstruction with 11th rib cartilage and auricular cartilage grafts, analyzing 123 patients selected from 653 cases of rhinoplasties performed between January 1990 and October 2007 at the Department of Plastic and Reconstructive Surgery of the University of Rome "Tor Vergata." We present our experience with the correction of deformities of the nasal dorsum using rib cartilage and auricular cartilage grafts. The majority of the time, nasal dorsum deformities are complicated defects to correct surgically. They can be a consequence of naso-ethmoid-orbital fractures and of surgical procedures in the nasal area where a loss of bone or septal cartilaginous support has occurred. After a review of the techniques employed in the reconstruction, we describe the advantage of the use of rib cartilage and our experience using this procedure. In the sample examined, 84% of treated patients showed cosmetic improvements, with satisfactory results to both surgeon and patient. A functional improvement has been achieved in 94% of the operated cases.
The extended latissimus dorsi flap has been widely used for breast reconstruction. However, seroma at the donor site is a common complication and makes it difficult for reconstructive surgeons to choose it as a primary option. We analyzed the association between seroma and reconstructions with extended latissimus dorsi flaps. A series of 120 consecutive cases were included in this study. The average body mass index (BMI) was 22.1 kg/m, and the mean ratio of the flap weight to the extirpated breast weight was equivalent to 101.6%. The mean age of patients was 40.3 years. Donor-site seroma was reported in 69.2% (83 cases) of the total patients. With respect to BMI, flap weight, and age, the incidence and duration of donor-site seroma showed statistically significant differences (P<0.05). Both the incidence and duration of seroma were significantly higher and longer in patients who had high BMI (>23 kg/m), large flap (>450 g) for reconstructions, or advanced age (>45 y). In these cases, greater attention and additional adjunctive procedures would be needed to prevent seroma.
Breast reconstruction using autologous tissue is increasingly gaining in interest. A review of results obtained from a series of consecutive patients undergoing breast reconstruction with the latissimus dorsi flap (LDF) was carried out to evaluate the effects of the authors' refinements to the procedure. Data collected during the perioperative course and a minimum follow-up of 12 months in 121 patients (mean age, 47 years; 50% with previous radiotherapy) who underwent treatment from 1994 to 1998 were analyzed retrospectively. In addition, a structured interview was conducted to evaluate patient satisfaction. Eighteen different surgeons in one teaching hospital were involved in the operative procedures. No patient was referred to the intensive care unit. An additional implant was used in 25% of patients. With the exception of the occurrence of seroma, the complication rate was low (seroma, 60%; bleeding, 4%; hematoma, 5%; minor wound dehiscence, 3%; wound infection, 2%). No flap was lost. Donor site morbidity was extremely low; 90% of patients had no complaints. The result of surgery was rated as excellent or good by 59% of patients, 89% would undergo this type of breast reconstruction again, and 91% would recommend it to other women. Refinements that improved the technique substantially included incision lines exclusively in the bra line, improved flap volume resulting from the harvest of an extended fat pad, and quilting sutures to reduce the formation of seroma. In the current study, endoscopic muscle harvest did not represent an improvement in procedure. The technique of breast reconstruction with the LDF has been improved substantially during the past few years, and provides the plastic surgeon with an excellent, safe, and consistently successful method for breast reconstruction.
Optimal surgical management of subungual malignant melanoma (SMM) has been debated. Our tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome. During a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8%) and hallux (25.0%) were affected most. At diagnosis, most had local (83.9%) and regional nodal involvement (12.9%). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9%), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0%).Disease progression occurred in 61 (49.2%) patients, and most commonly occurred as regional nodal (62.3%) and distant metastasis (42.6%). Disease progression-free survival rates at 5, 10, and 15 years were 57.1%, 49.9%, and 47.0%, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3%, 49.3%, and 45.2%. Overall survival rates at 5, 10, and 15 years were 60.5%, 43.8%, and 33.1%.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival. Diagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.
Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is a rare autosomal dominant condition characterized by typical eyelid malformations that include blepharophimosis, ptosis, epicanthus inversus, and telecanthus. We retrospectively reviewed 125 consecutive BPES patients who underwent staged surgical intervention from July 2003 to December 2011. All patients underwent initial medial and lateral canthoplasties, followed by blephroptosis correction 6 to 12 months afterward. The parameters that were studied included horizontal palpebral fissure length (PFL), vertical interpalpebral fissure height, inner intercanthal distance (IICD), the ratio of IICD to PFL, and frontalis function (FF). Facial photographs were taken preoperatively and postoperatively. Paired and group t tests were used for statistical analysis to evaluate surgical outcomes. After consecutive operations, the mean PFL increased from 19.5 to 25.7 mm (mean difference, 6.2 mm; P < 0.01). The mean interpalpebral fissure height increased from 3.4 to 8.5 mm (mean difference, 5.1 mm; P < 0.01). The mean IICD decreased from 38.0 to 30.9 mm (mean difference, 7.1 mm; P < 0.01). The mean FF was 7.3 mm for BPES patients approximately 5 years old and 10.4 mm for patients approximately 7 years old. There was no difference between children who underwent muscle flap suspension and healthy children of the same age (P > 0.05). The modified staged surgical intervention, including Y-V flap, von Ammon, and frontalis muscle flap suspension, provided effective results both in function and cosmesis for BPES. The FF was not weakened by surgery.
Donor-site morbidity continues to be a significant complication in patients undergoing abdominally based breast reconstruction. The purposes of our study were to critically examine abdominal donor-site morbidity and to present our algorithm for optimizing donor site closure to reduce these complications. We performed a retrospective cohort study examining all patients undergoing abdominally based free tissue transfer for breast reconstruction from 2005 to 2011 at our institution. Data were analyzed for overall donor site morbidity, as defined by hernia/bulge or reoperation for debridement and/or mesh removal and for hernia/bulge alone. A total of 812 patients underwent 1261 free tissue transfers. Fifty-three patients (6.5%) experienced donor-site morbidity, including 27 hernias/bulges (3.3%). No significant difference in overall abdominal morbidity was found between unilateral and bilateral reconstructions (P = 0.39) or the use of muscle in the flap (P = 0.11 unilateral msfTRAM, P = 0.76 bilateral). Prior lower abdominal surgery was associated with higher rates of donor-site morbidity (P = 0.04); hypertension (P = 0.012) and multiple medical comorbidities (P < 0.001) were also significantly more common in these patients. Obesity was the only patient characteristic associated with higher rates of hernia/bulge (P = 0.04). Delayed abdominal would healing was associated with hernia/bulge (P < 0.001); these patients were significantly more likely to develop this complication (odds ratio = 6.3, P < 0.001). Particular attention must be provided to donor-site closure in obese patients and those with hypertension and multiple medical comorbidities. Low rates of abdominal wall morbidity result from meticulous fascial reconstruction and reinforcement and careful attention to tension-free soft tissue closure.
The patient described in this article is a 45-year-old woman who developed an infiltrating ductal carcinoma in her left breast next to a Silastic mammary implant that had been used for augmentation some 13 years previously. She underwent a modified radical mastectomy and removal of the silicone prosthesis with an axillary lymph node dissection. Twenty-six axillary lymph nodes were negative for metastatic disease. The 165-gram silicone gel prosthesis was surrounded by a thin fibrous capsule with an attached 1-cm carcinoma that did not invade the fibrous capsule. It appeared that the capsule presented a barrier to the invading ductal carcinoma. The fibrous capsule surrounding the Silastic implant may have altered the spread of the breast cancer without being related to its genesis.
Two experimental models for tissue transplantation between unrelated individuals of a primate species have been designed to study survival and reinnervation. The first is a neurovascular free flap consisting of the entire soft tissue coverage of the index finger. The second is an entire hand transplant through the distal forearm. Ongoing studies show that cyclosporin A at high doses, in combination with a tapering regimen of steroids to a low maintenance level, permits prolonged survival of both transplant models. Careful biochemical, hematological, and cyclosporin A serum trough level monitoring permits use of this drug a very high dosages in primates. Continuing experiments should yield detailed neurophysiological data on the reinnervation of these transplants over the next 6 to 18 months.
A 37-year-old woman presented with Mondor's thrombophlebitis 13 years after augmentation mammaplasty with subpectoral saline implants. She presented complaining of 1 week of "band-like" cords and pain involving the thoracoepigastric and lateral thoracic vessels. She was evaluated and ruled out for other etiologies of her breast symptoms. Mondor's disease is a benign and self-limiting disease characterized by thrombophlebitis of the subcutaneous veins of the chest and abdominal wall. The inflammation causes painful superficial cords manifesting as skin retraction. Mondor's disease has been described in aesthetic breast surgery literature, but most cases occur within the first few postoperative weeks. Mondor's disease may be idiopathic, iatrogenic, or a manifestation of underlying pathology such as breast cancer. The diagnosis of iatrogenic Mondor's disease can be made with high clinical certainty when following aesthetic breast surgery in the early postoperative period. However, in late presentations that are not immediately related to surgery, Mondor's disease remains a diagnosis of exclusion, and other underlying pathologic etiologies must be ruled out.
Various complications can result from titanium plate internal fixation, including infection, exposure, pain, cold intolerance, and palpability. The incidence of such complications has become a topic of recent interest with the advent of resorbable plating. We undertook a retrospective review to determine complication rates of titanium fixation in a facial fracture population. Out of 266 patients with operative management of traumatic facial fracture between 1991 and 2004, 135 patients had titanium plate fixation. We evaluated 16 panfacial fractures, 22 zygomatic-orbital complex fractures, 49 midface fractures, and 48 fractures of the mandible. Overall, 33.3% (45/135) of patients had plates removed; 64.4% (29/45) of plate removals were for complications, ie, discomfort, exposure, and infection; 35.6% (16/45) were removed during secondary reconstruction. The most common complication was discomfort related to palpability, cold intolerance, and pain. This constituted 72.4% (21/29) of all plate removals for complications. Higher rates of plate discomfort were noted near the supraorbital, infraorbital, and mental foramina.
Pseudoaneurysms resulting from vascular impingement by osteochondromas are extremely rare. The authors detail the case of a 19-year-old man who represents the third known report in the English literature of a brachial artery pseudoaneurysm associated with a humeral osteochondroma. In patients presenting with a painful upper arm mass and a history of multiple hereditary exostoses, one must have a high index of suspicion for pseudoaneurysm.
Clearance of intradermally injected xenon 133 was used to measure blood flow in distant flaps in humans with the donor pedicle temporarily clamped just prior to division. All 18 flaps with a blood flow of 0.5 ml per 100 gm of tissue per minute or more survived completely after separation. Of 7 with lesser flow, 3 underwent marginal necrosis adjacent to the line of division and 4 survived entirely. The false-negative result (complete flap survival in 4 patients) was artifactual due to isotope injection too close to the clamp, reflecting increased local tissue tension caused by the clamp rather than low blood flow in the flap. Xenon 133 washout does permit quantitative evaluation of blood flow, and since it is a clean isotope, it appears superior to sodium 24 and technetium 99m, which have been used in a similar manner. The test is proposed as an adjunct to clinical judgment in timing pedicle division.
The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.
Parry first described the syndrome of progressive facial atrophy in 1825, followed by Romberg in 1846. The clinical hallmark of the syndrome is atrophy of the facial soft tissues, including fat and muscle as well as underlying bone. Clinicians have classically reserved treatment until the end of the disease process, after the "burn out" stage. Various treatment modalities have been attempted with differing results. In this study, we present a case of Parry-Romberg syndrome treated with autologous fat grafting. This case report reviews the history of the disease, examines the safety and clinical outcomes of fat grafting as a treatment modality, and challenges the classic timing of that treatment. Additionally, long-term follow-up with photos and histological analysis of specimens are included.
From August 1995 to June 1999, 140 free anterolateral thigh (ALT) flaps were transferred to reconstruct a variety of soft-tissue defects. The size of ALT flap ranged from 10 to 33 cm in length and 4 to 14 cm in width. Based on the anatomic variations of the perforators, the blood supply to the skin island came from the septocutaneous perforators only in 19 patients (13.6%), arising from the descending or transverse branch of the lateral circumflex femoral artery (LCFA), or originating directly from LCFA. The other flaps were supplied by musculocutaneous perforators that were elevated as a true perforator flap via intramuscular dissection (N = 34, 24.3%), or used a cuff of vastus lateralis muscle for added bulk (N = 87, 62.1%). The overall success rate was 92% (129 of 140). After a 2-year follow-up, all flaps have healed unevenffully and donor thigh morbidity is minimal. Anatomic variations must be considered if the ALT flap is to be used safely and reliably.
The Natrelle 150 offers the advantage of single-stage reconstruction. However, there is lack of published data on its long term outcomes, which does not allow for definitive conclusions as to whether it truly meets its design objective of a lasting single stage breast reconstruction. This is a retrospective review of all Natrelle 150 reconstructions by a single surgeon over 5 years. A total of 143 procedures were performed in 125 patients with a mean follow-up of 33 months (range, 3-65 months). Most (120, 84%) received the implant after oncological mastectomies, 22 (15%) after risk-reducing mastectomies, and 1 (0.8%) for hypoplasia. Fifty-one (35.7%) implants were explanted an average of 12.9 months after implantation. A Kaplan-Meier survival analysis demonstrates an explantation rate of 25% by 11 months. Explantation was more likely after subpectoral placement compared to reconstructions in combination with latissimus dorsi flaps (P < 0.05). Risk-reducing reconstructions were also more likely to undergo explantation (P < 0.05) compared to reconstructions for oncological reasons. Our data suggest that this prosthesis is only successful as a 1-stage procedure in certain patients, and has led to more careful patient selection and counseling.
One-hundred fifty patients with silicone gel breast implants were investigated using ultrasound (US) studies, to assess the integrity of their implants. US testing demonstrated 8 patients (5.33%) with implant rupture, which was subsequently confirmed at surgery. A further 4 patients were "false negatives," wherein they presented with normal US tests, but at subsequent surgery, demonstrated secondary alterations in their implant envelopes. Two of these patients demonstrated profound local silicone gel "bleed," whereas the 2 others had frank implant rupture. There was also one "false positive" patient. The total known prevalence of patient implant alteration was therefore 12, i.e., 10 with ruptures and 2 with profound local gel "bleed," in 150 patients (8.0%). Five of the 10 patients with ruptured implants had undergone multiple closed capsulotomies in the past. The mean time of diagnosis after implant insertion was 8.5 years (range, 2.0-18 yr). US analysis may provide a safe, simple, inexpensive, noninvasive tool to assist in the identification of ruptured silicone gel breast implants. There were significant limitations with technique, however, in that there were 4 false negatives, and 1 false positive result, and US analysis was not helpful in diagnosing profound silicone gel bleeds.
Endoscopic excision is a growing treatment option for benign facial tumors; however, its outcome has not been reported in a large series with long-term follow-up. The purpose of this study was to present the outcome of our decade-long experience with endoscopic excision, compared with direct excision.We retrospectively reviewed patients who underwent surgical treatment using either the endoscopic or direct approach for benign facial tumors from January 2001 to January 2012. Patient demographics, complications, recurrence, and pathological results were collected. Patient satisfaction was assessed using survey questionnaires. The results of endoscopic excision and direct excision were compared.Endoscopic excision was performed for 152 patients consisting of 77 lipomas (50.7%), 45 osteomas (29.6%), 24 dermoid cysts (15.8%), and 6 others (3.9%). The masses were located on the forehead in 138 patients (90.8%) and on the cheeks in 14 patients (9.2%). Direct excision was performed for 123 patients composed of 62 lipomas (50.4%), 46 dermoid cysts (37.4%), 11 osteomas (8.9%), and 4 others (3.3%). The mean follow-up period was 4.6 years. In the endoscopic excision group, hematomas developed in 2 and wound dehiscence in 1 patient. In the direct excision group, 1 hematoma and 1 wound dehiscence occurred. There were 4 recurrent cases in the endoscopic excision group and 1 recurrent case in the direct excision group, but there was no statistically significant difference in the recurrence rate between the 2 groups (2.6% vs 0.8%, P = 0.258). Patient satisfaction was higher in the endoscopic excision group than in the direct excision group (satisfaction for aesthetics, 92.98 vs 71.71%, P < 0.001; satisfaction for procedure, 89.9 vs 76.15%, P = 0.001).Compared with direct excision, endoscopic excision provided a comparable recurrence rate and higher patient satisfaction in this decade-long study. Endoscopic excision is a safe and valuable treatment option for selected benign tumors on the forehead and cheek.
Even with excellent operative techniques, prolonged ischemic periods may cause unwanted results because of a complex mechanism called reperfusion injury. Various pharmacological and immunological agents have been used to prevent this type of injury. Another known way to diminish reperfusion injury is the gradual reperfusion of the ischemic tissues. In this study, the effect of a gradual increase in blood flow on ischemia-reperfusion injury of the skeletal muscle was investigated. The right hind limbs of 15 rats were partially amputated, leaving the femoral vessels intact. Preischemic femoral arterial blood flow was measured by using a transonic small-animal blood flowmeter (T106) in all animals. The rats were divided into three groups: Group I consisted of control rats; no ischemia was induced. Group II was the conventional clamp release group. Clamps were applied to the femoral vessels to induce 150 minutes of ischemia. The clamps were then released immediately and postischemic blood flow was measured. Group III was the gradual clamp release group. After 150 minutes of ischemia, clamps were released gradually at a rate so that the blood flow velocity would reach one fourth the mean preischemic value at 30 seconds, one half at 60 seconds, three fourths at 90 seconds, and would reach its preischemic value at 120 seconds. Total clamp release was allowed when blood flow was less than 1.5 fold of the preischemic values. Postoperatively the soleus muscles were evaluated histopathologically, and malonyldialdehyde and myeloperoxidase levels were measured. The mean preischemic blood flow was 13.6 +/- 2.24 ml per kilogram per minute in all groups. In the conventional release group, postischemic flow reached four to five fold its preischemic values (61.06 ml per kilogram per minute). Histopathology revealed more tissue damage in the conventional release group. Malondialdehyde and myeloperoxidase levels were also significantly lower in the gradual release group. Depending on histological and biochemical findings, a gradual increase in blood flow was demonstrated to reduce the intensity of ischemia-reperfusion injury in the soleus muscle of this animal model.
The authors have performed reverse dorsal metacarpal flaps in 153 cases to cover skin defects over fingers or stumps during the past 15 years. Its indications included acute and chronic skin defects over the second to fifth fingers or stumps. The coverage of the flap ranged from the base of the fingers to the distal interphalangeal joint. One hundred forty-three cases survived uneventfully, and 8 cases presented venous congestion postoperatively, which led to epidermal necrosis. The reverse dorsal metacarpal flap is a reliable and excellent method to cover skin defects over the fingers.
Retrospective review of charts of 180 consecutive patients with frontal sinus fractures managed by plastic surgeons at the University of Kentucky between 1987 and 2007 was performed with institutional review board approval. Twenty-six charts did not meet the criteria. The remaining 154 records provided 1-to-20-year follow-up. The study included 34 patients who underwent cranialization and 120 patients who did not. A low-complication rate of 6% after cranialization is ascribed by the authors to meticulous sinus mucosal debridement; thorough obliteration of the frontal sinus outflow tract (with sterile gelatin sponge pledgets and bone chips from the outer cortex of the temporoparietal skull); and avoidance of avascular barriers, such as abdominal fat. As high-resolution computerized tomography with parasaggital views was introduced, an increasing ability to preoperatively define the extent of injury of the medial and lateral sinus floor was observed. The authors conclude selective use of cranialization is indicated.
Cerrahiyyetü'l-Haniyye (Imperial Surgery), written by the surgeon Serefeddin Sabuncuoğlu in the 15 century, is the first illustrated surgical book in Turkish-Islamic literature containing human figures. Sabuncuoğlu had begun a new era by demonstrating for the first time the application of many surgical methods on human beings, with illustrations in the style of miniatures in his handwritten work. This was a first in medical history, and, owing to this property, Sabuncuoğlu's book was one of the most important original works of that period. In this study in which we aim to examine Sabuncuoğlu's surgical book, in particular with regard to the disease of hermaphroditism, we first demonstrated the historical development of the subject through general sources. From sources concerning Sabuncuoğlu, we gathered information on his life and works. Then, examining the information on hermaphroditism in Sabuncuoğlu's work, we discussed this information in light of our current knowledge.
We reviewed the clinical features of 16 patients who underwent surgery for subungual exostosis, focusing on postoperative deformity of the nail. In 7 patients, the lesion did not destroy the nail bed and was excised with a fish-mouth-type incision. In 9 patients, the lesion destroyed the nail bed and was excised with a direct approach. In 5 of the 9 patients, artificial skin was applied after excision of the tumor because the defect of the nail bed was large. Good postoperative appearance of the nail was obtained by a fish-mouth-type incision when the tumor did not destroy the nail bed, although 2 patients had local recurrence. Onycholysis occurred postoperatively when the tumor destroyed the nail bed and the defect of the nail bed was large after excision of the tumor. Secondary nail bed reconstruction may be indicated in such cases with postoperative deformity of the nail.
Top-cited authors
Isao Koshima
  • Hiroshima University
Grant W Carlson
  • Emory University
Bernard T Lee
  • Beth Israel Deaconess Medical Center
Charles S Hultman
  • University of North Carolina at Chapel Hill
Takumi Yamamoto
  • National Center for Global Health and Medicine in Japan