bluuebunny/crossref_metadata_2025 huggingface dataset:
Why Some Mastectomy Patients Opt to Undergo Delayed Breast Reconstruction: Results of a Long-Term Prospective Study
Authors: Metcalfe Kelly A. , Semple John , Quan May-Lynn , Holloway Claire , Wright Frances , Narod Steven , Hofer Stefan , Bagher Shaghayegh , Zhong Toni
Published: February 2017

Background:

Delayed breast reconstruction is an option for women who have undergone mastectomy; however, uptake is low. The purpose of this study was to identify premastectomy and postmastectomy demographic, clinical, and psychosocial predictors of uptake of delayed breast reconstruction in the long-term survivorship period.

Methods:

This was a prospective longitudinal survey study of mastectomy patients in which a repeated measures design was used to evaluate uptake of delayed breast reconstruction. Demographic, clinical, and psychosocial variables were collected before mastectomy and 1 year after mastectomy. Information regarding uptake of delayed breast reconstruction was collected at approximately 6 years after mastectomy. A predictive model was designed using a multivariate logistic regression model and Akiake information criterion stepwise algorithm.

Results:

Ninety-six mastectomy patients were followed from before mastectomy to 75.2 months after mastectomy, and 35 women (36.5 percent) underwent delayed breast reconstruction. Women who elected for delayed breast reconstruction experienced worsening of body concerns from before mastectomy to 1 year after mastectomy, compared with women who did not elect to undergo delayed breast reconstruction (p = 0.03). Mean scores for psychological distress were significantly worse both before mastectomy and 1 year after mastectomy in women who went on to undergo delayed breast reconstruction compared with those who did not undergo delayed breast reconstruction (p = 0.034 and p = 0.022, respectively). A predictive model for the uptake of delayed breast reconstruction was developed using demographic, clinical, and psychosocial characteristics. The area under the receiver operating characteristic curve was 85 percent, indicating good precision.

Conclusions:

Women who are experiencing higher levels of distress, anxiety, and body concerns both before and after mastectomy appear to be significantly likely to select delayed breast reconstruction. This may have implications for postreconstruction satisfaction and psychosocial functioning.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, III.
A Qualitative Study of Breast Reconstruction Decision-Making among Asian Immigrant Women Living in the United States
Authors: Fu Rose , Chang Michelle Milee , Chen Margaret , Rohde Christine Hsu
Published: February 2017

Background:

Despite research supporting improved psychosocial well-being, quality of life, and survival for patients undergoing postmastectomy breast reconstruction, Asian patients remain one-fifth as likely as Caucasians to choose reconstruction. This study investigates cultural factors, values, and perceptions held by Asian women that might impact breast reconstruction rates.

Methods:

The authors conducted semistructured interviews of immigrant East Asian women treated for breast cancer in the New York metropolitan area, investigating social structure, culture, attitudes toward surgery, and body image. Three investigators independently coded transcribed interviews, and then collectively evaluated them through axial coding of recurring themes.

Results:

Thirty-five immigrant East Asian women who underwent surgical treatment for breast cancer were interviewed. Emerging themes include functionality, age, perceptions of plastic surgery, inconvenience, community/family, fear of implants, language, and information. Patients spoke about breasts as a function of their roles as a wife or mother, eliminating the need for breasts when these roles were fulfilled. Many addressed the fear of multiple operations. Quality and quantity of information, and communication with practitioners, impacted perceptions about treatment. Reconstructive surgery was often viewed as cosmetic. Community and family played a significant role in decision-making.

Conclusions:

Asian women are statistically less likely than Caucasians to pursue breast reconstruction. This is the first study to investigate culture-specific perceptions of breast reconstruction. Results from this study can be used to improve cultural competency in addressing patient concerns. Improving access to information regarding treatment options and surgical outcomes may improve informed decision-making among immigrant Asian women.
Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results
Authors: Sigalove Steven , Maxwell G. Patrick , Sigalove Noemi M. , Storm-Dickerson Toni L. , Pope Nicole , Rice Jami , Gabriel Allen
Published: February 2017

Implant-based breast reconstruction is currently performed with placement of the implant in a subpectoral pocket beneath the pectoralis major muscle, by means of the dual-plane approach. Although the safety and breast aesthetics of this approach are well recognized, it is not without concerns. Animation deformities and accompanying patient discomfort, which are direct consequences of muscle elevation, can be severe in some patients. Moving the implant prepectorally may eliminate these concerns. For a successful prepectoral approach, the authors advocate use of their bioengineered breast concept, which was detailed in a previous publication. In this report, the authors discuss the rationale for prepectoral implant reconstruction, its indications/contraindications, and preliminary results from over 350 reconstructions.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Single Implantable FK506 Disk Prevents Rejection in Vascularized Composite Allotransplantation
Authors: Unadkat Jignesh V. , Schnider Jonas T. , Feturi Firuz G. , Tsuji Wakako , Bliley Jacqueline M. , Venkataramanan Raman , Solari Mario G. , Marra Kacey G. , Gorantla Vijay S. , Spiess Alexander M.
Published: February 2017

Background:

In vascularized composite allotransplantation, medication nonadherence leads to increased acute rejections. Improving medication adherence would improve overall allograft survival. Regionally delivered immunosuppression, targeted to sites of allorecognition, may reduce or eliminate the need for daily systemic immunosuppression.

Methods:

The authors developed biodegradable FK disks containing FK506-loaded double-walled microspheres and tested their efficacy at preventing rejection in a Brown-Norway–to-Lewis rat hindlimb transplantation model. In some experimental group animals, one FK disk was implanted subcutaneously either in native nontransplanted leg or in a transplanted allograft. Regular blood FK506 levels were measured. The endpoint was 180-day allograft survival or grade 3 rejection. At the endpoint, tissue FK506 levels were measured and mixed lymphocytic reaction was performed.

Results:

A single FK disk maintained systemic blood FK506 levels between 5 and 15 ng/ml for 146 ± 11.1 days. After that, the levels declined to less than 5 ng/ml through the endpoint. There was significantly increased FK506 concentration in groin lymph nodes draining the implanted FK disk. Compared with other groups, animals with an FK disk in the transplanted allograft had 100 percent allograft survival to more than 180 days despite subtherapeutic levels below 5 ng/ml. In these animals, significant T-cell hyporesponsiveness was seen in groin lymph nodes draining the FK disk compared with robust splenic T-cell proliferation.

Conclusions:

Sustained regional immunosuppression (with a single FK506 disk) maintained the allograft by means of a high regional concentration of FK506. Notably, this was achieved at subtherapeutic blood concentrations of FK506, without any further systemic FK506 administration.
The Severity of Deformity in Metopic Craniosynostosis Is Correlated with the Degree of Neurologic Dysfunction
Authors: Yang Jenny F. , Brooks Eric D. , Hashim Peter W. , Reuman Hannah S. , Travieso Roberto , Terner Jordan , Mayes Linda C. , Steinbacher Derek M. , Persing John A. , McPartland James C.
Published: February 2017

Background:

In recent years, metopic synostosis has represented up to 25 percent of all nonsyndromic craniosynostosis cases, manifesting with varying degrees of trigonocephaly. It is unknown whether the degree of severity of anterior dysmorphology is proportionate to neurologic dysfunction. This knowledge is essential to guide future surgical treatment recommendations. Given the reported correlation of abnormal auditory processing with future language dysfunction and poorer academic performance in craniosynostosis patients, the present study aims to evaluate auditory processing in preoperative patients with moderate and severe metopic synostosis, and in control infants, to discern the neurologic risk carried by different severities of trigonocephaly.

Methods:

Thirty-eight infants underwent evaluation of auditory processing: nine patients with severe metopic synostosis, seven with moderate metopic synostosis, and 22 controls. Brain activity was recorded by electroencephalography while the participants listened to language-based stimuli. Electroencephalographic data were analyzed to extract event-related potentials evoked by the speech sounds.

Results:

Severe metopic synostosis patients demonstrated significantly attenuated event-related potential responses in the left frontal scalp region overlying the left frontal lobe compared with controls (p < 0.05). The moderate metopic synostosis patients did not show significantly different language processing compared to the control infants or the severe metopic synostosis patients in the frontal scalp region.

Conclusions:

The results of this study suggest that untreated severe metopic synostosis is associated with reduced language response in the frontal cortex. Less severe (moderate) forms are indeterminate, and mild forms do not show calculable irregularity by the event-related potential method of analysis.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Worldwide Testing of the eFACE Facial Nerve Clinician-Graded Scale
Authors: Banks Caroline A. , Jowett Nathan , Azizzadeh Babak , Beurskens Carien , Bhama Prabhat , Borschel Gregory , Coombs Christopher , Coulson Susan , Croxon Glen , Diels Jaqueline , Fattah Adel , Frey Manfred , Gavilan Javier , Henstrom Douglas , Hohman Marc , Kim Jennifer , Marres Henri , Redett Richard , Snyder-Warwick Alison , Hadlock Tessa
Published: February 2017

Background:

The electronic, clinician-graded facial function scale (eFACE) is a potentially useful tool for assessing facial function. Beneficial features include its digital nature, use of visual analogue scales, and provision of graphic outputs and scores. The authors introduced the instrument to experienced facial nerve clinicians for feedback, and examined the effect of viewing a video tutorial on score agreement.

Methods:

Videos of 30 patients with facial palsy were embedded in an Apple eFACE application. Facial nerve clinicians were invited to perform eFACE video rating and tutorial observation. Participants downloaded the application, viewed the clips, and applied the scoring. They then viewed the tutorial and rescored the clips. Analysis of mean, standard deviation, and confidence interval were performed. Values were compared before and after tutorial viewing, and against scores obtained by an experienced eFACE user.

Results:

eFACE feedback was positive; participants reported eagerness to apply the instrument in clinical practice. Standard deviation decreased significantly in only two of the 16 categories after tutorial viewing. Subscores for static, dynamic, and synkinesis all demonstrated stable standard deviations, suggesting that the instrument is intuitive. Participants achieved posttutorial scores closer to the experienced eFACE user in 14 of 16 scores, although only a single score, nasolabial fold orientation with smiling, achieved statistically significant improvement.

Conclusions:

The eFACE may be a suitable, cross-platform, digital instrument for facial function assessment, and was well received by facial nerve experts. Tutorial viewing does not appear to be necessary to achieve agreement, although it does mildly improve agreement between occasional and frequent eFACE users.
The Evolution of Surgical Simulation: The Current State and Future Avenues for Plastic Surgery Education
Authors: Kazan Roy , Cyr Shantale , Hemmerling Thomas M. , Lin Samuel J. , Gilardino Mirko S.
Published: February 2017

Alongside the ongoing evolution of surgical training toward a competency-based paradigm has come the need to reevaluate the role of surgical simulation in residency. Simulators offer the ability for trainees to acquire specific skills and for educators to objectively assess the progressive development of these skills. In this article, the authors discuss the historical evolution of surgical simulation, with a particular focus on its past and present role in plastic surgery education. The authors also discuss the future steps required to further advance plastic surgery simulation in an effort to continue to train highly competent plastic surgery graduates.
The Association between Smoking and Plastic Surgery Outcomes in 40,465 Patients: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program Data Sets
Authors: Goltsman David , Munabi Naikhoba C. O. , Ascherman Jeffrey A.
Published: February 2017

Background:

Smoking is known to negatively impact postoperative wound healing and increase infection risk. However, few studies have investigated whether the negative effects of smoking are similar for different procedures. The authors examined the association between smoking and postoperative outcomes for a diverse range of plastic surgery procedures.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program data set, demographics and outcomes were examined for patients who underwent plastic surgery between 2007 and 2012. Multivariable logistic regression models assessed the relationship between smoking status and a range of postoperative outcomes, including medical and surgical complications and impaired wound healing. Patients were also evaluated for length of inpatient hospitalization while controlling for multiple demographic factors and type of procedure.

Results:

Forty thousand four hundred sixty-five patients were identified from the data set, including patients who had undergone breast, upper and lower extremity, abdominal, and craniofacial procedures. Current smokers constituted 15.7 percent of the cohort. Smokers had a higher likelihood of surgical (OR, 1.37; p < 0.0001) and medical complications (OR, 1.24; p = 0.0323) and increased odds for wound complications (OR, 1.49; p < 0.0001) and wound dehiscence (OR, 1.84; p < 0.0001). Smokers were also found to have increased odds of these complications even when subgroup analysis was performed according to major Current Procedural Terminology categories. Smoking also increased the odds of superficial wound infections (OR, 1.40; p < 0.0001). No difference was observed in hospital length of stay between smokers and nonsmokers.

Conclusions:

Smoking increases a multitude of postoperative complications after plastic surgery procedures. The effects of smoking on plastic surgery outcomes should be used to guide patients in preoperative smoking cessation and to evaluate protocols for managing patients who smoke.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Risk, II.
Cosmetic Professionals’ Awareness of Body Dysmorphic Disorder
Authors: Bouman Theo K. , Mulkens Sandra , van der Lei Berend
Published: February 2017

Background:

Preoccupation with a perceived appearance flaw is the main feature of body dysmorphic disorder. The majority of these patients seek and often receive some sort of cosmetic procedure, although this condition is considered to be a contraindication. This study evaluates cosmetic professionals’ recognition of body dysmorphic disorder and the way they act on this.

Method:

Members of Dutch professional associations for aesthetic plastic surgery, dermatology, and cosmetic medicine received an online survey by means of their association’s digital mailing lists; the survey was completed by 173 respondents.

Results:

Most participants indicated being more or less familiar with the diagnostic criteria and clinical picture of body dysmorphic disorder. Approximately two-thirds of the participants reported that they had encountered between one and five of these patients in their practice over the past year, a percentage that is significantly lower than the estimated prevalence of body dysmorphic disorder. The majority of professionals sometimes or often address body image problems during consultation, most of them collaborate with psychologists or psychiatrists when encountering a patient with body dysmorphic disorder, and approximately 70 percent had refused to perform a procedure in such a patient.

Conclusions:

Our results converge with those of previous studies, showing that most cosmetic professionals have some degree of awareness of body dysmorphic disorder, although the number they report encountering in clinical practice departs from prevalence figures. When a patient is identified as having body dysmorphic disorder, the professionals use this knowledge to guide their decision to perform a cosmetic procedure.
What Is the Lobular Branch of the Great Auricular Nerve? Anatomical Description and Significance in Rhytidectomy
Authors: Sharma Vicki S. , Stephens Robert E. , Wright Barth W. , Surek Christopher C.
Published: February 2017

Background:

Current literature suggests that preserving the lobular branch of the great auricular nerve has greater impact on sensory function of the auricle than preservation of the posterior branch during rhytidectomy. However, no methodology exists to efficiently and accurately determine the topographic location of the lobular branch. This study describes the branching characteristics of the lobular branch and algorithmic surface markings to assist surgeons in preservation of the great auricular nerve during rhytidectomy flap elevation.

Methods:

The lobular branch was dissected in 50 cadaveric necks. Measurements were taken from the lobular branch to conchal cartilage, tragus, and antitragus. The anterior branch was measured to its superficial musculoaponeurotic system insertion, and the posterior branch was measured to the mastoid process. The McKinney point was marked and the great auricular nerve diameter was recorded. Branching pattern and location of branches within the Ozturk 30-degree angle were documented. Basic statistics were performed.

Results:

The lobular branch was present in all specimens and distributed to three regions. In 85 percent of specimens, the lobular branch resided directly inferior to the antitragus; in the remaining specimens, it was located directly inferior to the tragus. Preoperative markings consisting of two vertical lines from the tragus and antitragus to the McKinney point can be used to outline the predicted location of the lobular branch.

Conclusions:

This study delineates the location of the lobular branch of the great auricular nerve. The authors translate these findings into a quick and simple intraoperative marking, which can assist surgeons in avoiding lobular branch injury during rhytidectomy dissection.
Comparison of a Small Central versus a Large Peripheral Perforator in a Rat Model of Extended Dorsal Three–Vascular Territory Perforator Flap
Authors: Ding Jian , Feng Xiaoliang , Gao Weiyang , Yan Hede , Tao Xianyao , Wang Long , Tang Maolin
Published: February 2017

Background:

Selection of suitable perforators is critical for satisfactory postreconstructive surgery outcome. This study aims to compare a small central versus a large peripheral perforator flap in a rat extended dorsal three–vascular territory perforator flap model.

Methods:

An extended intercostal artery perforator flap with three vascular territories was used to model a small central perforator flap. An extended deep circumflex iliac artery flap with three vascular territories was used to model a large peripheral perforator flap. Flap viability, angiography, and perfusion were compared.

Results:

Intercostal artery flaps showed significantly higher relative viable area than deep circumflex iliac artery flaps (98.5 ± 3.2 percent versus 87.1 ± 7.3 percent; p < 0.01). Angiography revealed that the anatomical and the first adjacent territories were perfused successfully in both types of flap, but the second adjacent territory of deep circumflex iliac artery flaps was not perfused sufficiently, thus ultimately leading to flap necrosis. Perfusion at the anatomical and the first adjacent territories of both types of flap increased significantly for 3 days (p < 0.05) and became stable 5 to 7 days after surgery. Perfusion at the second adjacent territory of deep circumflex iliac artery flaps diminished continuously.

Conclusions:

A small central perforator may supply a larger vascular territory than a large peripheral perforator. Both the size and the location of a perforator should be considered for optimizing the design of an extended perforator flap.
Advanced Imaging Techniques for Investigation of Acellular Dermal Matrix Biointegration
Authors: DeGeorge Brent R. , Ning Bo , Salopek Lisa S. , Pineros-Fernandez Angela , Rodeheaver George T. , Peirce-Cottler Shayn , Hu Song , Cottler Patrick S. , Campbell Christopher A.
Published: February 2017

Background:

Biointegration, a concept involving a dynamic interplay among three processes—inflammation, cellular infiltration, and angiogenesis—is key to understanding the interaction between acellular dermal matrices and the host. The current standard for evaluating acellular dermal matrix biointegration involves histologic analysis at fixed time points; however, the authors’ approach uses advanced imaging techniques to serially assess biointegration in real time.

Methods:

The authors have adapted two advanced imaging techniques—two-photon microscopy and photoacoustic microscopy—to investigate biointegration in a murine deepithelialized dorsal skin-fold window chamber model, specifically engineered to recapitulate the host microenvironment of acellular dermal matrix–assisted breast reconstruction. Four mice per group were assessed. Two-photon imaging of dual-transgenic mice allows for detection of fluorescently labeled perivascular cells, and macrophage lineage cells. Photoacoustic microscopy noninvasively assesses oxygen and hemoglobin concentration in living tissues, generating high-resolution, three-dimensional mapping of the nascent acellular dermal matrix–associated microvasculature and metabolic consumption of oxygen. These outcomes were corroborated by confirmatory histologic analysis at the terminal time point.

Results:

The acellular dermal matrix/host interface is characterized by robust inflammation (0 to 3 days), increased oxygen consumption and neoangiogenesis in the matrix border zone (10 to 14 days), and vascular and inflammatory cell penetration into the center of the matrix (>21 days).

Conclusion:

The data broaden the core knowledge of acellular dermal matrix biology, and serve as a potential template for elucidating the key differences among various commercially available and developmental products to guide the reconstructive surgeon to better select a reconstructive adjunct that meets their specific needs.
Perforator-Based Interposition Flaps Perform Better Than Full-Thickness Grafts for the Release of Burn Scar Contractures: A Multicenter Randomized Controlled Trial
Authors: Stekelenburg Carlijn M. , Jaspers Mariëlle E. H. , Jongen Sandra J. M. , Baas Dominique C. , Gardien Kim L. M. , Hiddingh Jakob , van Zuijlen Paul P. M.
Published: February 2017

Background:

Burn scar contractures remain a significant problem for the severely burned patient. Reconstructive surgery is often indicated to improve function and quality of life. Skin grafts (preferably full-thickness grafts) are frequently used to cover the defect that remains after scar release. Local flaps are also used for this purpose and provide healthy skin subcutaneous tissue. The vascularization and versatility of local flaps can be further improved by enclosing a perforator at the base of the flap. Until now, no randomized controlled trial has been performed to determine which technique has the best effectiveness in burn scar contracture releasing procedures.

Methods:

A multicenter randomized controlled trial was performed to compare the effectiveness of perforator-based interposition flaps to full-thickness skin grafts for the treatment of burn scar contractures. The primary outcome parameter was change in the surface area of the flap or full-thickness skin graft. Secondary outcome parameters were width, elasticity, color, Patient and Observer Scar Assessment Scale score, and range of motion. Measurements were performed after 3 and 12 months.

Results:

The mean surface area between flaps (n = 16) and full-thickness skin grafts (n = 14) differed statistically significantly at 3 months (123 percent versus 87 percent; p < 0.001) and 12 months (142 percent versus 92 percent; p < 0.001). In terms of the secondary outcome parameters (specifically, the Patient and Observer Scar Assessment Scale observer score and color), interposition flaps showed superior results compared with full-thickness skin grafts.

Conclusion:

Perforator-based interposition flaps result in a more effective scar contracture release than full-thickness skin grafts and should therefore be preferred over full-thickness skin grafts when possible.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, I.
Complications and Long-Term Outcomes of Free Fibula Reconstruction following Resection of a Malignant Tumor in the Extremities
Authors: Houdek Matthew T. , Wagner Eric R. , Bishop Allen T. , Shin Alexander Y. , Rose Peter S. , Sim Franklin H. , Moran Steven L.
Published: February 2017

Background:

To achieve limb salvage and provide the patient with a functional extremity, vascularized free fibula transfer has become the workhorse for segmental bony reconstruction. Because of various host factors, there has been a high complication rate following oncologic reconstruction. The authors reviewed the experience of their institution with the use of free fibula reconstruction following an oncologic resection in the extremities.

Methods:

The authors reviewed 56 cases of free fibula transfer performed for limb salvage following oncologic resection from 1994 through 2013. The cohort consisted of 30 male patients and 26 female patients; with a mean age of 19 years and a mean follow-up of 7 years. Sixty-three percent of the tumors were located in the lower extremity.

Results:

The overall 2-, 5-, 10-, and 15-year survival rates were 98, 86, 73, and 73 percent, respectively. With regard to disease-specific survival, the overall 2-, 5-, 10, and 15-year survival rates were 82, 75, 67, and 50 percent, respectively. Seventy-five percent of cases healed primarily, with a mean time to union of 10 months. The overall union rate was 98 percent following supplemental bone grafting. Chemotherapy following the free fibula graft increased the risk (hazard ratio, 2.10; p = 0.03) of a delayed union. The overall rate of limb salvage was 93 percent, with four patients requiring an amputation.

Conclusions:

The free fibula is considered the workhorse vascularized bone graft for extremity reconstruction in limb salvage surgery. In the oncologic setting, a repeated bone grafting procedure was common, and should be expected in patients undergoing chemotherapy. Limb salvage rates are high with this technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
An Oncoplastic Breast Augmentation Technique for Immediate Partial Breast Reconstruction following Breast Conservation
Authors: Barnea Yoav , Friedman Or , Arad Ehud , Barsuk Daphna , Menes Tehillah , Zaretski Arik , Leshem David , Gur Eyal , Inbal Amir
Published: February 2017

Background:

Patients with a small breast volume and a relative large lumpectomy volume are at risk of developing severe breast deformity and asymmetry following breast conservation, presenting a unique surgical challenge.

Methods:

A series of patients undergoing immediate reconstruction by means of an oncoplastic breast augmentation technique following breast conservation are described. The technique includes local tissue rearrangement and bilateral subpectoral breast augmentation with implants of different sizes and shapes, immediately after lumpectomy for a malignant tumor.

Results:

Twenty-one consecutive patients underwent the oncoplastic breast augmentation technique (mean follow-up, 23 months; range, 12 to 48 months). Three patients (14.3 percent) had tumor-positive surgical margins. Postoperative complications included grade III/IV capsular contracture in five patients (23.8 percent) and breast infection in two patients (10 percent). All patients received postoperative radiation therapy. The cosmetic outcome was evaluated at least 6 months after radiation therapy, and it was favorable according to the reported high patient satisfaction (81 percent) and independent observers’ evaluation scores (76 percent).

Conclusions:

The oncoplastic breast augmentation technique described in this article is an acceptable option in small-breasted patients with a relatively large lumpectomy volume who elect to undergo breast conservation. This technique allows conservation of the affected breast and minimizes potential breast deformation and asymmetry following radiation therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Prophylactic Leukotriene Inhibitor Therapy for the Reduction of Capsular Contracture in Primary Silicone Breast Augmentation: Experience with over 1100 Cases
Authors: Bresnick Stephen D.
Published: February 2017

Background:

The role of leukotriene inhibitors used immediately postoperatively to potentially influence the development of capsular contracture is unknown. The purpose of this study was to evaluate the incidence of capsular contracture among women undergoing primary smooth silicone gel breast augmentation, with or without postoperative leukotriene inhibitor therapy.

Methods:

Between 2007 and 2013, 1122 consecutive women undergoing primary silicone gel breast augmentation were evaluated retrospectively. All underwent augmentation with smooth, Mentor Memory Gel implants, using a dual-plane technique, with periareolar or inframammary approaches. Patients were treated voluntarily with either no leukotriene inhibitor, montelukast (Singulair), or zafirlukast (Accolate) for 3 months. All patients received informed consent for the off-label use of leukotriene inhibitors. Liver function studies were obtained for all patients undergoing Accolate therapy after 1 month of therapy. The presence of capsular contracture was measured by the Baker scale at 1 year postoperatively.

Results:

Patients receiving Accolate therapy (n = 520) demonstrated an encapsulation rate of 2.19 percent. Women receiving Singulair therapy (n = 247) had an encapsulation rate of 3.27 percent. Patients not receiving leukotriene inhibitor therapy had an encapsulation rate of 5.02 percent. There were no long-term complications among patients evaluated.

Conclusions:

Accolate therapy used for 3 months postoperatively was associated with significantly lower capsular contracture rates compared with untreated patients at 1-year follow-up (p < 0.05). Patients treated with Singulair demonstrated lower contracture rates compared with controls, but the differences were not statistically significant. The findings suggest that Accolate therapy, with monitoring and consent, reduces the incidence of capsular contracture following primary smooth silicone gel breast augmentation.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, III.
Accurate Prediction of Tissue Viability at Postoperative Day 7 Using Only Two Intraoperative Subsecond Near-Infrared Fluorescence Images
Authors: Wada Hideyuki , Vargas Christina R. , Angelo Joseph , Faulkner-Jones Beverly , Paul Marek A. , Ho Olivia A. , Lee Bernard T. , Frangioni John V.
Published: February 2017

Background:

The ability to predict the future viability of tissue while still in the operating room and able to intervene would have a major impact on patient outcome. Although several objective methods to evaluate tissue perfusion have been reported, none to date has sufficient accuracy.

Methods:

In eight Sprague-Dawley rats, reverse McFarlane dorsal skin flaps were created. Continuous near-infrared fluorescence angiography using indocyanine green was performed immediately after surgery, for a total of 30 minutes. These dynamic measurements were used to quantify indocyanine green biodistribution and clearance, and to develop a simple metric that accurately predicted tissue viability at postoperative day 7. The new metric was compared to previously described metrics.

Results:

Reproducible patterns of indocyanine green biodistribution and clearance from the flap permitted quantitative metrics to be developed for predicting flap viability at postoperative day 7. Previously described metrics, which set the boundary between healthy and necrotic tissue as either 17 or 25 percent of peak near-infrared fluorescence at 2 minutes after indocyanine green injection, underestimated the area of necrosis by 75 and 48 percent, respectively. Our data suggest that both the shape and area of clinical necrosis occurring at postoperative day 7 can be predicted intraoperatively, with the boundary defined as near-infrared fluorescence intensities of 40 to 55 percent of peak fluorescence measured at 5 minutes.

Conclusion:

Two 750-msec intraoperative near-infrared fluorescence images obtained at time 0 and at 5 minutes after injection of indocyanine green accurately predicted skin flap viability 7 days after surgery.
Infant Robotic Cleft Palate Surgery: A Feasibility Assessment Using a Realistic Cleft Palate Simulator
Authors: Podolsky Dale J. , Fisher David M. , Wong Riff Karen W. Y. , Looi Thomas , Drake James M. , Forrest Christopher R.
Published: February 2017

Background:

A surgical robot offers enhanced precision, visualization, and access and the potential to improve outcomes in cleft palate surgery. The goal of this study was to investigate the feasibility of using the da Vinci robot for cleft palate repair in infants using a cleft palate simulator test bed.

Methods:

A high-fidelity cleft palate simulator was developed that allows performance of a robotic cleft palate repair procedure. A complete cleft palate repair was performed with the da Vinci Si with 5-mm instruments and the da Vinci Xi with 8-mm instruments. The advantages of the robotic approach were assessed in comparison with using standard instruments. For each system, arm repositioning, collisions, instrument and endoscope excursion, wrist orientation, and vision were compared for 12 steps of the repair.

Results:

The cleft palate simulator provided a reproducible platform for testing robotic cleft palate surgery. The advantages of the robotic approach were the ability to articulate a miniature wrist intraorally with superior visualization, increased ambidexterity, and improved ergonomics compared with using standard instruments. Cleft palate repair with the Xi was superior to the Si with respect to arm repositioning, instrument collisions and excursion, and wrist orientation. However, Xi performance remained suboptimal because of the larger instruments.

Conclusions:

Robotic cleft palate repair using the da Vinci system offers advantages compared with the traditional approach. Cleft palate repair is more feasible with the Xi and 8-mm instruments. However, performance is limited by the instrumentation, which requires modification to ensure safety and efficacy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Pedicled Temporalis Muscle Flap for Craniofacial Reconstruction: A 35-Year Clinical Experience with 366 Flaps
Authors: Spanio di Spilimbergo Stefano , Nordera Paolo , Mardini Samir , Castiglione Giusy , Chim Harvey , Pinna Vittore , Brunello Massimo , Cusino Claudio , Roberto Squaquara , Baciliero Ugo
Published: February 2017

Background:

In the past 130 years, the temporalis muscle flap has been used for a variety of different indications. In this age of microsurgery and perforator flaps, the temporalis muscle flap still has many useful applications for craniofacial reconstruction.

Methods:

Three hundred sixty-six temporalis muscle flaps were performed in a single center between 1978 and 2012. The authors divided the cases into two series—before and after 1994—because, after 1994, they started to perform free flap reconstructions, and indications for reconstruction with a temporalis muscle flap were changed

Results:

In the series after 1994, flaps were most commonly used for reconstruction of defects in the maxilla, mandible, and oropharynx, in addition to facial reanimation and filling of orbital defects. Complications included total flap necrosis (1.6 percent) and partial flap necrosis (10.7 percent). The rate of material extrusion at the donor site decreased after porous polyethylene was uniformly used for reconstruction from 17.1 to 7.9 percent.

Conclusions:

The pedicled temporalis muscle flap continues to have many applications in craniofacial reconstruction. With increasing use of free flaps, the authors’ indications for the pedicled temporalis muscle flap are now restricted to (1) orbital filling for congenital or acquired anophthalmia; (2) filling of unilateral maxillectomy defects; and (3) facial reanimation in selected cases of facial nerve palsy.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, IV.
Daily Suction Provided by External Volume Expansion Inducing Regeneration of Grafted Fat in a Murine Model
Authors: Ye Yuan , Liao Yunjun , Lu Feng , Gao Jianhua
Published: February 2017

Background:

Fat grafting has variable and sometimes poor outcomes, and therefore new methods are needed. Multiple studies have demonstrated the excellent performance of external volume expansion and focused only on preexpansion with emphasis on the recipient.

Methods:

Two mouse models (a suction model and a fat-exchange transplantation model) were established to investigate changes in the origins and biological behaviors of regeneration-related cells in grafted fat under daily suction provided by external volume expansion.

Results:

Blood supply increased from new host-derived capillaries or macrophage infiltration under suction. CD34-positive cells showed increased migration from the host into the grafts under suction. At week 12, nearly half of the mature adipocytes regenerated in the grafts in the suction group were derived from the host. Peroxisome proliferator-activated receptor γ expression of the suction group was significantly higher than that of controls at weeks 2 and 4 during adipogenesis. The normalized sample weight of the grafted fat was significantly greater than that of controls at 1 (0.081 ± 0.001 versus 0.072 ± 0.005; p < 0.001), 4 (0.060 ± 0.002 versus 0.048 ± 0.001; p = 0.002), 8 (0.060 ± 0.001 versus 0.046 ± 0.001; p < 0.001), and 12 weeks (0.060 ± 0.001 versus 0.046 ± 0.001; p = 0.002).

Conclusions:

The mechanical effect of daily suction provided by external volume expansion favors the regeneration of grafted fat and improves retention by promoting the migration of regeneration-related cells and the differentiation of adipocytes. Thus, more mature fat tissue with a well-organized structure was formed under suction.
Identification of Key Modules and Hub Genes of Keloids with Weighted Gene Coexpression Network Analysis
Authors: Liu Wenhui , Huang Xiaolu , Liang Xiao , Zhou Yiwen , Li Haizhou , Yu Qingxiong , Li Qingfeng
Published: February 2017

Background:

Keloid scarring impairs patients’ quality of life, and although many therapeutic strategies have been developed, most remain unsatisfactory because of limited understanding of the mechanisms underlying keloid development.

Methods:

A microarray gene expression data set from keloid tissue was acquired from the Gene Expression Omnibus. Differentially expressed genes in fibroblasts and keratinocytes underwent functional annotation and pathway analysis. Weighted gene coexpression network analysis was applied to identify the gene targets of keloid scars within differentially expressed genes. Modules and hub genes for keloids were identified. Enrichment analysis was undertaken to verify the modules’ and hub genes’ relationship with keloids.

Results:

Enrichment analysis and pathway analysis showed gene ontology terms and pathways related to keloids. Each cell type generated three modules in weighted gene coexpression network analysis, with one module most related to keloids. Enrichment analysis showed that the modules concerned are enriched with terms related to keloids. Three hub genes were selected for fibroblasts and keratinocytes, and their relationship to keloids was verified. Immunohistochemical staining verified expression change of some hub genes.

Conclusions:

This is the first study to describe the gene networks underlying keloids. Modules and hub genes generated in the present study are highly related to keloids and may identify novel therapeutic targets for treatment of keloids.

CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.
Public Perception of Cosmetic Surgeons versus Plastic Surgeons: Increasing Transparency to Educate Patients
Authors: Shah Ajul , Patel Anup , Smetona John , Rohrich Rod J.
Published: February 2017

Background:

The American Society of Plastic Surgeons’ “Do Your Homework” campaign strives to educate the public on how to identify providers who can safely perform aesthetic/cosmetic/plastic surgery. Although the campaign continues to heighten awareness, misperceptions remain in determining who these providers are. This study aims to examine whether the general public is confused by the titles “plastic surgeon” or “cosmetic surgeon,” and accordingly, evaluates whether misperceptions need to be remedied to have an informed and safe patient.

Methods:

A 19-question survey was created under the guidance of a survey methodologist. Responses were obtained and cross-tabulation analyses were performed with statistical analysis.

Results:

Five thousand one hundred thirty-five individuals completed the survey. Eighty-seven percent of patients either believed that surgeons must be appropriately credentialed to legally advertise themselves, or were unsure. The majority of respondents were uncomfortable with obstetrician-gynecologists (92 percent), dermatologists (68 percent), general surgeons (74 percent), and family practice physicians (93 percent) performing surgery to improve their appearance. Persons with lower education and lower income levels were more likely to believe that surgeons must be appropriately credentialed to legally market themselves, and were more likely to assume that to legally perform aesthetic surgery, one must be board certified in plastic surgery.

Conclusion:

The authors’ data demonstrate that the combination of problematic medical marketing, recognized and unrecognized boards, and varying categorizations of surgeons has made it increasingly difficult for a patient to interpret the necessary information to decide which physician can safely perform surgery to improve one’s appearance.
Facial Reanimation: Basic Surgical Tools and Creation of an Effective Toolbox for Treating Patients with Facial Paralysis. Part A: Functional Muscle Transfers in the Long-Term Facial Palsy Patient
Authors: Rozen Shai M.
Published: February 2017

The literature on facial paralysis is vast; however, detailed videos of the basic tools of dynamic reanimation within the context of patient scenarios accompanied by detailed narrative emphasizing both technique and thought processes are not common. Although not all scenarios of facial paralysis can be discussed in one setting, videographic visualization of basic surgical procedures, including facial marking, facial dissection, donor nerve preparation, cross-facial nerve graft, nerve transfers, and muscle harvest and inset, may provide a strong toolbox. Using these tools in various combinations depending on the unique case details enables the surgeon to treat a great majority of facial palsy patients. Part A, with the first of two videos, concentrates on free functional muscle transfer in the setting of longstanding facial paralysis. It includes preoperative markings, preparation of the patient in the operating room before incision, facial dissection including exposure of the masseter nerve, partial gracilis muscle harvest, and perhaps most importantly, the inset of the muscle on the paralyzed side. Part B (with the second video) concentrates on the cross-facial nerve graft and nerve transfers, used in the context of acute facial palsy, providing the short-term goal of mimetic musculature salvage in addition to longer term specific regional reinnervation by means of cross-facial nerve grafting. We hope that these videos provide a strong learning tool for enthusiastic novice medical students, residents, and fellows wishing to prepare for their cases, and faculty level physicians who wish to use them as a refresher before surgery.
Excess Dermal Tissue Remodeling In Vivo: Does It Settle?
Authors: Leavitt Tripp , Hu Michael S. , Zielins Elizabeth R. , Barnes Leandra A. , Marshall Clement D. , Wan Derrick C. , Lorenz H. Peter , Gurtner Geoffrey C. , Longaker Michael T.
Published: February 2017

Background:

Surgical manipulation of skin may result in undesired puckering of excess tissue, which is generally assumed to settle over time. In this article, the authors address the novel question of how this excess tissue remodels.

Methods:

Purse-string sutures (6-0 nylon) were placed at the midline dorsum of 22 wild-type BALB/c mice in a circular pattern marked with tattoo ink. Sutures were cinched and tied under tension in the treatment group, creating an excess tissue deformity, whereas control group sutures were tied without tension. After 2 or 4 weeks, sutures were removed. The area of tattooed skin was measured up to 56 days after suture removal. Histologic analysis was performed on samples harvested 14 days after suture removal.

Results:

The majority of excess tissue deformities flattened within 2 days after suture removal. However, the sutured skin in the treatment group decreased in area by an average of 18 percent from baseline (n = 9), compared to a 1 percent increase in the control group (n = 10) at 14 days after suture removal (p < 0.05). This was similarly observed at 28 days (treatment, −11.7 percent; control, 4.5 percent; n = 5; p = 0.0243). Despite flattening, deformation with purse-string suture correlated with increased collagen content of skin, in addition to increased numbers of myofibroblasts. Change in area did not correlate with duration of suture placement.

Conclusions:

Excess dermal tissue deformities demonstrate the ability to remodel with gross flattening of the skin, increased collagen deposition, and incomplete reexpansion to baseline area. Further studies will reveal whether our findings in this mouse model translate to humans.