Annals of plastic surgery

1.
Ann Plast Surg. 2019 Jun 21. doi: 10.1097/SAP.0000000000001913. [Epub ahead of print]
Emergency Repair of Severe Limb Injuries With Free Flow-Through Chimeric Anterolateral Thigh Perforator Flap.
Zheng X, Zhan Y1, Li H, Zhang Z, Xue X, Wang B, Qi J1.
Author information
1
Department of Microsurgery, Orthopedic Trauma and Hand Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
Abstract
BACKGROUND:
Complex limb trauma often involves both soft tissue and vascular defects, and is challenging for surgeons. The traditional musculocutaneous flap cannot achieve a 3-dimensional wound repair. Here we report our experience with a single-stage reconstruction and revascularization performed on complex extremity injuries using a free flow-through chimeric anterolateral thigh perforator (ALTP) flap.

PATIENTS AND METHODS:
Seventeen patients (16 men; aged 19-55 years) with complex soft tissue defects attended our hospital from January 2010 to November 2017. All patients underwent reconstruction based on free flow-through chimeric ALTP flap for complex injuries in their extremities. The wound size ranged from 16 × 8 to 45 × 30 cm. The injured artery was flow-through anastomosed with the descending branch of the lateral femoral circumflex artery to regain blood flow. The muscle flap was used to fill the deep dead space on the injury site. The skin and fascial flaps were used for superficial cover. The donor site defects were sutured directly in 6 patients; simultaneous skin grafts were applied in the remaining 11 patients.

RESULTS:
The ALTP flaps survived in 15 patients. Failure necessitated limb amputation in 2 patients. Six patients received both skin and fasciae flaps; 11 received flaps comprising the skin, fasciae, and vastus lateralis muscle. Partial necrosis after skin grafting was observed in 11 patients, and the wounds healed either by dressing change (1 patient) or second skin graft (10 patients). All donor sites healed without complications. All patients were followed up for 5 to 60 months (mean, 21.8 months).

CONCLUSIONS:
The flow-through chimeric ALTP flap can be used for 1-stage reconstruction of 3-dimensional soft tissue defects and vascular gap. It is feasible for managing complex injuries of both the upper and lower extremities in emergency settings.

PMID: 31233403 DOI: 10.1097/SAP.0000000000001913
Select item 31232825
2.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001904. [Epub ahead of print]
Two-Dimensional Ablation of Apocrine Glands With the Use of Hydrosurgical Treatment of Axillary Osmidrosis: An Analysis of 480 Cases.
Wu M, Wu WH1.
Author information
1
Division of Plastic and Reconstructive Surgery, Department of Surgery, Kuang Tien General Hospital, Hungkuang University, Taichung, Taiwan.
Abstract
Axillary osmidrosis is a distressing social problem. Topical antiperspirants are only transient solutions. Permanent solutions always need invasive operation. In this study, we evaluated the effectiveness and complications of a minor surgical procedure. From January 2010 to December 2017, 480 patients (376 females and 104 males) whose ages ranged from 8 to 72 years, with an average age of 28 years, were treated for axillary osmidrosis with hydrosurgery (Versajet unit surgical instruments) under local anesthesia on an outpatient basis. Patients were followed for 4 to 80 months with an average of 24 months. The total satisfaction rate was 99.6% (478/480). The patient complication rate was 2.7% (13/480) and the wound complication rate was 1.8% (17/960). There was 2 patient (3 axillae) got recurrent malodor cured with second operation. There were no contracture scars, arm abduction limitation, or any nerve injury in our series. The minor procedure can be an efficient and predictable treatment choice for axillary osmidrosis.

PMID: 31232825 DOI: 10.1097/SAP.0000000000001904
Select item 31232824
3.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001905. [Epub ahead of print]
End-to-Side Venous Anastomosis to a Ligated Vein Stump for Free Flap Transfer in Head and Neck Reconstruction.
Akazawa T, Sekido M, Adachi K, Sasaki K, Aihara Y, Shibuya Y, Makino S1.
Author information
1
Department of Oral Surgery, Hokuto Hospital, Obihiro, Hokkaido, Japan.
Abstract
INTRODUCTION:
In head and neck reconstruction, use of a free flap paired with end-to-side anastomosis to a preserved vein is generally performed. However, it is frequently difficult to select the recipient vein after a neck dissection in which there is only a ligated internal jugular vein/external jugular vein (IJV/EJV). Here, a new anastomosis technique using a ligated IJV/EJV stump is described.

PATIENTS AND METHODS:
End-to-side anastomoses to ligated vein stump surgeries for free flap transfer in head and neck reconstruction were performed at the Department of Plastic and Reconstructive Surgery, University of Tsukuba, from 2009 to 2016.

RESULTS:
The subject pool comprised 6 patients. All patients received a free flap transfer after head and neck tumor excision. The free flaps used were 1 free radial forearm flap, 1 free tensor fascia lata muscle perforator flap, and 4 free rectus abdominis musculocutaneous flaps. The cervical vessels used were 3 IJVs and 3 EJVs. All veins of the free flaps could be anastomosed end-to-side to ligated vein stumps without vein grafting. All flaps survived completely without complications.

CONCLUSIONS:
The end-to-side venous anastomosis to a ligated vein stump procedures were easy to perform and not dependent on the vessel diameters of the free flaps. No complications were observed in any patient owing to differences in vessel diameter, ease of anastomosis, and safety. Results suggest that this new technique is a simple and very useful option in head and neck reconstruction where the IJV/EJV cannot be preserved.

PMID: 31232824 DOI: 10.1097/SAP.0000000000001905
Select item 31232823
4.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001914. [Epub ahead of print]
The Flower Petal Training System in Microsurgery: Validation of a Training Model Using a Randomized Controlled Trial.
Volovici V, Dammers R1, Lawton MT2, Dirven CMF3, Ketelaar T4, Lanzino G5, Zamfirescu DG6.
Author information
1
From the Department of Neurosurgery, Erasmus Stroke Center, and.
2
Department of Neurosurgery, The Barrow Neurological Institute, Phoenix, AZ.
3
Department of Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands.
4
Department of Plant Biology, Wageningen University, The Netherlands.
5
Department of Neurosurgery, The Mayo Clinic, Rochester, MN.
6
Zetta Plastic and Reconstructive Microsurgery Clinic, Bucharest, Romania.
Abstract
INTRODUCTION:
Despite hundreds of training models for microsurgery being available in the literature, very few of them are scientifically validated. We chose to validate our low-fidelity training model on flower petals by comparing it head-to-head with a moderate fidelity training model, the anastomosis on chicken leg femoral artery.

MATERIALS AND METHODS:
A total of 16 participants of different levels of expertise were randomized into 2 groups, 1 training on flower petals and 1 on chicken leg femoral arteries. The groups were evaluated on performing a rat femoral artery anastomosis using the validated Stanford Microsurgical Assessment (SMaRT) Scale. The Mann-Whitney U test was used to check for statistically significant differences between the groups. The flower petal sutures were also evaluated and Pearson correlation was used to check for associations between better petal anastomosis scores and better final SMaRT results.

RESULTS:
After 6 weeks of flower petal training, microsurgical trainees had significantly better overall SMaRT scores than trainees using chicken leg training, better fine tissue feeling, and better scores in knot tying. The anastomosis times for the rat femoral arteries did not differ between the 2 groups. Good scores for flower petals strongly correlated with a better SMaRT score for the anastomosis. The number of rats used in training reduced after the implementation of this model in continuous training.

CONCLUSIONS:
The flower petal technique, despite being a low-fidelity model, shows superiority in developing fine tissue feeling and improved knot tying in microsurgery beginners and intermediate level practitioners adding this training model to their program. Further research needs to establish if the improvements also apply to already seasoned microsurgeons and whether the petal score has predictive value for future clinical application.

PMID: 31232823 DOI: 10.1097/SAP.0000000000001914
Select item 31232822
5.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001968. [Epub ahead of print]
Preexpansion in Phalloplasty Patients: Is It Effective?
Elfering L, van der Sluis WB, Bouman MB, Buncamper ME, van de Grift TC, Lissenberg-Witte BI1, Middelkoop E2, Mullender MG.
Author information
1
Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam.
2
Association of Dutch Burn Centers, the Netherlands.
Abstract
BACKGROUND:
Phalloplasty is performed as genital gender-affirming surgery in transmasculine persons. It requires the harvest of sizeable autologous fasciocutaneous flaps, which is associated with donor-site morbidity and extensive scarring. Flap preexpansion has been used to facilitate wound closure and reduce scarring, but the efficacy of flap preexpansion in phalloplasty is unclear. The objective of this study was to assess the safety and effectiveness of preexpansion before phalloplasty.

METHODS:
Transmasculine persons who underwent phalloplasty between December 2006 and July 2014 at our institution were identified and invited to participate. A chart review was performed to obtain patient demographics and expander-related complications. Outcomes regarding the donor-site scar (Patient Observer Scar Assessment Scale, scar size, patient satisfaction) were measured at the outpatient clinic and compared between transmasculine persons treated with and transmasculine persons treated without preexpansion.

RESULTS:
Of 33 transmasculine persons who underwent phalloplasty, 17 underwent preexpansion. Phalloplasty techniques included the use of the radial forearm free flap, the anterolateral thigh flap, or a combination of both. In total, 34 tissue expanders were placed in the forearm (n = 12) and/or thigh (n = 22). Complications occurred in 18 (52.9%) of 34 tissue expanders and in 13 (76.5%) of 17 transmasculine persons. Seven reoperations were performed because of extrusion (n = 2), infection (n = 2), port failure (n = 2), or leakage (n = 1). Sixteen transmasculine persons visited our clinic for scar assessment (8 with and 8 without preexpansion). Primary closure was achieved in 4 (31%) of 13 expanded donor sites. Relative scar size was reduced when the wound could be closed primarily, but overall scar size, quality, and satisfaction did not differ significantly between groups.

CONCLUSION:
Donor-site expansion before phalloplasty was associated with high rates of expander-related complications and expander failure. Primary closure of the donor site was achieved in less than a third of the cases. Primary closure may potentially lead to smaller scars and greater satisfaction; however, we concluded that the potential advantages of preexpansion do not outweigh the high risk of complications and lack of success.

PMID: 31232822 DOI: 10.1097/SAP.0000000000001968
Select item 31232821
6.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001900. [Epub ahead of print]
Auto-Allo Graft Parallel Juxtaposition for Improved Neuroregeneration in Peripheral Nerve Reconstruction Based on Acellular Nerve Allografts.
Boriani F, Savarino L1, Fazio N1, Pedrini FA1, Fini M2, Nicoli Aldini N2, Martini L2, Zini N, Bernardini M3, Bolognesi F4, Marchetti C4, Baldini N.
Author information
1
Orthopaedic Pathophysiology and Regenerative Medicine Unit and.
2
Laboratory of Preclinical and Surgical Studies, IRCCS Istituto Ortopedico Rizzoli.
3
Department of Animal Medicine, Production and Health, Padova University, Padua.
4
Department of Maxillofacial Surgery, University of Bologna, Bologna, Italy.
Abstract
INTRODUCTION:
Nerve repair poses a significant surgical challenge, and much research on this topic for improvement in reconstruction of segmental defects is ongoing. The aims of the study were to reconfirm the accuracy and safety of a previously described nerve decellularization method on a larger experimental population of rabbits, as well as on human nerves, and to establish in vivo the efficacy of a new-concept mixed graft, comprising autologous and acellular nerve allograft components within the same graft.

METHODS:
Acellular nerve allografts were implanted into tibial nerve defects of 5 rabbits (group A), autografts were implanted, representing the criterion standard, in other 5 animals (group B), and the innovative technique was used in the remaining 5 (group C). Twelve weeks postoperatively, nerve conduction evaluations were performed; animals were euthanatized, and grafts were harvested and morphologically, histomorphometrically, and immunohistochemically analyzed. Eventually, a preliminary in vitro validation of the decellularization method was performed on human nerves from a cadaver.

RESULTS:
No clinical adverse effect was revealed during all the experimental times. No tissue reaction was observed, and in all groups, regenerated fascicles and bundles were shown by histology. However, both histology and histomorphometry demonstrated a better regenerative efficiency in group C. The morphological evaluation of the human nerve treated with the novel method showed complete decellularization.

CONCLUSION:
The microsurgical combined model demonstrated a better neuroregeneration than did pure autografts and acellular nerve allografts. The decellularization method seemed effective also on human nerves. Deeper investigations are necessary to further validate and transfer this new encouraging protocol to the clinical arena.

PMID: 31232821 DOI: 10.1097/SAP.0000000000001900
Select item 31232820
7.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001969. [Epub ahead of print]
Long-Term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm.
Prasetyono TOH1, Tunjung N.
Author information
1
From the Division of Plastic Surgery, Department of Surgery, Cipto Mangunkusumo Hospital/Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
Abstract
BACKGROUND:
Full-awake hand surgery (FAHS) has been gaining attention in recent years. However, the extent of full-awake approach for longer and more complicated major surgeries for the hand in trauma cases remains unclear. This study aimed to report the clinical nature of major flexor tendon trauma cases with subsequent repair under FAHS.

METHODS:
Retrospective study was performed on 9 male patients with an average age of 32.22 (SD, 9.67) years who experienced surgery for major flexor tendon ruptures under FAHS. Besides involving 3 digits in fingers, hand, or forearm, extensive surgery involved 3 cases with surgical dissection similar to the one needed to repair flexor tendons of 3 digits in zone 2.

RESULTS:
The assessment that was performed at least 3 years after surgery included not only the efficacy of FAHS but also the total active range of motion, opposition function, Medsger severity scale, and Disabilities of Arm, Shoulder, and Hand score. All repairs and explorations were performed under FAHS with 2 subjects who needed conversion to general anesthesia owing to intraoperative visual analog scale score of greater than 4. Average surgery duration under FAHS was 225 (170-309) minutes. Through an average follow-up of 4.1 years, all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion and 8 cases, excellent opposition. Median Disabilities of Arm, Shoulder, and Hand score was 15 (9-28.5).

CONCLUSIONS:
Full-awake hand surgery is potential surgical approach for major flexor tendon trauma cases resulting in satisfactory long term functional outcome.

PMID: 31232820 DOI: 10.1097/SAP.0000000000001969
Select item 31232819
8.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001951. [Epub ahead of print]
Keloid Excision and Adjuvant Treatments: A Network Meta-analysis.
Siotos C, Uzosike AC, Hong H1, Seal SM2, Rosson GD, Cooney CM, Cooney DS.
Author information
1
Bloomberg School of Public Health and.
2
Welch Medical Library, Johns Hopkins University, Baltimore, MD.
Abstract
BACKGROUND:
Keloid disease treatment continues to be unsatisfactory with high recurrence rates. We evaluated the literature regarding the effectiveness of keloid excision with various adjuvant treatments following surgery and assessed recurrence rates.

METHODS:
We systematically searched databases through November 2016. We performed pairwise meta-analyses and Bayesian network meta-analyses on the number of recurrences.

RESULTS:
Following screening, 14 studies including 996 patients with various types of keloids were eligible for inclusion. Patients were categorized based on the receipt of surgery and the type of adjuvant treatment employed afterward. Paired meta-analysis (6 meta-analyses) showed that "excision + 1 adjuvant drug" led to statistically significantly higher odds of recurrence compared to "excision + radiation" (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.35-7.67). Based on the network meta-analyses, the ORs of keloid recurrence following various treatments compared to no excision were as follows: "excision + pressure, 0.18 (95% CI, 0.01-7.07); excision + 2 adjuvants drugs, 0.47 (95% CI, 0.02-12.82); excision + radiation, 0.39 (95% CI, 0.04-3.31); excision + skin grafting, 0.58 (95% CI, 0.00-76.10); excision + 1 adjuvant drug, 1.76 (95% CI, 0.17-21.35); and excision only, 2.17 (95% CI, 0.23-23.95).

CONCLUSIONS:
According to our results, "excision + radiation" had significantly better outcomes than excision alone. "Excision + pressure" had better outcomes than excision + any other treatment modality, and excision + nonradiation adjuvant therapies were also better than "excision only," although these findings did not reach statistical significance.

PMID: 31232819 DOI: 10.1097/SAP.0000000000001951
Select item 31232818
9.
Ann Plast Surg. 2019 Jun 19. doi: 10.1097/SAP.0000000000001931. [Epub ahead of print]
Comprehensive Assessment of Vascularized Composite Allotransplantation Patient-Oriented Online Resources.
Noel DY1, Kimberly LL, DeMitchell-Rodriguez EM1, Levy-Lambert D1, Ramly EP1, Alfonso AR1, Jacoby A1, Gelb BE2, Diaz-Siso JR1, Kantar RS1, Rodriguez ED1.
Author information
1
From the Hansjörg Wyss Department of Plastic Surgery.
2
Division of Transplant Surgery, New York University Langone Health, New York, NY.
Abstract
INTRODUCTION:
Online resources have become a major source of medical information for the general public. To date, there has not been an assessment of patient-oriented online resources for face and upper extremity transplantation candidates and patients. The goal of this study is to perform a comprehensive assessment of these resources.

METHODS:
Our analysis relied on 2 dimensions: comprehensiveness and readability. Comprehensiveness was evaluated using 14 predetermined variables. Readability was evaluated using 8 different readability scales through the Readability Studio Professional Edition Software (Oleander Software, Ltd, Vandalia, Ohio). Data were also collected from solid organ transplantation (SOT), specifically kidney and liver, programs for comparison.

RESULTS:
Face and upper extremity transplantation programs were significantly more likely to list exclusion criteria (73.9% vs 41.2%; P = 0.02), the need for life-long immunosuppression (87.0% vs 58.8%; P = 0.02), and benefits of transplantation (91.3% vs 61.8%; P = 0.01) compared with SOT programs. The average readability level of online resources by all face and upper extremity transplantation programs exceeded the sixth grade reading level recommended by the National Institutes of Health and the American Medical Association. The average reading grade level of online resources by these programs was also significantly higher than those of SOT with both exceeding the recommended reading level (13.95 ± 1.55 vs 12.60 ± 1.65; P = 0.003).

CONCLUSIONS:
Future efforts in face and upper extremity transplantation should be directed toward developing standardized, comprehensive, and intelligible resources with high-quality content and simple language.

PMID: 31232818 DOI: 10.1097/SAP.0000000000001931
Select item 31232817
10.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001954. [Epub ahead of print]
Micro/nanobubbles: Improving Pancreatic Islet Cell Survival for Transplantation.
Sayadi LR1, Alexander M2, Sorensen AM1, Sarantopoulos N1, Lau H2, Klopfer M3, Ziegler ME1, Banyard DA1, Evans GRD1, Lakey JRT2, Widgerow AD1.
Author information
1
From the Center for Tissue Engineering, Department of Plastic Surgery.
2
Departments of Surgery and Biomedical Engineering, and.
3
Biomedical Engineering, University of California, Irvine, Orange, CA.
Abstract
PURPOSE:
The preservation of transplantable tissue is directly tied to and limited by the ischemia time. Micro/nanobubbles (MNBs) are miniature gaseous voids that allow for the oxygenation of tissue given their high oxygen-carrying capacity. One of the current limitations of islet cell transplantation for type 1 diabetes is poor islet survival, caused by hypoxia, after harvesting the cells from pancreata. As such, the purpose of this study was to elucidate whether MNBs, when added to standard culture medium, improve islet cell survival postharvest.

MATERIALS AND METHODS:
Islet cells were harvested from Sprague-Dawley rat pancreas tissue via a standard collagenase digestion and gradient purification. To create the MNB solution, a shear-based generation system was used to produce both air- and oxygen-filled MNBs in standard Connaught Medical Research Laboratories (CMRL) medium. Four groups, consisting of 500 islet equivalents, were cultured with either the standard CMRL medium, macrobubble-CMRL, MNB (air)-CMRL, or MNB (O2)-CMRL, and they were incubated at 37°C. Each treatment solution was replenished 24 hours postincubation, and after 48 hours of culture, dithizone staining was used to determine the islet cell counts, and the viability was assessed using Calcein AM/propidium iodide staining.

RESULTS:
Islet cells that were preserved in macrobubble-CMRL, MNB (air)-CMRL, and MNB (O2)-CMRL conditions showed an increased survival compared with those cultured with standard CMRL. The islet cells cultured in the MNB (air)-CMRL condition demonstrated the greatest cell survival compared with all other groups, including the pure oxygen-carrying MNBs. None of the MNB treatments significantly altered the viability of the islet cells compared to the control condition.

CONCLUSIONS:
The addition of MNBs to culture medium offers an innovative approach for the oxygenation of transplantable tissue, such as islet cells. This study demonstrated that MNBs filled with air provided the most optimal addition to the islet cell culture medium for improving islet cell survival amongst the treatment groups we tested. Given these findings, we hypothesize that MNBs may also improve the oxygenation and survival of a variety of other tissues, including fat grafts from lipoaspirate, chronic wounds, and solid organs.

PMID: 31232817 DOI: 10.1097/SAP.0000000000001954
Select item 31232816
11.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001944. [Epub ahead of print]
Mercedes Flap With Modified "V-Y" Releasing Incisions for Scalp Defects.
Russo F1.
Author information
1
Hospital Punta Europa Algeciras, Cádiz, Spain russo@aedv.es.
PMID: 31232816 DOI: 10.1097/SAP.0000000000001944
Select item 31232815
12.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001939. [Epub ahead of print]
Posterior Perichondrioadipodermal flap: A Versatile Option for Revision Otoplasty.
Ersen B1.
Author information
1
From the Plastic Reconstructive and Aesthetic Surgery Department, Jimer Hospital, Bursa, Turkey.
Abstract
INTRODUCTION:
Complications after otoplasty procedure can be divided into early and late-period complications, with the former occurring up to 14 days postoperatively and the latter occurring after the initial 14-day period. Indications for revision surgery of ear deformations after primary otoplasty are generally related to late complications. The majority of patients demand secondary treatment because of unsatisfactory cosmetic results.

METHODS:
A total of 32 patients (18 male and 14 female patients) underwent revision otoplasty with the same surgeon between May 2015 and May 2018. Patient ages ranged from 24 to 70 years. In total, 21 patients underwent bilateral revision otoplasty, whereas 11 patients underwent unilateral revision otoplasty. Patients were also evaluated for complaint and deformity type such as suture extrusion, recurrence, asymmetry, and postauricular area sensitivity or pain. Patients were also evaluated for previously performed primary otoplasty technique.

RESULTS:
There were mainly 4 long-term complications for revision otoplasty: suture extrusion, asymmetry, recurrence, and long-term pain and sensitivity in the posterior auricular area. In 12 cases, the complaint was suture extrusion; in 8 cases, patients complained about both suture extrusion and asymmetry. Bilateral recurrence was present in 10 cases, and in 2 cases, revision otoplasty was performed because of long-term pain and sensitivity.

DISCUSSION:
In this study, it was aimed to demonstrate that posterior perichondrioadipodermal flap is a safe and simple method for revision otoplasty. The technique is highly advantageous if the primary otoplasty technique is a cartilage-sparing method. However, if the primary otoplasty technique is a cartilage-sculpting method, the efficiency of this technique remains unknown because no patient in this study had cartilage-sculpting otoplasty as primary otoplasty, which is possibly the main drawback of this study.

PMID: 31232815 DOI: 10.1097/SAP.0000000000001939
Select item 31232814
13.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001934. [Epub ahead of print]
Isolated Fat Grafting for Reconstruction of Lower Face Volumetric Asymmetry in Skeletally Immature Patients: A Clinical Outcome Study.
Denadai R1, Raposo-Amaral CA, Buzzo CL, Raposo-Amaral CE.
Author information
1
From the Institute of Plastic and Craniofacial Surgery, SOBRAPAR Hospital, Campinas, São Paulo, Brazil.
Abstract
BACKGROUND:
The purpose of this study was to assess the objective and subjective outcomes of lower face volumetric (contour) asymmetry correction with isolated fat grafting in skeletally immature patients.

METHODS:
A prospective analysis was conducted of skeletally immature patients (n = 73) with craniofacial microsomia and Parry-Romberg syndrome who underwent isolated fat grafting (with no previous or concomitant bone surgery) using anatomical surgical principles (facial subunits and fat compartments) for the reconstruction of lower face volumetric asymmetry. Objective ultrasound and photogrammetric lower face symmetry analyses were blindly performed preoperatively and at 3 and 12 months postoperatively. A panel assessment of blinded surgical professionals and laypersons was also obtained to grade the subjective lower face symmetry.

RESULTS:
There were significant (all P  <  0.05) postoperative objective and subjective lower face symmetry enhancements (preoperative < postoperative) after isolated fat grafting, with no differences (all P > 0.05) between 3 versus 12 months' postoperative comparisons.

CONCLUSIONS:
Growing patients with unilateral lower face volumetric asymmetries presented with improvement of objective and subjective symmetry after a single isolated fat grafting procedure.

PMID: 31232814 DOI: 10.1097/SAP.0000000000001934
Select item 31232813
14.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001935. [Epub ahead of print]
Incidence of Secondary Lip Correction for Children With Unilateral Cleft Lip: A Single-Center Retrospective Study.
Zhang Z1, Miyabe M, Morioka D, Nomura M, Tosa Y, Ohkubo F, Kadomatsu K.
Author information
1
From the Department of Plastic Surgery, Showa University, Tokyo, Japan.
Abstract
BACKGROUND:
Numerous reports have described the incidence of secondary lip correction for patients with cleft lip (CL), and this incidence broadly varies among centers. The purpose of this study was to determine this revision rate for a reasonably large number of patients in our center and identify the clinical factors that contribute to the revision rate.

METHODS:
A retrospective chart review was conducted for all infants with unilateral CL with or without cleft palate who underwent primary cheiloplasty at our cleft center from 2006 to 2012. Four surgeons were in charge of almost all operations. We investigated how many children underwent lip revisions by the end of 2017.

RESULTS:
In total, 490 infants underwent primary lip repair, and 47 underwent revision surgery by the age of 8 years. Half of them (24 children) underwent revisions at the age of 5 or 6 years. There was no significant difference in the revision rate by sex or cleft side. The revision rate in children with CL only tended to be lower than that in children with alveolar cleft or cleft palate, but it was not significantly associated with the cleft type. The revision rate ranged from 2.8% to 15.2% among surgeons.

CONCLUSIONS:
The overall revision rate was 9.6%, which is relatively lower than that in other cleft centers. However, the repair technique and cleft care program should not be evaluated using the revision rate only. Various factors, including surgeons' preference, contribute to the indications for revision, and these factors can change with age. We plan to follow up the patients until our completion of the cleft care program and report the final revision rate.

PMID: 31232813 DOI: 10.1097/SAP.0000000000001935
Select item 31232812
15.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001920. [Epub ahead of print]
Labiolysis, Corrective Surgery for Iatrogenic Labium Minus Fusion.
Ostrzenski A1.
Author information
1
From the Institute of Gynecology Inc, St. Petersburg, FL.
Abstract
BACKGROUND:
In this study, corrective labium minus iatrogenic fusion was termed labiolysis. This procedure is a new surgical concept for the therapy of iatrogenic, symptomatic labium minus fusion by revising scar and releasing the labium minus from iatrogenic unnatural fusion with the labium majus and intralabial crease. This study presents a new surgical technique and a review of the pertinent literature on labial fusion and its therapy. In addition, this investigation identified labial fusion risk factors associated with esthetic labioreduction of the labia minora and the likelihood of prevention of this surgical complication. The objectives were to (a) describe step-by-step labiolysis surgical intervention, (b) ascertain surgical outcomes of labiolysis, (c) authenticate specific symptom(s) associated with iatrogenic labium minus fusion and how these symptoms affect the quality of life, (d) assess the labiolysis' ability to relief symptoms of labium minus iatrogenic fusion, and (e) present a specific postoperative care.

METHODS:
A prospective cohort study with a control group was conducted. The study group consists of 7 subjects associated with iatrogenic, symptomatic labium minus fusion and the control group, which also consists of 7 women who were subjected to fenestration labioreduction of the labia minora. The follow-up was conducted for 3 years in both groups. All subjects, from both groups, consented in writing their participation in the study. Validated instruments were used before and after labiolysis to evaluate the outcomes.

RESULTS:
There are no data in the medical literature describing a conservative medical or surgical treatment for iatrogenic, symptomatic labium minus fusion. In both groups, surgeries were performed under local anesthesia. In either group, no reoperation was performed, and no major or minor complications were observed. All preoperative symptoms associated with iatrogenic labial fusion were cured by labiolysis. Anatomical deformities were either corrected or classified as a satisfactory anatomical outcome. In both groups, the postoperative course was uneventful with full ambulation on the first postoperative day, driving a car on the third day, and returning back to work within 1 week.

CONCLUSIONS:
Labiolysis is a simple surgical operation with a short learning curve, which relieves symptoms, improves quality of life associated with iatrogenic labium minus fusion, and provides an esthetically pleasing surgical outcome. In this study group, no minor and no major surgical complications were observed, and no reoperation was performed.

PMID: 31232812 DOI: 10.1097/SAP.0000000000001920
Select item 31232811
16.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001909. [Epub ahead of print]
Distally Based Posterior Tibial Artery Perforator Flaps for Reconstruction of the Defects in Achilles Region.
Li P, Li Z, Shen G1.
Author information
1
Department of Burn Plastic Surgery, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, China.
Abstract
BACKGROUND:
Patients with Achilles region defects remain a challenge for clinicians. The purpose of this article is to evaluate the surgical procedure to reconstruct the defects in Achilles region using distally based posterior tibial artery perforator flaps.

METHODS:
Between May 2015 and May 2017, 10 patients (aged from 35 to 68 years. 4 females and 6 males) with soft-tissue defects (sizes from 3 × 2 cm to 8 × 4 cm) in Achilles region received surgical therapy of posterior tibial artery perforator flap transplantation in the Affiliated Hospital of Xuzhou Medical University.

RESULTS:
The length of hospital stay ranged from 10 to 15 days (mean, 12 days). Local small superficial necrosis (5% of the area) was observed in only 1 case; however, it healed well after dressing was changed. All the others survived and healed well. At follow-up ranging from 12 to 24 months, all patients were satisfied with the aesthetic and functional aspects.

CONCLUSIONS:
Using the posterior tibial artery perforator flaps to cover the Achilles region defects is a promising, feasible, first-line, safe option and should be extensively applied in clinical therapy.

PMID: 31232811 DOI: 10.1097/SAP.0000000000001909
Select item 31232810
17.
Ann Plast Surg. 2019 Jun 17. doi: 10.1097/SAP.0000000000001859. [Epub ahead of print]
Rezoning Free Muscle-Sparing Transverse Rectus Abdominis Myocutaneous Flaps Based on Perforasome Groupings and a New Understanding of the Vascular Architecture of the Deep Inferior Epigastric Artery-Based Flaps.
Tan J1, Ohjimi H, Takagi S, Kawakami Y, Eto A.
Author information
1
From the Department of Plastic and Reconstructive Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan.
Abstract
BACKGROUND:
We compare the vascular territory of free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, deep inferior epigastric perforator (DIEP) flaps, and crossover anastomosis (CA) flaps using intraoperative ex vivo angiography. We also use ex vivo angiography to analyze the vascular architecture of the MS-TRAM flap.

METHODS:
Our study includes 84 lower abdominal free flaps: MS-TRAM, DIEP-1 (1 perforator), DIEP-2 (2 perforators), and CA. We compare the arterial perfusion area and vascular territory pattern in each group. We also analyze the vascular architecture in MS-TRAM flaps and determine the number and location of their dominant perforators and the direction of the axial arteries connecting them.

RESULTS:
The CA's arterial perfusion area is the largest, and the DIEP-1's, the smallest of our groups; there is no statistically significant difference between MS-TRAM and DIEP-2. In all groups, average arterial perfusion area in the vascular pedicle's ipsilateral side is larger than in its contralateral side. The MS-TRAM and DIEP-2 flaps have homologous perfusion patterns and the same arterial perfusion areas. The DIEP-1 perfusion pattern varies with perforator location. Ex vivo angiograms show the MS-TRAM flap's axial arteries heading laterally to be larger and longer than those heading medially.

CONCLUSIONS:
Two dominant perforators are preferable in DIEP flap breast reconstruction. Lateral perforators play a more important role in flap perfusion than do medial ones. Crossover anastomosis is an effective technology for increasing arterial perfusion areas. Our rezoning shows which areas are better for surgery and which have a high risk of complications-valuable information for a surgeon designing a flap for breast reconstruction.

PMID: 31232810 DOI: 10.1097/SAP.0000000000001859
Select item 31232809
18.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001929. [Epub ahead of print]
Orbital Volume Increases With Age: A Computed Tomography-Based Volumetric Study.
Ugradar S, Lambros V1.
Author information
1
Department of Plastic Surgery, University of California, Irvine, Newport Beach, CA.
Abstract
OBJECTIVE:
The aim of the study was to determine whether the bony orbital volume (BOV) changes with age in males and females.

METHODS:
This case-control study reviewed high-resolution (<1-mm slices) computed tomography (CT) scans of consecutive patients seen for 4 years. The scans were requested as part of the patient's routine care for symptoms related to sinus symptoms. Eligible participants were adults aged between 18 and 30 years and 60 and 75 years. Exclusion criteria included previous surgery, any medical conditions that might affect the bone or soft tissue of the orbit, and any abnormalities seen on imaging. Male patients aged between 18 and 30 years were compared with males aged 60 to 75 years. The same was done for females. The main outcome measure was measurement of the BOV. Both orbits of each patient were included using the generalized estimating equation, to avoid any bias from correlation between 2 orbits of the same patient.

RESULTS:
A total of 240 orbits from 120 patients were used for this study. Each age group contained 30 patients. There were no significant differences in the ages between males and females in each age category (P = 0.88 for ages 20-30 years and P = 0.74 for ages 60-75 years). The mean (SD) BOV for females aged between 20 and 30 years was 19,153.69 mm (3776.21), whereas that for females aged between 60 and 75 years was 20,939.38 mm (2837.34). The difference between the groups was significant (Pr(>|W|) = 0.05). The mean (SD) BOV for males aged between 20 and 30 years was 22,2721 mm (2977.35), whereas that for males aged between 60 and 75 years was 22,892.92 mm (2389.46) (Fig. 1). The difference between these 2 groups was not significant (Pr(>|W|) = 0.40). The mean BOV was significantly greater for males than females (P ≤ 0.01) across both age groups.

CONCLUSIONS:
This study found that female orbits expand with age, whereas male orbits showed no significant changes. Changes to the orbital volume in females may contribute to the appearance of aging.

PMID: 31232809 DOI: 10.1097/SAP.0000000000001929
Select item 31232808
19.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001925. [Epub ahead of print]
Simultaneous Bilateral Microtia Reconstruction Using Single-expanded Postauricular Flap Without Skin Grafting.
Pu Y1, Cen Y.
Author information
1
Department of Burn and Reconstructive Surgery West China Hospital West China School of Medicine Sichuan University Chengdu, China cy551025@163.com.
PMID: 31232808 DOI: 10.1097/SAP.0000000000001925
Select item 31232807
20.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001924. [Epub ahead of print]
Reply to the Letter to the Editor.
Chen X1, Liu G.
Author information
1
Department of Plastic and Reconstructive Surgery Shanghai Tenth People's Hospital Shanghai, China guangpengliu@163.com.
PMID: 31232807 DOI: 10.1097/SAP.0000000000001924
Select item 31232806
21.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001923. [Epub ahead of print]
Influence of Recipient Site on the Function and Survival of Fat Grafts.
Yu P1, Yang X, Qi Z.
Author information
1
Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, China. Plastic Surgery Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, China public_qi@163.com.
PMID: 31232806 DOI: 10.1097/SAP.0000000000001923
Select item 31232805
22.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001919. [Epub ahead of print]
Implications of Demographics and Socioeconomic Factors in Breast Cancer Reconstruction.
Zahedi S, Colvill K, Lopez M1, Phillips LG2.
Author information
1
Center for Reconstructive Surgery, Department of Plastic Surgery, University of Texas, MD Anderson Cancer Center, Houston.
2
Division of Plastic Surgery, Department of Surgery, University of Texas Medical Branch, Galveston, TX.
Abstract
BACKGROUND:
Not all women undergo breast reconstruction despite its vital role in the recovery process. Previous studies have reported that women who are ethnically diverse and of lower socioeconomic status are less likely to undergo breast reconstruction, but the reasons remain unclear. The purpose of this study is to evaluate the demographic characteristics of our patient population and their primary reason for not undergoing breast reconstruction.

METHODS:
An institutional review board-approved, single-institution study was designed to evaluate all female breast cancer patients of all stages who underwent mastectomy but did not undergo breast reconstruction from 2008 to 2014. Patients were contacted via telephone and asked to participate in a validated, prompted survey. Data regarding their demographic information and primary reason for not undergoing breast reconstruction were collected.

RESULTS:
Inclusion criteria were met by 181 patients, of which 61% participated in the survey. Overall, the most common reason for not undergoing breast reconstruction (26%) was unwillingness to undergo further procedures. However, the most common reason for patients that identified as Hispanic, Spanish-speaking, high school graduates, or having an annual income less than US $25,000 (P < 0.05) was insufficient information received.

CONCLUSIONS:
This study demonstrates that ethnicity and socioeconomic factors play a key role in determining why patients forego breast reconstruction. Ethnicity, language, education, income, and employment status are associated with patients not receiving appropriate education regarding their reconstructive options. Breast surgeons with a diverse patient population should ensure that these patients are adequately educated regarding their options, and if perhaps, more of these patients would decide to partake in the reconstruction process.

PMID: 31232805 DOI: 10.1097/SAP.0000000000001919
Select item 31232804
23.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001918. [Epub ahead of print]
The Molecular Pathogenesis of Dupuytren Disease: Review of the Literature and Suggested New Approaches to Treatment.
Sayadi LR, Alhunayan D, Sarantopoulos N, Kong C, Condamoor S, Sayadi J1, Banyard DA, Shaterian A, Leis A, Evans GRD, Widgerow AD.
Author information
1
Stanford University School of Medicine, Stanford, CA.
Abstract
BACKGROUND:
Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the molecular underpinnings of the disease and develop better treatment modalities for patients. The aim of this article is to systematically review the basic science literature pertaining to Dupuytren disease and suggest a new approach to treatment.

METHODS:
Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using the MEDLINE database to identify basic science literature on Dupuytren pathophysiology falling under 1 or more of the following categories: (1) Molecular alterations, (2) Structural alterations, and (3) Genetic predisposition.

RESULTS:
A total of 177 articles were reviewed of which 77 studies met inclusion criteria. Articles were categorized into respective sections outlined in the study methods.

CONCLUSION:
The pathophysiological changes involved in Dupuytren's disease can be divided into a number of molecular and structural alterations with genetic predisposition playing a contributory role. Understanding these changes can allow for the development of biologics which may disrupt and halt the disease process.

PMID: 31232804 DOI: 10.1097/SAP.0000000000001918
Select item 31232803
24.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001917. [Epub ahead of print]
Rembrandt's Aging Face in Plastic Surgical Perspective.
Hage JJ, Lange J, Karim RB1.
Author information
1
Treant Zorggroep, Scheper-Emmen, the Netherlands.
Abstract
BACKGROUND AND AIM:
When the painter Rembrandt van Rijn (1607-1669) died 350 years ago, he left us some 90 self-portraits showing his aging face. Recognizing aging characteristics of the male face is fundamental to the planning of a surgical procedure and a prerequisite when communicating to the male patient. Rembrandt's recordings through the years might offer an optimal aid to train such recognition, provided that they are truthful. In this article, we present an inventory of age-related changes observed in these self-portraits to assess whether they are truthful.

METHODS:
High-quality photographs of 25 self-portraits that are generally accepted as works by Rembrandt were independently assessed in a standardized fashion for the presence of 25 aging characteristics, by 2 plastic surgeons and a physician-portraitist.

RESULTS:
The observed proportion of agreement between assessments reached 0.87 (κ = 0.68, indicating good agreement). We found Rembrandt's self-portraits to reflect his facial aging as a chronologically increasing process. Observed characteristics set in as of 1642, the year that he lost his beloved first wife, Saskia. His face appears to have particularly aged from 1652 to 1659, in which period Rembrandt's second great love Hendrickje was summoned because of her living in sin with Rembrandt, and Rembrandt himself faced financial problems. As of 1660, Rembrandt seems to have been less intended to depict his facial aging characteristics.

CONCLUSIONS:
We conclude that Rembrandt truthfully reflected his ongoing age in the self-portraits, up to 1660. These self-portraits therefore may allow for training the art of observation of such characteristics.

PMID: 31232803 DOI: 10.1097/SAP.0000000000001917
Select item 31232802
25.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001908. [Epub ahead of print]
Depression Rates After Facial Paralysis.
Saadi R1, Shokri T1, Schaefer E2, Hollenbeak C3, Lighthall JG1.
Author information
1
From the Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, and.
2
Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey.
3
Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA.
Abstract
INTRODUCTION:
Facial paralysis (FP) has many functional consequences with a large impact on daily life. Although an association with FP and depression has been observed and described in the literature, there are currently no large-scale studies to further validate this correlation. Our goal was to determine whether patients with FP become depressed at a higher rate compared with matched controls.

METHODS:
We performed a retrospective cohort study using MarketScan Commercial Claims and Encounters Database by Truven Health. From the database, all inpatient and outpatient claims with International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for FP and depression between 2005 and 2013 were extracted. Patients younger than 18 years were categorized as children and those 18 years or older as adults. Patients were subcategorized as having a history of depression if a diagnosis of depression preceding a diagnosis of FP was noted. We matched each patient to a control in the MarketScan database based on age, sex, and state of residence. We compared rates of depression between these patients and matched controls using conditional logistic regression. The method of Kaplan and Meier was used to estimate cumulative incidence curves of depression by each group.

RESULTS:
Approximately 57,941 patients were identified with International Classification of Diseases, Ninth Revision, codes for FP. Among children and adult patients without a diagnosis of depression before the index date for FP, 6.4% (285) and 9.7% (4733), respectively, had a diagnosis of depression within 2 years of the diagnosis of FP. Matched controls showed depression rates within 2 years of 3.9% for children (P < 0.001) and 6.1% for adults (P < 0.001).

CONCLUSIONS:
The present study adds to the current body of knowledge on FP and depression given its large sample size and analysis of adult and pediatric populations over 2 years. Indeed, we found that depression rates were significantly increased in both adults and children as compared with matched controls. Our results suggest a need for long-term depression screening in patients with FP.

PMID: 31232802 DOI: 10.1097/SAP.0000000000001908
Select item 31232801
26.
Ann Plast Surg. 2019 Jun 20. doi: 10.1097/SAP.0000000000001888. [Epub ahead of print]
Externalized Mesentery Monitoring of Vascularized Jejunum Transfers.
Arata J1, Suzuki M, Marukawa Y, Kaito S, Kumakiri M.
Author information
1
From the Department of Plastic and Reconstructive Surgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
Abstract
PURPOSE:
The use of externalized jejunal monitoring flaps for jejunum transfers could be facilitative for the direct clinical assessment. Although this monitoring method would seem to be highly reliable, we modified this method and used mesentery only as a monitor to make it easy to manage the monitor more.

METHODS:
Between 2013 and 2018, 43 patients underwent vascularized jejunum transfer for reconstruction of laryngopharyngectomy using the externalized mesentery monitor. There were 39 men and 4 women, and patient ages ranged from 40 to 80 years (average, 66.6 years). The nursing staff monitored the externalized mesentery by using handheld Doppler ultrasonography every 2 hours for 7 days after surgery.

RESULTS:
Three patients had rather weak signal of handheld Doppler ultrasonography on the externalized mesentery monitors during operation, and handheld Doppler ultrasonography could not be applied. Of the remaining 40 patients using the externalized mesentery monitor with handheld Doppler ultrasonography, 39 had an uncomplicated postoperative period. In 1 patient, no signal of Doppler ultrasonography and lack of bleeding by pin prick from the monitor segment were noted in the immediate postoperative period, and revision of the vascular anastomosis was performed. Finally, the graft was salvaged. There was no case of infection in the monitoring flap or hypertrophic scar at the resected part of the flap.

CONCLUSIONS:
Using the externalized mesentery monitoring flaps, clinical monitoring by examining the exteriorized monitoring flap is possible, and only mesentery monitors were managed easily compared with jejunum monitoring flaps.

PMID: 31232801 DOI: 10.1097/SAP.0000000000001888