Plastic and Reconstructive Surgery

Harvesting Split-thickness Skin from the Scalp Using a Scalpel Background: Split-thickness skin grafts (STSGs) from the scalp may be an attractive option for patients who do not want scars on their limbs or trunk. However, not all institutions have the equipment typically used to perform STSGs. Methods: Between January 2015 and June 2017, STSGs were harvested with a No. 15 blade under local anesthesia from the scalps of 4 patients and grafted on small skin defects from facial trauma, a tattoo, and scarring, and on a large defect from burns. Epithelialization of the donor sites and graft take, secondary contraction, and color and texture match of the recipient sites were observed. Thickness of the harvested skin was confirmed by histopathologic examination. Results: Mean patient age was 39.8 years; 2 patients were male. Epithelialization of the donor sites took a mean of 8.75 days. No hypertrophic scarring or alopecia was observed. Good graft take and relatively good color and texture match of the recipient site were achieved. Mild secondary contraction was noted in 2 cases. Histopathologic examination showed no damage to the hair follicles. The thickness of the harvested skin varied from 0.3 to 0.7 mm. Conclusions: Using the scalpel technique, surgeons can perform STSGs with only several blades, minimizing surgical costs. The hair follicles remain intact because the thickness of the graft skin is <1 mm. Epithelialization of the donor site is quick, and there is no visible wound on the limb or trunk. It is especially useful to cover small defects.

The Single Incision Minimally Invasive (SIMI) Neck Lift Background: With the increased focus on the neck and chin in the era of selfies and social media, neck contouring continues to be an in-demand procedure. Full correction of the neck typically requires both submental and postauricular incisions, but the postauricular incisions can be unsightly and painful. This article introduces a viable alternative for the patient. Methods: A case series of appropriate candidates undergoing a novel neck lift technique (the single incision minimally invasive neck lift) is described. Participants include men and women with an age range of 30–70. The surgical technique incorporates shifting of the typical submental incision used in a full neck lift to a cervicomental incision, and when accompanied by wide undermining, the postauricular incisions are avoided entirely. Results: Among the 20 patients in this case study, photographs show that it is possible to achieve results commonly associated with a full neck lift but without the postauricular incisions typically associated with a full neck lift. Conclusions: The single incision minimally invasive neck lift allows the surgeon to offer an effective procedure for appropriate candidates who want to treat excess fat, a sagging platysma muscle and loose, misplaced skin in the submental region without postauricular incisions typically utilized in a traditional full neck lift.

Periorbital Aesthetic Surgery: A Simple Algorithm for the Optimal Youthful Appearance Background: Blepharoplasty is one of the most common procedures performed. To achieve optimal results in periorbital rejuvenation, a systematic approach to patients that addresses all the problems in the periorbital region is important. The aim of this study is to analyze blepharoplasty patients according to preoperative deformities and postoperative results and to create a basic algorithm for periorbital aesthetic surgery. Methods: Patients who underwent periorbital aesthetic surgery were examined retrospectively. Patients' medical records and preoperative and postoperative photographs were analyzed. Preoperative and postoperative photographs were analyzed for 6 main criteria: brow position, blepharoptosis, canthal tilt, excess skin or deficiencies, excess subcutaneous tissue or deficiencies, and periorbital skin rhytides. After the anatomical analyses, researchers rated the results as optimal or suboptimal. Results: In total, 176 patients' medical records were analyzed. Among them, 154 were women and 22 were men. The mean age was 43.8 years. No comorbid situation was detected in 133 of these patients. The postoperative result was evaluated as suboptimal in 151 patients (86%) and optimal in 25 patients (14%). An algorithm was proposed for the systematic evaluation of periorbital surgery patients to achieve satisfactory results. Conclusions: A simple 6-step checklist is designed to define periorbital deformities and to achieve the optimal youthful appearance.

Gluteal Augmentation with Polymethyl Methacrylate: A 10-year Cohort Study Background: Many techniques for buttocks augmentation have been developed and published, for a more natural, satisfactory, and safe result for the patient. It has been a challenge to find a technique that presented not only volume gain but also gluteal remodeling. Methods: A total of 1,681 patients who underwent gluteal augmentation with Polymethyl methacrylate (PMMA) between 2009 and 2018 were selected for this retrospective cohort study. Data collected included demographics, procedures data, and postoperative outcomes. Side effects were calculated and compared using the Student's t test. Results: A total of 1,681 patients (1,583 women and 98 men) who underwent 2,770 gluteal fillings had their cases retrospectively analyzed. They were injected with 540,751.00 mL of PMMA injected. The patients' mean age was 39 years, and the mean volume injected in each section was 237 mL during the first procedure and 147 mL during the second procedure. The authors observed 52 cases presenting side effects, representing a rate of 1.88% of 2,770 procedures carried out. The statistically significant (P = 0.02) presence of side effects was detected in relation to the total filling volume. Conclusions: This study has demonstrated that gluteal augmentation with PMMA is one of the best options for this type of procedure. In addition, the findings suggest that the guidelines concerning gluteal augmentation must include PMMA filler as an option because PMMA proved to cause few side effects, as demonstrated by this patient cohort.

Outcome of Beveled versus Vertical IncisionTechnique after Reconstructive or Aesthetic Facial Surgery Background: We suggest that the degree of scar improvement with a beveled incision technique with an angle of about 20 degrees to the skin can be translated for various reconstructions on the face and can be verified by a validated clinical assessment scale and histology. Methods: A total of 5 patients (2 men and 3 women) with a mean age of 68 years (range 54–84 years) undergoing elective surgeries on the face for tumor excision or cosmetic procedures were included. The beveled incision technique was compared with the conventional vertical incision (control group). Outcome measures were major and minor complications, pain and scar quality using the Patient and Observer Scar Assessment Scale, and histomorphologic scar assessment. Results: After a mean follow-up of 7.6 months (range 6–13 months), all patients healed uneventfully without pain, hypertrophic scars, or infection. We found a better overall Patient and Observer Scar Assessment Scale score in the beveled incision technique group (15 ± 3.4) compared with the conventional vertical incision group (18.4 ± 7.8, P = 0.7). Histomorphologic analyses showed after 6 months less scar zone, less inflammatory reaction, fewer macrophages, less foreign body reaction, and more hair follicles in the beveled incision technique group compared with the vertical incision group. Conclusion: We showed that the beveled incision technique using a 20-degree angle in elective surgeries on the face yields a cosmetic pleasant result for both the patient and the surgeon, which also goes in line with our histomorphologic analyses.

Techniques, Principles and Benchmarks in Asian Blepharoplasty Background: Asian blepharoplasty is a deceptively simple procedure where the goal is to create an upper lid crease. The author presents a retrospective self-analysis of 362 cases performed over the past 12 years. Methods: 362 cases that fits the inclusion criteria were tabulated into spreadsheet data format. Recorded were age, gender, date of service and follow-ups, whether the AB performed was for primary or revisional purpose; the preoperative lid crease status, the patient-chosen crease height as well as shape preferred. Intraoperative observation included presence or absence of preaponeurotic fat, whether partially resected, or reposited were noted. Results: Of 362 patients (724 upper lids), primary AB constituted 81% (295) and revisional AB contributed 19% (67). The gender distribution was 87% female (315) and 13% male (47). The age distribution ranged from 12 to 75 years. The crease height selected ranged from 6.0 to 8.0 mm, with the median being 7.0 mm. Of the crease shape chosen, parallel shape was 65% (236) and nasally-joining crease shape was 35% (126). Conclusions: Asian blepharoplasty via trapezoidal debulking of preaponeurotic platform is a safe, effective and anatomically-based technique that does not involve the use of permanent buried sutures. The article discussed the 5 essential factors (aponeurotic attachment, selective block clearance of preaponeurotic space, precise positioning of the crease formation loci, detection of latent droopy eyelids and avoidance of Faden-like suture effect) and the author's benchmarks to achieve a better success rate. Results for primary and revisional Asian blepharoplasty, strategies and potential pitfalls are presented. (JOURNAL/prcsgo/04.03/01720096-201905000-00006/inline-graphic1/v/2019-06-24T053747Z/r/image-tiffhttp://links.lww.com/PRSGO/B141)

The Effect of Axillary Lymph Node Sampling during Mastectomy on Immediate Alloplastic Breast Reconstruction Complications Background: Tissue expander-based immediate breast reconstruction is currently the most common technique used for postmastectomy breast reconstruction. During mastectomy, axillary lymph nodes are biopsied to stage patients. The purpose of this study is to investigate postoperative complications with respect to extent of lymph node dissection. Methods: A retrospective review of all patients undergoing tissue expander-based immediate breast reconstruction at our institution from 2010 to 2012 was conducted. Charts were analyzed to determine the association between the absolute number of axillary lymph nodes removed and postreconstructive incidence of skin necrosis, cellulitis, seroma, and expander removal. Independent sample t test and linear regression were used to analyze data. Results: In total, 282 patients with 467 reconstructions were included. Overall incidence of all postoperative complications per breast was 23.8%. Breasts in which a complication occurred had a mean of 6 nodes removed versus 4 nodes in uncomplicated breasts (P = 0.018). Complications were noted at a significantly higher rate in patients who underwent axillary lymph node dissection compared with sentinel lymph node biopsy (P = 0.008). Expander removal and seroma occurred more frequently in breasts that had a greater number of nodes removed (P = 0.006 and P = 0.015, respectively). Preoperative radiation resulted in higher incidence of cellulitis and skin necrosis. Postoperative radiation and chemotherapy did not adversely affect reconstruction. Conclusions: Axillary lymph node removal of >4 nodes confers a greater risk of postreconstructive seroma formation and tissue expander loss in patients undergoing immediate reconstruction following mastectomy. Axillary lymph node dissection has a higher incidence of breast reconstruction complications compared with sentinel lymph node biopsy. Therefore, we encourage plastic surgeons to consider degree of lymphadenectomy when discussing reconstructive options with patients, as this may significantly impact their reconstructive outcome.

Adoption of Enhanced Recovery after Surgery Protocols in Breast Reconstruction in Alberta Is High before a Formal Program Implementation Background: Enhanced recovery after surgery (ERAS) techniques have consistently demonstrated improved patient outcomes across multiple surgical specialties. We have lead international consensus guidelines on ERAS protocols for breast reconstruction and recently implemented these guidelines in Alberta. This study looks at adoption rates of ERAS pathways for breast reconstruction within Alberta, whereas also addressing barriers to ERAS implementation. Methods: A retrospective analysis of online operative reports in the Synoptec database consisting of patients undergoing alloplastic or autogenous breast reconstruction in Alberta was conducted. Primary outcomes of interest included whether ERAS protocols were utilized and what the reported barriers to ERAS utilization were. Results: Of the 372 patients undergoing breast reconstruction surgery, 215 (57%) patients were placed on an ERAS protocol. Autogenous reconstruction patients were more likely than alloplastic reconstruction patients to be placed on ERAS protocols (72% versus 53%, P = 0.002). A lack of resources was the most commonly cited reason for not adopting ERAS protocols for both autogenous and alloplastic reconstruction groups (53% and 53%). Surgeons in Southern Alberta were more likely than surgeons in Northern Alberta to utilize ERAS protocols for their alloplastic (73% versus 8%, P < 0.001) and autogenous (99% versus 4%, P < 0.001) reconstructions. Conclusions: Adoption of ERAS protocols in Alberta was strong (57% adherence) before a formal program implementation. We are encouraged that the recent official launch of ERAS protocols in breast reconstruction within the province will further enhance the uptake and care of this unique surgical population.

Anthropometric Changes in a Prospective Study of 100 Patients Requesting Breast Reduction Background: The anthropomometry of the "ideal" breast is well described, but changes that occur with enlarged breasts are not. The aim of this study was to assess the prevalence of nipple asymmetry in the horizontal plane and changes in the inframammary fold (IMF) in patients presenting with macromastia (defined as excessive development of the mammary glands by Merriam-Webster dictionary). Methods: One hundred patients (200 breasts) presenting to the Plastic Surgery Clinic for bilateral breast reduction were enrolled in this study. Patients' characteristics captured for this study included age, body mass index (BMI), and breast anthropometric measurements, such as suprasternal notch to nipple, nipple to IMF, IMF projected to cubital fossa, midhumeral point, and nipple measurement from meridian. Basic univariate statistical analyses were performed to evaluate the impact of nipple asymmetry. Results: The average age was 37 years (SD 12 years), and the median BMI was 33 (IQR 28–37). More patients presented with nipple asymmetry, of whom 45% were classified as lateral to the meridian, 19% were classified as medial to the meridian, and 36% were classified as central to the meridian. Patients with lateral asymmetry and medial asymmetry had a significantly higher BMI (median BMI 35) compared with patients with central positioning (median BMI 30). Increasing breast size was positively associated with nipple asymmetry, whereas BMI (R = −0.30, P = 0.003) and macromastia correlated negatively with IMF position (R = −0.38, P = 0.0001). Conclusion: In macromastia, nipple displacement from the breast meridian, especially lateral displacement, is common and is aggravated by an increase in BMI. The IMF also descends, and this is also more common in patients with a raised BMI. These changes have clinical implications.

Nipple Reconstruction: A Novel Triple Flap Design Background: Restoring the nipple–areola complex completes the breast reconstructive process. Local flaps are often used for the nipple reconstruction; however, the number of techniques indicates the lack of a superior design. The aims of this study were to test the feasibility of a new triple flap design for nipple reconstruction and to evaluate complication rate and nipple projection. Methods: From November 2015 to November 2018, we performed the triple flap nipple reconstruction guided by a template for preoperative mark-up. Patients were followed up postoperatively to evaluate healing and signs of complications including wound dehiscence, infection, and flap necrosis, and nipple projection. The areola was tattooed 3 months postoperatively. Results: Twenty-six nipple reconstructions were successfully performed in 22 women. Four nipple reconstructions (15%) were performed in irradiated tissue. One reconstruction had a superficial infection, while there were no cases of wound dehiscence or flap necrosis. Three nipple reconstructions (12%) experienced prolonged healing that did not require intervention. None of these reconstructions had received radiation therapy. The nipple projection was 7.3 mm (range 6–9 mm) at the time of surgery and 3.1 mm (range 0–6 mm), 2.5 mm (range 2–3 mm), and 1.6 mm (range 0–3 mm) at follow-up of 3, 6, and 12 months, respectively. Conclusions: We present the new triple flap design for nipple reconstruction guided by a template for mark-up. The preliminary results indicate a low complication rate in both irradiated and nonirradiated patients while sustaining the projection over time remains to be a challenge.

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Read the latest global plastic surgery science in this compendium: 

Review Article
Getting Better Results in Facelifting

Original: Cosmetic

Complications of Cosmetic Surgery Abroad – Cost Analysis and Patient Perception

Original: Pediatric/Craniofacial

A Cross-Sectional Study of the Association between Homelessness and Facial Fractures

Ideas and Innovations

• Obturator Nerve Split for Gracilis Free-flap Double Re-innervation in Facial Paralysis
• Three-dimensional Camera Imaging in Postoperative Evaluation of Distraction Osteogenesis

Experimental
Molecular Mechanisms of Adipose Tissue Survival during Severe Hypoxia: Implications for Autologous Fat Graft Performance

Special Topic

• Reading Between the Lines: A Plastic Surgeon's Guide to Evaluating the Quality of Evidence in Research Publications
• Frontiers in Oncologic Reconstruction
• Role of Ancillary Procedures in Facial Rejuvenation
• Nerve Transfers - A Paradigm Shift in the Reconstructive Ladder

Case Report

• Unique Uses of SPY: Revision Rhinoplasty
• Unique Uses of SPY: High-risk Facelift
• Unique Uses of SPY: An Approach to Groin Lymphatic Complications
• Application of SPY Angiography in the Management of a Chronic Sternal Wound