Faculty Bibliography

BACKGROUND: Several alternatives exist for breast cancer reconstruction with perforator flaps. For those patients in whom the buttock is the best choice as a source for autologous tissue, the IGAP and SGAP flaps are an excellent option. These flaps allow the reliable transfer of skin and soft tissue from the buttock without the associated donor site morbidity of a muscle flap. INDICATIONS: Most women requiring tissue transfer to the chest from the buttock for breast reconstruction or other reasons are candidates for IGAP or SGAP flaps. Do to an improved donor site contour and scar, we now prefer to use the IGAP to the SGAP flap. Absolute contraindications specific to perforator flap breast reconstruction in our practice include history of previous liposuction of the donor site or active smoking (within 1 month prior to surgery). ANATOMY AND TECHNIQUE: IGAP and SGAP flaps are based on perforators from either the superior or inferior gluteal artery. These perforators are carefully dissected free from the surrounding gluteus maximus muscle, which is spread in the direction of the muscle fibres and safely preserved. The vascular pedicle is anastomosed to recipient vessels in the chest and the donor site closed primarily. CONCLUSIONS: IGAP and SGAP flaps allow the safe and reliable transfer of tissue from the buttock for breast reconstruction as an alternative to soft tissue transfer from an abdominal donor site or even as a first choice in selected patients

BACKGROUND: The reported incidence of hematoma following male rhytidectomy ranges from 7.9 to 12.9 percent. In 1976, it was demonstrated that postoperative hypertension is a key etiologic factor in hematoma formation and postoperative use of Thorazine was recommended to control blood pressure. This study analyzes the incidence of hematoma after male rhytidectomy at one institution after a strict and aggressive perioperative blood pressure control regimen was initiated. METHODS: From 1982 to 2002, 985 patients with a mean age of 61 years (range, 49 to 72 years) underwent rhytidectomy. Thirty-six patients required surgical evacuation of expanding hematoma after rhytidectomy. Operative procedures were performed by more than 100 different plastic surgery attending surgeons, residents, and fellows. RESULTS: The overall incidence of hematoma during this study period was 4.24 percent. Age, medical history, medications, type of anesthesia, rhytidectomy technique and combination of procedures, and length of operation were not independent risk factors for determining who was more likely to develop a hematoma. Thirty-three percent of the patients requiring surgical evacuation had systolic blood pressure greater than 150 mmHg and diastolic blood pressure greater than 90 mmHg preoperatively, intraoperatively, and postoperatively. Over a 30-year period, the incidence of hematoma requiring surgical evacuation has decreased from 8.7 percent to 3.97 percent after initiation of a strict perioperative blood pressure control regimen. CONCLUSION: Despite the lower incidence of hematoma following male rhytidectomy today as compared with 30 years ago, the incidence in men (3.97 percent) remains higher than that in women (1 to 3 percent).

BACKGROUND: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. METHODS: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. RESULTS: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). CONCLUSIONS: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment

Radiation therapy (RT) is considered by some to be a contraindication to nipple-areola reconstruction (NAR) particularly in patients with breast implant reconstruction. In this retrospective chart review, all patients who underwent breast reconstruction with tissue expanders and implants from 1997-2003 were reviewed. A subset of patients with a history of radiation therapy (pre- or postoperative) was identified. Postoperative complications, surgical technique, and the time course of reconstructive procedures were analyzed. Thirteen percent of patients with a history of RT had NAR compared with 36% of similarly reconstructed patients without a history of RT. Reconstruction was accomplished using a variety of local flaps, with an overall complication rate of 25%. Nipple-areola reconstruction after chest-wall irradiation in patients reconstructed with breast implants should be performed in carefully selected patients. Acceptable surgical candidates demonstrate resolution of acute radiation changes, no evidence of late radiation changes, and appropriate thickness of the mastectomy skin flaps.

Apert syndrome, first described in 1906, is one of the most severe of the craniosynostosis syndromes and is further characterized by midface hypoplasia, syndactyly, and other visceral abnormalities. Affected individuals generally require lifelong management by a multidisciplinary team of health care specialists. Apert syndrome results almost exclusively from one or the other of two point mutations in fibroblast growth factor receptor 2. Tremendous scientific advances have been made recently in understanding the molecular basis for Apert syndrome through clinical genetic, biochemical, and structural approaches. In this review, the authors provide the clinician with a basic overview of these findings and their therapeutic implications

Since its introduction in 1992, endoscopic brow lift has gained tremendous recognition because it has been promoted as a novel technique to correct brow ptosis as well as glabella rhytids in a minimally invasive manner with fewer complications than the classic coronal brow lift method. In this retrospective study, 628 endoscopic brow lift procedures performed over a 5-year period (1997-2001) at Manhattan Eye Ear and Throat Hospital were reviewed. The number of endoscopic brow lift procedures performed at this institution has declined 70 percent. The purpose of this study was to elucidate the causes of this striking trend by soliciting the opinions of 21 New York plastic surgeons on their current brow ptosis management. The response rate was 84 percent (21 of 25 surgeons contacted). Currently, 25 percent of the interviewed plastic surgeons perform endoscopic brow lift regularly, 50 percent of the plastic surgeons perform endoscopic brow lift occasionally, and 25 percent of the participants no longer perform endoscopic brow lift. While most patients (70 percent) were satisfied with their results, only 50 percent of the plastic surgeons were pleased with the long-term results (after more than 2 years of follow-up). Observed postsurgical complications of endoscopic brow lift included alopecia, hairline changes, infected hardware, brow asymmetry requiring surgical revision, prolonged forehead/brow paresthesia, frontal branch nerve paralysis, and scalp dysesthesia. These complications were similar to those resulting from open brow lifts. Seventy-one percent of the surveyed New York plastic surgeons routinely administered botulinum toxin type A (Botox) within 6 months of the endoscopic brow lift procedure. Possible explanations for the decline in the overall number of endoscopic brow lift procedures include the following: (1) the selection criteria for the ideal endoscopic brow lift patients are currently more limited; (2) other techniques equal or surpass endoscopic brow lift in effectiveness and predictability; and (3) endoscopic brow lift is ineffective in the majority of patients. There is no single superior surgical procedure for brow ptosis management available at this time

The epidermal growth factor receptor (EGFR) and the non-receptor protein tyrosine kinases Src and Pyk2 have been implicated in linking a variety of G-protein-coupled receptors (GPCR) to the mitogen-activated protein (MAP) kinase signaling cascade. In this report we apply a genetic strategy using cells isolated from Src-, Pyk2-, or EGFR-deficient mice to explore the roles played by these protein tyrosine kinases in GPCR-induced activation of EGFR, Pyk2, and MAP kinase. We show that Src kinases are critical for activation of Pyk2 in response to GPCR-stimulation and that Pyk2 and Src are essential for GPCR-induced tyrosine phosphorylation of EGFR. By contrast, Pyk2, Src, and EGFR are dispensable for GPCR-induced activation of MAP kinase. Moreover, GPCR-induced MAP kinase activation is normal in fibroblasts deficient in both Src and Pyk2 (Src-/-Pyk2-/- cells) as well as in fibroblasts deficient in all three Src kinases expressed in these cells (Src-/-Yes-/-Fyn-/- cells). Finally, experiments are presented demonstrating that, upon stimulation of GPCR, activated Pyk2 forms a complex with Src, which in turn phosphorylates EGFR directly. These experiments reveal a role for Src kinases in Pyk2 activation and a role for Pyk2 and Src in tyrosine phosphorylation of EGFR following GPCR stimulation. In addition, EGFR, Src family kinases, and Pyk2 are not required for linking GPCRs with the MAP kinase signaling cascade