Faculty Bibliography

Facial fractures are a common source of emergency department consultations for the plastic surgeon. A working understanding of evaluation, assessment, management, and prevention of further injury when dealing with these fractures is vital. This two-part series detailing the management of midface fractures serves as a guide for the appropriate workup and management of the wide variety of fracture patterns that are commonly encountered.

The impact of specific patient comorbidities on outcomes in craniosynostosis surgical repair is not well defined. The aim of this retrospective review was to evaluate the short-term 30-day reoperation rate, unplanned readmission rate, and overall morbidity of craniosynostosis surgical repair using the 2012 through 2014 American College of Surgeons National Surgical Quality Improvement Program-Pediatrics (ACS NSQIP-Pediatric) database. Overall morbidity included pneumonia, wound occurrence, shock/sepsis, venous thromboembolism, cardiac complication, renal and urinary complications, or nerve injury. The authors identified patients undergoing craniosynostosis repair by CPT code resulting in 2,037 patients. A univariate and multivariate analysis was performed to identify risk factors for reoperation, readmission, and morbidity. The reoperation rate was 2.4%, the overall morbidity rate was 2.8%, and readmission rate was 3.4%.Regression analysis identified age, high American Society of Anesthesiologists (ASA) classification, and history of either neurologic or pulmonary disorders as associated with unplanned reoperations within 30 days. High ASA classification also demonstrated significant correlation with unplanned 30-day readmission, and a history of neurologic disorders was associated with overall morbidity. The most common reason for readmission was wound complications (n = 15) followed by respiratory complications (n = 7). Gender, gastrointestinal comorbidities, blood disorders, cardiac risk factors, and prior operation within 30 days did not show significant association with any outcome. Craniosynostosis surgical repair is safe and associated with low complication and readmission rates. Careful patient selection and preoperative optimization of these factors should be sought to reduce detrimental outcomes.

A proper knowledge of noninvasive facial rejuvenation is integral to the practice of a cosmetic surgeon. Noninvasive facial rejuvenation can be divided into patient- versus physician-directed modalities. Patient-directed facial rejuvenation combines the use of facial products such as sunscreen, moisturizers, retinoids, α-hydroxy acids, and various antioxidants to both maintain youthful skin and rejuvenate damaged skin. Physicians may recommend and often prescribe certain products, but patients are in control with this type of facial rejuvenation. On the other hand, physician-directed facial rejuvenation entails modalities that require direct physician involvement, such as neuromodulators, filler injections, laser resurfacing, microdermabrasion, and chemical peels. With the successful integration of each of these modalities, a complete facial regimen can be established and patient satisfaction can be maximized. This article is the last in a three-part series describing noninvasive facial rejuvenation. Here the authors review the mechanism, indications, and possible complications of lasers, chemical peels, and other commonly used noninvasive modalities.

BACKGROUND:Microcystic lymphatic malformations (LM) are congenital birth defects that can cause severe functional or esthetic deformity. At this time, several treatment interventions are possible, but there is no ideal therapy. A recently published article noted a coincidental improvement in microcystic LMs with the use of sildenafil for pulmonary hypertension, but conclusive and reproducible data is lacking regarding its efficacy. METHODS AND RESULTS/RESULTS:A prospective study was conducted to examine the subjective and objective results associated with sildenafil use in the treatment of microcystic LMs. Patients under the age of 18 were enrolled, and after evaluation with pre-intervention magnetic resonance imaging (MRI) studies, each was given a 6-week course of sildenafil. Subjective outcomes were obtained, and postoperative MRIs were used to objectively quantify changes. Five patients between the ages of 4 and 11 were enrolled in the study. All patients had microcystic LMs of the head and neck. All patients had undergone previous treatment interventions utilizing various modalities, and each was now seeking treatment for functional and cosmetic purposes. All patients had minimal to no response from a subjective standpoint. Comparison of pre- and post-treatment MRIs also demonstrated minimal to no response. CONCLUSIONS:The use of sildenafil for the treatment of microcystic lymphatic malformations did not have any appreciable effect on our selected population of pediatric patients who had been resistant to previous therapies. Further studies would be necessary to determine if other cohorts may benefit.

Transhiatal herniation of abdominal organs after oesophageal resection and reconstruction is rare and sparsely described in the literature. The commonest organ to herniate is the colon. Pancreatic herniation has been reported twice before. We report a case of postoesophagectomy transhiatal pancreatic herniation in an asymptomatic patient.

BACKGROUND:Free silicone injection for breast augmentation, which became widespread in the 1960s and continues illicitly to this day, has well-known adverse effects. In this retrospective chart review of 14 patients treated for silicone mastitis from 1990 to 2002, we present our experience with the surgical management of patients with silicone mastitis. METHODS:All the patients were women, ranging in age from 49 to 76 years old (mean age = 58.8). Patients presented to us a mean of 29.9 years after their free silicone breast injection. Treatment modalities were analyzed, and, specifically, methods of breast reconstruction involving autologous tissue transfers, implants, or a combination were evaluated. RESULTS:The majority of patients (12 of 14) required mastectomies for extensive silicone-infiltrated tissues. The remaining two patients had focal areas of disease and were successfully treated with excision and local breast parenchyma flaps. Autologous reconstruction was performed with a total of 20 flaps, including 12 free transverse rectus abdominis myocutaneous flaps, 4 free superior gluteal artery perforator (SGAP) flaps, and 4 pedicled latissimus dorsi (LD) flaps. Two patients had bilateral implant-based breast reconstruction. CONCLUSION/CONCLUSIONS:A variety of reconstructive options are available for patients presenting with silicone mastitis. Once an appropriate breast cancer workup has been performed, the surgical goal is to excise as much of the silicone-infiltrated tissues as possible before reconstruction. To our knowledge, this is the first reported series that incorporates the use of SGAP and LD flaps as a means of autologous tissue reconstruction for silicone-infiltrated breasts. LEVEL OF EVIDENCE IV/METHODS:This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Van Nes rotationplasty is a limb-salvage used for reconstruction after resection of a distal femoral or proximal tibial osteosarcoma in the pediatric patient. After resection, the distal leg is reapproximated to the level of tumor resection. The goal is to optimize extremity functionality such that the ankle functions as a knee joint. Traditionally, the vessels and nerves around the tumor are preserved within the distal leg. In the first case of our series, this method resulted in thrombosis, flap loss, and ultimately amputation secondary to venous torsion and thrombosis. In the following 2 cases, the intervening vasculature was resected along with the tumor, and the distal pedicles were anastomosed to their proximal counterparts using microvascular techniques. In addition to expediting resection of the tumor as well as allowing wider tumor resection margins, this technique also precludes thrombosis and subsequent flap loss.

Over the past 5 years we have developed a multidisciplinary service for the treatment of extremity sarcoma. This service includes orthopedic oncology, neurosurgery, medical and radiation oncology, and plastic surgery. Prior to 2007, the role of plastic surgery in this multidisciplinary team was limited. After 2007, plastic surgery at our institution played an increasingly integral role in multidisciplinary care. Based on the development of the plastic surgery service at our institution, we were able to evaluate the role of plastic surgery in the outcomes following extremity reconstruction after sarcoma resection. We hypothesize that plastic surgery involvement would reduce the amputation rate without altering recurrence rates. We found a decrease in lower-extremity amputation of approximately 20% without any significant change in recurrence rates. The incidence of infectious complications requiring IV antibiotics decreased by about 20%. The incidence of skin graft loss decreased by 75%. We do report a significant increase in partial flap necrosis. Overall, plastic surgery is an essential component of the multidisciplinary team in the care of extremity sarcoma.