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"Outcomes of the Use of Fresh Frozen Costal Cartilage in Rhinoplasty"

Hanna, Steven A; Mattos, David; Datta, Shaishav; Reish, Richard G
BACKGROUND:Rhinoplasty is made more challenging when there is insufficient septal cartilage for use as graft material. Several autologous and homologous graft options have been used in the past, though each comes with its own set of challenges. Fresh frozen costal cartilage (FFCC) is an increasingly popular alternative that yields the benefits of homologous tissue while having a lower theoretical risk profile. Given the relatively novel nature of this option, this study aims to analyze the complication rates of MTF (Musculoskeletal Transplant Foundation) FFCC. METHODS:A retrospective chart review of the use of FFCC in rhinoplasty in the senior author's practice was conducted between March 2018 to December 2021. 282 cases were reviewed and analyzed for rates of infection, warping, and resorption. The inclusion criteria were cases with a minimum of 12 months of follow-up. RESULTS:The mean age of our study group was 35.8 years old, with 27 males and 255 females. 40 cases were primary rhinoplasties while the remaining 242 were revisions. Mean follow-up period was 20.3 months. Six patients (2.1%) required empiric antibiotics postoperatively, zero patients had clinical signs of warping, resorption, or displacement, and six patients (2.1%) required operative revision unrelated to the FFCC. CONCLUSIONS:This study provides long-term follow up data on the complication profile of FFCC in rhinoplasty. Acute infection, warping, and resorption rates were found to be no greater than rhinoplasty complication rates when autologous or homologous tissue are used. FFCC is a safe, convenient, and patient-centered option for graft tissue in rhinoplasty.
PMID: 37815290
ISSN: 1529-4242
CID: 5645792

Optimizing the Use of Autografts, Allografts, and Alloplastic Materials in Rhinoplasty

Chen, Kevin; Schultz, Benjamin D; Mattos, David; Reish, Richard G
LEARNING OBJECTIVES:After studying this article, the participant should be able to: 1. Understand the autologous graft options available to the rhinoplasty surgeon, including septal cartilage, auricular cartilage, costal cartilage, and bone. 2. Understand the autograft and allograft options available to the rhinoplasty surgeon, including cadaveric costal cartilage, silicone, Medpor, and Gore-Tex. 3. Identify the ideal situations to use each of these implant materials. 4. Understand the advantages and disadvantages of the different autografts, allografts, and implants in rhinoplasty. SUMMARY:This review focuses on the graft options available to the modern rhinoplasty surgeon. Autologous options are varied in the quality of cartilage harvested and the morbidity of the donor site. In addition, surgeons should understand the allograft options should autologous grafting be unfeasible or undesirable. New technological advances in processing of allograft cartilage makes this an attractive secondary option.
PMID: 36041000
ISSN: 1529-4242
CID: 5645802

Entrapment Neuropathy Causing Persistent Headache Symptoms after Nonsurgical Rhinoplasty

Benjamin, Martin; McGregor, Andrew; Yousif, Sarah; Shaikh, Dooniya; Reish, Richard G
The frequency of nonsurgical rhinoplasty has increased in recent years. The occurrence of headaches or migraine symptoms, and their treatment following nonsurgical rhinoplasty, have been scarcely described in the literature. Here, we present a patient who presented with subjective complaints of a new onset headache immediately after nonsurgical rhinoplasty, with subsequent reversal of her symptoms using hylauronidase. Furthermore, a literature review was conducted to establish a possible anatomical pathophysiologic mechanism of these symptoms seen in this patient.
PMID: 33425572
ISSN: 2169-7574
CID: 5047932

Surgeons' Dilemma: Treatment of Implant-Associated Infection in the Cosmetic Breast Augmentation Patient

Vasilakis, Vasileios; Yamin, Feras; Reish, Richard G
BACKGROUND:Augmentation mammaplasty is the most common plastic surgical procedure performed in the USA. The management of severe implant-associated infection is a challenge, and the traditional two-stage treatment is associated with significant limitations. The aim of this literature review is to provide a comprehensive analysis of all studies dealing with the management of severe infection or implant exposure following cosmetic breast augmentation. METHODS:The PubMed and Cochrane databases were searched through February 2018 for studies on the management of severe infection and threatened or actual implant exposure following primary augmentation mammaplasty. Search terms used were "breast implant," "breast prosthesis," "breast augmentation," "breast augmentation complications," "infected implant," "implant salvage" and "implant exposure." RESULTS:Five articles met inclusion criteria. There was inconsistency in the reporting of several key factors, such as the antibiotic regimens employed, culture sensitivities, time from diagnosis to treatment, implant characteristics, as well as the precise treatment of the capsule and pocket. A total of 58 implants were treated, of which 37 (63.8%) were exposed in the setting of infection and 21 (36.2%) were infected without exposure. One-stage implant salvage was employed in 31 implants and was successful in all. The capsular contracture rate with this approach was 6.5%. Antibiotic-alone, non-operative treatment was employed in the salvage of 22 implants, with success and capsular contracture rates of 77.3 and 13.6%, respectively. In the setting of severe periprosthetic infection in the absence of implant exposure, antibiotic-alone treatment was successful in the salvage of 13 out of 14 implants (92.9%). CONCLUSIONS:The inconsistency and paucity of the data in the literature preclude definitive conclusions with regard to the optimal management of the threatened implant following augmentation mammaplasty. Given the excellent salvage rates in this setting, a more prominent role and liberal utilization of implant salvage are proposed. LEVEL OF EVIDENCE IV: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 .
PMID: 30944965
ISSN: 1432-5241
CID: 5047922

Buccal Fat Pad Excision: Proceed with Caution

Benjamin, Martin; Reish, Richard G
Background/UNASSIGNED:Buccal fat pad excision is offered as a means of obtaining a more aesthetic midface. This procedure has been documented in the form of countless videos on Instagram and other social media platforms with no long-term patient follow-up. We performed a retrospective analysis of published data regarding buccal fat pad excision and sought to better elucidate pitfalls regarding this underreported procedure. Methods/UNASSIGNED:A literature search was conducted in October 2017 through the PUBMED database regarding the utility of buccal fat pad excision in the setting of aesthetic improvement of the midface. Reference articles were screened to obtain relevant studies. A total of 121 citations were identified in the search but after eliminating duplicate studies and abstracts and utilizing predefined inclusion/exclusion criteria only 11 articles were satisfactory. None of these articles demonstrated any long-term patient follow-up. Results/UNASSIGNED:Out of the 121 relevant citations identified, only 2 studies published describe a case series of > 5 patients regarding cheek or midface sculpturing with buccal fat pad excision for aesthetic purposes, the total sample size between these 2 studies was 53 patients. Neither of the studies had follow-up regarding patient satisfaction or related outcomes. Conclusions/UNASSIGNED:Buccal fat pad resection as an aesthetic improvement of the midface has been described, but follow-up regarding loss of subcutaneous fat with aging and late secondary deformities have not been published in the literature. Further research in long-term patient follow-up including patient satisfaction and the encouragement of reporting postoperative complications is warranted.
PMID: 30534506
ISSN: 2169-7574
CID: 5047912

Facial Implants: Controversies and Criticism. A Comprehensive Review of the Current Literature

Rojas, Yoel A; Sinnott, Catherine; Colasante, Cesar; Samas, John; Reish, Richard G
BACKGROUND:Polyethylene (Medpor) and silicone are two of the most popular materials used today for facial skeleton implantation. Previous studies have identified common complications with the use of these implants, but patient follow-up has been short. This review of the literature examines complications and patient follow-up in cases using Medpor and silicone implants for reconstructive and aesthetic operations of the mid and lower face over the past 20 years. METHODS:A literature search was conducted through the PubMed database. Keywords used were as follows: ("mandible implants" or "malar implants" or "chin implants") AND ("reconstruction" or "augmentation") AND ("Medpor" or "silicone"). RESULTS:There were nine studies with 626 patients in the Medpor group and five studies with 365 patients in the silicone group. The silicone group had a higher incidence of infections and displacements. The Medpor group showed a higher incidence of prominence problems. Exposure/extrusion rates were low for both implant types. Chin and mandibular implants were the safest, whereas malar implants had a high incidence of prominence problems. The average follow-up for Medpor was 36.6 months and 24 months for silicone. There were wide ranges of follow-up times, from 2 weeks up to 15 years. A limited number of articles included an averaged time within their ranges. Reported follow-up times were not linked to specific complications. CONCLUSIONS:Medpor implantation is more common than silicone. Complication rates are low with the use of both materials. Patient follow-up is deficient and has not improved in the past 20 years, raising questions on the reliability of complication rates.
PMID: 29994843
ISSN: 1529-4242
CID: 5047902

Severe Delayed Hemorrhage After Cosmetic Rhinoplasty in the Setting of Maxillary Vascular Malformation [Case Report]

Vasilakis, Vasileios; Reish, Richard G
Late epistaxis after rhinoplasty is a rare but potentially life-threatening occurrence. This case report concerns a 20-year-old woman who had severe epistaxis 5 and 10 days after a closed rhinoplasty with internal osteotomies and who ultimately required transcatheter arterial embolization for definitive control of the hemorrhagic source. Arterial hypervascularity, with signs of arteriovenous malformation, of the midface at the level of the piriform aperture and maxilla was seen on angiography.
PMID: 29846211
ISSN: 1536-3708
CID: 5047892

Occult Histopathology and Its Predictors in Contralateral and Bilateral Prophylactic Mastectomies

Mattos, David; Gfrerer, Lisa; Ling, Irving T C; Reish, Richard G; Hughes, Kevin S; Halpern, Elkan F; Cetrulo, Curtis; Colwell, Amy S; Winograd, Jonathan M; Yaremchuk, Michael J; Austen, William G; Liao, Eric C
BACKGROUND:The last decade has seen an increasing prevalence of prophylactic mastectomies with decreasing age of patients treated for breast cancer. Data are limited on the prevalence of histopathologic abnormalities in this population. This study aimed to measure the prevalence of histopathologic findings in contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) patients and identify predictors of findings. METHODS:Our institution's prophylactic mastectomies from 2004 to 2011 were reviewed. Breast specimens with prior malignancies were excluded. Patient factors and pathology reports were collected. Independent predictive factors were identified with univariate and multivariate logistic analysis. RESULTS:A total of 524 specimens in 454 patients were identified. Malignancy was found in 7.0% of CPM and 5.7% of BPM specimens. In CPM patients, ipsilateral lobular carcinoma-in situ [odds ratio (OR) 4.0] and mammogram risk group (OR 2.0) were predictive of malignancy. Age group (OR 1.5), ipsilateral lobular carcinoma-in situ (OR 2.3), and prior bilateral salpingo-oophorectomy (OR 0.3) were predictive of moderate- to high-risk histopathology. Only increasing age group was predictive of increased moderate- to high-risk histopathology in BPM patients (OR 2.3). There were no independent predictors of malignancy in BPM. BRCA status was not predictive in either CPM or BPM. CONCLUSIONS:Patients with lobular carcinoma-in situ in the index breast or high-risk mammograms have a higher prevalence of malignancies. Although BRCA patients may benefit from prophylactic mastectomy, the genetic diagnosis does not increase the prevalence of detecting occult pathology. BPM patients can be counseled about relative risk, where occult pathology increases with age.
PMID: 26577123
ISSN: 1534-4681
CID: 5047872

Lifetime Costs of Prophylactic Mastectomies and Reconstruction versus Surveillance

Mattos, David; Gfrerer, Lisa; Reish, Richard G; Hughes, Kevin S; Cetrulo, Curtis; Colwell, Amy S; Winograd, Jonathan M; Yaremchuk, Michael J; Austen, William G; Liao, Eric C
BACKGROUND:The past decade has seen an increasing prevalence of prophylactic mastectomy with decreasing ages of patients treated for breast cancer. Data are limited on the fiscal impacts of contralateral prophylactic mastectomy trends, and no study has compared bilateral prophylactic mastectomy with reconstruction to surveillance in high-risk patients. METHODS:Lifetime third-party payer costs over 30 years were estimated with 2013 Medicare reimbursement rates. Costs were estimated for patients choosing contralateral or bilateral prophylactic mastectomy versus surveillance, with immediate reconstructions using a single-stage implant, tissue expander, or perforator-based free flap approach. Published cancer incidence rates predicted the percentage of surveillance patients that would require mastectomies. Sensitivity analyses were conducted that varied cost growth, discount rate, cancer incidence rate, and other variables. Lifetime costs and present values (3 percent discount rate) were estimated. RESULTS:Lifetime prophylactic mastectomy costs were lower than surveillance costs, $1292 to $1993 lower for contralateral prophylactic mastectomy and $15,668 to $21,342 lower for bilateral prophylactic mastectomy, depending on the reconstruction. Present value estimates were slightly higher for contralateral prophylactic mastectomy over contralateral surveillance but still cost saving for bilateral prophylactic mastectomy compared with bilateral surveillance. Present value estimates are also cost saving for contralateral prophylactic mastectomy when the modeled contralateral breast cancer incidence rate is increased to at least 0.6 percent per year. CONCLUSIONS:These findings are consistent with contralateral and bilateral prophylactic mastectomy being cost saving in many scenarios, regardless of the reconstructive option chosen. They suggest that physicians and patients should continue to receive flexibility in deciding how best to proceed clinically in each case.
PMID: 26595028
ISSN: 1529-4242
CID: 5047882

GHOST Protocol: Greatest Healing Opportunity for Soft Tissue, a Treatment Paradigm for Complex Sarcoma Reconstruction

Kobraei, Edward M; Eberlin, Kyle R; Ricci, Joseph A; Reish, Richard G; Winograd, Jonathan M; Cetrulo, Curtis L Jr
Modern sarcoma treatment has created new challenges for plastic surgeons. This study was designed to review the recent experience and practice patterns following complex sarcoma resection at a large sarcoma center. All cases from October 2013 to October 2014 involving rare nonepithelial tumors, a multidisciplinary surgical team, radiation and/or chemotherapy treatments, and plastic surgical reconstruction were included in the analysis. In addition to evaluating clinical outcomes, cases were reviewed to identify factors associated with excellent or poor patient care. Review of these cases formed the basis of the greatest healing opportunity for soft tissue (GHOST) protocol. Our patient population included seven males (64%) and four females (36%). All except one patient was exposed to radiotherapy, chemotherapy, or some combination. Diverse procedures were used for reconstruction. Early complications occurred in two patients (18%), and late complications in four patients (36%). Sarcoma resection was found to be highly morbid in our series. Patients with poor preoperative nutritional status were more likely to experience complications postoperatively. The decision to stage a reconstruction was complex and influenced by several factors. Multimodal sarcoma treatments may involve highly morbid procedures and create complex wounds. The GHOST protocol is a useful reference for plastic surgeons.
PMID: 26031266
ISSN: 1555-9823
CID: 2697732