Faculty Bibliography

OBJECTIVES/OBJECTIVE:The medial sural artery perforator (MSAP) free flap is an uncommonly utilized soft tissue flap in head and neck reconstruction. It is a thin, pliable, fasciocutaneous flap that provides significant pedicle length. The donor site can be closed primarily, and its location is more aesthetically pleasing to patients. We aim to describe the MSAP flap and compare it to other commonly used free flaps in the head and neck. STUDY DESIGN/METHODS:Retrospective case series. METHODS:A retrospective review of all MSAP cases performed at New York University Langone Health was performed from July 2016 to November 2017. We examined the patients' age, diagnosis, history of prior radiation therapy, and comorbidities, as well as flap-specific information and recipient site. RESULTS:(15 cm × 8 cm). The flaps ranged from 5 to 12 mm in thickness. Venous coupler size ranged from 2.0 to 3.5 mm. Primary closure of the donor site was achieved in 18 of 21 flaps. Twenty of 21 flaps were transferred successfully. CONCLUSION/CONCLUSIONS:The MSAP flap is a highly versatile and reliable option for a thin, pliable soft tissue flap with a donor site that may be preferable over the radial forearm free flap and anterolateral thigh flap in complex head and neck reconstruction. LEVEL OF EVIDENCE/METHODS:4. Laryngoscope, 2018.

Cells are transplanted to regenerate an organs' parenchyma, but how transplanted parenchymal cells induce stromal regeneration is elusive. Despite the common use of a decellularized matrix, little is known as to the pivotal signals that must be restored for tissue or organ regeneration. We report that Alx3, a developmentally important gene, orchestrated adult parenchymal and stromal regeneration by directly transactivating Wnt3a and vascular endothelial growth factor. In contrast to the modest parenchyma formed by native adult progenitors, Alx3-restored cells in decellularized scaffolds not only produced vascularized stroma that involved vascular endothelial growth factor signalling, but also parenchymal dentin via the Wnt/β-catenin pathway. In an orthotopic large-animal model following parenchyma and stroma ablation, Wnt3a-recruited endogenous cells regenerated neurovascular stroma and differentiated into parenchymal odontoblast-like cells that extended the processes into newly formed dentin with a structure-mechanical equivalency to native dentin. Thus, the Alx3-Wnt3a axis enables postnatal progenitors with a modest innate regenerative capacity to regenerate adult tissues. Depleted signals in the decellularized matrix may be reinstated by a developmentally pivotal gene or corresponding protein.

BACKGROUND:Oncologic outcomes with nipple-sparing mastectomy (NSM) continue to be established. We examine oncologic trends, outcomes, and risk factors, including tumor-to-nipple distance (TND), in therapeutic NSMs. METHODS:Demographics, outcomes, and overall trends for all NSMs undertaken for a therapeutic indication from 2006 to 2017 were analyzed. Oncologic outcomes were investigated with specific focus on recurrence and associated factors, including TND. RESULTS:A total of 496 therapeutic NSMs were performed with average follow-up time of 48.25 months. The most common tumor types were invasive carcinoma (52.4%) and ductal carcinoma in situ (50.4%). Sentinel lymph node sampling was performed in 79.8% of NSMs; 4.1% had positive frozen sentinel lymph node biopsies while 15.7% had positive nodal status on permanent pathologic examination. The most common pathologic cancer stage was stage IA (42.5%) followed by Stage 0 (31.3%).Per NSM, the rate of local recurrence was 1.6% (N=8); the rate of regional recurrence was 0.6% (N=3). In all, 171 NSMs had magnetic resonance imaging available to assess tumor-to-nipple distance (TND). NSMs with TND ≤1 centimeter (25.0% versus 2.4%, p=0.0031/p=0.1129) and ≤2 centimeters (8.7% versus 2.0%; p=0.0218/p=0.1345) trended to higher rates of locoregional recurrence. In univariate analysis, TND ≤1 centimeter was the only significant risk factor for recurrence (OR=13.5833, p=0.0385). No factors were significant in regression analysis. CONCLUSIONS:In this group of early stage and in situ breast carcinoma, therapeutic NSM appears oncologically safe with a locoregional recurrence rate of 2.0%. Tumor-to-nipple distances of ≤1 centimeter and ≤2 centimeters trended to higher rates of recurrence.

BACKGROUND:The opioid crisis in America has sparked a shift toward a multimodality perioperative pain regimen. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) in the perioperative period decreases opioid consumption and increases efficacy. However, many plastic surgeons avoid their use because of antiplatelet effects. The purpose of this article is to systematically review the plastic surgery literature to assess the risk of intraoperative or postoperative bleeding and hematoma formation. METHODS:A systematic review of articles published in PubMed was performed in September 2018 to investigate the incidence of increased bleeding and hematoma formation with use of NSAIDs in the perioperative period in plastic surgery. All articles were reviewed for primary outcome measures, and a selective literature review was performed to examine perioperative NSAID use in other surgical subspecialties. Random-effect meta-analysis was performed. RESULTS:Our search yielded 806 total articles, with 15 meeting inclusion criteria, and this included 3064 patients (1679 with perioperative NSAIDs, 1385 with no NSAIDs). There was no significant difference in overall incidence of bleeding/hematoma in the treatment group versus control (no NSAIDs). The overall pooled odds ratio (OR) and corresponding 95% confidence interval were 1.20 and 0.73 to 1.97 (P = 0.48). When separated by drug administered across all plastic surgery procedures, there were no statistically significant differences in incidences of hematoma or increased bleeding with use of ketorolac (OR, 1.48 [0.86-2.56]; P = 0.57), ibuprofen (OR, 0.55 [0.14-2.14]; P = 0.87), or celecoxib (OR, 0.22 [0.02-2.52]; P = 0.39). When examining NSAID use in breast surgery, there was no statistically significant difference in incidence of hematoma or increased bleeding when combining all 3 drug types (OR, 1.39 [0.82-2.37]; P = 0.60). Some individual studies demonstrated trends toward increased bleeding/hematoma in reduction mammoplasties. CONCLUSIONS:Nonsteroidal anti-inflammatory drugs significantly improve pain control and decrease opioid use when used in plastic surgery. The majority of evidence in plastic surgery does not support an increased incidence of bleeding/hematoma with the use of perioperative NSAIDs.

BACKGROUND:Penile inversion vaginoplasty (PIV) is the most common procedure for genital reconstruction in transwomen. While PIV usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. Here, we describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen. METHODS:Between 2017 and 2018, 41 female-to-male patients were identified who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6cm wide by 8cm long peritoneal flaps are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina. RESULTS:The 41 patients had an average age of 34 +/- 14 years. Average length of procedure was 262 +/- 35 minutes and the average length of stay was 5 days. Average length of follow up was 114 +/- 79 days and at most recent follow up, vaginal depth and width were measured to be 14.2 +/- 0.7 cm and 3.6+/- 0.2 cm respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin. CONCLUSION/CONCLUSIONS:Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well-vascularized apex with acceptable anticipated complications.

In conjunction with social transition, hormones, and counseling, gender-affirming surgery (GAS) is a key component in the treatment gender dysphoria. Gender affirming surgeries can be divided into genital surgery (phalloplasty, metoidioplasty, oophorectomy, vaginoplasty, and orchiectomy) and non-genital surgeries. The non-genital surgeries for transmasculine individuals include chest masculinization and body contouring. For transfeminine individuals, they include breast augmentation, and facial feminization. Chest masculinization eliminates the need for binding and improves overall confidence and quality of life. Choice of technique depends on body habitus and patient preference. For transfeminine individuals, some breast growth can be achieved with the use of estrogen over the course of 1-2 years, but many still require breast augmentation for breasts that are proportionate to their frame. Facial surgery for transfeminine patients is highly effective in changing classic masculine anatomic features to feminine norms. The most common of these procedures include forehead contouring, rhinoplasty, lip lift, mandible angle reduction, genioplasty and chondrolaryngoplasty. These non-genital surgeries are critical to treating gender dysphoria in transgender and gender non-binary individuals. Further research with standardized and validated assessments of patient reported outcomes is needed to fully understand long term effects on quality of life and gender dysphoria.

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.

BACKGROUND: The prevalence of obesity in the United States continues to grow and is estimated to affect over a quarter of the working-age population. Some studies have identified obesity as a risk factor for flap failure and complications in free flap-based breast reconstruction, but its clinical significance is less clear in nonbreast reconstruction. The role of obesity as a risk factor for failure and complications following lower extremity reconstruction has not been well described, and the limited existing literature demonstrates conflicting results. METHODS:-tests for continuous variables. Multivariate regression was performed to control for confounders. RESULTS: = 0.14) for local flaps of the lower extremity. CONCLUSIONS: Evaluation of a large, multicenter, validated and risk-adjusted nationwide cohort demonstrated that obesity is not an independent risk factor for early complications following lower extremity reconstruction, suggesting that these procedures may be performed safely in the obese patient population.