Faculty Bibliography

BACKGROUND:In October 2012, a freely available, internet-based cleft simulator was created in partnership between academic, nonprofit, and industry sectors. The purpose of this educational resource was to address global disparities in cleft surgery education. This report assesses demographics, usage, and global effect of our simulator, in its fifth year since inception. OBJECTIVE:Evaluate the global effect, usage, and demographics of an internet-based educational digital simulation cleft surgery software. SETTING AND PARTICIPANTS/METHODS:Simulator modules, available in five languages demonstrate surgical anatomy, markings, detailed procedures, and intraoperative footage to supplement digital animation. Available data regarding number of users, sessions, countries reached, and content access were recorded. Surveys evaluating the demographic characteristics of registered users and simulator use were collected by direct e-mail. RESULTS:The total number of simulator new and active users reached 2865 and 4086 in June 2017, respectively. By June 2017, users from 136 countries had accessed the simulator. From 2015 to 2017, the number of sessions was 11,176 with a monthly average of 399.0 ± 190.0. Developing countries accounted for 35% of sessions and the average session duration was 9.0 ± 7.3 minutes. This yields a total simulator screen time of 100,584 minutes (1676 hours). Most survey respondents were surgeons or trainees (87%) specializing in plastic, maxillofacial, or general surgery (89%). Most users found the simulator to be useful (88%), at least equivalent or more useful than other resources (83%), and used it for teaching (58%). CONCLUSIONS:Our internet-based interactive cleft surgery platform reaches its intended target audience, is not restricted by socioeconomic barriers to access, and is judged to be useful by surgeons. More than 4000 active users have been reached since inception. The total screen time over approximately 2 years exceeded 1600 hours. This suggests that future surgical simulators of this kind may be sustainable by stakeholders interested in reaching this target audience.

Growing public awareness of hereditary breast cancers, notably BRCA1 and BRCA2, and increasing popularity of personalized medicine have led to a greater number of young adult patients presenting for risk-reduction mastectomies and breast reconstruction. Plastic surgeons must be familiar with treatment guidelines, necessary referral patterns, and particular needs of these patients to appropriately manage their care. Genetic testing for BRCA1 and BRCA2 is most often reserved for patients older than the age of consent, and can be performed in the young adult population (aged 18 to 25 years) with the appropriate preemptive genetic counseling. Subsequent risk-reduction procedures are usually delayed until at least the latter end of the young adult age range, and must be considered on an individualized basis with regard for a patient's level of maturity and autonomy. Prophylactic mastectomies in young adults also can serve to aid the unique psychosocial needs of this population, although the long-term psychological and physical ramifications must be considered carefully. With the development of nipple-sparing mastectomy and improvement in reconstructive techniques, risk-reducing surgery has become more accepted in the younger population. Immediate, implant-based reconstruction is a common reconstructive technique in these patients but requires extensive discussion regarding reconstructive goals, the risk of possible complications, and long-term implications of these procedures. Comprehensive, continuous support with multispecialty counseling is necessary throughout the spectrum of care for the high-risk, young adult patient.

INTRODUCTION/BACKGROUND:Breast augmentation is the most common aesthetic surgery performed in the United States (US) annually. Analysis of Google Trends (GT) data may give plastic surgeons useful information regarding worldwide, national, and regional interest for breast augmentation and other commonly performed aesthetic surgeries. METHODS:Data were collected using GT for breast augmentation and associated search terms from January 2004 to May 2017. Case volume was obtained from the American Society of Plastic Surgeons (ASPS) annual reports for the calendar year 2005-2016. RESULTS:Trend analysis showed that total search term volume for breast augmentation and breast implants gradually decreased worldwide and in the US over the study period while the search term boob job slowly increased. Univariate linear regression demonstrated a statistically significant positive correlation between average annual Google search volume of "breast augmentation" and the annual volume of breast augmentations performed in the US according to ASPS data (R 2 = 0.44, p = 0.018). There was no significant correlation between national volume of breast augmentations performed and search volume using the terms "breast implants" or "boob job" over time (p = 0.84 and p = 0.07, respectively). In addition, there appears to be country specific variation in interest based on time of year and peaks in interest following specific policies. CONCLUSIONS:To our knowledge, this is the first and only analysis of GT data in the plastic surgery literature to date. To that end, this study highlights this large and potentially powerful data set for plastic surgeons both in the US and around the world. LEVEL OF EVIDENCE V/UNASSIGNED: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 .

BACKGROUND:Reconstructive trends and outcomes for nipple-sparing mastectomy continue to be defined. The graduated impact of breast size and mastectomy weight remains incompletely evaluated. METHODS:All patients undergoing nipple-sparing mastectomy from 2006 to June of 2016 were identified. Demographics and outcomes were analyzed and stratified by mastectomy weight of 800 g or higher (large group), between 799 and 400 g (intermediate group), and less than 400 g (small group). RESULTS:Of 809 nipple-sparing mastectomies, 66 (8.2 percent) had mastectomy weights of 800 g or higher, 328 (40.5 percent) had mastectomy weights between 799 and 400 g, and 415 nipple-sparing mastectomies (51.3 percent) had mastectomy weights less than 400 g. Nipple-sparing mastectomies in the large group were significantly more likely to be associated with major mastectomy flap necrosis (p = 0.0005), complete nipple-areola complex necrosis (p < 0.0001), explantation (p < 0.0001), cellulitis treated with oral (p = 0.0008) and intravenous (p = 0.0126) antibiotics, abscess (p = 0.0254), and seroma (p = 0.0126) compared with those in the intermediate group. Compared with small nipple-sparing mastectomies, patients in the large group had greater major mastectomy flap necrosis (p < 0.0001), complete (p < 0.0001) and partial (p = 0.0409) nipple-areola complex necrosis, explantation (p < 0.0001), cellulitis treated with oral (p < 0.0001) and intravenous (p < 0.0001) antibiotics, abscess (p = 0.0119), and seroma (p < 0.0001). Patients in the intermediate group were more likely to experience major (p < 0.0001) and minor (p < 0.0001) mastectomy flap necrosis, complete (p = 0.0015) and partial (p < 0.0001) nipple-areola complex necrosis, cellulitis treated with oral antibiotics (p = 0.0062), and seroma (p = 0.0248) compared with those undergoing small nipple-sparing mastectomies. Larger mastectomy weights were significant predictors of complications on logistic regression analysis. CONCLUSION/CONCLUSIONS:Reconstructive and ischemic complications in nipple-sparing mastectomy are progressively greater as mastectomy weight and breast size increase. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Risk, II.

Facial transplantation (FT) has attracted the interest of individuals with facial disfigurement as a path to social reintegration. The perception among face transplant recipients and the reconstructive surgery community appears to be that superior functional and esthetic outcomes can be obtained with FT compared to autologous reconstruction (AR). Although lifelong immunosuppression adds well-known risks to FT, its benefits have proven difficult to quantify, especially because of its non-life-saving nature. Evidence that the general public perceives facial allograft recipients as less disfigured than AR patients may dramatically alter the currently accepted risk/benefit ratio of this novel procedure. A survey containing independent images of individuals in nondisfigured (ND), autologous facial reconstruction, and FT groups was administered to the general public in an urban environment. Participants assigned a disfigurement score to each photograph using the Observer-Rated Facial Disfigurement Scale, a validated instrument used to rate facial disfigurement among head and neck cancer patients. One-way analysis of variance was used to calculate differences in mean level of perceived facial disfigurement among the 3 groups. A total of 250 participants completed the survey. Mean perceived disfigurement scores assigned to the ND, FT, and AR groups were 1.2 ± 0.4, 4.9 ± 1.3, and 8.5 ± 0.6, respectively. A significant difference in disfigurement score was observed between all 3 groups (P < 0.001). This pilot study suggests that the general public perceives the esthetic outcome of FT to be superior to those obtained with AR in patients with severe facial defects.

Face transplantation has evolved over the last 12 years into a safe and feasible reconstructive solution, with good aesthetic and functional outcomes for patients with severe facial defects who are not amenable to reconstruction through conventional and autologous approaches. Among patients who underwent face transplantation to date, a significant proportion did so following trauma, mostly ballistic and thermal injuries. It is therefore important for trauma surgeons who deal with these injuries regularly to be familiar with the literature on face transplantation following traumatic injuries. In this study, we provide a focused review on this topic, with an emphasis on highlighting the limitations of conventional craniomaxillofacial reconstruction, while emphasizing data available on the risks, benefits, surgical indications, contraindications, as well as aesthetic and functional outcomes of face transplantation. The authors also provide an update on all face transplants performed to date including traumatic mechanisms of injury, and extent of defects. They finally describe 2 cases performed by the senior author for patients presenting with devastating facial ballistic and thermal injuries. The authors hope that this work serves as an update for the trauma surgery community regarding the current role and limitations of face transplantation as a craniomaxillofacial reconstructive option for their patient population. This can potentially expedite the reconstructive process for patients who may benefit from face transplantation.

This study evaluated the influence of polishing protocols on the surface roughness of flowable and regular bulk fill composites. Five bulk fill composites were tested: SureFil SDR Flow (SDR), Tetric EvoFlow Bulk fill (TEF), Filtek Bulk Fill Flowable (FIF), Tetric EvoCeram Bulk Fill (TEC), and Filtek Bulk Fill Posterior (FIP). Two polishing protocols were tested: Sof-Lex and Astropol. Astropol created a smoother surface for FIP (P < .05); however, the polishing protocol did not influence surface roughness on TEC (P > .05). SDR, TEF, and FIF exhibited rougher surfaces when polished. Sof-Lex created rougher surfaces for bulk fill composites. It was concluded that surface roughness was related to material composition rather than the polishing system.

BACKGROUND: Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. METHODS: Retrospective review (1979-2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. RESULTS: = 0.39) found no difference in flap failure rates between proximal and distal groups. CONCLUSION/CONCLUSIONS: Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

Background/UNASSIGNED:Widespread application of vascularized composite allotransplantation (VCA) is currently limited by the required lifelong systemic immunosuppression and its associated morbidity and mortality. This study evaluated the efficacy of ex vivo (after procurement but before transplantation) engineering of allografts using small interfering RNA to knockdown major histocompatibility complex I (MHC-I) and prolong rejection-free survival. Methods/UNASSIGNED:Endothelial cells (ECs) were transfected with small interfering RNA targeted against MHC-I (siMHC-I) for all in vitro experiments. MHC-I surface expression and knockdown duration were evaluated using quantitative polymerase chain reaction (qPCR) and flow cytometry. After stimulating Lewis recipient cytotoxic lymphocytes (CTL) with allogeneic controls or siMHC-I-silenced ECs, lymphocyte proliferation, CTL-mediated and natural killer-mediated EC lysis were measured. Using an established VCA rat model, allografts were perfused ex vivo with siMHC-I before transplantation. Allografts were analyzed for MHC-I expression and clinical/histologic evidence of rejection. Results/UNASSIGNED:< 0.05). Conclusions/UNASSIGNED:Ex vivo siMHC-I engineering can effectively modify allografts and significantly prolong rejection-free allograft survival. This novel approach may help reduce future systemic immunosuppression requirements in VCA recipients.

Background/UNASSIGNED:Achieving excellent aesthetic outcomes in reconstruction of large or ptotic breasts is especially challenging. Incorporating a Wise pattern into the mastectomy design is effective in reducing the excess breast skin, however it increases the risk of mastectomy skin necrosis. The aim of this study is to describe surgical maneuvers which optimize aesthetic outcomes, anticipate flap volume requirements, and limit mastectomy skin necrosis in autologous reconstruction in patients with macromastia and grade III ptosis. Methods/UNASSIGNED:This is a retrospective review of operative and clinical records of patients who underwent unilateral or bilateral breast reconstruction with autologous tissue between August 2015 and May 2017. Patients were divided into macromastia and ptosis groups. Key surgical maneuvers for safely achieving aesthetically optimal results were identified. Results/UNASSIGNED:A total of 29 breasts were successfully reconstructed in 19 patients with a Wise pattern mastectomy skin reduction. Free flap weights were similar in both groups, mastectomy weights were greater in the macromastia group, p < 0.05. Complications were limited to three cases of wound breakdown and one case of mastectomy skin necrosis. Total number of revision stages was reduced in unilateral reconstructions when a contralateral breast reduction or mastopexy was performed during the first stage. Conclusions/UNASSIGNED:A Wise pattern can safely and effectively be incorporated into a mastectomy incision design in patients who are not candidates for a nipple sparing mastectomy. Optimal aesthetics are achieved with similar volume flaps for both macromastia and ptosis patients. In cases of unilateral breast reconstruction a contralateral breast reduction or mastopexy should be performed at the time of the immediate breast reconstruction.