Faculty Bibliography

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.

BACKGROUND:It is common teaching that treatment of index finger alone is a relative contraindication for arthroplasty of the proximal interphalangeal joint (PIPJ). However, limited data exist reporting the digit-specific complication of PIPJ arthroplasty for the treatment of osteoarthritis or posttraumatic arthritis. The purpose of this article is to perform a systematic review and meta-analysis of the literature to assess whether the 3 ulnar digits may bear a similar instability and complication profile. METHODS:Systematic searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases were performed for PIPJ arthroplasty specifying by digit. We reviewed both descriptive and quantitative data to: (1) report aggregate instability and instability-related complications after non-index digit PIPJ arthroplasty; and (2) perform statistical testing to assess relative rates by digit and compared with index digits. RESULTS:Computerized search generated 385 original articles. Five studies reporting digit-specific instability-related outcomes of silicone, pyrocarbon, or metal surface arthroplasty on 177 digits were included in the review. Meta-analysis demonstrated a 29% instability rate for long digits (n = 65), 6% for ring digits (n = 53), and 6% for small digits (n = 17), compared with 33% for index digits (n = 42). There was no difference in the overall deformity, instability, and complication rates of long versus index fingers ( P = .65). CONCLUSIONS:Instability-related deformity and complication rates of long finger PIPJ arthroplasty may not be different from that of the index finger. Treatment of the long finger may be a relative contraindication to PIPJ arthroplasty. Future biomechanical and clinical studies are needed.

Craniomaxillofacial congenital anomalies comprise approximately one third of all congenital birth defects and include deformities such as alveolar clefts, craniosynostosis, and microtia. Current surgical treatments commonly require the use of autogenous graft material which are difficult to shape, limited in supply, associated with donor site morbidity and cannot grow with a maturing skeleton. Our group has demonstrated that 3D printed bio-ceramic scaffolds can generate vascularized bone within large, critical-sized defects (defects too large to heal spontaneously) of the craniomaxillofacial skeleton. Furthermore, these scaffolds are also able to function as a delivery vehicle for a new osteogenic agent with a well-established safety profile. The same 3D printers and imaging software platforms have been leveraged by our team to create sterilizable patient-specific intraoperative models for craniofacial reconstruction. For microtia repair, the current standard of care surgical guide is a two-dimensional drawing taken from the contralateral ear. Our laboratory has used 3D printers and open source software platforms to design personalized microtia surgical models. In this review, we report on the advancements in tissue engineering principles, digital imaging software platforms and 3D printing that have culminated in the application of this technology to repair large bone defects in skeletally immature transitional models and provide in-house manufactured, sterilizable patient-specific models for craniofacial reconstruction.

BACKGROUND:A primary goal in chest wall reconstruction ('top surgery') for trans men is achieving a symmetrical, aesthetically pleasing position of the reconstructed male NAC. In the context of existing surgical techniques for top surgery, the ability to achieve this goal is limited. METHODS:The senior author's technique for component NAC creation in chest wall reconstruction for trans men with a modified skate flap and free areolar graft, in conjunction with double-incision mastectomy, is described. A retrospective analysis of 50 consecutive patients who underwent primary, bilateral chest wall reconstruction with this technique was undertaken for the period of March 2015 to October 2016. RESULTS:Average patient age was 30.64 years, with an average BMI of 28.54 kg/m. Eighty two percent of the sample received pre-operative testosterone therapy, and average operative time was 2 hours and 59 minutes. Average overall mastectomy specimen weight was 627.80 grams. Average length of hospital stay was 0.96 days. Average follow-up duration was 19.02 months.Complications occurred in 10% (n = 5) of patients, including seroma (4%), cellulitis (2%), hematoma (2%), and suture granuloma (2%). Only 5 patients (10%) underwent postoperative revision to adjust NAC size, projection, or symmetry. Twenty-eight patients (56%) underwent secondary revisions, including scar revisions (56%), liposuction (12%), and fat grafting (2%). CONCLUSIONS:The use of a modified nipple flap and free areolar graft in transgender chest wall reconstruction for trans men allows for flexible, component construction of the male NAC, in a safe and effective manner.

OBJECTIVES/OBJECTIVE:To investigate how muscle and fasciocutaneous flaps influence the progression of bone healing in acute Gustilo IIIB tibia fractures. DESIGN/METHODS:Retrospective Chart Review. SETTING/METHODS:Urban Academic Level I Trauma Center. PATIENTS/PARTICIPANTS/METHODS:Between 2006 and 2016, 39 patients from a database of operatively treated long bone fractures met the inclusion criteria, which consisted of adults with acute Gustilo IIIB tibia shaft fracture requiring flap coverage and having at least 6 months of radiographic follow-up. INTERVENTION/METHODS:Soft tissue coverage for patients with Gustilo IIIB open tibia fractures was performed with either a muscle flap or fasciocutaneous flap. MAIN OUTCOME MEASUREMENTS/METHODS:A radiographic union score for tibia (RUST) fractures, used to evaluate fracture healing, was assigned to patients' radiographs postoperatively, at 3, 6, and 12 months from the initial fracture date. Mean RUST scores at these time points were compared between those of patients with muscle flaps and fasciocutaneous flaps. Union was defined as a RUST score of 10 or higher. RESULTS:There was a significant difference (P = 0.026) in the mean RUST score at 6 months between the muscle group (8.54 ± 1.81) and the fasciocutaneous group (6.92 ± 2.46). There was no significant difference in the mean RUST score at 3 months (P = 0.056) and at 12 months (P = 0.947) between the 2 groups. There was also significance in the number of fractures reaching union, favoring muscle flaps, at 6 months (P = 0.020). CONCLUSIONS:Patients with acute Gustilo IIIB tibia fractures who received muscle flaps have significantly faster radiographic progression of bone healing in the first 6 months than do patients who received fasciocutaneous flaps. Furthermore, according to radiographic evaluation, more Gustilo IIIB tibia fractures receiving muscle flaps reach union by 6 months than those flapped with fasciocutaneous tissue. LEVEL OF EVIDENCE/METHODS:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND:Barbed sutures have become increasingly popular in the field of aesthetic plastic surgery, particularly in body contouring and breast surgeries, in which the use of barbed sutures may offer both time and cost savings. Scar aesthetics is an important outcome for both the surgeons and patients in these procedures; however, there is a paucity of studies assessing the aesthetic outcome of barbed sutures with regards to scarring. METHODS:A systematic review of PubMed, EMBASE, and Cochrane databases was performed from the date of their inception through July 2017 using the search terms barbed suture combined with scar or wound. Studies were included if they were prospective evaluator-blind randomized controlled trials, closed the dermal layer of incisions using barbed sutures, and included an evaluator-blind aesthetic assessment of scarring. RESULTS:Six prospective randomized controlled trials met inclusion criteria. The cosmetic result of scars in 926 patients was evaluated after an average of 8.1 months. Five of the 6 controlled trials found the aesthetic results of wounds closed with barbed sutures to be equivalent to those closed with traditional sutures, and 1 study showed significantly superior aesthetic results with barbed sutures. Use of barbed sutures resulted in shorter operating times in 4 of the 5 studies that timed incision closure. Similar complication rates were observed in all evaluated studies. CONCLUSION/CONCLUSIONS:Based on this systematic review, the majority of studies concluded that there were no differences in scarring aesthetics when dermal layers were closed using barbed sutures compared with traditional suturing techniques.

BACKGROUND:Initially performed only in prophylactic cases, indications for nipple-sparing mastectomy have expanded. Trends and surgical outcomes stratified by nipple-sparing mastectomy indication have not yet been fully examined. METHODS:Demographics and outcomes for all nipple-sparing mastectomies performed from 2006 to 2017 were compared by mastectomy indication. RESULTS:A total of 1212 nipple-sparing mastectomies were performed: 496 (40.9 percent) for therapeutic and 716 (59.1 percent) for prophylactic indications. Follow-up time was similar between both the therapeutic and prophylactic nipple-sparing mastectomy groups (47.35 versus 46.83 months, respectively; p = 0.7942). Therapeutic nipple-sparing mastectomies experienced significantly greater rates of major (p = 0.0165) and minor (p = 0.0421) infection, implant loss (p = 0.0098), reconstructive failure (p = 0.0058), and seroma (p = 0.0043). Rates of major (p = 0.4461) and minor (p = 0.2673) mastectomy flap necrosis and complete (p = 0.3445) and partial (p = 0.7120) nipple necrosis were equivalent. The overall rate of locoregional recurrence/occurrence per nipple-sparing mastectomy was 0.9 percent: 2.0 percent in therapeutic nipple-sparing mastectomies and 0.1 percent in prophylactic nipple-sparing mastectomies (p < 0.0001). CONCLUSIONS:Approximately 40 percent of nipple-sparing mastectomies are currently performed for therapeutic indications. Therapeutic nipple-sparing mastectomies had higher rates of infectious complications and reconstructive failure. Rates of locoregional cancer recurrence/occurrence are low, but occur significantly more often after therapeutic nipple-sparing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, III.

We conducted a retrospective chart review of 27 patients-7 men and 20 women, aged 47 to 94 years (mean: 71.3)-with symptomatic epiphora secondary to dacryostenosis who had undergone thulium: YAG (Tm:YAG) laser dacryocystorhinostomy (DCR). Among them, dacryostenosis had been documented in 35 eyes by dacryocystography. The Tm:YAG procedure involved the administration of local anesthesia, after which a 600-μm laser fiber was inserted into the lacrimal canaliculi and then into the nasolacrimal duct. Under endoscopic visualization, the DCR was performed anterior and inferior to the middle turbinate, which created an opening. Silicone stents were then inserted and tied intranasally. In the immediate postoperative period, all 27 patients noted initial improvement. During a follow-up of 22 days to 25 months (mean: 11.3 mo), 24 of the 27 patients (89%) remained symptom-free, while the remaining 3 patients (11%) experienced a treatment failure and required revision surgery. To the best of our knowledge, only two articles on thulium laser therapy for DCR have been previously published, both approximately 25 years ago; both involved the use of a thulium along with holmium and chromium in cadavers. As far as we know, our case series is the largest in the English-language literature that has documented the use of the thulium in laser therapy for DCR, and it is the only in vivo study. We found that DCR with the Tm:YAG laser was an effective and affordable option for patients with symptomatic epiphora secondary to lacrimal obstruction.

BACKGROUND:Concerns exist that immediate breast reconstruction may delay adjuvant chemotherapy initiation, impacting oncologic outcomes. Here, we determine how post-operative complications impact chemotherapy timing, and identify factors associated with greater risk for delays. METHODS:Retrospective chart review identified patients undergoing immediate breast reconstruction and adjuvant chemotherapy at a single institution from 2010 to 2015. Patients were analyzed based on occurrence of post-operative complications and time to chemotherapy. RESULTS:A total of 182 patients (244 breast reconstructions) were included in the study; 210 (86%) reconstructions did not experience post-operative complications, 34 (13.9%) did. Patients who experienced post-operative complications had a higher mean age (53.6 vs. 48.1 years, p=0.002), and higher rates of diabetes (23.5% vs. 3.8%, p<0.001).The complication group had delays in initiation of chemotherapy (56 vs. 45 days, p=0.017). Only the immediate autologous reconstruction subgroup demonstrated a statistically significant delay in initiation of chemotherapy.Patients who initiated chemotherapy >48.5 days were of higher mean age (55.9 vs. 50.7 years, p=0.074), had increased rates of diabetes (36.8% vs. 6.7%, p=0.053), and immediate autologous reconstruction (31.6% vs. 0%, p=0.027). A predictive model based on these findings determined that patients with at least 1 of these 3 risk factors have a 74% chance of experiencing prolonged times to chemotherapy initiation vs. 18% without risk factors (p=0.003). CONCLUSIONS:Risk factors for delayed chemotherapy in the context of post-operative complications are age >51.7 years, diabetes, and autologous reconstruction. Reconstructive candidates who fit this profile are at highest risk and merit extra consideration and counseling.