Faculty Bibliography

Recent technical and scientific advances in fat grafting procedures and concepts have improved predictability of fat grafting. Large-volume fat injection is gaining much attention as an attracting procedure for body contouring and reconstruction, but an increasing number of complications also has been recognized over the world. In this article, typical complications after fat grafting are described, as well as an explanation of how and why they occur, and how surgeons can avoid and treat complications.

The controversy over fat grafting to the breasts has now been settled. In 2009, the American Society of Plastic Surgeons Fat Graft Task Force stated that "Fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries; however, results are dependent on technique and surgeon expertise." This article discusses the history, indications, planning, complications, and present technique of fat grafting to the breast using the Coleman technique.

INTRODUCTION: Protocols for the treatment of Robin sequence (RS) consider the presence of laryngomalacia as a contraindication to mandibular distraction osteogenesis (MDO). The authors report their institutional experience of MDO applied to infants with RS and associated laryngomalacia. METHODS: An 8-year (2005-2013) retrospective review of all infants with RS and laryngomalacia who underwent MDO at a tertiary care children's hospital was performed. Patients were excluded if they possessed an airway anomaly other than laryngomalacia. Laryngomalacia was identified on laryngoscopy before MDO. Laser supraglottoplasty was performed at the discretion of the otolaryngologist. Recorded variables included preoperative and postoperative AHI, syndromic diagnosis or genetic anomalies, cardiac, central nervous system (CNS), and gastrointestinal (GI) abnormalities. The primary outcomes measured were avoidance or decannulation of tracheostomy and decrease in postoperative AHI. RESULTS: Eleven infants met inclusion criteria. Mean follow-up was 28 months. 18.2% of patients had a syndromic diagnosis, 36.4% cardiac, 9.1% CNS, and 72.7% GI abnormalities. Mean preoperative AHI was 46.1 +/- 31.8 and mean postoperative AHI was 4.1 +/- 3.0 (P = 0.002). All patients without a tracheostomy before intervention avoided tracheostomy after MDO. One patient had a tracheostomy before MDO and was subsequently decannulated. One patient died 1 year after MDO due to complex congenital heart disease. CONCLUSIONS: Infants with RS and laryngomalacia can be successfully treated with MDO to relieve upper airway obstruction. Close cooperation with a pediatric otolaryngologist and treatment of laryngomalacia can significantly enhance tracheostomy avoidance in infants with Robin sequence.

Pediatric frontal sinus fractures are a rare clinical entity. Owing to the large amount of force required to fracture the frontal sinus, it is often associated with severe intracranial and craniofacial injuries. The treatment of frontal sinus fractures is controversial, with many different established algorithms based mainly on the adult population. The authors present their experience with pediatric frontal sinus fractures; they also present a treatment algorithm.A retrospective review of the Cincinnati Children's Hospital Medical Center trauma database was performed. From 1998 to 2010, the authors identified patients between the ages of 0 and 18 with frontal sinus fractures and analyzed demographics, fracture pattern, associated injuries, methods of treatment, and complications. Descriptive statistics and univariate analyses were performed.A total of 39 patients were included in the study with a mean follow-up of 31.2 months. Fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and cerebrospinal fluid leak. There were no differences in short- and long-term complications. Additionally, these patients were more likely to be treated surgically in the form of obliteration or cranialization.Patients without NFOT involvement can be managed with observation only. Patients with NFOT involvement or persistent cerebrospinal fluid leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.

BACKGROUND: Lateral canthal procedures are often indicated to correct or prevent lower eyelid malposition. When determining an appropriate lateral canthal procedure, planning is essential and includes proper analysis and identification of any contributory anatomical factors. METHODS: A 12-month retrospective review was performed on patients undergoing lateral canthal procedures. Important components of the preoperative examination were studied to relate patient anatomy and results. Outcomes were followed for a minimum of 5 years. RESULTS: Of 288 consecutive lower eyelid canthal procedures, a total of 146 met the inclusion criteria. Common designated abnormal preoperative findings included a negative vector (62 percent), lid margin eversion (12 percent), scleral show (21 percent), neutral or negative canthal tilt (49 percent and 18 percent, respectively), and lateral canthus -to -orbital rim distance of more than 1 cm (11 percent). The distribution of lateral canthal procedures performed in our study population included inferior retinacular lateral canthopexy (n = 36), inferior retinacular lateral canthoplasty (n = 88), tarsal strip lateral canthoplasty (n = 15), and dermal-orbicular pennant lateral canthoplasty (n = 7). Successful outcomes were noted to be 86 percent and 91 percent according to surgeons and patients, respectively. CONCLUSIONS: Specific findings on the preoperative physical examination identify when simple or more complex lateral canthal procedures should be performed. The authors report seven key physical findings that should be documented to effectively determine a lateral canthal procedure that is appropriate for prevention and management of lower eyelid malposition. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

BACKGROUND: The purposes of this study were to report a 7-year experience of microvascular reconstruction of scalp defects, compare flap type and outcomes, and evaluate the implications of short and long term complications. METHODS: Following institutional review board approval, a single surgeon's patients requiring microvascular scalp reconstruction were retrospectively reviewed from 2005 to 2011. Flap choice, complications, and outcomes were statistically analyzed. RESULTS: Nineteen patients met inclusion criteria (10 male and 9 female) with a mean age of 60.2 +/- 21.4 years (range, 23-90 years). All free tissue transfers (n = 20) achieved 100% soft tissue coverage. Mean size calvarial defect was 106.6 +/- 67.2 cm (range, 35-285 cm), with 11 requiring cranioplasty. Free flaps included the following: 13 anteriolateral thigh, 5 ulnar, 1 latissimus dorsi, and 1 thoracodorsal artery perforator. Mean flap size was 154.1 +/- 87.3 cm (range, 42-336 cm). Early complications (<30 days following surgery) occurred in 21.1% of patients and late complications (>30 days following surgery) in 52.6% of patients. Patients with an early complication were 2 times more likely to develop a late complication (relative risk, 2.1) but did not reach statistical significance. Late complications were more likely to require surgical intervention, 84.2% versus 60% of early complications (P = 0.079). CONCLUSIONS: Microvascular free tissue transfer is the mainstay of complex scalp defects but carries a high likelihood of future reoperations. Early complications are less concerning than late complications, as the need for future surgical intervention is associated with late complications. There is lack of evidence to support a superior flap choice.

The authors present a new and unique pattern of sutural fusion "peace sign synostosis" (PSS) characterized by synostosis of the metopic, bicoronal, and sagittal sutures and associated with abnormalities of the TWIST1 gene known to be associated with Saethre-Chotzen syndrome (SCS). To do so, we performed a retrospective review of patients with bicoronal, metopic, and at least partial anterior sagittal synostoses at the Children's Hospital of Philadelphia and Seattle Children's Hospital. Patients' demographics, genetic analysis, perioperative and clinic notes were reviewed. Five patients were identified with PSS and abnormalities of TWIST1 consistent with SCS. One patient, with the longest follow-up of 7 years, underwent 5 intracranial procedures and required a ventriculoperitoneal (VP) shunt. The remaining 4 patients underwent posterior cranial vault distraction as the initial procedure, followed by anterior cranial vault remodeling. Two patients required a VP shunt. To conclude, synostosis of the metopic, bicoronal, and sagittal sutures (PSS) appears to be associated with SCS and produces a characteristic skull morphology that can be readily identified on physical examination. Early data suggest a high rate of reoperation, increased necessity for a VP shunt, and potential complications. Of note, this novel phenotype had not been previously observed at our respective institutions, reported in the literature, or observed in association with TWIST1 abnormalities as described in association with SCS.

INTRODUCTION: Outcomes for patients with burn injuries are optimized by multidisciplinary care in a specialized burn center. Plastic surgeons traditionally have played a significant role in the care of burn patients; however, this may be evolving. We aim to examine the role and employment satisfaction of plastic surgeons in burn surgery. METHODS: Members of the American Society of Plastic Surgery with available contact information and US senior plastic surgery residents were asked to complete a survey examining practice profiles and employment satisfaction. Responses were analyzed between groups stating that their practice did and did not involve burn surgery. RESULTS: Of the 573 attending respondents, 135 (23.6%) indicated that part of their practice included burn surgery. Nineteen (41.9%) residents indicated they desired their practice to include burn surgery. About 41.9% of respondents with less than 3 years of experience, 25% with between 3 and 10 years of experience, and 21.7% with greater than 10 years of experience practiced burn surgery. Twenty-one (15.3%) respondents were completely satisfied with their practice, 62 (45.3%) were mostly satisfied, and 36 (26.3%) were satisfied. Fourteen (10.2%) respondents were mostly dissatisfied and 4 (2.9%) were completely dissatisfied (P = 0.0315). CONCLUSIONS: Despite residents' interest and junior plastic surgeons' involvement in burn surgery, the role of burn surgery in responding plastic surgeons' practices diminished over time. Those practicing burn surgery are less likely to be satisfied and more likely to be dissatisfied with their practice. Plastic surgeons should therefore examine their role in burn surgery to optimize their desired involvement and satisfaction within the field.

INTRODUCTION: The anatomy of the facial artery, its tortuosity, and branch patterns are well documented. To date, a reliable method of identifying the facial artery, based on surface landmarks, has not been described. The purpose of this study is to characterize the relationship of the facial artery with several facial topographic landmarks, and to identify a location where the facial artery could predictably be identified. METHODS: Following institutional review board approval, 20 hemifacial dissections on 10 cadaveric heads were performed. Distances from the facial artery to the oral commissure, mandibular angle, lateral canthus, and Manson's point were measured. Distances were measured and confirmed clinically using Doppler examination in 20 hemifaces of 10 healthy volunteers. RESULTS: Manson's point identifies the facial artery with 100% accuracy and precision, within a 3 mm radius in both cadaveric specimens and living human subjects. Cadaveric measurements demonstrated that the facial artery is located 19 mm +/- 5.5 from the oral commissure, 31 mm +/- 6.8 from the mandibular angle, 92 mm +/- 8.0 from the lateral canthus. Doppler examination on healthy volunteers (5 male, 5 female) demonstrated measurements of 18 mm +/- 4.0, 50 mm +/- 6.4, and 79 mm +/- 8.2, respectively. CONCLUSIONS: The identification of the facial artery is critical for the craniofacial surgeon in order to avoid inadvertent injury, plan for local flaps, and in preparation of a recipient vessel for free tissue microvascular reconstruction. Manson's point can aid the surgeon in consistently indentifying the facial artery.