Faculty Bibliography

BACKGROUND: The authors sought to review the various types of patients with psychological abnormalities who may present to the plastic surgeon and the psychological impact of various plastic surgery procedures on these patients. METHODS: After systematically searching the Embase and PubMed databases and following further refinement (based on the authors' inclusion and exclusion criteria), the authors identified 65 studies. In addition, the authors felt that important information was contained in four textbooks, two press releases, and one Internet database. The inclusion criteria were studies that investigated the psychological outcomes, background, and personality types of patients seeking specific plastic surgery procedures. In addition, studies that addressed the impact of plastic surgery on patients' psychological status and quality of life were also included. The authors excluded studies with fewer than 30 patients, studies that did not pertain to the particular plastic surgery procedures, and studies that addressed psychological sequelae of revision operations. RESULTS: Narcissistic and histrionic personality disorders and body dysmorphic disorder are the three most common psychiatric conditions encountered in patients seeking cosmetic surgery. Overall, plastic surgery not only restores the appearance and function of the disfigured body unit but also alleviates psychological distress. CONCLUSION: Identifying the psychologically challenging patient before surgical intervention will allow the patient to obtain the appropriate psychological assistance and may result in a healthier individual with or without associated plastic surgery procedures.

Complications and undesired outcomes happen to some patients of virtually all physicians, at all stages in their careers. Bad outcomes can be a consequence of disease processes, the premorbid condition of the patient, or the errors that occur in the process of health care. These errors include, but are by no means confined to, surgeon error. Regardless of the reason for the bad outcome, the surgeon is obligated to discuss the event with the patient and the family. This article reviews the benefits, barriers, and legal implications of the discussion and describes the disclosure process.

BACKGROUND: Acute postoperative pain following craniofacial or esthetic surgery, or trauma is readily treated with medicinal regimens. Facial pain persisting for more than six months is defined as chronic and must be distinguished from nontraumatic atypical facial pain or "tic-douloureaux." Our surgical experience managing chronic facial (trigeminal) pain is reviewed to provide insight into the success of our current algorithm for managing patients with chronic facial pain. METHODS: We performed a retrospective review of nine consecutive patients operated for post-traumatic chronic trigeminal nerve pain. Most patients were women (mean age 41 years). Data evaluated included mechanism of nerve injury, physical exam, CT scans, computer-aided neurosensory testing, and diagnostic nerve blocks. Surgical management included hardware removal, neurolysis, and/or neuroma resection with nerve grafting when indicated. Primary outcome measurement included Likert pain scale score (range 0-10). Secondary outcome measurements included sensory exam, medication requirement, and return to work. Based on these outcome measures, results were defined as excellent, good, fair, or poor. RESULTS: Five of the nine patients had excellent outcomes, one was good, two were fair, and one was poor. The one patient with a poor result had temporary improvements, but later returned to baseline. No patient was made symptomatically worse or had operative complications. CONCLUSIONS: Successful treatment of chronic, post-traumatic trigeminal nerve pain can be expected using an algorithm that measures sensory function of the involved trigeminal nerve branch. Then either preserves that function through neurolysis or reconstruction with a nerve graft, or eliminates that function through neuroma resection.

PURPOSE: Diagnosis and treatment of frontal sinus fractures (FSFs) have progressed over the previous 30 years. Despite advances in computed tomography, there is no current diagnostic uniformity with regard to classification and treatment. We developed a statistically valid treatment protocol for FSFs based on injury pattern, nasofrontal outflow tract (NFOT) injury, and complication(s). These data outlined predictable injury patterns based on specific computed tomographic findings critical to the diagnosis and ultimate treatment of this potentially fatal injury. MATERIALS AND METHODS: A retrospective review was conducted on patients with FSF from 1979 to 2005 under institutional review board approval. All computed tomographic scans were reviewed by the authors and fractures categorized by location, displacement, comminution, and degree of NFOT injury. RESULTS: One thousand ninety-seven patients with FSF were identified, 87 expired and 153 had inadequate data, leaving a group of 857 patients. Simultaneous displacement of anterior-posterior tables constituted the largest group (38.4%). NFOT injury occurred in most patients (70.7%) and was strongly associated with anterior (92%) and posterior (88%) table involvement (comminuted 98%). Sixty-seven percent of patients with NFOT injury had obstruction. Five hundred four patients (59.6%) had surgery with 10.4% complications and 353 patients were observed with 3.1% complications. All but 1 patient with complications had NFOT injury (98.5%). CONCLUSIONS: Predictable patterns of injury based on specific computed tomographic data play a pivotal role in classification and surgical management of potentially fatal frontal sinus injuries. Radiologic diagnosis of NFOT injury in FSFs, particularly obstruction, plays a decisive role in surgical planning.

BACKGROUND: Since 2005, seven facial composite tissue allotransplantations have been performed in five different centers in three countries. Four teams have reported their outcomes in separate publications. The authors sought to review the first four global experiences and compare several factors. This review facilitates discussion of indications and future implications for facial composite tissue allotransplantation. METHODS: A thorough review of five publications by the four transplantation groups was conducted. Additional information gathered from official press releases or surgeon presentations was also included. Summary of data and comparative analysis were performed. RESULTS: Patient selection is of utmost importance; specifically, patient compliance with the immunosuppressive and postoperative regimen. Functional and aesthetic improvement must be achieved by composite tissue allotransplantation reconstruction to justify lifelong immunosuppression; therefore, patients with loss of perioral and/or periorbital structures have priority. Objective measures are required to monitor this functional restoration. The importance of viral mismatch was demonstrated by the severe cytomegalovirus viremia observed in the third facial transplant patient. Finally, the mucosa appears to be a predictor of rejection and is more antigenic than skin. Histopathologic diagnosis of mucosal rejection may allow early treatment and prevention of subsequent diffuse composite tissue allotransplant rejection. CONCLUSIONS: The pioneering teams that ventured into facial composite tissue allotransplantation offered their patients improved aesthetic, functional, and social outcomes not possible with conventional measures in a single procedure. In addition, these innovative facial composite tissue allografts have provided early data on important factors related to patient selection, donor/recipient matching, immunosuppressive protocols, objective measures of functional recovery, and monitoring of acute graft rejection.

Soft-tissue reconstruction of traumatic patella and proximal tibial defects is challenging. Pedicled perforator-based adipocutaneous rotation flaps are a versatile local option as they have axial perfusion and greater freedom of transposition compared with random-pattern flaps, and replace the ideal tissue properties of this anatomic region.Experimental: Anatomic dissections were performed on 15 fresh cadaver legs and location of the dominant perforator measured. Clinical: A retrospective review was conducted at the University of Maryland/R Adams Cowley Shock Trauma Center evaluating patients over a 3-year period.Experimental: Cadaver dissections confirmed a principal perforator at 11.4 +/- 1.6 cm inferior to the patella. This vessel is consistently suitable in length and caliber for large rotation flap design. Clinical: Anterior tibial artery perforator flaps were performed on 4 patients following Gustilo IIIB wounds to the patella and tibial plateau. Two patients had rotation flap reconstructions to salvage failed gastrocnemius muscle flaps. All flaps were successful, however, one patient had overwhelming hardware infection several months later despite successfully healed flap.Local anterior tibial artery perforator flaps based on predictable perforators provide reliable coverage of patella and knee defects, bestowing versatility and flexibility to the reconstructive surgeon's armamentarium.

High velocity injuries have traditionally been covered with free muscle flaps. We sought to evaluate the utility of the anterolateral thigh flap (ALT) flap as a primary choice in reconstructing traumatic injuries in Western patients.A retrospective chart review was conducted of 122 patients treated at the R Adams Cowley Shock Trauma Center and at the Louisiana State University Trauma Center. Data collected included defect size, donor site location, flap composition and size, number of anastamoses, number of perforators, donor site closure, and complications.A total of 127 ALT flap reconstructions were performed. About 74% involved the lower extremity, 12% head and neck, 11% upper extremity, 2% abdomen, <1% chest, and <1% pelvis. The success rate was 96% with 3 total flap failures and 2 partial flap failures. Average follow-up was 9.3 months.The results of this review confirm that the ALT flap is a reliable, versatile tool for managing composite traumatic injuries.

OBJECTIVES: One of the unfortunate sequelae in obstetric brachial plexus palsy (OBPP) is upper limb length discrepancy. However, the influence of primary nerve reconstruction remains undetermined. In this study, the resultant discrepancy in children with OBPP who underwent primary reconstruction was analyzed in relation to the severity of the lesion, the timing of surgery, and the functional outcome following surgery. METHODS: Fifty-four patients that met the inclusion criteria were included in this study. Preoperative and postoperative bilateral scanograms were obtained to document the effect of reinnervation on bone growth. The length of the humerus, ulna, third metacarpal, third proximal phalange, and total limb length were measured and the percentage between the affected and normal side were accessed. Correlations between all the measures of limb length and measures of active motion (i.e., three different classification systems) were performed. RESULTS: Spearman's rank correlation coefficients revealed significant correlations between limb length discrepancies and nearly all measures of active upper extremity movement. The timing of surgery and the severity of the lesion significantly influenced the resultant limb length discrepancy. CONCLUSIONS: The prevention of a non-acceptable upper limb discrepancy is fundamental for both the patient and family. The extent of the resultant discrepancy appeared to be strongly related to the time between injury and surgery, degree of severity, and the outcome of surgery. Patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length.

The authors' experience with the supraclavicular approach for the treatment of patients with primary thoracic outlet syndrome (TOS) and for patients with recurrent TOS or iatrogenic brachial plexus injury after prior transaxillary first rib resection is presented. The records of 33 patients (34 plexuses) with TOS who presented for evaluation and treatment were analyzed. Of these, 12 (35%) plexuses underwent surgical treatment, and 22 (65%) plexuses were managed non-operatively. The patients who were treated non-operatively and had an adequate follow-up (n = 11) were used as a control group. Of the 12 surgically treated patients, five patients underwent primary surgery; four patients had secondary surgery for recurrent TOS; and three patients had surgery for iatrogenic brachial plexus injury. All patients presented with severe pain, and most of them had neurologic symptoms. All nine (100%) patients who underwent primary surgery (n = 5) and secondary surgery for recurrent TOS (n = 4) demonstrated excellent or good results. On the other hand, six (54%) of the 11 patients from the control group had some benefit from the non-operative treatment. Reoperation in three patients with iatrogenic brachial plexus injury resulted in good result in one case and in fair results in two patients; however, all patients were pain-free. No complications were encountered. Supraclavicular exploration of the brachial plexus enables precise assessment of the contents of the thoracic inlet area. It allows for safe identification and release of all abnormal anatomical structures and complete first rib resection with minimal risk to neurovascular structures. Additionally, this approach allows for the appropriate nerve reconstruction in cases of prior transaxillary iatrogenic plexus injury. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11552-009-9253-0) contains supplementary material, which is available to authorized users.

Even though total absence of elbow flexion in obstetric brachial plexus palsy (OBPP) is rare, weakness is a frequent problem. Numerous procedures for elbow flexion restoration in late obstetric brachial plexus palsy have been described. In this study, children with OBPP who underwent secondary reconstruction for elbow flexion restoration were studied. A retrospective review of 15 patients (16 elbows) who underwent 16 pedicled and eight free-muscle transfers for elbow flexion restoration was conducted. The mean follow-up period was 8.4 +/- 2.9 years (range, 25 months to 12.2 years). The mean age at operation (elbow surgery) was 5.4 +/- 1.9 years. The total arc of elbow motion was the result of the active elbow flexion less the flexion contracture. There was significant improvement in biceps muscle power from an average grading of 2.49 +/- 0.80 preoperatively to 3.64 +/- 0.46 postoperatively (p < 0.001). Thirteen of 16 elbows (81%) achieved good and excellent results (>/=M3+); and three elbows (19%) fair results (M3- or M3). The average arc of motion was significantly improved from 36 degrees +/- 25 degrees preoperatively to 94 degrees +/- 26 degrees postoperatively (p < 0.001). The preoperative and postoperative average elbow flexion contracture was 10.9 degrees +/- 8.9 degrees and 20 degrees +/- 12.2 degrees , respectively. Pedicled and/or free-muscle transfers can significantly improve elbow flexion in late obstetric brachial plexus palsy. Choice of the procedure should be individualized and determined on the basis of the type of paralysis, availability of donor muscles, previous reconstruction, and experience of the surgeon.