Faculty Bibliography

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a "one-size-fits-all" mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.

Ethmoidal dural arteriovenous fistulas are vascular malformations with arterial supply from the anterior ethmoidal artery and ultimate drainage into the sagittal sinus.1-3 They are characterized by a high risk of hemorrhage. Microsurgical disconnection of the fistula represents a safe and robust treatment option. Endovascular treatment requires catheterization of the ophthalmic artery and carries a risk of visual deficits. The supraorbital craniotomy provides an excellent corridor to the anterior skull base and is well suited for the treatment of ethmoidal dural arteriovenous fistulas. The supraorbital craniotomy may be performed through a transpalpebral "eyelid" incision. The transpalpebral incision allows for a well-hidden scar and does not have any associated hair loss, as can be seen with the eyebrow incision. The patient consented to the procedure and being videotaped.

Mycobacterium avium-intracellulare complex (MAC) is one of the most common forms of non-tuberculous mycobacterial (NTM) infection. MAC is a ubiquitous bacterium that resides in both natural and man-made environments. Surgical intervention is well established in NTM infections causing cervical lymphadenitis, but its role in airway disease is not well understood. Invasive pulmonary infection is usually associated with immunocompromised patients, but it occurs in otherwise healthy children as well. We present a challenging clinical case of an 18-month-old female with severe mediastinal MAC causing bilateral bronchogenic obstruction and respiratory compromise requiring emergent intubation and intervention, likely due to a genetic predisposition secondary to Interferon Gamma Receptor 2 (IFNGR2) haploinsufficiency. During the initial bronchoscopy, the left bronchus was 99% obstructed while the right bronchus was 60% obstructed. The right lesion was biopsied and drained whitish fluid with improvement in clinical status shortly thereafter. A culture was sent. Follow-up bronchoscopy with excision of residual right mass allowed for extubation in the operating room with discharge on azithromycin, rifabutin, and ethambutol. Repeat bronchoscopy after discharge revealed recurrence of bilateral lesions. The patient was started on nebulized amikacin in addition to her current regimen with full resolution after treatment. Despite subtotal removal of MAC lesions possibly increasing the chances of recurrence, surgical intervention in this patient resulted in rapid improvement in respiratory status, and it may represent the preferred treatment in patients with any airway concerns.

BACKGROUND: Given the relatively small size of thigh-based flaps and the possible necessity for a multiflap reconstruction, it is imperative to arrive at an accurate estimation of flap weight during preoperative planning. It was our objective to develop a novel technique for the preoperative estimation of profunda artery perforator (PAP) flap weight. METHODS: All patients that underwent transverse PAP flap breast reconstruction at two institutions were retrospectively reviewed. Subcutaneous tissue thicknesses were measured on axial computed tomography angiography scans at several predetermined points. The distance from the inferior gluteal crease to the PAP was also recorded. Linear regression was used to estimate flap weight. RESULTS:has a value of 1 if the patient was scanned in the supine position or 0 if prone. The aforementioned formula yielded a median estimated flap weight of 305 g (IQR: 234-402) and a median percent error of 10.5% (IQR: 6.1-16.2). CONCLUSION/CONCLUSIONS: The authors demonstrate a simple and accurate formula for the preoperative estimation of transverse PAP flap weight for breast reconstruction.

PURPOSE/OBJECTIVE:To three-dimensionally evaluate the internal fit at the implant-abutment interface of abutments fabricated with different workflows using a combination of the silicone replica technique and microcomputed tomography (μCT). MATERIALS AND METHODS/METHODS:) were assessed. Data were statistically evaluated using ANOVA and Tukey test (P < .05). RESULTS:in the full digital group, which exhibited higher mean values compared to the other regions (P = .000). The 3D measurements for quantification of internal discrepancy were strongly associated with the 2D measurements. CONCLUSION/CONCLUSIONS:Ti-Base and UCLA abutments exhibited better internal fit at the implant-abutment interfaces compared to a fully digitalized workflow (CAD/CAM custom abutments).

PURPOSE/OBJECTIVE:A hoverboard, or self-balancing scooter, is a battery-powered vehicle with 2 wheels connected by a longboard that requires handsfree operation. The purpose of the present study was to characterize the emergency department visits for hoverboard-related craniomaxillofacial trauma and determine predictors of injuries and hospital admission. MATERIALS AND METHODS/METHODS:and t tests. RESULTS:The final sample included 440 patients, of whom 51% were male and 74% were pediatric (age, ≤18 years). Pediatric and male patients were both less likely to wear helmets (P < .01). The injuries had most commonly occurred in the winter (38%) and in a home setting (77%). Facial fractures were more likely in adults (P = .03) and in the summer (P = .04). The overall admission rate was 4.3%. The admission rates were greater for those with facial fractures (P = .02) and intracranial injuries (P = .03) but lower for those with soft tissue injuries (P < .01). Street injuries resulted in a greater admission rate compared with home injuries (P = .01). CONCLUSIONS:Craniomaxillofacial injuries from hoverboard accidents have resulted in emergency department visits and hospital admissions since the vehicle's introduction to the consumer market in 2015. Most cases occurred in the winter, which might reflect increased sales and novice riders during the holiday season. Injuries to adults, in the summer or outdoors, appear to be more severe. Intracranial injuries were the most frequent diagnosis; thus, helmet wear is recommended.

BACKGROUND:Skin color matching is an essential factor in achieving optimal aesthetic outcome in partial facial transplantation. However, there is no published literature evaluating the success of color matching to date. Furthermore, a medical professional's perception of an optimal color match may not necessarily translate to that of the general public. The purpose of our study was to evaluate skin color matching between the donor allograft and recipient native tissue in partial facial transplantations to determine the level of success perceived by the general public and medical professionals. METHODS:Published photographs of partial face transplant recipients were used to create a survey where recipient native and donor allograft skin samples were juxtaposed. Thirty-three members of the general public and 30 medical professionals were asked to rate skin color match on a scale from "excellent match" to "not a match." RESULTS:Overall, 47% of given ratings were positive, indicating an "excellent" or "good match," and 53% of ratings were negative, indicating a "poor match" or "lack of match" between the skin sample pairings shown. Of the 19 partial face transplant patients who were rated, 9 patients received >50% positive ratings, and 10 patients received <50% positive ratings. Medical professionals consistently gave more positive ratings, with statistically significant differences in 7 of the 19 rated patients (P < 0.05). CONCLUSION/CONCLUSIONS:The results suggest that there is need for improvement in color matching in partial facial transplantation, and that the general public is more critical of skin color matching compared to medical professionals.

BACKGROUND:Plastic surgery education consists of technical skills, surgical decision-making, and the knowledge necessary to provide safe patient care. Competency in these modalities is ensured by requiring case minimums and oral and written examinations. However, there is a paucity of information detailing what teaching modalities residency programs use outside of the operating room. METHODS:A 16-question survey was sent to all integrated and independent program directors. Information regarding nonsurgical resident education was collected and analyzed. RESULTS:There were 44 responses (46 percent). Most programs had six to 10 faculty (43 percent), and a majority (85 percent) required faculty to participate in resident education outside of the operating room. Residents most commonly had 3 to 4 hours (43 percent) of protected educational time 1 day per week (53 percent). Nonsurgical education consisted of weekly lectures by attending physicians (44 percent) and residents (54 percent), in addition to weekly CoreQuest (48 percent), teaching rounds (38 percent), and Plastic Surgery Education Network lectures (55 percent). Monthly activities included morbidity and mortality conference (81 percent) and journal club (86 percent). Indications conference was either monthly (41 percent) or weekly (39 percent). Cadaver laboratories, visiting professors, board preparation, in-service review, and meetings with the program director occurred yearly or several times per year. Forty-nine percent of programs sponsor one educational course per resident. In addition, most programs (65 percent) do not receive outside funding for education. CONCLUSIONS:These findings improve understanding of the current state of nonsurgical resident education in plastic surgery. They illustrate that residents participate in a diverse number of nonsurgical educational activities without any significant standardization.

Cancer invading into nerves, termed perineural invasion (PNI), is associated with pain. Here we show that oral cancer patients with PNI report greater spontaneous pain and mechanical allodynia compared with patients without PNI, suggesting unique mechanisms drive PNI-induced pain. We studied the impact of PNI on peripheral nerve physiology and anatomy using a murine sciatic nerve PNI model. Mice with PNI exhibited spontaneous nociception and mechanical allodynia. PNI induced afterdischarge in A high threshold mechanoreceptors (AHTMRs), mechanical sensitization (i.e., decreased mechanical thresholds) in both A and C HTMRs, and mechanical desensitization in low threshold mechanoreceptors (LTMRs). PNI resulted in nerve damage, including axon loss, myelin damage, and axon degeneration. Electrophysiological evidence of nerve injury included decreased conduction velocity, and increased percentage of both mechanically-insensitive and electrically-unexcitable neurons. We conclude that PNI-induced pain is driven by nerve injury and peripheral sensitization in HTMRs.