Breast reduction in adolescents: indication, timing, and a review of the literature.

BACKGROUND: Adolescent breast hypertrophy can have long-term negative medical and psychological impacts. In select patients, breast reduction surgery is the best treatment. Unfortunately, many in the general and medical communities hold certain misconceptions regarding the indications and timing of this procedure. Several etiologies of adolescent breast hypertrophy, including juvenile gigantomastia, adolescent macromastia, and obesity-related breast hypertrophy, complicate the issue. It is our hope that this paper will clarify these misconceptions through a combined retrospective and literature review. METHODS: A retrospective review was conducted looking at adolescent females (≤18 years old) who had undergone bilateral breast reduction surgery. Their preoperative comorbidities, BMI, reduction volume, postoperative complications, and subjective satisfaction were recorded. In addition, a literature review was completed. RESULTS: 34 patients underwent bilateral breast reduction surgery. The average BMI was 29.5 kg/m(2). The average volume resected during bilateral breast reductions was 1820.9 g. Postoperative complications include dehiscence (9%), infection (3%), and poor scarring (6%). There were no cases of recurrence or need for repeat operation. Self-reported patient satisfaction was 97%. All patients described significant improvements in self body-image and participation in social activities. The literature review yielded 25 relevant reported articles, 24 of which are case studies. CONCLUSION: Reduction mammaplasty is safe and effective. It is the preferred treatment method for breast hypertrophy in the adolescent female and may be the only way to alleviate the increased social, psychological, and physical strain caused by this condition.

Treatment of mandibular angle fractures with a matrix strut miniplate.

New innovative techniques and more efficacious hardware allowing rapid and reliable fixation have resulted in better mandibular angle fracture management. This article presents follow-up data to our previous report, "Treatment of mandibular angle fracture with a matrix miniplate: a preliminary report," regarding the safety and efficacy of the 2.0 matrix strut miniplate in clinical practice. Mandibular angle fractures repaired with a single 2.0 matrix strut miniplate, using an intraoral approach, were selected for chart review over a 10-year period. Demographics including patient information, fracture etiology, site of fracture, treatment, surgical duration, and follow-up were collected. Complications were recorded along with the method of treatment. The significance (P = 0.05) of association between demographic and clinical factors with surgical complications was examined using Fisher exact tests. Thirty-four patients with mandibular angle fractures underwent matrix miniplate fixation via an intraoral approach. These patients were followed up for a mean follow-up period of 12 months. Four patients developed complications: 2 with infection requiring hardware removal and external fixation (5.9%), 1 infection treated with incision and drainage (2.9%), and 1 nonunion (2.9%). The matrix strut miniplate offers surgeons another tool to successfully accomplish mandibular fixation expediently while minimizing additional risk to patients. This system adds superior stability without negatively impacting other aspects of care and should be strongly considered for angle fixation.

Hyperplastic breast anomalies in the female adolescent breast.

Macromastia in adolescents is multifactorial and usually idiopathic, associated with obesity or hormonal imbalances. Less commonly, it can result from virginal or juvenile breast hypertrophy, a rare condition of unknown etiology, where an alarmingly rapid breast enlargement occurs during puberty. Breast hypertrophy in the adolescent population can have significant long-term medical and psychological impacts. Although symptoms can be severe, many plastic surgeons, pediatricians, and parents are often reluctant to surgically treat adolescent macromastia. However, reduction mammoplasty is a safe and effective treatment and may be the only way to alleviate the increased social, psychological, and physical strain caused by macromastia in adolescents.

Tip nuances for the nose of African descent.

Patients of African descent are seeking rhinoplasties today more than ever. As a result, the rhinoplasty surgeon must be aware of the ethnic, cultural, anatomic, and surgical issues pertaining to this patient population. In this article, the nuances of rhinoplasty as it pertains to the nasal tip in patients of African descent are discussed.

Abdominal wall reconstruction with mesh and components separation.

Incisional hernias in the abdominal wall are a by-product of multiple previous laparotomies. Unfortunately, the incidence of incisional hernias has risen, as we have progressed with new surgical techniques in the treatment of abdominal pathologies. Many methods have been attempted in the past to achieve a better and more durable repair, namely using components separation to bring the fascia into the midline, and reinforce incisional hernias with different mesh materials. The authors review the recent literature regarding the efficacy of these synthetic materials and biomaterials in incisional hernia repair, as well as share their experience in treating complex abdominal wall defects using components separation and biologic mesh.

Late seroma during pregnancy, a rare complication in prosthetic breast augmentation: case report.

A 29 year old Hispanic woman with a history of breast augmentation and a pregnancy complicated by placental abruption presented to the plastic surgery service for evaluation of a swollen right breast. The patient was examined and several tests were performed to rule out infection, galactocele, and malignancy. The swelling was attributed to fluid adjacent to her implant which was aspirated and found to contain red blood cells and foam cells but no infectious agent or malignant cells. One month after aspiration and continued drainage, the patient returned with recurrent swelling and pain. Repeat imaging showed recurrent fluid collection in the right breast. Excision and capsulectomy were performed and the patient was found to have a double capsule with a seroma. This article presents the first known case of pregnancy-associated late implant seroma formation, as well as a brief review of the literature regarding this rare finding in prosthetic breast augmentation.

Experience of sternal secondary closure by means of a titanium fixation system after transverse thoracosternotomy.

Sternal dehiscence is a common complication after transverse thoracosternotomy in patients undergoing bilateral sequential lung transplantation (BSLT). These patients can be treated with conservative therapy, but severe dehiscence requires surgical reapproximation and secondary closure of the sternum. Seventy-one cases of patients who underwent BSLT between January 2007 and May 2009 were reviewed retrospectively. Out of 71 patients, the sternum was intact in two cases due to the use of bilateral anterolateral thoracotomy, and a clamshell incision had been utilized in 69 patients. Four patients (6.8%) presented with persistent chest pain with severe sternal dehiscence diagnosed by chest X-ray and/or chest computed tomography, and underwent sternal reapproximation using the Synthes Titanium Sternal Fixation System for longitudinal sternal plating. All four patients had successful sternal realignment and resolution of their preoperative clinical symptoms. No perioperative or postoperative complications were observed. The Synthes Titanium Sternal Fixation System is an appropriate and effective method for internal fixation of the sternum when used for symptomatic severe sternal dehiscence after sequential BSLT via transverse thoracosternotomy.

The variable position of the ear in lambdoid synostosis.

Isolated unilateral lambdoid craniosynostosis is often confused with posterior positional plagiocephaly because of a general overlap in their clinical presentations; however, distinction between these 2 entities is important because of the differences in appropriate management. Historical literature teaches that ear position is posterior in lambdoid synostosis, whereas it is anterior in positional plagiocephaly. Recently, several cases of anterior ear position in isolated unilateral lambdoid synostosis presented to the Texas Children's Hospital. A review of the cases and literature revealed that there are now 37 cases of unilateral lambdoid synostosis in the literature in which ipsilateral ear position is reported. Twelve cases (32%) had anteriorly displaced ears, 6 cases (16%) were nondisplaced, 7 cases (19%) were displaced posteriorly, 4 cases (11%) anteroinferiorly, 1 case (3%) inferiorly, and 7 cases (19%) posteroinferiorly. Based on this review, it seems that the diagnostic significance of the external ear position is unclear at this point.

Contemporary techniques in inferior turbinate reduction: survey results of the American Society for Aesthetic Plastic Surgery.

BACKGROUND: Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management. OBJECTIVE: The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author's (SS) preferred technique. METHODS: A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy. RESULTS: One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%). CONCLUSIONS: Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon's skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.

Reconstructive outcomes in patients with sarcoma of the breast.

BACKGROUND: Primary soft-tissue sarcomas account for less than 1 percent of all breast malignancies. Many of these are associated with prior radiation therapy. Few studies have evaluated this patient population. The purpose of this study was to examine reconstruction techniques and outcomes in a cohort of patients with breast sarcoma to elucidate the optimal type and timing of reconstruction. METHODS: The authors conducted a retrospective review of all patients diagnosed and treated for soft-tissue breast sarcomas between July 1, 1988, and December 9, 2009, at a tertiary cancer center. Data collected included demographics, histology, oncologic and reconstructive treatment, and clinical outcomes. RESULTS: Twenty-three breast sarcoma patients underwent 24 reconstructions. The mean age at diagnosis was 42 years (range, 17 to 78 years). The most common histologic finding was angiosarcoma; six of the 11 angiosarcomas developed following irradiation for either breast carcinoma or lymphoma. The median follow-up was 44 months. Twenty patients were alive through the follow-up period. Reconstruction was immediate in 20 cases and delayed in four. The reconstruction used autologous tissue in 16 cases, implants in five, and both in three. All patients who underwent irradiation during treatment underwent autologous tissue reconstruction. Surgical complications included implant displacement, tissue expander displacement, total flap loss, seroma, implant exposure, and partial skin graft loss. CONCLUSIONS: Soft-tissue breast sarcomas are uncommon and demand aggressive, multimodal treatment and well-planned reconstruction. Most sarcoma patients receive radiotherapy; to minimize complications, we recommend delayed autologous reconstruction after completion of radiotherapy.

Pearls of mandibular trauma management.

Mandibular trauma is a common problem seen by plastic surgeons. When fractures occur, they have the ability to affect the patient's occlusion significantly, cause infection, and lead to considerable pain. Interventions to prevent these sequelae require either closed or open forms of reduction and fixation. Physicians determining how to manage these injuries should take into consideration the nature of the injury, background information regarding the patient's health, and the patient's comorbidities. Whereas general principles guide the management of the majority of injuries, special consideration must be paid to the edentulous patient, complex and comminuted fractures, and pediatric patients. These topics are discussed in this article, with a special emphasis on pearls of mandibular trauma management.

Abdominal wall repair using human acellular dermal matrix: a follow-up study.

BACKGROUND: The role of acellular dermal matrix (ADM) in abdominal wall reconstruction (AWR) is unclear. The aim of this study was to review the management, complications, and long-term outcomes of AWR using ADM in a large surgical cohort. METHODS: Retrospective chart review of patients undergoing AWR using ADM from 2004 to 2007 was performed. Demographic data, comorbidities, complications, and long-term outcomes were collected. RESULTS: There were 77 cases in 68 patients with mean age of 61.1 +/- 1.4 years. The most common indication was infected fascia (n = 19 [25%]). Wound closure was achieved in 75% of the cases via primary (n = 26 [45%]), secondary intention (n = 17 [29%]), or skin graft (n = 15 [26%]). Nonprimary closure was achieved in 5.7 +/- .7 months. There were 32 perioperative (39%) and 33 long-term (43%) complications. Over a mean follow-up period of 13.2 +/- 1.5 months, the hernia recurrence rate was 27% (n = 21). CONCLUSION: Although ADM is a viable option in AWR, the high hernia recurrence rate warrants a continued search for alternative biologic materials to improve outcomes.

Effective breast reconstruction in female veterans.

BACKGROUND: Despite increasing female veteran numbers, literature regarding reconstruction after breast cancer is lacking. The purpose of this study was to examine breast reconstruction referral rates and reconstruction outcomes at a tertiary Veterans Affairs hospital. METHODS: Female breast cancer patients (1997-2008) were identified. Demographics, tumor stage, oncologic therapies, reconstructive timings and procedures, and complications were noted. RESULTS: Eighty-two women underwent mastectomy (46%) or breast conservation (43%). The referral rates to plastic surgery were 61% (mastectomy) and 32% (overall). Reconstruction rates were 42% (mastectomy) and 22% (overall). Sixty-nine percent were suitable candidates and chose immediate (67%) or delayed (33%) reconstruction, with implant-based (44%), autologous (39%), or autologous plus implants (17%). There were complications (28%) but no mortalities. Comorbidities were not correlated with outcomes. CONCLUSIONS: Breast reconstruction can be effectively delivered within the Veterans Affairs system. It is essential that sufficient Veterans Affairs resources be deployed to address the increasing reconstructive needs of female veterans.

Tongue dysmorphology in craniofacial microsomia.

BACKGROUND: Craniofacial microsomia is one of the most common and well-characterized craniofacial anomalies. Tongue dysmorphism, however, has been neither thoroughly investigated nor reported in the context of this disease. This review focuses on the true prevalence of tongue dysmorphology in craniofacial microsomia and its relation to the deformities seen in this condition. METHODS: A 20-year retrospective study was performed to determine the number of patients who had a documented tongue anomaly and any relation to the development of abnormal speech. In recognition of the limitations of this approach, a 1-year prospective study was also performed to see the true prevalence of tongue dysmorphology in these patients. RESULTS: Eight of 167 patients (4.8 percent) in the retrospective study were found to have tongue dysmorphologies, as opposed to 24 of 55 (43.6 percent) in the prospective study. The majority of tongue anomalies were mild. Of the eight retrospective patients, seven currently have intelligible speech with a combination of intensive speech therapy and/or surgical correction. The eighth patient is without intelligible speech. Tongue dysmorphology was positively correlated with the degree of hard- and soft-tissue deformity. CONCLUSIONS: Tongue dysmorphologies in craniofacial microsomia, although usually mild, are frequently overlooked. The correlation of the tongue, soft tissue, and mandible anomalies may point to a common error early in gestation or an interdependence of adjacent growth centers.

Keloids: pathogenesis, clinical features, and management.

Cutaneous wound healing is a complex response to skin injury. Deregulation of this process can lead to excessive scar formation, as seen in keloids. Keloids are common skin lesions that are difficult to treat and are associated with high recurrence rates despite the large number of available treatment options. With increased knowledge of the disease process and further scientific advancements, future approaches will hopefully improve keloid treatment. In this article, we review the epidemiology, genetic basis, etiology, clinical features, pathogenesis, and management of keloids.

The changing epidemiologic spectrum of single-suture synostoses.

PURPOSE: Classic literature indicates an infrequency of metopic craniosynostosis (3 to 10 percent) compared to other single-suture craniosynostosis. Recent observation challenges these conceptions, warranting long-term demographic analysis. METHODS: Syndromic craniofacial dysostoses and multiple suture involvement were exclusion criteria, leaving only single suture synostoses treated between 1975 and 2004. A chart review was performed and patient information recorded. Chi square analysis and Fisher's exact were used to determine differences in patient characteristics. A Moran's I statistic was used to determine differences in spatial means and whether changes in incidence of single-suture synostoses over time are a function of regional phenomena. RESULTS: Over 800 patients presented to The Children's Hospital of Philadelphia with a diagnosis of single-suture synostosis. There was an outpacing of sagittal suture involvement over other sutures. Data demonstrate a decrease in unicoronal synostosis and an increase in metopic synostosis (p = 0.011). Geostatistical analysis reveals increasing separation between populations over the study period: 9.8 miles in the first 5 years to 20.8 miles in the last 5 years. Metopic maternal age increased between 1975-1989 and 1990-2004 (p = 0.002, 0.0002), while unicoronal maternal age did not. The proportion of male patients increased considerably in the metopic group compared to unicoronals from 1990-2004 (p = 0.0001), as did the proportion of syndromic metopic patients (p = 0.02). Plausible etiologies for these epidemiological shifts are discussed. CONCLUSIONS: Metopic synostosis is on the rise. Changing demographic bases and increasing proportions of syndromic patients may be clues to the etiology of this epidemiologic event.