A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy.

BACKGROUND: Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature. METHODS: A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed. RESULTS: Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery. CONCLUSIONS: Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.

A systematic examination of the effect of tissue glues on rhytidectomy complications.

BACKGROUND: Fibrin glue has widespread use in multiple fields of surgery. There have been numerous studies on the use of fibrin glue in facelifts, with no consensus regarding differences in outcomes. OBJECTIVES: This study compared the risk of hematoma, seroma, and the 24-hour drainage volume in all published prospective controlled trials. METHODS: A MEDLINE search of English-language articles on fibrin glue and rhytidectomy published up to July 2013 yielded 49 citations. After screening, we examined 7 relevant controlled trials. The DerSimonian and Laird random-effects model was used to perform the meta-analysis. RESULTS: Seven controlled trials measuring the outcomes of fibrin glue in facelifts were used to estimate the pooled relative risk of complications and confidence intervals. Hematoma formation was four times less likely with the use of fibrin glue (relative risk 0.25, P = .002). There was no significant reduction in seroma formation (relative risk 0.56, P = .19). There was not enough data to properly measure 24-hour drainage and ecchymoses. CONCLUSIONS: This analysis suggests that fibrin glue reduces the rates of hematoma formation, but does not significantly reduce the rates of seroma development. LEVEL OF EVIDENCE: 3 Therapeutic.

The Delay Phenomenon: A Compilation of Knowledge across Specialties.

Objective The purpose of this article is to review and integrate the available literature in different fields to gain a better understanding of the basic physiology and optimize vascular delay as a reconstructive surgery technique. Methods A broad search of the literature was performed using the Medline database. Two queries were performed using "vascular delay," a search expected to yield perspectives from the field of plastic and reconstructive surgery, and "ischemic preconditioning," (IPC) which was expected to yield research on the same topic in other fields. Results The combined searches yielded a total of 1824 abstracts. The "vascular delay" query yielded 76 articles from 1984 to 2011. The "ischemic preconditioning" query yielded 6534 articles, ranging from 1980 to 2012. The abstracts were screened for those from other specialties in addition to reconstructive surgery, analyzed potential or current uses of vascular delay in practice, or provided developments in understanding the pathophysiology of vascular delay. 70 articles were identified that met inclusion criteria and were applicable to vascular delay or ischemic preconditioning. Conclusion An understanding of IPC's implementation and mechanisms in other fields has beneficial implications for the field of reconstructive surgery in the context of the delay phenomenon. Despite an incomplete model of IPC's pathways, the anti-oxidative, anti-apoptotic and anti-inflammatory benefits of IPC are well recognized. The activation of angiogenic genes through IPC could allow for complex flap design, even in poorly vascularized regions. IPC's promotion of angiogenesis and reduction of endothelial dysfunction remain most applicable to reconstructive surgery in reducing graft-related complications and flap failure.

Does empiric antibiotic therapy change MRSA [corrected] hand infection outcomes? Cost analysis of a randomized prospective trial in a county hospital.

BACKGROUND: The incidence of community-acquired methicillin-resistant Staphylococcus aureus infections is rising at an alarming pace. Effective treatment has historically involved early débridement and antibiotic administration. This study was designed to prospectively determine the effectiveness of empiric therapy in treating hand infections. METHODS: A prospective randomized trial was conducted at a level I county hospital. Patients with a hand infection received either empiric intravenous vancomycin at admission or intravenous cefazolin. Outcomes were tracked using severity of infection, appropriate clinical response, and length of stay. Cost-effectiveness was calculated using total cost for each patient in both groups. Statistical analyses were performed. RESULTS: Forty-six patients were enrolled in the study. Twenty-four were randomized to cefazolin (52.2 percent) and 22 (47.8 percent) to vancomycin. There was no statistical difference between cost of treatment (p < 0.20) or mean length of stay (p < 0.18) between the groups. Patients randomized to cefazolin had higher mean costs of treatment compared with patients who were randomized to vancomycin (p < 0.05). Patients with more severe infections had more expensive mean costs of treatment (p < 0.0001) and longer mean length of stay (p = 0.0002). Near the end of the study, the incidence of community-acquired methicillin-resistant S. aureus at the authors' county hospital was discovered to be 72 percent, which caused the study to be terminated prematurely by the institutional review board because of the high incidence precluding further randomization. CONCLUSIONS: Appropriate early treatment for methicillin-resistant S. aureus has not been definitively established. No difference in outcome using cefazolin versus vancomycin as a first-line agent was identified.

The ultra-thin, fascia-only anterolateral thigh flap.

BACKGROUND: While many potential donor sites have been described for fascial (fascia-only) flaps, a fascial flap harvested from the anterolateral thigh (ALT) donor site has not gained popularity, likely because of concerns regarding inadequate perfusion of the deep fascia. However, recent clinical experience demonstrates that the ALT fascia-only flap is a suitable option for reconstructions necessitating thin and pliable coverage. METHODS: In this study a retrospective chart review was performed examining the clinical experience of two plastic surgeons with the fascia-only ALT perforator flap from 2008 to 2012. Each flap was initially raised as a standard ALT flap, but all the overlying skin and adipose tissue was excised off the deep fascia before the inset, resulting in the creation of a fascia-only ALT flap. Immediate split- or full-thickness skin grafts were used to cover the flap. The results are reported in this article. RESULTS: Overall seven patients underwent reconstruction of wounds using either free (six) or pedicled (one) fascia-only ALT flaps (length, 10-20 cm, width, 5-10 cm). The following regions were successfully reconstructed using a fascia-only ALT flap: occipital scalp, lower extremity, upper extremity, and groin. All patients were followed for at least 6 months postoperatively. CONCLUSIONS: The fascia-only ALT flap was successfully used to reconstruct a variety of defects in seven patients. The authors experience demonstrates the viability of the fascia-only version of the ALT flap for reconstructions requiring thin coverage with good contour, and further adds to the versatility of the ALT as a donor site for flaps.

Increased FDG activity in a dermatofibroma in esophageal cancer patient.

PET using the radiotracer (18)F-FDG is used for staging patients with esophageal cancer. Nonmalignant conditions, mainly inflammation and some benign tumors, however, can cloud the clinical picture by taking up FDG and producing a false-positive result. We report the case of a 46 year-old man with squamous cell carcinoma of the thoracic esophagus who underwent combined PET/CT and had false-positive uptake in a chest wall dermatofibroma. Dermatofibroma is a benign skin lesion with a characteristic large presence of fibroblasts and macrophages. Macrophage uptake of FDG is likely responsible for the false-positive result on PET/CT.

Congenital synmastia with concurrent fibroadenomas in a pediatric patient.

Congenital synmastia, or absence of the intermammary sulcus, is a rare breast anomaly in the pediatric population. While acquired synmastia after breast augmentation is a well-documented entity, congenital synmastia is a rare condition with only four previous cases reported in the surgical literature. We describe the first patient with concurrent presentation of congenital synmastia and multiple fibroadenomas. A combined technique was used to both address the patient's breast lesions and correct the defect.

An algorithmic approach to the management of limb ischemia in infants and young children.

BACKGROUND: Vascular injuries in newborns are rare and most commonly occur in the process of obtaining vascular access for monitoring organ system functions or interventions in critical care. Care of vascular injuries in neonates poses several challenges, with the most significant arguably being the lack of clinical experience with such injuries. An algorithm for the management of arterial injuries in pediatric patients is investigated and reported. METHODS: A retrospective chart analysis was performed on all patients consulted for the management of vascular injury by the plastic surgery service at Texas Children's Hospital between 1997 and 2005. The outcomes and procedures were reviewed. RESULTS: Thirty vascular insults in 28 patients were evaluated and treated by the senior author (J.D.F.) using this protocol. Thirty-seven percent (11 of 30) were approached surgically, including two cases treated with thrombolysis alone. The remaining 63 percent (19 of 30) were managed with more conservative interventions, including anticoagulation and clinical optimization. When color Doppler imaging was used preoperatively to locate and describe the characteristics of vascular injuries, visualized lesions coincided with the surgical findings in 100 percent (11 of 11 cases). Twenty-three limbs (77 percent) were salvaged completely using this algorithm, one was initially salvaged but later developed limb-length discrepancy requiring amputation, and one experienced complete limb loss. The remaining patients (five of 30) died as a result of complications of their primary medical conditions before limb salvage could be assessed. CONCLUSION: This evaluation demonstrates the efficacy of the proposed algorithm used to determine direction of care in the event of arterial injury in small children.

Anatomy of the supratrochlear nerve: implications for the surgical treatment of migraine headaches.

BACKGROUND: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed. METHODS: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated. RESULTS: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro-orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially. CONCLUSIONS: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Implant-associated anaplastic large cell lymphoma of the breast: Insight into a poorly understood disease.

Implant-associated anaplastic large cell lymphoma (ALCL) is the subject of much debate in the field of plastic surgery. Only a few published cases have been reported and the rarity of the disease may make proving causality exceedingly difficult. Despite this, it is of utmost importance that full attention be devoted to this subject to ensure the safety and well-being of patients. The authors report one new case of implant-associated ALCL that recently presented to their institution. Implant-associated ALCL is a poorly understood disease. It should likely be considered its own clinical entity and categorized into two subtypes: one presenting as a seroma and the other as a distinct mass or masses. When reported, only textured implants have been associated with ALCL. The United States Food and Drug Administration and American Society of Plastic Surgeons have initiated a registry and have collected critical data to gain further understanding of this disease.

Le lymphome anaplasique à grandes cellules (LAGC) associé à un implant mammaire suscite d'abondants débats en chirurgie plastique. Seuls quelques cas publiés ont été signalés et, en raison de la rareté de la maladie, il est très difficile d'en prouver la causalité. Pourtant, il est capital de se pencher sérieusement sur le sujet afin de garantir la sécurité et le bien-être des patients. Les auteurs rendent compte d'un récent cas de LAGC associé à un implant mammaire au sein de leur établissement. Le LAGC associé à un implant mammaire est une maladie mal comprise. Il faudrait probablement le considérer comme une entité clinique distincte et le classer en deux sous-types: l'une se manifestant sous forme de sérome et l'autre, sous forme de masse(s) distincte(s). Seuls les implants texturés s'y associent. La Food and Drug Administration des États-Unis et l'American Society of Plastic Surgeons ont créé un registre et colligé des données essentielles pour mieux comprendre cette maladie.

Frontal sinus fractures: a conservative shift.

This article reflects on the changing management of frontal sinus fractures. Severity of these injuries has decreased tremendously since the universal adoption of seat belts and air bags. Recently, there has been a shift from aggressive surgical management to more conservative management strategies, some forgoing surgery all together. New technologies, such as bioabsorbable plates and endoscopic sinus surgery, are leading the way in improved surgical management strategies and offer promising alternatives to the more traditional approaches.

Avoidance and management of complications in soft tissue facial reconstruction.

Complications in nasal soft tissue reconstruction are inevitable, and all reconstructive surgeons should be comfortable with their management. Patient and surgical complications can be minimized with appropriate preoperative planning and coordination with the anesthesiologist. When managing undesirable results, it is important to realize that most results will improve over time with appropriate wound care and dermabrasion. Patience and attentiveness to the patient are the most-effective strategies for dealing with poor results.

Contemporary techniques for the correction of temporal hollowing: augmentation temporoplasty with the classic dermal fat graft.

INTRODUCTION: Temporal hollowing is a depression within the soft tissues overlying the temporal fossa, sometimes seen after surgical dissection for access to the facial skeleton. Surgeons have successfully used bone grafts, hydroxyapatite, methyl methacrylate, and autogenous tissue to correct the deformity. A systematic review of the literature demonstrated that the most popular technique for the correction of temporal hollowing seems to be the use of nonbiologic materials. These materials have been used successfully but are associated with some complications. There has been a growing experience with augmentation of the soft tissues of the temporal fossa using dermal fat grafts at our institutions, and this article describes this experience. METHODS: Two senior surgeons' recent experience with the correction of temporal hollowing was reviewed and analyzed. RESULTS: The retrospective review revealed 5 cases of temporal hollowing treated with dermal fat graft placement. Follow-up at 1 year revealed aesthetically pleasing results. CONCLUSIONS: A thorough understanding of temporal anatomy and conscious effort to respect structural integrity during dissection are essential in avoiding temporal hollowing. Sometimes, however, this deformity is impossible to avoid. In these patients, there are a number of options for correction. Open placement of the classic dermal fat graft is a technique that seems to offer good long-term aesthetic results.

A paradigm shift in correcting medial orbital fracture-related enophthalmos: volumetric augmentation through a lateral approach.

BACKGROUND: Posttraumatic enophthalmos resulting from medial orbital wall fractures presents a complex challenge. Access to this area through traditional incisions is limited, making visualization of the fracture site difficult. This can be ameliorated by the transcaruncular approach, but with the potential for complications both with access and with reconstructive materials. The authors sought a new technique where enophthalmos correction would be based on augmenting soft tissue volume, rather than reducing the volume of the bony orbital cone. This was successfully accomplished using porous high-density polyethylene wedges. In an effort to increase overall knowledge of this technique, a retrospective review was undertaken. METHODS: A retrospective chart review was undertaken to examine the senior authors' (J.F.T. and L.H.H.) experience using a lateral approach to address medial orbital fracture-related enophthalmos, aided by porous high-density polyethylene wedges to increase orbital volume. The relevant literature was reviewed and reported here. RESULTS: Three patients with post-medial orbital wall fracture enophthalmos were treated using a lateral approach to place porous high-density polyethylene wedges; this technique adequately corrected enophthalmos in these patients. CONCLUSIONS: Porous high-density polyethylene wedges can be placed into the orbit through a small lateral incision to reverse enophthalmos secondary to loss of volume after medial orbital wall fractures. Current techniques for orbital reconstruction typically focus on reduction of bony volume; this technique focuses on augmentation of soft tissue volume.

Optimizing pediatric interdental fixation by use of a paramedian palatal fixation site.

Condylar fractures are the most common injury seen in pediatric mandibular trauma. These injuries often cannot be adequately stabilized by conservative techniques such as splinting. The pediatric condyle fracture often requires a period of intermaxillary fixation. Because of the characteristics of the developing dentition, circumdental wiring is often not possible. Surgeons commonly achieve interdental stabilization by the connection of a circum-mandibular wire and a second wire placed through a drill hole in the piriform aperture. This method can be problematic in the young patient whose palatal suture is still patent. In this brief technical note, the use of a paramedian drill hole through the palate posterior to the maxillary incisors is described. It is believed that this method is superior to other techniques because it avoids injury to the deciduous tooth buds and allows for the maxillary wire to be seated in more structurally sound tissues.