Local Infiltration Anesthesia Versus Ultrasound-Guided Pectoralis (PEC1) + Serratus Anterior Plane (SAP) Blocks on Postanesthetic Care Unit Pain Control in Patients Undergoing Primary Submuscular Augmentation Mammoplasty.

BACKGROUND: Ultrasound-guided regional field blocks are not widely used in outpatient plastic surgeries. The efficacy of truncal blocks (PEC1 + SAP) has not been established in plastic surgery. The purpose of this study was to analyze the outcomes of these newer anesthetic techniques compared with traditional blind local anesthetic infiltration in patients undergoing breast augmentation. METHODS: This retrospective institutional review board-approved cohort study compared the outcomes of the different practices of 2 plastic surgeons at the same accredited outpatient surgery center between 2018 and 2022. Group 1 received an intraoperative blind local infiltration anesthetic. Group 2 underwent surgeon-led, intraoperative, ultrasound-guided PEC1 (Pectoralis 1) + SAP (serratus anterior plane) blocks. Patients who underwent any procedure other than primary submuscular augmentation mammoplasty were excluded from the study. The outcomes measured included operative time, opioid utilization in morphine milligram equivalents (MME), pain level at discharge, and time spent in the post anesthetic care unit (PACU). RESULTS: Sixty patients met the inclusion criteria for each group for a total of 120 patients. The study groups were similar to each other. Patients receiving PEC1 + SAP blocks (group 2) had significantly lower average MME requirements in the PACU (3.04 MME vs 4.52 MME, P = 0.041) and required a shorter average PACU stay (70.13 minutes vs 80.38 minutes, P = 0.008). There were no significant differences in the pain level at discharge, operative time, or implant size between the 2 groups. CONCLUSIONS: Surgeon-led, intraoperative, ultrasound-guided PEC1 + SAP blocks significantly decreased opioid utilization in the PACU by 33% and patient time in the PACU by 13%, while achieving similar patient pain scores and operating times.

Ultrasound-Guided Transversus Abdominis Plane Blocks Versus Local Infiltration Anesthesia on Postanesthesia Care Unit Pain Control in Patients Undergoing Abdominoplasty.

GOALS/PURPOSE: The goal of this study was to compare ultrasound-guided transversus abdominis plane (TAP) blocks to local infiltration anesthesia with or without blind rectus sheath blocks in patients who underwent abdominoplasty at an outpatient surgery center. METHODS/TECHNIQUE: A retrospective review was conducted of patients who underwent outpatient abdominoplasty performed by the senior surgeon (J.T.L.). Group 1 received local infiltration anesthesia with or without blind rectus sheath blocks between April 2009 and December 2013. Group 2 received surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks between January 2014 and December 2021. Outcomes measured were opioid utilization (morphine milligram equivalents), pain level at discharge, and time spent in postanesthesia care unit (PACU). RESULTS: Sixty patients in each of the 2 study groups met the study criteria for a total of 120 patients. The study groups were similar except for a lower average age in group 1. Patients who received TAP blocks (group 2) had significantly lower morphine milligram equivalent requirements in the PACU (3.07 vs 8.93, P = 0.0001) and required a shorter stay in PACU (95.4 vs 117.18 minutes, P = 0.0001). There were no significant differences in pain level at discharge. CONCLUSIONS: Surgeon-led, intraoperative, ultrasound-guided, 4-quadrant TAP blocks statistically significantly reduced opioid utilization in PACU by 65.6% and average patient time in the PACU by 18.5% (21.8 minutes).

Defining the Cervical Line in Face-Lift Surgery: A Three-Dimensional Study of the Cervical and Marginal Mandibular Branches of the Facial Nerve.

BACKGROUND: Continuous sub-superficial musculoaponeurotic system (SMAS) dissection in the cheek with subplatysmal dissection in the neck is an important feature of many face-lift techniques, yet the neural anatomy in this area remains unclear, and recommendations regarding continuous dissection of these adjacent areas vary widely. The purpose of this study was to define the vulnerability of the facial nerve branches in this transitional area from the face-lift surgeon's perspective and to specifically identify the location of the cervical branch penetration through the deep cervical fascia. METHODS: Ten fresh and five preserved cadaveric facial halves were dissected under 4× loupe magnification. The skin was reflected, followed by elevation of a SMAS-platysma flap, with identification of the location of cervical branch penetration through the deep cervical fascia. The cervical and marginal mandibular branches were then dissected retrograde through the deep cervical fascia to the cervicofacial trunk to confirm identifications. RESULTS: Cervical and marginal mandibular branch anatomy was found to be similar to that of the other facial nerve branches, all of which initially course deep to the deep fascia in their postparotid course. The emergence of the terminal branch or branches of the cervical branch through the deep cervical fascia was consistently at or distal to a line from a point 5 cm below the mandibular angle on the anterior border of the sternocleidomastoid muscle to the point where the facial vessels course over the mandibular border (cervical line). CONCLUSIONS: Continuous dissection of the SMAS in the cheek, with subplatysmal dissection in the neck crossing over the mandibular border, is possible without jeopardizing the marginal mandibular or cervical branches if done proximal to the cervical line. This study serves as the anatomical justification for continuous SMAS-platysma dissection, and has implications for all types of SMAS flap manipulations.

The Use of Mean Gray Value (MGV) as a Guide to Tension-Reducing Strategies in Body Contouring Surgery Reduces Wound-Related Morbidity.

BACKGROUND: Currently there are no known structural parameters of the integument that can be measured noninvasively which are used in the planning of body contouring surgery. OBJECTIVES: The aim of this study was to see if mean gray value (MGV), when taken into account preoperatively, can reduce wound-related morbidity. METHODS: This project was a prospective cohort study. Ultrasound imaging of the subcutaneous tissue was performed prospectively on patients undergoing body contouring surgery to quantify the superficial fascial system so that average MGV could be calculated over the proposed surgical sites. Patients with average to poor MGV (≤0.127) were identified preoperatively for tension-reducing procedures. Wound complication rates were compared with rates in a retrospective cohort which did not undergo preoperative imaging. RESULTS: There were 115 patients in each of the 2 cohorts. There were 3 exclusions due to loss of ultrasound images, leaving 112 patients available for analysis in the prospective cohort. The cohorts were similar except for a higher incidence of patients with diabetes in the retrospective group (1 vs 9, P = 0.026). The wound complication rate was significantly reduced in the prospective group (5/112, 4.4%) when compared with the retrospective group (20/115, 17%, P = 0.0062). The revision and infection rates were also significantly reduced in the prospective group (1/112, 0.9%; 3/112, 2.6%) when compared with the retrospective group (8/115, 7%, P = 0.019; 10/115 8.6%, P = 0.051). CONCLUSIONS: MGV is a unique, patient- and area-specific structural parameter of the integument, and its measurement may be useful in reducing wound-related morbidity in body contouring surgery.

Mapping 216 Perforator Flaps Using Highly Portable Tablet-Based Color Doppler Ultrasound (PT-CDU).

BACKGROUND: The first reports of using color Doppler ultrasound for evaluation of the microvasculature were in the 1990s. Despite the early reports of its efficacy, color Doppler ultrasound did not achieve popularity nor general usage in part due to the cumbersome size, cost and poor resolution. This is the first study to demonstrate the potential utility of a new, highly portable, tablet-based color Doppler ultrasound (PT-CDU) system for imaging perforator flaps. METHODS: The deep inferior epigastric artery (DIEP), lateral arm (LA), anterolateral thigh (ALT), thoracodorsal artery (TDAP), and the medial sural artery (MSAP) perforator flaps were imaged within classic topographic landmarks to visualize and measure variables related to perforator flap anatomy. The Philips Lumify L12-4 linear array probe attached to the Samsung Galaxy Tab A tablet was the system used for all examinations. RESULTS: A total of 216 flaps were scanned in 50 healthy adult volunteers: 44 DIEP, 44 LA, 40 ALT, 48 TDAP, and 40 MSAP. Precise anatomic information regarding perforator size, number, and location was obtained. Overall, the percent of flaps having at least 1 perforator within the specified topographical landmarks was 89% for the DIEP, 84.1% for the LA, 72.5% for the ALT, 50% for the TDAP, and 30% for the MSAP (p = 2.272e-09). The percent of patients having an asymmetry (right versus left) in the number of perforators was 72.7% (ALT), 65% (DIEP), 59.1% (LA), 41.7% (TDAP), and 30% (MSAP) (p = 0.0351). CONCLUSION: Portable, tablet-based color Doppler ultrasound offers high-resolution images of perforators and represents a facile technology that may be of interest to microsurgeons in the planning of perforator flaps. Variations in vascular anatomy were well-demonstrated. This surgeon-driven imaging technology may represent an excellent alternative to other imaging modalities.

Fully Digital Workflow for Fabrication of A 3D Printed Ear Stent for Auricular Keloids: A Technique Article.

Keloids are skin lesions which result from an aberration in the physiological healing process marked with overgrowth of collagen fibers. Keloid of the ear is cosmetically challenging and has an increased chance of re-growth. To minimize recurrence, pressure therapy in combination with other treatment forms has been used. Various techniques have been used to fabricate a passive or active stent. This report presents a fully digital workflow to fabricate an ear stent after intralesional excision and skin autografting of an extensive recurrence of a keloid lesion of the left ear involving the helix, antihelix, scapha, and conchal bowl.

The Case for Onlay Biologic Mesh in Abdominal Wall Reconstruction Using Progressive Tension Suture Fixation.

BACKGROUND: After many years of debate, underlay and sublay placement of mesh slowly emerged as the standard of care in abdominal wall reconstruction because of lower hernia recurrence rates. However, onlay has the advantages of being faster, less invasive, and technically easier compared with underlay and sublay. Therefore, if a similar recurrence could be achieved, then onlay should be a consideration. In this study, we present a new onlay method using multipoint progressive tension suture fixation. METHODS: This was a retrospective chart review of patients who underwent abdominal wall reconstruction from 2012 to 2019. Inclusion criteria included onlay mesh placement and at least 1 year of follow-up. The core principles of the surgical technique are establishing myofascial continuity by component separation and reinforcing the repair with onlay mesh that is fixated with multipoint progressive tension sutures. RESULTS: The number of patients after exclusions was 59, and the average body mass index was 32.52 ± 6.44 kg/m2. More than half (62.7%) of patients had a history of hypertension, 95% had at least 1 prior abdominal/pelvic surgery, and 61% had at least 1 prior hernia repair. Postoperative complications included 20.3% of patients requiring drainage of a fluid collection in the clinic setting, and 29.3% of patients requiring return to the operating room for any reason (including superficial wound debridement). The average defect size was 231.88 ± 195.86 cm2, the mean follow-up was 3.11 ± 1.83 years, and the recurrence rate was 5.1%. CONCLUSIONS: We report a hernia recurrence rate of 5.1% in a high-risk population with complex defects at a mean of 3.1 years of follow-up using onlay mesh fixated with multipoint progressive tension sutures. This recurrence rate is similar to that reported for both underlay and sublay techniques. However, the onlay approach is technically easier, faster, and less invasive compared with underlay and sublay techniques, which may translate into wider reproducibility, lower costs, and improved patient safety.

Enhanced Recovery After Surgery Protocol With Ultrasound-Guided Regional Blocks in Outpatient Plastic Surgery Patients Leads to Decreased Opioid Prescriptions and Consumption.

BACKGROUND: Opioids are a mainstay of pain management. To limit the use of opioids, enhanced recovery after surgery (ERAS) protocols implement multimodal approaches to treat postoperative pain. OBJECTIVES: The aim of this paper was to be the first to assess the efficacy of an ERAS protocol for plastic surgery outpatients that includes ultrasound-guided, surgeon-led regional blocks. METHODS: A retrospective review of patients undergoing outpatient plastic surgery on an ERAS protocol was performed. These patients were compared to a well-matched group not on an ERAS protocol (pre-ERAS). Endpoints included the amounts of opioid, antinausea, and antispasmodic medication prescribed. ERAS patients were given a postoperative questionnaire to assess both pain levels (0-10) and opioid consumption. ERAS patients anticipated to have higher levels of pain received ultrasound-guided anesthetic blocks. RESULTS: There were 157 patients in the pre-ERAS group and 202 patients in the ERAS group. Patients in the pre-ERAS group were prescribed more opioid (332.3 vs 100.3 morphine milligram equivalents (MME)/patient; P < 0.001), antinausea (664 vs 16.3 mg of promethazine/patient; P < 0.001), and antispasmodic (401.3 vs 31.2 mg of cyclobenzaprine/patient; P < 0.001) medication. Patients on the ERAS protocol consumed an average total of 22.7 MME/patient postoperatively. Average pain scores in this group peaked at 5.32 on postoperative day 1 and then decreased significantly daily. CONCLUSIONS: Implementation of an ERAS protocol for plastic surgery outpatients with utilization of ultrasound-guided regional anesthetic blocks is feasible and efficacious. The ability to significantly decrease prescribed opioids in this unique patient population is noteworthy.

Ranking United States Plastic Surgery Residency Programs Based on Academic Achievement of Faculty Members.

INTRODUCTION: The Doximity Residency Navigator is currently the only resource that ranks plastic surgery residency programs. Given the paucity of objective program rankings, in this study, we devised a new algorithm to rank plastic surgery programs based on academic achievement of faculty members. METHODS: The Fellowship and Residency Electronic Interactive Database was used to obtain the following information on plastic surgery programs: the amount of 2017 National Institute of Health and Veterans Administration funding, lifetime and 5-year faculty h-indices, and the number of faculty on editorial boards of journals. Based on all of this information, an overall ranking of the top 25 plastic surgery programs was created. RESULTS: The top program for annual National Institutes of Health and Veteran Affairs funding was the University of Southern California (integrated and independent). The top programs for faculty lifetime h-index were the University of Michigan (integrated) and New York University (independent). The top program for faculty 5-year h-index was the University of Pennsylvania (integrated and independent). The top program for the number of faculty members who are on the editorial boards of major journals was Harvard University (integrated and independent). The top program overall was Harvard University (integrated and independent). CONCLUSION: We ranked plastic surgery residency programs based on objective data related to faculty academic achievement. Academic achievement rankings are just one of numerous other factors that medical students should synthesize when making informed decisions when applying to residency.

Alloderm and Cortiva Have Similar Perioperative Wound Complications in Abdominal Wall Reconstruction.

BACKGROUND: Although controversial, the use of acellular dermal matrices (ADMs) for abdominal wall reconstruction (AWR) is increasing. There are now many different ADMs available, but there is a lack of studies directly comparing ADMs in terms of outcomes. MATERIALS AND METHODS: A retrospective chart review was performed to compare perioperative wound complications (up to 120 d postoperatively) between patients who underwent AWR with the human noncrosslinked ADMs Alloderm or Cortiva from January 2012 to March 2020. Surgical technique uniformly consisted of open component separation, onlay implantation of ADM, and progressive tension suture fixation of ADM. RESULTS: After exclusions, 53 patients were in the Alloderm group, and 29 patients were in the Cortiva group. The overall perioperative wound complication rate between Alloderm (51.92%) and Cortiva (72.41%) was not significantly different (P = 0.09921). The average follow-up for Alloderm was 76.69 ± 29.52 d and for Cortiva was 66.93 ± 35.16 d (P = 0.2088). There were no cases that required explantation of ADM. CONCLUSIONS: Given the similar perioperative wound complication profiles, the more cost-effective ADM may be a consideration for use in AWR. The fact that there were zero instances of ADM explantation also supports the use of ADM in these high-risk cases.

Ultrasound Imaging of the Superficial Fascial System Can Predict the Subcutaneous Strength of Abdominal Tissue Using Mean Gray Value Quantification.

BACKGROUND: This study is the first to correlate sonographic findings of subcutaneous tissue to structural and biomechanical properties. METHODS: Precisely sized tissue specimens (59 samples) were collected from five abdominoplasty procedures. A Philips Lumify L12-4 linear array probe, connected to an Android tablet, was used to obtain ultrasound images of the superficial fascial system. A no. 1 Vicryl suture on a CTX needle placed though a needle guide within a three-dimensionally printed template ensured equal bites of subcutaneous tissue across specimens. Suture pull-out strength was measured until failure at a displacement rate of 2.12 mm/second using an Admet MTEST Quattro. Mean gray value for the superficial fascial system in associated ultrasonographic images was quantified by CellProfiler. RESULTS: Superficial fascial system visualization can be accomplished using high-resolution portable ultrasound. Comparing multiple specimens' imaging, interpatient and intrapatient variability of superficial fascial system quantity and structural characteristics are apparent. The superficial fascial system is highly abundant in some patients, but has limited presence in others. Individual-specimen mean gray value and whole-patient mean gray value positively correlated with tissue tensile strength (p = 0.006) and patient-average tissue tensile strength (p = 0.036), respectively. Whole-patient mean gray value accounted for 98.5 percent of the variance seen in patient-average tensile strength, making it a strong predictor for tensile strength. CONCLUSIONS: Portable ultrasound and image-processing technology can visualize, quantify, and predict subcutaneous tissue strength of the superficial fascial system. The superficial fascial system quantity correlates with suture tensile strength. Clinically, preoperative superficial fascial system quantification may aid in outcome predictions, manage patient expectations, and potentially lower complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, V.

Preoperative Evaluation of the Superficial Fascial System Can Predict Wound Complications in Body Contouring Surgery.

BACKGROUND: The demand for body contouring surgery continues to rise. The inclusion of the superficial fascial system (SFS) during closure of such procedures has been shown to improve outcomes; however, currently reported wound complication rates remain high. The authors assess whether decreased quantities of SFS are associated with wound complications in these patients. METHODS: A retrospective study of patients undergoing body contouring surgery was performed. Preoperatively, ultrasound images were obtained of the SFS. Using Cellprofiler, the mean gray values (MGVs) of the SFS were calculated to quantify this structure. Chart review was performed to identify postoperative wound complications. RESULTS: Thirty-six patients were included: 30 abdominoplasties, 3 bilateral medial thigh lifts, and 3 bilateral brachioplasties. The overall wound complication rate was 22.5%. There were no significant differences in body mass index, age, smoking status, weight of resected specimen, or diabetes when comparing the complication and noncomplication groups. However, the MGV was significantly greater in the noncomplication group compared with the complication group (0.135 ± 0.008 vs 0.099 ± 0.005, respectively, P = 0.03). The average MGV for the entire cohort was 0.127. Patients with an MGV of greater than 0.127 had a wound complication rate of 0% compared with that of 39% for patients with an MGV of 0.127 or less (P = 0.005). CONCLUSIONS: Poor quantities of SFS identified by ultrasound were associated with increased wound complications in patients undergoing body contouring surgery. Furthermore, patients with better than average SFS seem to be protected from such complications.

Portable Color-Flow Ultrasound Facilitates Precision Flap Planning and Perforator Selection in Reconstructive Plastic Surgery.

BACKGROUND: Precise flap planning and perforator selection are paramount for successful perforator flap surgery. Portable color-flow ultrasound (PCFU) is a convenient, low-cost, easily accessible imaging modality that is pivotal in the planning of perforator flaps where anatomic variability is the rule. METHODS: Perforator mapping was performed using an L12-4 linear-array ultrasound probe connected to an Android tablet. Images were obtained with the Lumify app (Philips Lumify, usa.philips.com). Perforator characteristics were recorded (arterial diameter, emergence points from fascia, subcutaneous course, and projection onto the skin surface) using still images and real-time videos. RESULTS: Thirty consecutive patients had 40 perforator or musculocutaneous flap reconstructions over a 2-year period. For the 15 flaps that had preoperative computed tomographic angiography (CTA) imaging, the preoperative sonographic measurements correlated with CTA and intraoperative findings. Portable color-flow ultrasound allowed perforator flap design and selection based on the largest available perforator, the most appropriate flap thickness, and comparison of multiple donor sites including left versus right. Two deep inferior epigastric perforator patients required take-back to the operating room for debridement of devitalized nonflap tissue. The superior gluteal artery perforator flap was abandoned intraoperatively due to proximal vascular anomalies. Overall flap success rate was 98% (39/40 flaps). CONCLUSIONS: Our experience with PCFU has rapidly improved, allowing individualized perforator flap selection and design based on each patient's unique perforator anatomy, reconstructive requirements, and donor site characteristics. In our practice, PCFU has supplemented CTA and in many cases has supplanted CTA as the primary imaging modality of choice in the planning of perforator flap reconstruction.

Regional Anesthetic Blocks in Plastic Surgery Using Portable Ultrasound: A Simplified Approach.

BACKGROUND: With the introduction of latest generation ultrasound technology and its easy availability and portability, regional anesthetic blocks, which were formally in the domain of anesthesiologists, have now become available to practicing plastic surgeons. Enhanced Recovery After Surgery protocols for other specialties such as orthopedics and colorectal surgery have incorporated regional anesthetic blocks. These regional blocks have been shown to be effective in improving the patient comfort and experience and decreasing reliance on opioid medications. METHODS: Patients scheduled for elective plastic surgery received PEC-1, serratus anterior plane, or transversus abdominis plane blocks as indicated for the proposed procedure. All blocks were performed under ultrasound guidance using the Philips Lumify system with the linear array 12-4 probe by the operating surgeon. RESULTS: A total of 83 patients received regional anesthetic blocks by the senior author. Thirty-three patients undergoing cosmetic breast augmentation or implant-based breast reconstruction received the PEC-1 and the serratus anterior plane blocks after the induction of anesthesia but before the prep and drape. Fifty patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction received intraoperative transversus abdominis plane blocks. Anatomic planes were clearly visualized with this new ultrasound technology. Patients experienced good to excellent analgesia with less reliance on opioid medications and decreased need for refills. For hospitalized patients, length of stay in some cases was decreased up to 1 day, and PCA pumps were eliminated. There were no complications or adverse sequelae observed in any of these patients related to the regional blocks. CONCLUSIONS: Incorporation of these known regional anesthetic techniques in this single-surgeon experience seems to confirm reports of effectiveness in the anesthesia literature and may be of benefit to a wide range of plastic surgery patients.

Ultrasound and Plastic Surgery: Clinical Applications of the Newest Technology.

BACKGROUND: Color Doppler ultrasound (CDUS) has not been routinely used in plastic and reconstructive surgery. Barriers to use have included large, cumbersome equipment, low-definition images, cost, and availability. In addition, programs in plastic surgery have not included training with ultrasound (US); thus, many current-day practitioners are unfamiliar with and reluctant to use this technology. Nevertheless, recent studies have demonstrated the utility of US in surgical planning. With the miniaturization, clearer imaging, and decreased costs of the latest US technology, previous barriers to use have largely been eliminated. METHODS: Fifty-six patients scheduled for either reconstructive or aesthetic surgery were evaluated preoperatively and/or intraoperatively by a single surgeon with the linear 12-4 probe of a Philips Lumify CDUS device (Philips, Reedsville, Penn). For patients undergoing flap reconstruction, potential donor sites were imaged in order to locate the largest perforator. For patients undergoing abdominal procedures, intraoperative visualization of the abdominal muscular layers was used for the delivery of anesthesia during transversus abdominis plane block. Lastly, the superficial fascial system (SFS) was subjectively evaluated in all preoperative patients. RESULTS: For flap reconstruction, 11 patients were preoperatively examined with CDUS in order to locate the largest perforators prior to perforator flap reconstruction. Flaps studied included the deep inferior epigastric perforator, anterolateral thigh, tensor fascia lata, thoracodorsal artery perforator, superior gluteal artery perforator, and the gracilis musculocutaneous. Color Doppler ultrasound findings were confirmed intraoperatively for all cases (100%). In 2 (18.2%) of 11 cases, CDUS identified perforators not detected by computed tomography angiography. Twenty-five patients undergoing either abdominoplasty or deep inferior epigastric perforator flap reconstruction had successful intraoperative visualization of the abdominal wall muscular layers, thus allowing administration of transversus abdominis plane blocks by the operating surgeon. Twenty patients undergoing body contouring surgery had preoperative visualization of the SFS. The SFS was found to be varied not only among different patients but also within individual patients. CONCLUSIONS: The newest, miniaturized CDUS technology has a variety of applications that may improve patient outcomes and experience in plastic surgery. Our observations require further investigation to quantify the perceived benefits of this new technology.