Managing Alar Flare in Rhinoplasty.

Alar flare is a common feature that contributes to the width of the lower third of the nose. In the right patient, alar flare reduction can improve nasal harmony and facial aesthetic balance; however, it is also difficult to correct if conducted inappropriately or overzealously. The unique anatomy and diverse morphologies of the alar lobule, and the dynamic relationship between flare and changes in tip projection, must be considered. The authors provide guidelines for flare reduction: when it is appropriate and how to tailor the excision pattern to safely and effectively refine nasal width. Alar flare is classified into three types according to alar rim shape on basal view analysis. By designing the excision pattern based on specific flare type, the lower third of the nose is narrowed without creating an operated appearance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Simplifying the Forehead Flap for Nasal Reconstruction: A Review of 420 Consecutive Cases.

BACKGROUND: The forehead flap is an important tool in nasal reconstruction. The authors present objective data and recommendations based on over a decade of consecutive forehead flap nasal reconstructions performed by the senior author (J.F.T.). In addition, the authors separate the technique into its individual steps and provide details of the senior author's approach to each. METHODS: The authors performed a retrospective analysis of patients who underwent nasal reconstruction with the forehead flap over a 10-year period performed by the senior author (J.F.T.). Each case was evaluated for defect location, pedicle design, time of division, number of stages, use of cartilage grafts, lining reconstruction, donor-site closure, and complications. RESULTS: Four hundred twenty patients underwent forehead flap nasal reconstruction. Average time to pedicle division was 32 days. Three-fourths of patients completed reconstruction in two stages. Defects most commonly involved the nasal ala and tip. Approximately half of patients received cartilage grafts and half underwent lining reconstruction. There were 16 complications, ranging from partial flap loss to postoperative death (n = 1). CONCLUSIONS: Confidently grasping the nuances of forehead flap nasal reconstruction arms the reconstructive surgeon with a reliable tool that can effectively treat a variety of defects. It is safe to use in an outpatient setting even in elderly patients. Recommendations include ipsilateral flap design and turn-in component as the first choice for lining replacement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Perioperative Corneal Abrasion: Updated Guidelines for Prevention and Management.

Corneal abrasion is the most common ocular complication in surgery. Treatment requires pain control, antimicrobial prophylaxis, and close monitoring. Pain improves significantly after 24 hours and should be resolved by 48 hours. Persistent, worsening, or new symptoms warrant immediate specialist consultation. The authors review the pathophysiology of perioperative corneal abrasion, and propose updated evidence-based guidelines for improved patient care.

Collagenase Dupuytren Contracture: Achieving Single Treatment Success with a Hand Therapist-Based Protocol.

UNLABELLED: Surgery remains the gold standard in the treatment of Dupuytren contracture but is technically demanding, carries significant risk of complications, and requires prolonged recovery time. Collagenase injection is an efficacious alternative to surgery; however, contracture release often requires multiple treatments spaced a month apart. We report our experience with a new collagenase treatment protocol aimed to minimize the total treatment time per joint contracture. METHODS: We performed a single institution retrospective review of patients with Dupuytren contracture treated with collagenase using our protocol from 2011 to 2013. Patients returned 24 hours after collagenase injection for cord manipulation by a certified hand therapist while under digital block. Treatment success was defined as reduction in contracture to 5 degrees or less. Successfully treated joints were evaluated for recurrence (>10 degrees contracture) at 30-day and 6-month follow-up appointments. Serious adverse events, including skin tears, were recorded. RESULTS: Success was achieved in 36 of 47 treated joints (76.6%) after a single injection. There were 2 recurrences in 32 joints at 30-day follow-up (6.2%) and no recurrences in 17 joints available at 6-month follow-up. Skin tears were the only serious adverse event occurring in 18 of 47 cord ruptures (38.3%). All healed secondarily without complication. CONCLUSIONS: Our protocol preserves treatment efficacy while maximizing efficiency. Achieving successful cord rupture with a single injection allows earlier return of function, reduced cost of treatment, and increased convenience for the patient. Patients, particularly those with greater contractures, should be counseled regarding the risk of skin tear during cord manipulation.

Closed Microfracture Technique for Surgical Correction of Inferior Turbinate Hypertrophy in Rhinoplasty: Safety and Technical Considerations.

An abundance of surgical procedures are in use for the management of inferior turbinate hypertrophy in rhinoplasty patients. An ideal treatment approach is elusive, given the variability of patient presentation regarding obstructive nasal airway, significant complications associated with techniques that cause mucosal trauma, and the high recurrence rates associated with more conservative techniques. In an effort to improve patient safety, the authors describe a conservative technique-the closed microfracture-that provides an effective functional airway improvement and minimal to no complications. The authors propose a treatment approach for enlarged inferior turbinates based on turbinate subtype.

The discordant histology of grafted fat: a systematic review of the literature.

BACKGROUND: All combinations of harvesting, processing, and injection have been attempted to maximize fat graft take following transplantation. Two theories behind fat transplantation have been proposed: cell survival and host replacement. Although the cell survival theory states that fat cells survive and undergo neovascularization following transfer, host replacement theory predicts adipocyte necrosis and replacement of cells by host tissues. Whether or not transferred fat survives, proliferates, or is replaced by fibrous tissue is relevant for the investment of future resources into this thriving field of research. METHODS: A literature search of the MEDLINE and Cochrane databases was performed for studies focusing on the histology of grafted fat after transplantation up to December of 2013. Histologic examinations of grafted fat were reviewed and compared in humans and animals. RESULTS: Sixty-six articles met inclusion criteria, and eight of them were human studies. There was widespread diversity in the method of fat harvest and transfer among the studies, and the date of examination after transfer. Many studies reported the presence of viable adipocytes, although an extensive amount of fibrosis and inflammatory infiltration was also seen, depending on the period of examination. CONCLUSIONS: Free fat grafts show a variable response following transplantation, with significant disagreement in the reported evidence. Although neovascularization and preservation of adipocyte architecture appear possible, other fat grafts are completely replaced by necrotic ghost cells and fibrotic ingrowth. Adipocyte survival likely contributes to volume maintenance, but fibrosis may also play a role.

Soft-tissue composition of the columella and potential relevance in rhinoplasty.

BACKGROUND: The columella serves as the medial limb of the nasal tripod, with the medial crura functioning as the cartilaginous framework. Although soft-tissue of the columella may have both functional and aesthetic implications, it is a topic not often discussed in the rhinoplasty literature. The objective of this study was to evaluate soft-tissue histology of the columella and discuss findings that are pertinent to clinical rhinoplasty. METHODS: Ten fresh cadaver heads were obtained from The University of Texas Southwestern Willed Body Program. En bloc resections of the columella were harvested. Specimens were fixed in formalin and embedded in paraffin. Subsequently, specimens were sectioned serially and stained. Staining with hematoxylin and eosin was performed to evaluate collagen and fat composition. Van Gieson elastin stain was completed to assess for elastin fibers. RESULTS: Laterally, the columella was framed by stratified squamous epithelium, which transitioned to mucosa at the level of the membranous septum. An areolar tissue plane was found between the skin and adjacent medial crura. Much greater soft-tissue volume was present between the bilateral medial crura. Soft-tissue composition was found to be heterogenous, with varying distributions of tissue at different levels of the columella. Present in notable volume were fibroblasts, collagen fibers, elastin fibers, adipocytes, and neurovascular structures. CONCLUSIONS: Columella soft-tissue is remarkable for the presence of fibroblasts, collagen and elastin fibers, muscle fibers, and adipocytes. These findings may have significant implications regarding surgical maneuvers influencing tip projection, effects of aging on the nose, and columellar aesthetics and function.

Insights from San Francisco match rank lists, part II: are programs doing it wrong?

BACKGROUND: It is well known that the ideal method of creating rank lists for the match is the "true-preference" strategy. However, there is anecdotal and survey-based evidence that programs and applicants often deviate from this strategy. We analyzed rank lists of applicants and programs participating in the Plastic Surgery San Francisco Match to investigate whether programs were following an optimal strategy. METHODS: We obtained deidentified program and applicant rank lists and their match results from SF Match for 4 years (2010-2013). Statistical analysis was carried out with Microsoft Excel. RESULTS: The number of applicants, applications submitted, interviews offered, and match rate were all relatively stable over this 4-year period (range, 117-138 applicants, 36-41 applications, 9.0-10.3 interviews per applicant, and 78%-86% match rate). The "number needed to match" for programs was 4 (range, 1-21). A subset of applicants had poor average ranks on program rank lists but was nevertheless ranked to match by one program. Forty-six percent of these applicants matched at their top choice compared to 20% of matched controls. CONCLUSIONS: The independent Plastic Surgery Match has become less competitive over the last decade. The low average number needed to match in the context of a high applicant match rate supports the hypothesis that programs and applicants may be modifying rank lists from a true-preference list. Noncompetitive applicants are occasionally ranked to match by a program, and these applicants tend to match at their top choice far more often than the average applicant-providing further support to this hypothesis.

Insights from the San Francisco Match rank list data: how many interviews does it take to match?

BACKGROUND: For many years, the independent plastic surgery match has been regarded as a competitive process. Applicants expend significant time and resources applying to, and interviewing with, many programs to increase their chance for success. Public data from the San Francisco (SF) Match provide no predictors of success in the Match. Previous survey-based studies have provided some data, but suffer from recall and sampling bias. The purpose of this study was to provide match participants with objective primary-source data that can aid them in making informed decisions with regard to planning their interviews. METHODS: Four years of fully deidentified individual-level and program-level data from the SF Match (2010-2013) were analyzed. Data included number of programs applied to, interview offers, and length of rank lists. For applicants who matched, data included the applicant's rank of program and the program's rank of applicant. RESULTS: During the 4 match years, 434 (86.3%) of 503 applicants received at least 1 interview offer. Of these candidates, 355 (82%) matched. Match rate increased with number of interviews, reaching 96% for those with 5 or more interview offers; 95% of applicants matched within their top 7 choices. On average, applicants matched at number 2.9 on their rank lists. CONCLUSIONS: Number of interview invitations is a strong predictor of success in the independent plastic surgery match, with the "magic number" being 5. Applicants rarely match to programs below number 7 on their rank lists. These data can aid applicants wishing to maximize their potential while minimizing unnecessary expenditures.

Prosthetic breast reconstruction after implant-sparing mastectomy in patients with submuscular implants.

Women with previous submuscular breast augmentation who contract breast cancer have several options for breast reconstruction. Our institution offers implant-sparing mastectomy with delayed implant exchange. A retrospective review of 10 patients who underwent implant-sparing mastectomies with delayed implant exchange between 2006 and 2010 was performed. The average age at implant exchange was 48.7 years. The average time between initial augmentation and mastectomy was 7.45 years. The average time between mastectomy and implant exchange was 7.1 months. One patient underwent partial mastectomy with radiation. The average size of implant at initial augmentation was 366 mL. The average size of implant exchange on side of mastectomy was 565.5 mL. One patient underwent a second exchange for larger implants. No other complications were noted. Implant-sparing mastectomy with delayed exchange provides an alternative to tissue expander placement and associated morbidities. This technique provides excellent results with minimal complications for this patient population.