Societal-Perceived Health Utility of Hypertrophic Facial Port-Wine Stain and Laser Treatment.

Background: Port-wine stain (PWS) is a congenital capillary malformation occurring commonly in the head and neck. Left untreated, affected areas may darken and hypertrophy over time, resulting in pronounced disfigurement, risk of spontaneous hemorrhage, and functional impairment. The burden of hypertrophic facial PWS and the benefit of laser therapy have not heretofore been well characterized. Herein, the health utility of these two states is assessed among naïve observers. Methods: Naïve observers (n = 262) ranked the utility of four randomized health states (monocular blindness, binocular blindness, hypertrophic facial PWS, and laser-treated facial PWS) by means of visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO) techniques. Health states are presented using standardized facial photographs. Results: Health utilities (VAS, SG, and TTO) were reported as follows (mean ± standard deviation): monocular blindness (0.73 ± 0.21, 0.86 ± 0.21, 0.87 ± 0.18), binocular blindness (0.51 ± 0.26, 0.72 ± 0.27, 0.69 ± 0.27), hypertrophic facial PWS (0.71 ± 0.24, 0.83 ± 0.23, 0.83 ± 0.21), and laser-treated facial PWS (0.87 ± 0.16, 0.91 ± 0.18, 0.92 ± 0.16). Laser-treated facial PWS showed significantly higher utility measures than the untreated hypertrophic state (p < 0.001, all measures), with a difference of 3.24 quality-adjusted life years. Linear regression analysis revealed that non-Caucasian race and higher level of education were associated with lower SG and TTO utility scores for the hypertrophic facial PWS state among naïve observers. Conclusions: Societal-perceived utility of hypertrophic facial PWS is similar to that of monocular blindness. Laser-treated facial PWS is perceived significantly more favorably than the untreated hypertrophic state. These findings provide insight into the societal burden of facial PWS and impact of laser treatment, facilitating objective comparisons with other disparate disease states.

Evidence-Based Performance Measures for Autologous Breast Reconstruction: An American Society of Plastic Surgeons Quality Performance Measure Set.

The American Society of Plastic Surgeons commissioned the Autologous Breast Reconstruction Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing autologous breast reconstruction and other breast reconstruction surgery. Four outcome measures and one process measure were identified. Outcomes include patient satisfaction with information for all breast reconstruction, a subscale of the BREAST-Q, and the length of stay, operative time, and rate of blood transfusion for autologous blood transfusion. The process measure looks at coordination of care around managing the breast reconstruction patient's care, with the physician coordinating the ongoing care, be it an oncologist, radiologist, other specialist, or primary care physician. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and the American Society of Plastic Surgeons Executive Committee. The Work Group recommends the use of these measures for quality initiatives, continuing medical education, maintenance of certification, American Society of Plastic Surgeons' Qualified Clinical Data Registry reporting, and national quality-reporting programs.

Population-Based Health Utility Assessment of Migraine Headache Symptoms before and after Surgical Intervention.

BACKGROUND: Approximately 30 million Americans suffer from migraine headaches. The primary goals of this study are to (1) use Migraine-Specific Symptoms and Disability criteria and Migraine Headache Index to describe the symptomatic improvement following decompressive surgery for refractory migraines, and (2) use the average Migraine Headache Index preoperatively and postoperatively for health utility assessment from a healthy patient's perspective. METHODS: The Migraine-Specific Symptoms and Disability criteria and the Migraine Headache Index were used to characterize migraine symptoms in the authors' patient population before and after decompressive surgery. Healthy individuals were randomized to a scenario in which they assumed either the preoperative or postoperative average patient symptom profile described by the authors' migraine patients. Health utility assessments were used to quantify the evaluation of health states the authors' patients experienced before and after surgical migraine therapy. RESULTS: Twenty-five patients underwent surgery for migraine headaches. The Migraine-Specific Symptoms and Disability questionnaire showed a significant decrease in both frequency of headaches per month (p < 0.0001) and overall pain score (p = 0.007). The Migraine Headache Index demonstrated a statistically significant improvement (p = 0.03). Healthy individuals in the preoperative group had significantly lower utility scores compared with the postoperative group in all of the health utility assessments completed for migraine symptoms. CONCLUSION: This is the first study to use health utility assessments to attest the efficacy of decompressive therapy by demonstrating the population perspective, which perceived a significant improvement in quality of life following the surgical treatment of migraines in the authors' patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Single Staged Mastopexy With Autologous Fat Grafting: An Alternative to Augmentation Mastopexy With Implants.

BACKGROUND: Improving the ptotic breast with mastopexy and restoring upper pole fullness with augmentation continues to be a challenging issue for plastic surgeons. Autologous fat grating (AFG) for shaping and contouring of implant augmented breasts has shown positive outcomes with few complications. OBJECTIVES: The objective of this study was to evaluate our experience with combined mastopexy and fat grafting for women with existing breast ptosis who prefer not to receive prosthetic breast implants but do desire volume enhancement. METHODS: A retrospective review of patients undergoing a single staged mastopexy with AFG, from 2006 to 2017, was performed. Inclusion criteria were women with breast ptosis or tuberous breasts desiring improved breast shape and volume. Patients were excluded if they were undergoing implant removal before the procedure. Clinical aesthetic outcomes were assessed by fellow plastic surgeons according to the Telemark Breast Scoring system. RESULTS: A total of 284 breasts, in 140 women, underwent a single staged mastopexy with AFG. The mean amount of fat grafted per breast was 299.4 mL (range, 50-710 mL). There were no surgical site infections, hematomas, or seromas. There were 3 major and 8 minor (0.06%) postoperative breast complications. A total of 13 plastic surgeons, of the 183 invited (7.1%), completed the breast outcomes survey. Regarding each category, there was significant improvement (P ≤ 0.0001) in upper pole fullness, ptosis, overall aesthetics, and symmetry postoperatively. CONCLUSIONS: AFG combined with mastopexy is not associated with significant postoperative complications and results in excellent breast aesthetic outcomes.

Health utility of rhinectomy, surgical nasal reconstruction, and prosthetic rehabilitation.

OBJECTIVES: Advanced nasal malignancies may require rhinectomy, which can have profound psychosocial impacts. Rhinectomy defects can be rehabilitated through surgery or prosthetics. We seek to understand the health utility of the rhinectomy defect, surgical, and prosthetic reconstruction, which have not been previously studied. STUDY DESIGN: Prospective clinical study METHODS: Adult naïve observers (n = 273) ranked the utility of five randomized health states (monocular blindness, binocular blindness, post-rhinectomy nasal defect, postsurgical reconstruction, and post-prosthetic rehabilitation). Health utilities were measured using visual analogue scale (VAS), standard gamble (SG), and time trade-off (TTO). One-way analysis of variance (ANOVA) with post hoc Scheffe's test and the independent samples T-test for a priori comparisons were performed. Multiple linear regression was performed using participant demographics as independent predictors of utility scores. RESULTS: Health utilities (VAS, SG, TTO) were reported as follows (mean ± SD): monocular blindness (0.71 ± 0.21, 0.84 ± 0.20, 0.85 ± 0.19), binocular blindness (0.48 ± 0.25, 0.68 ± 0.28, 0.63 ± 0.28), post-rhinectomy nasal defect (0.59 ± 0.24, 0.74 ± 0.24, 0.74 ± 0.24), postsurgical reconstruction (0.88 ± 0.16, 0.90 ± 0.18, 0.89 ± 0.13), and post-prosthetic rehabilitation (0.67 ± 0.22, 0.80 ± 0.23, 0.82 ± 0.20). Both surgical reconstruction (P < .001) and prosthetic rehabilitation (P < .001) significantly improved health utility. SG and TTO utility scores were inversely associated with observer age (P < .001) and participants who identified themselves as non-Caucasians (P < .05) in post-rhinectomy nasal defect, post-nasal surgical reconstruction, and post-nasal prosthetic rehabilitation health states, while higher levels of education were directly associated with SG scores (P < .05), respectively. CONCLUSION: This is the first study to demonstrate the significant negative impact of the rhinectomy nasal defect on health utility. Rehabilitation by surgical or prosthetic techniques significantly increases health utility as rated by naïve observers. Laryngoscope, 130:1674-1679, 2020.

Can It Be Safe and Aesthetic? An Eight-year Retrospective Review of Mastopexy with Concurrent Breast Augmentation.

BACKGROUND: The safety of concurrently performing mastopexy and breast augmentation is controversial, due to the risk of breast tissue and nipple neurovascular compromise and overall potential high complications rates. This article describes a concurrent procedure of augmentation with implants and a "Tailor-Tack" mastopexy that consistently achieves an aesthetically pleasing breast with acceptable complication rates. METHODS: This is a retrospective chart review of all consecutive breast augmentations performed concurrently with mastopexy using the "Tailor-Tack" technique by the 2 senior authors (M.M. and O.T.) over an 8-year period. Independent variables were patient demographics, surgical approach, implant type, shape, size, duration of follow-up, and complications. Complications were categorized as "early" (ie, first 30 days) or "late" (ie, after 30 days). Potential early complications include hematoma, skin necrosis, infection, and nipple loss. Potential late complications include recurrent breast ptosis, poor shape of the nipple areolar complex, hypertrophic scarring, implant rupture, capsular contracture, decreased nipple sensation, implant extrusion, reoperation, and scar revisions. The key principle of the technique is to place the breast implant in the dual plane first, and then perform the tailor tacking of the skin for the mastopexy second. RESULTS: Fifty-six consecutive patients underwent augmentation and mastopexy over 8 years with this technique. The average age of the studied patients was 41.2 years. The average follow-up time period was 2.1 years (±8.9 months). Fifty-four patients (96.4%) had implants placed through the periareolar approach, 2 patients (3.6%) had implants placed via the inframammary approach. All implants were placed in a dual plane. Fifty-two patients (92.9%) received silicone implants and 4 patients (7.1%) received saline implants. Patient preference determined implant choice. All but 5 patients had textured implants. Average implant size was 277 cm3 (range 120-800 cm3). Ten patients had complications (17.9%). Complications included hypertrophic scarring in 5 (8.9%) patients; poor nipple-areola complex shape in 4 patients (7.1%); implant ruptures in 3 patients (5.4%); capsular contracture in 3 patients (5.4%); and recurrent ptosis in 2 patients (3.6%). There were no reported early complications such as nipple loss, breast skin necrosis, decreased nipple sensation, implant infections, or extrusions. However, 6 patients (10.7%) required return trips to the operating room for revisions, and 1 patient (1.8%) had a nipple areolar complex scar revised in the office, yielding a 12.5% surgical revision rate for the late complications. CONCLUSIONS: It is safe to concurrently perform mastopexy and breast augmentation. In our 8-year review, there were no early catastrophic complications such as skin loss, nipple loss, implant extrusion, or infection. The complications that occurred were the same complications known to occur with the independent performance of mastopexy alone or breast augmentation alone, and they occurred at rates comparable to or less than the national averages for those procedures when they are performed independently. The paramount principle for the success of this technique is to first adjust breast volume and then perform an intraoperatively determined skin resection to fit the new breast volume.

American Society of Plastic Surgeons Member Post-Operative Opioid Prescribing Patterns.

INTRODUCTION: Despite the widespread use of opioids in pain management, there are currently no evidence-based guidelines for the treatment of postoperative pain with opioids. Although other surgical specialties have begun researching their pain prescribing patterns, there has yet to be an investigation to unravel opioid prescribing patterns among plastic surgeons. METHODS: Survey Monkey was used to sample the American Society of Plastic Surgeons (ASPS) members regarding their opioid prescribing practice patterns. The survey was sent randomly to 50% of ASPS members. Respondents were randomized to 1 of 3 different common elective procedures in plastic surgery: breast augmentation, breast reduction, and abdominoplasty. RESULTS: Of the 5,770 overall active ASPS members, 298 responses (12% response rate) were received with the following procedure randomization results: 106 for breast augmentation, 99 for breast reduction, and 95 for abdominoplasty. Overall, 80% (N = 240) of respondents used nonnarcotic adjuncts to manage postoperative pain, with 75.4% (N = 181) using nonnarcotics adjuncts >75% of the time. The most commonly prescribed narcotics were Hydrocodone with Acetaminophen (Lortab, Norco) and Oxycodone with Acetaminophen (Percocet, Oxycocet) at 42.5% (N = 116) and 38.1% (N = 104), respectively. The most common dosage was 5 mg (80.4%; N = 176), with 48.9% (N = 107) mostly dispensing 20-30 tablets, and the majority did not give refills (94.5%; N = 207). CONCLUSIONS: Overall, plastic surgeons seem to be in compliance with proposed American College of Surgeon's opioid prescription guidelines. However, there remains a lack of evidence regarding appropriate opioid prescribing patterns for plastic surgeons.

Mosaic Fleur-de-Profunda Artery Perforator Flap for Autologous Breast Reconstruction.

Perforator-free flaps, in autologous breast reconstruction, have expanded to exploit tissue available at smaller donor sites while retaining high success and low risk rates. Abdominal based flaps, such as the deep inferior epigastric perforator, remain the most common; however, when the abdomen is not an appropriate donor site, lower extremity flaps are options. The profunda artery perforator has the benefit of hiding unsightly scar in the gluteal crease but has the drawback of poor donor site volume. Our mosaic fleur-de-profunda artery perforator flap technique for breast reconstruction has shown to increase volume with the addition of a vertical limb, include full angiosome of perforators, and exhibit donor site morbidity equivalent to a medial thigh lift.

Stacked Lateral Thigh Perforator Flap as a Novel Option for Autologous Breast Reconstruction.

BACKGROUND: Autologous breast reconstruction using perforator flaps offers excellent outcomes, minimizes donor-site morbidity, and allows for precise donor-site selection. The deep inferior epigastric artery perforator, profunda artery perforator, and gluteal artery perforator flaps along with the stacked flap technique are the most common options. This study reports the first series of the stacked lateral thigh perforator flap. METHODS: A retrospective review of all stacked lateral thigh perforator flaps done by a single group of surgeons was performed. Demographics, flap weights, complications, indications, and surgical technique were tabulated for each patient. RESULTS: Eight female patients with a history of breast cancer underwent delayed unilateral breast reconstruction with stacked lateral thigh perforator flaps for a total of 16 flaps. Mean patient age, body mass index, flap weight, and stacked flap weight were 47.3 years, 26.2 kg/m, 333.1 g, and 666.1 g, respectively. Microsurgical revascularization was completed in anterograde and retrograde fashion to the internal mammary vasculature. Flap survival was 100 percent and one subsequent flap revision was performed. Two patients developed a seroma at the donor site. Indications included insufficient abdominal tissue, prominent lateral thigh lipodystrophy, prior abdominal surgery, and failed prior abdominally based autologous reconstruction. CONCLUSIONS: This series demonstrates that the lateral thigh perforator flap is a reliable and effective option for a stacked breast reconstruction. Its ease of harvest (stemming from reliable anatomy), straightforward dissection, and intraoperative positioning make it an appealing flap option. The stacked lateral thigh perforator flap allows the reconstructive surgeon to tailor breast reconstruction to the patient, focusing on body habitus and minimizing morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Botulinum Toxin A: A Novel Therapeutic Modality for Upper Extremity Chronic Regional Pain Syndrome.

BACKGROUND: Complex regional pain syndromes (CRPS) is a disease that is poorly understood. It is a chronic pain syndrome characterized by sympathetic disruptions as well as CNS sensitization. Botulinum Toxin-A has been shown to have efficacy in Raynaud's as well as other neuropathic pain disorders. Perhaps BTX-A warrants experimentation in the treatment of CRPS. METHODS: Patients with CRPS refractory to 2 or more regional sympathetic nerve blocks in 2007 were included in the study. Patient's were asked to rank their initial pain on a visual analog scale of 0 to 10 (10 being the worst pain). "Tenderness maps" were marked on patient's areas of most pain in 1 by 1 centimeter grids. Each box on the grid was injected with 10 IU of BTX-A after nerve blocks with 1% lidocaine. Treatment sessions occured on a monthly basis with VAS pain scores being re-assessed immediately before the new treatment. t Test, linear regression, and Cohen's D-test were used to analyze the correlation of the data. RESULTS: Study sample was 20 patients. Etiology of CRPS was 6 amputations, 4 crush injuries, 4 penetrating injuries, and 2 lacerations. Average pain reduction on VAS scale achieved was 2.05 points. Average percentage pain reduction was 22.94%. Cohen's D Test also showed a meaningful difference with a score of 1.01. Linear regression R2 = 0.491. Maximum pain reduction, on average, was achieved by treatment 9. CONCLUSION: Despite the esoteric etiology of CRPS, BTX-A has a well-demonstrated mechanism of effect. BTX-A should be further explored as a treatment modality for CRPS.

Assessing Age as a Risk Factor for Complications in Autologous Breast Reconstruction.

BACKGROUND: Breast cancer is primarily a diagnosis of older women. Many patients seeking breast reconstruction are elderly women (aged 65 years or older). However, many surgeons anecdotally believe that surgery in elderly patients is inherently dangerous, or at least prone to more complications. METHODS: The authors conducted a retrospective cohort study composed of chart review of all deep inferior epigastric perforator flap breast reconstruction patients at a single institution divided into an elderly cohort (65 years or older) and a nonelderly cohort (younger than 65 years). Cohort was the primary predictor variable. Demographic and comorbidity data were secondary predictor variables. Primary outcomes were complete flap loss, partial flap loss, or need for flap reexploration. Secondary outcomes such as wound healing problems, seroma, and others were also assessed. RESULTS: There were 285 flaps in the nonelderly cohort and 54 flaps in the elderly cohort. The elderly cohort had higher rates of diabetes, hypertension, and hyperlipidemia. Chi-square analysis showed no significant differences in primary outcomes between the two cohorts. Breast wound dehiscence was significantly higher in the elderly cohort (p < 0.01). On logistic regression, being elderly was seen as a significant risk factor for complete flap loss (OR, 10.92; 95 percent CI, 0.97 to 122.67; p = 0.05). The overall success rate for the nonelderly cohort was 99.6 percent, whereas the success rate for the nonelderly cohort was 96.3 percent. CONCLUSIONS: Elderly women desire breast reconstruction. Free flap breast reconstruction is a viable and safe procedure in these patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Peroneal Nerve Repair of a 9 Year Old: Return of Motor Function after 2 Years.

Major factors that influence functional nerve recovery, postrepair, are length of the nerve defect, type of injury, operative technique, time until treatment, and age of the patient. We present a severe motor nerve defect in a complicated peroneal nerve injury in a 9-year-old that showed functional return after a delayed period of 23 months with sural nerve cable grafting. This case revealed the increased resiliency and regenerative capacity of motor end plates in young patients. In conclusion, autograft for a deep peroneal nerve repair, by means of sural nerve graft, proved to be an acceptable option in children.

Association of Hair Loss With Health Utility Measurements Before and After Hair Transplant Surgery in Men and Women.

IMPORTANCE: Androgenetic alopecia is a highly prevalent condition across both sexes and can be surgically corrected through hair transplant. Health utility scores, which represent quantitative estimates of individual preferences for a given state of health, are a measure of health-related quality of life. The health utility scores for sex-specific alopecia and the posttransplant state have not previously been quantified. OBJECTIVE: To obtain health utility measurements for the objective assessment of sex-specific alopecia and hair transplant surgery and to analyze layperson perception of alopecia compared with other chronic health conditions. DESIGN, SETTING, AND PARTICIPANTS: A prospective clinical study was conducted from August 1 to December 31, 2017, at the Harvard Decision Science Laboratory. Adult casual observers (n = 308) completed an internet-based health utility questionnaire. Health states were presented using still patient images and a description of 5 health states, including monocular blindness, binocular blindness, male alopecia, female alopecia, and male posttransplant state. MAIN OUTCOMES AND MEASURES: Health utility measures of sex-specific alopecia, posttransplant state, and monocular and binocular blindness were measured by visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO) in quality-adjusted life-years (QALYs). Groups were analyzed with 1-way analysis of variance and post hoc Tukey pairwise comparison. RESULTS: The 308 participants included 157 (51.0%) women with a mean (SD) age of 30.8 (13.5) years. Mean (SD) health utility measures included 0.85 (0.18) QALYs for the VAS, 0.93 (0.17) QALYs for the SG, and 0.93 (0.17) QALYs for the TTO in male alopecia; 0.83 (0.19) QALYs for the VAS, 0.92 (0.17) QALYs for the SG, and 0.91 (0.18) QALYs for the TTO in female alopecia; and 0.93 (0.11) QALYs for the VAS, 0.95 (0.15) QALYs for the SG, and 0.95 (0.16) QALYs for the TTO in a man in the posttransplant state. The mean (SD) health utility of monocular blindness was 0.76 (0.17) QALYs for the VAS, 0.87 (0.21) QALYs for the SG, and 0.86 (0.20) QALYs for the TTO. The health utility score for the posttransplant state was significantly improved compared with the health utility score for alopecia in both sexes (female VAS: +0.10 [95% CI, 0.06-0.14; P < .001]; male VAS, +0.08 [95% CI, 0.04-0.12; P < .001]). Hair loss in women and men demonstrated significantly lower QALYs on the VAS compared with the posttransplant state (female: -0.10 [95% CI, -0.14 to -0.06; P < .001]; male: -0.08 [95% CI, -0.12 to -0.04; P < .001]). CONCLUSIONS AND RELEVANCE: Alopecia has a meaningful negative influence on health utility measures in both sexes. Hair transplant surgery significantly increases health utility measures compared with untreated alopecia in both sexes as rated among layperson observers. LEVEL OF EVIDENCE: NA.

Evaluation of Societal Health Utility of Facial Palsy and Facial Reanimation.

IMPORTANCE: The severity of a health state may be quantified using health utility measures. The utility of flaccid unilateral facial paralysis and unilateral moderate to severe postparalytic facial nerve syndrome with synkinesis may be challenging to discern from photographs alone. OBJECTIVE: To determine the societal health utility of flaccid unilateral facial paralysis, unilateral moderate to severe postparalytic facial nerve syndrome, and post-facial reanimation using standard video. DESIGN, SETTING, AND PARTICIPANTS: This survey study was conducted at the Massachusetts Eye and Ear and the Harvard Decision Science Laboratory from June 14, 2017, to August 3, 2017. Healthy adult naïve observers were recruited through advertising in the Cambridge, Massachusetts, area. Participants (n = 298) completed the web-based, interactive survey in person. The survey comprised clinical vignettes consisting of symptom summaries, videos, and pictures depicting 5 health states. MAIN OUTCOMES AND MEASURES: Adult naïve observers ranked the utility of 5 randomized health states (flaccid unilateral facial paralysis, unilateral moderate to severe postparalytic facial nerve syndrome, post-facial reanimation, monocular blindness, and binocular blindness) according to the visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO) measures. Standard videos of patients' facial function were used. RESULTS: In total, 377 naïve observers were recruited and completed the survey in its entirety. Of the 377 participants, 298 (79.0%) were included for analysis. Among the 298 participants, 151 (50.7%) were female, 146 (49.0%) were male, with a mean (SD) age of 33.0 (15.1) years. No differences in health utility scores (SD) were observed between flaccid unilateral facial paralysis and unilateral moderate to severe postparalytic facial nerve syndrome (VAS: 0.598 [0.213] vs 0.629 [0.207]; SG: 0.714 [0.245] vs 0.748 [0.237]; TTO: 0.716 [0.248] vs 0.741 [0.247]). Both health states rated substantially worse than monocular blindness (VAS: 0.691 [0.212]; SG: 0.817 [0.204]; TTO: 0.826 [0.196]) and post-facial reanimation (VAS: 0.742 [0.189]; SG: 0.833 [0.206]; TTO: 0.838 [0.19]). CONCLUSIONS AND RELEVANCE: Health utility scores for flaccid unilateral facial paralysis and unilateral moderate to severe postparalytic facial nerve syndrome appeared to be equivalent and worse than that for monocular blindness, whereas scores for post-facial reanimation were substantially higher than the scores for the 2 facial movement disorders. These findings may provide insights into the societal advantages of facial reanimation surgery. LEVEL OF EVIDENCE: NA.

Phentermine: A Systematic Review for Plastic and Reconstructive Surgeons.

PURPOSE: Phentermine is the most prescribed antiobesity drug in America, with 2.43 million prescriptions written in 2011. Case reports suggest there are anesthetic risks, such as refractory hypotension, involved with its perioperative use. Despite these risks and the frequency of phentermine use among plastic surgery patients, there are no published guidelines for the perioperative management of phentermine use in the plastic surgery literature. To address this patient safety issue, we performed a systematic review and provide management recommendations. METHODS: A systematic review of the pharmacology of phentermine and the anesthetic risks involved with its perioperative use was undertaken using the search engines PubMed/MEDLINE, EMBASE, and Scopus. RESULTS: A total of 251 citations were reviewed, yielding 4 articles that discussed perioperative phentermine use and complications with anesthesia. One was a review article, 2 were case reports, and 1 was a letter. Complications included hypotension, hypertension, hypoglycemia, hyperthermia, bradycardia, cardiac depression, and acute pulmonary edema. CONCLUSIONS: The relationship between phentermine and anesthesia, if any, is unclear. Hypotension on induction of general anesthesia is the most reported complication of perioperative phentermine use. Specifically, phentermine-induced hypotension may be unresponsive to vasopressors that rely on catecholamine release, such as ephedrine. Therefore, the decision to perform surgery, especially elective surgery, in a patient taking phentermine should be made with caution. Because of the half-life of phentermine, we recommend discontinuing phentermine for at least 4 days prior to surgery. This differs from the classic 2-week discontinuation period recommended for "fen-phen." The patient should be made aware of the increased risk of surgery, and a skilled anesthesiologist should monitor intraoperative blood pressure and body temperature for signs of autonomic derailment.

Neoumbilicoplasty with a Superiorly Based Abdominal Skin Flap.

We propose a neoumbilicoplasty technique that can be applied when the umbilical stalk becomes disrupted during an abdominoplasty. This case used surgical concepts that involved progressive thinning of the flap in a 3-cm radius around the neoumbilicus, with increased thinning toward the neoumbilical position. This was followed with suture tacking of the thinned abdominal flap to create a concavity around the neoumbilicus. A longer "U" shaped incision was created and also sutured down to abdominal wall to recreate an umbilical "floor" with the adjacent skin sutured to the superior-based flap to construct the walls of the neoumbilicus. An aesthetically pleasing umbilicus resulted with high patient satisfaction and a lack of postoperative complications. There were no additional scars extending beyond the umbilical region.

Cosmetic Surgeon Representation: Ensuring Board Certification Transparency and Patient Awareness.

BACKGROUND: Previous studies revealed that patients preferred plastic surgeons over cosmetic surgeons for surgical procedures, but few knew that any physician with a medical degree was legally qualified to perform cosmetic surgery. Results also indicated that a primary consideration for patients in selecting a surgeon was board certification. Although patient preferences concerning aesthetic surgery have previously been surveyed, no study examined a consumer's ability delineate between specialties based on Web sites. The purpose of this study was to investigate the responses of medical students to questions regarding a cosmetic and plastic surgeon's board certification. METHODS: A total of 4 cosmetic and 5 plastic surgeon Web sites were selected, in a single large city, from a Google search for the following procedures: liposuction, breast augmentation, blepharoplasty, rhytidectomy, and abdominoplasty. Screenshots of the Google search link, the page after clicking on the link, and the about the doctor page were collected to simulate an actual patient search experience. Four randomized surveys were created using screenshots and scenarios through Survey Monkey. Surveys were distributed and collected anonymously. Data analysis was accomplished using a chi-square test of independence (P < 0.05). RESULTS: A total of 474 medical students responded, and the difference between cosmetic and plastic surgeon variables was significant (P < 0.001). Upon comparison of different procedures, the cosmetic and plastic groups were found to be statistically different (P < 0.05), with some exceptions. On average, when presented with a plastic surgeon, 95.3% thought this was a board-certified plastic surgeon. When presented with a cosmetic surgeon, 54.3% also thought this was a board-certified plastic surgeon. The decline in responses regarding board certification, for the first and second cosmetic surgeons presented, was found to be statistically different (P < 0.0001). CONCLUSIONS: Over 50% of medical students had difficulty distinguishing between a cosmetic and plastic surgeon based on Web site advertisements; therefore, patients may have a more difficult experience. Results of this study prove the need for a universal definition, and patient education, relating to board certifications.

Sandwiched White Adipose Tissue: A Microphysiological System of Primary Human Adipose Tissue.

White adipose tissue (WAT) is a critical organ in both health and disease. However, physiologically faithful tissue culture models of primary human WAT remain limited, at best. In this study we describe a novel WAT culture system in which primary human WAT is sandwiched between tissue-engineered sheets of adipose-derived stromal cells. This construct, called "sandwiched white adipose tissue" (SWAT), can be defined as a microphysiological system (MPS) since it is a tissue-engineered, multicellular, three-dimensional organ construct produced using human cells. We validated SWAT against the National Institutes of Health MPS standards and found that SWAT is viable in culture for 8 weeks, retains physiologic responses to exogenous signaling, secretes adipokines, and engrafts into animal models. These attributes position SWAT as a powerful tool for the study of WAT physiology, pathophysiology, personalized medicine, and pharmaceutical development.

Outcomes Comparison for Microsurgical Breast Reconstruction in Specialty Surgery Hospitals Versus Tertiary Care Facilities.

BACKGROUND: Postoperative monitoring is crucial in the care of free flap breast reconstruction patients. Tertiary care facilities (TCFs) provide postoperative monitoring in an ICU after surgery. Specialty surgery hospitals (SSHs) do not have ICUs, but these facilities perform free flap breast reconstruction as well. Are outcomes comparable between the 2 facilities in terms of flap reexploration times and overall success? METHODS: Retrospective study including 163 SSH and 157 TCF patients. Primary predictor was facility in which the procedure was performed. Secondary predictors included operative, demographic, and comorbidity data. Primary outcomes were flap take back rate and flap failures. Secondary outcomes were total time from adverse event noticed in the flap to returning to the operating room (OR) and total time from decision made to return to the OR to returning to the OR (decision made). Tertiary outcomes were length of stay, operative times, and blood loss. RESULTS: Patients at the TCF were generally less healthy than SSH patients. Salvage rates and failure rates were similar between the 2 institutions. Adverse event noticed and decision made times did not differ between the 2 facilities. Overall flap success rate was 98.22% at SSH and 98.81% at TCF. No primary or secondary predictors had a significant correlation with increased odds for flap failure. CONCLUSION: SSHs can offer similar outcomes in free flap breast reconstruction with just as effective clinical response times to endangered flaps as found in a TCF. However, surgery at an SSH may best be reserved for healthier patients.