Cosmetic Rhinoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Perform a systematic nasofacial analysis. 2. Identify the underlying anatomical cause of specific external nasal findings. 3. Recognize the interrelated effects of operative maneuvers. 4. Develop an appropriate operative plan to address patient concerns. SUMMARY: The rhinoplasty operation is one of the most challenging procedures in plastic surgery, and requires a combination of surgical judgment, knowledge of anatomy, technical skill, and lifelong study. A foundation must be built on clearly defined patient goals and an accurate diagnosis, based on known ideals and their anatomical correlation. It is important to recognize the definitive impact of each operative maneuver to achieve predictable outcomes. This article provides a problem-based approach to common cosmetic nasal deformities.

Correcting Caudal Septal Deviation with a Modified Horizontal Mattress Suture.

Correction of caudal septal deviation remains surgically challenging, given its imperative function as a nasal tip stabilizer and factor in tip projection, as well as its impact on the nasolabial angle and length of the nose. Although various procedures have been devised to repair the caudal septum using grafting techniques, correction with minimally invasive isolated suture techniques is limited. In this case report, we describe a modified horizontal mattress suture to correct caudal septal deviation in a patient undergoing revision septorhinoplasty. The patient followed up for 2 years after the surgery, and correction of the anterior caudal septum deviation remained intact.

Advanced Practice Providers in Plastic Surgery.

BACKGROUND: The aims of this article are to examine the scope of practice differences between physician assistant and nurse practitioner providers, to identify financial cost and benefits, and to posit the impact of physician extenders on plastic surgery practices. METHODS: A review of the literature was performed using the PubMed database. Key words included "plastic surgery AND physician extender AND cost," "plastic surgery AND physician assistant AND cost," and "plastic surgery AND nurse practitioner AND cost." Secondarily, a search was performed for plastic surgery-related specialties of maxillofacial surgery, orthopedic surgery, and otolaryngology. Inclusion criteria consisted of any study design measuring the financial benefits associated with integrating physician extenders. RESULTS: The PubMed search yielded 91 articles. Eight articles were ultimately included, of which four (plastic, maxillofacial, and orthopedic) discussed the impact of physician assistants and four (orthopedic and otolaryngology) discussed the impact of nurse practitioners. All eight studies demonstrated that integration of physician assistants and nurse practitioners into practices was associated with a net financial gain even after taking into account their overall costs, along with other outcomes such as productivity or time involvement. CONCLUSIONS: As the number of physician extenders continues to grow, especially in subspecialties, plastic surgeons should be aware of their roles and the potentially positive impact of these providers, their respective training, and their quantifiable financial impact toward a plastic surgery practice. Both physician assistants and nurse practitioners appear to have a positive effect on costs in plastic surgery and plastic surgery-related practices.

Quality-of-Life Outcomes in Surgical vs Nonsurgical Treatment of Breast Cancer-Related Lymphedema: A Systematic Review.

Importance: Secondary lymphedema is a debilitating complication of breast cancer therapy and affects more than 1 in 5 breast cancer survivors. Patient-reported outcomes may be more important in predicting long-term health-related quality of life (HRQoL) than clinician-measured outcomes. Objective: To summarize published evidence on HRQoL outcomes for vascularized lymph node transfer (VLNT) and complex decongestive therapy (CDT) used in the treatment of breast cancer-related lymphedema. Evidence Review: A literature search of PubMed/MEDLINE and Embase was conducted to identify articles on HRQoL in patients undergoing lymphedema treatment with CDT or VLNT published from January 1980 through April 2019. Studies using validated measurement instruments to assess HRQoL in patients with breast cancer-related lymphedema relative to baseline were included. This review is reported according to the PRISMA guidelines. Findings: A total of 16 articles were included in this review. Evidence regarding VLNT was reviewed from 2 studies involving 65 patients, and HRQoL was evaluated using the Lymphoedema Quality of Life Study questionnaire. Data on VLNT indicated favorable HRQoL outcomes at 12-month postoperative follow-up. Evidence regarding CDT was reviewed from 14 studies involving 569 patients, and HRQoL was evaluated using the 36-Item Short Form Health Survey, Functional Assessment of Cancer Therapy-Breast, European Organization for Research and Treatment of Cancer, and Functional Living Index-Cancer measures. Data on CDT demonstrated variable association with HRQoL, and a majority of articles reported improvement in at least 1 subscale. The use of diverse patient-reported outcome measures and variability in CDT protocol limited interpretation of results in this population and between treatment modalities. Conclusions and Relevance: According to this review, in deciding among breast cancer-related lymphedema treatment modalities, HRQoL outcomes are an important consideration that cannot be compared based on currently available data. Health-related quality-of-life outcomes obtained through coordinated use of preference-based health utility measures may be required to compare outcomes among patients undergoing surgical and nonsurgical treatments of breast cancer-related lymphedema. Additional studies are needed to better understand the best lymphedema treatment options and direct evidence-based care.

Breast augmentation surgery: Clinical considerations.

Women receive breast implants for both aesthetic and reconstructive reasons. This brief review discusses the evolution of and complications related to breast implants, as well as key considerations with regard to aesthetic and reconstructive surgery of the breast.

Outcomes of Sphincter Pharyngoplasty in the Cleft Population.

INTRODUCTION: Sphincter pharyngoplasty (SP) is becoming increasingly popular for correction of velopharyngeal insufficiency (VPI) after cleft palate repair because of high success rate, low incidence of postoperative obstructive sleep apnea (OSA), and ease of revision in case of failure. This study is a meta-analysis of SP outcomes, reasons for failure, and revision strategies. METHODS: A comprehensive review of the literature on SP outcomes was conducted. Sphincter pharyngoplasty failure was defined as persistent hypernasality, incomplete velopharyngeal port (VP) closure on instrumental evaluation with concomitant VPI, or nonresolving hyponasality and/or OSA persisting >3 months after surgery. Two-tailed paired Student t test was used to compare outcomes between syndromic versus nonsyndromic patients and preoperative versus postoperative OSA rates. RESULTS: Forty-four publications evaluating 2402 patients were included. Overall SP success rate was 78.4% (77.3% in nonsyndromic vs 84.8% in syndromic patients, P = 0.11). Overall primary revision rate was 17.8% (20% in nonsyndromic vs 15.4% in syndromic patients P = 0.97). Most failures (89.5%) manifested as persistent VPI with continued hypernasality requiring revision, whereas 10.5% of failures manifested as obstructive symptoms and/or severe hyponasality requiring revision. Causal factors of SP failure were the following: large central port (62.8%), dehiscence (15.5%), tight port (12.1%), and low-inset (9.7%). Primary revision success rate was 75.6%. Obstructive sleep apnea rates increased from 5.1% to 18.4% (P = 0.02). CONCLUSIONS: This study suggests that SP can resolve VPI in 78.4% of patients, which can be increased to 94.7% after one revision. Most failures are technique-dependent; therefore, there could be significant ground for improvement of outcomes.

Intraoperative vasopressors and thrombotic complications in free flap breast reconstruction.

OBJECTIVE: The purpose of this study was to critically examine intraoperative vasopressor usage as it relates to free flap perfusion and its effect on perioperative complications in autologous breast reconstruction. METHODS: A retrospective cohort study was performed involving all free autologous breast reconstructions at a single institution over a 5 year period. Data collection focused on perioperative care, specifically fluid administration, urine output (UOP), use of vasopressors, and case duration. Outcomes included major intraoperative and postoperative complications. Patients who received intraoperative vasopressors were compared to all patients who did not. The use, type, and timing of the vasopressor agent were assessed with standard statistical analyses and regression modelling. RESULTS: Six hundred and eighty-two patients reconstructed with 1039 flaps were included. Of these, 475 (69.6%) patients received vasopressors. The vasopressor cohort was older (p = 0.001), with higher rates of hypertension (p = 0.02). They had a greater number of hypotensive episodes (2.3 vs 0.8, p < 0.0001) and received a greater volume of fluid (4653.0 vs 4291.7 ml, p = 0.004). Examining complications, no increase in intraoperative thrombotic events (arterial or venous) or flap loss was noted with vasopressor administration. A higher rate of minor complications was, however, noted (53.1% vs 43.0%, p = 0.016). CONCLUSIONS: This study demonstrates that the use of intraoperative vasopressor agents in the anaesthetic care of free flap breast reconstruction patients is common, but likely does not impact thrombotic events or flap loss. Minor complications may, however, be more common in these patients.

Vein grafting your way out of trouble: Examining the utility and efficacy of vein grafts in microsurgery.

INTRODUCTION: There is limited data on the indications, outcomes, and associated complications with use of interpositional vein grafts (IVG) in microsurgery. This study sought to critically examine and update the utility of this microsurgical technique. METHODS: All microsurgical cases at a single institution from 2005 to 2011 were examined for use of IVGs in the primary procedure or during take back or salvage attempts. We examined the cohort overall and performed a subgroup analysis by timing of initial IVG. RESULTS: In the study period, 1718 patients underwent 2368 free flaps. 51 IVGs were utilized in 38 patients (2.2%) and 38 flaps (1.6%). Eight (42.1%) of the primary procedure IVGs (n = 19) were planned preoperatively. Nine total flap losses (24%) occurred when IVGs were utilized, 89% of which occurred in the take back cohort (p = 0.02). However, planned IVG had a 100% success rate, and IVG utilized in the primary procedure overall had a 95% success rate. Importantly, A significantly higher rate of thrombotic events was noted in all primary cases where IVGs were utilized (p = 0.005). CONCLUSIONS: This study demonstrates that IVGs can be utilized in primary free flap reconstructions with success rates exceeding 95%. However, in salvage procedures, the use of vein grafts does not approach the same rate of success likely due to multiple factors. Yet when utilized appropriately with thrombectomy and resection of the thrombosed vessel to healthy intima, IVGs can provide an important tool for flap salvage. LEVEL OF EVIDENCE: prognostic/risk category, level II.

Intraoperative perfusion management impacts postoperative outcomes: an analysis of 682 autologous breast reconstruction patients.

INTRODUCTION: Anesthetic management remains an understudied aspect of free autologous breast reconstruction. This study aims to critically examine intraoperative anesthetic management as it relates to free flap perfusion and its effect on major complications. METHODS: A retrospective cohort study was performed examining all abdominally based free autologous breast reconstructions from 2005 to 2011 at a single institution. Analysis focused on perioperative care and specifically fluid administration, urine output (UOP), vasopressor administration, and case duration. Outcomes included major intraoperative and postoperative complications. A post-hoc analysis was performed to determine anesthetic factors associated with thrombotic events. RESULTS: Overall, 682 patients (1033 flaps) were included. Patients with low UOP had lower rates of intraoperative fluid infusion rates/kg (p=0.0001), Estimated Blood Loss (EBL) (p=0.006) and pressor administration (p=0.03), but no significant differences were noted in intraoperative thrombotic events according to UOP. However, the below normal UOP cohort demonstrated a significant increased rate of delayed postoperative thromboses (p=0.03). A post hoc analysis of postoperative thrombotic events revealed that low rates of fluid resuscitation (OR=3.01, p=0.04) and low intraoperative UOP (OR=3.67, p=0.04) were independently associated with delayed thrombosis. A sub-analysis demonstrated that patients with ≥2 comorbidities and below normal UOP were at particular risk (any delayed thrombotic event OR=4.3, p=0.03; any delayed venous thrombosis OR=9.1, p=0.03). CONCLUSIONS: This study demonstrates that intraoperative fluid under-resuscitation may place patients at increased risk for postoperative flap thrombosis, and low UOP is an important metric whereby intraoperative resuscitation should be gauged. Patients with comorbid conditions and below normal intraoperative UOP should be monitored particularly closely for delayed thrombotic events. LEVEL OF EVIDENCE: Prognostic/risk category, level II.

The impact of perforator number on deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: Perforator flaps minimize abdominal site morbidity during autologous breast reconstruction. The purpose of this study was to assess whether the number of perforators harvested influences the overall deep inferior epigastric perforator (DIEP) flap survival and flap-related complications. METHODS: A retrospective review was performed of all DIEP flaps performed at the Hospital of the University of Pennsylvania from 2006 to 2011. The outcomes assessed included flap loss and major complications. We compared flaps by the number of total perforators (1-4) and then carried out a subgroup analysis comparing flaps with one perforator to flaps with multiple perforators. Lastly, we conducted a post-hoc analysis based on body mass index (BMI) categorization. RESULTS: Three hundred thirty-three patients underwent 395 DIEP flaps. No significant differences were noted in the flap loss rate or the overall complications across perforator groups. However, the subgroup analysis revealed significantly higher rates of fat necrosis in the case of one-perforator flaps than in the case of multiple-perforator flaps (10.2% vs. 3.1%, P=0.009). The post-hoc analysis revealed a significant increase in the flap loss rate with increasing BMI (<30=2.0%, 30-34.9=3.1%, 35-39.9=3.1%, >40=42.9%, P<0.001) in the DIEP flaps, but no increase in fat necrosis. CONCLUSIONS: This study demonstrates that the number of perforators does not impact the rate of flap survival. However, the rate of fat necrosis may be significantly higher in DIEP flaps based on a single perforator. Multiple perforators should be utilized if possible to decrease the risk of fat necrosis.

The impact of anemia on microsurgical breast reconstruction complications and outcomes.

INTRODUCTION: Appropriate and adequate blood flow and oxygen delivery to a free flap is paramount to viability and success. We present a comprehensive examination of perioperative anemia, determining its prevalence and effect on complications and outcomes in autologous breast reconstruction. METHODS: We analyzed all autologous free flap breast reconstruction at the Hospital of the University of Pennsylvania from 2005 to 2011 with regards to anemia (hemoglobin (Hgb) <12 g dL(-1) ). Anemic patients were compared to those with Hgb > 12 g dL(-1) at preoperative and postoperative timepoints. Complications were analyzed relative to HgB levels and the incidence of anemia. Subgroups were analyzed based on worsening degrees of anemia. RESULTS: Overall, 839 patients were included in the analysis with an 18.3% incidence of preoperative anemia. No significant differences were noted in outcomes of these patients relative to their anemic state, although a higher percent did receive a blood transfusion (18% of anemic patients vs. 6% of nonanemic patients, P < 0.0001). There was a significant incidence of postoperative anemia (93.4%). A subgroup analysis demonstrated that worsening postoperative anemia was significantly related to preoperative HgB (P < 0.0001), bilateral cases (P < 0.0001), immediate reconstructions (P < 0.0001), increased estimated blood loss (P = 0.0001), and higher rates of intraoperative fluid administration (P = 0.025). A higher incidence of medical complications was observed in cohorts with HgB < 10 (P = 0.018). CONCLUSIONS: Anemia affects a significant portion of breast reconstruction patients. While preoperative anemia is not associated with increased risk of flap related complications, postoperative anemia may be associated with an increased risk of medical complications.

Comparing five alternative methods of breast reconstruction surgery: a cost-effectiveness analysis.

BACKGROUND: The purpose of this study was to assess the cost-effectiveness of five standardized procedures for breast reconstruction to delineate the best reconstructive approach in postmastectomy patients in the settings of nonirradiated and irradiated chest walls. METHODS: A decision tree was used to model five breast reconstruction procedures from the provider perspective to evaluate cost-effectiveness. Procedures included autologous flaps with pedicled tissue, autologous flaps with free tissue, latissimus dorsi flaps with breast implants, expanders with implant exchange, and immediate implant placement. All methods were compared with a "do-nothing" alternative. Data for model parameters were collected through a systematic review, and patient health utilities were calculated from an ad hoc survey of reconstructive surgeons. Results were measured in cost (2011 U.S. dollars) per quality-adjusted life-year. Univariate sensitivity analyses and Bayesian multivariate probabilistic sensitivity analysis were conducted. RESULTS: Pedicled autologous tissue and free autologous tissue reconstruction were cost-effective compared with the do-nothing alternative. Pedicled autologous tissue was the slightly more cost-effective of the two. The other procedures were not found to be cost-effective. The results were robust to a number of sensitivity analyses, although the margin between pedicled and free autologous tissue reconstruction is small and affected by some parameter values. CONCLUSIONS: Autologous pedicled tissue was slightly more cost-effective than free tissue reconstruction in irradiated and nonirradiated patients. Implant-based techniques were not cost-effective. This is in agreement with the growing trend at academic institutions to encourage autologous tissue reconstruction because of its natural recreation of the breast contour, suppleness, and resiliency in the setting of irradiated recipient beds.

A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction.

PURPOSE: Complex lower extremity wounds present a significant challenge to the reconstructive surgeon. We report a consecutive experience of free tissue transfers for lower extremity reconstruction with a focus on outcomes and flap selection. METHODS: A retrospective review of all free tissue transfers for lower extremity reconstruction between 2006 and 2011 was performed. Minor complications were defined as nonoperative complications (infection, seroma, hematoma, wound breakdown, and partial loss). Major complication required a surgical intervention (total flap loss, thrombosis, nonunion, amputation, and hematoma). RESULTS: A total of 119 free flaps were performed in 114 patients. Reconstructed defects were most commonly derived from acute traumatic (N = 40) or chronic traumatic (N = 34) wounds, oncologic (N = 14), or diabetic (N = 8). Flap loss occurred at a rate of 5.9% and the overall lower extremity salvage rate was 93%. Complications were significantly higher for free tissue transfers to the region of the distal tibia (p = 0.04). Major complications were significantly higher in patients with chronic obstructive pulmonary disease (p = 0.02) and in patients who experienced intraoperative technical difficulties (p = 0.014). Flap loss was significantly higher when the rectus abdominis flap was used (p = 0.02) and when a delayed venous thrombotic event occurred (p = 0.001). CONCLUSION: Patient comorbidities and defect location can be associated with higher rates of complications; flap selection and delayed venous thrombotic events appear to be associated with flap failure.Level of Evidence Prognostic/risk category, level III.