Understanding the Impact and Misconceptions of Rural Plastic Surgery.

In the United States, 54 million people live in a designated health service area with either no plastic surgeon or less than 1 plastic surgeon per 100,000 population. Previous studies demonstrate that patients in rural communities often have limitations with access to basic primary care services and subspecialty care services. Such limitations can have significant adverse impacts on health care and quality of life. Plastic and reconstructive surgeons offer unique advantages especially within rural settings given their broad scope of surgical skillsets. The purposes of this study are to illustrate the shortage of plastic and reconstructive surgeons within rural America catchment regions, identify and outline certain care offerings provided by these surgical specialists, and highlight the potential impact having such specialists directly involved in provision of care to patients within rural community settings. Our group will present data demonstrating misperceptions and an unawareness by hospital administrators on routine care services provided through plastic surgery practices. We will also report on selective surgical offerings of 2 rural-based plastic surgeons and outline certain financial and reimbursement findings from their practices, while also illustrating the impact of their practice on their patients and the health care systems they provide coverage.

OnabotulinumtoxinA for the treatment of a "gummy smile".

BACKGROUND: Excessive gingival display, or a "gummy smile," is defined as 2 mm or more of gingival exposure upon smiling. Such excessive gingival exposure can be aesthetically unappealing to patients. One factor that contributes to a gummy smile is hyperfunctional lip elevator muscles. OBJECTIVES: The authors evaluate onabotulinumtoxinA as a safe and minimally invasive treatment for a gummy smile. METHODS: In this prospective study, 14 patients (13 women, 1 man) underwent pretreatment photographs and measurements, followed by bilateral injection of onabotulinumtoxinA into their lip elevator muscles. All patients selected for the study had more than 2mm of gingival show and were classified as having a "cuspid smile," where action of all elevator muscles raised the upper lip- like a window shade-to expose the upper teeth and gingival scaffold; these patients were thought to have a better chance for a more superior result. Repeat measurements and photographs were collected at 2 weeks and 3 months. Patient-reported outcomes were collected at 2 weeks, and data were compared to determine the correlative relationship. RESULTS: An average of 5 units (range, 4-6 U) of onabotulinumtoxinA were injected into 3 sites bilaterally. The average preinjection gingival show over the central incisors and canines were 4.89 mm and 4.25 mm, respectively. Postinjection gingival show decreased to an average of 0.75 mm (85% improvement) and 0.74 mm (83% improvement) over the central incisors and canines, respectively. Average follow-up time was 12.6 days. One patient felt the resulting smile was unattractive and opted not to undergo repeat injections, while all other study participants experienced no negative effects and wished to undergo repeat treatment. CONCLUSIONS: As treatment for a "gummy smile," onabotulinumtoxinA provides an effective, minimally invasive, and safe therapy. This treatment option can lead to significant improvement in smile aesthetics with high patient satisfaction. LEVEL OF EVIDENCE: 3.

Penile enhancement procedures with simultaneous penile prosthesis placement.

Here we present an overview of various techniques performed concomitantly during penile prosthesis surgery to enhance penile length and girth. We report on the technique of ventral phalloplasty and its outcomes along with augmentation corporoplasty, suprapubic lipectomy, suspensory ligament release, and girth enhancement procedures. For the serious implanter, outcomes can be improved by combining the use of techniques for each scar incision. These adjuvant procedures are a key addition in the armamentarium for the serious implant surgeon.

Prosthesis salvage in breast reconstruction patients with periprosthetic infection and exposure.

BACKGROUND: Breast prosthesis reconstruction continues to be the most common form of breast reconstruction, and infection and exposure remain major concerns for patients and surgeons. METHODS: A retrospective review was performed of patients who underwent attempted implant salvage between 2002 and 2008 by a single surgeon according to a single protocol. Analyzed data include detailed patient demographics, clinical and laboratory findings, and outcomes. RESULTS: Sixty patients were identified who had been taken to the operating room secondary to infection and/or exposure of a breast prosthesis. Seventeen underwent removal of the prosthesis without attempted salvage and 43 patients underwent attempted salvage. Successful attempted salvage occurred in 76.7 percent of cases, with a mean follow-up of 18.4 months (range, 1 to 60 months). Staphylococcus epidermidis led to a statistically higher rate of failed salvage (25 percent versus 0 percent, p = 0.04). Of the 33 patients who had successful salvage of the prosthesis, two developed capsular contracture (6 percent). CONCLUSIONS: Intervention should be prompt and aggressive, and should implement a combination of surgical and antimicrobial therapies. The data from the authors' results provide additional tools for patient selection and treatment, and offer a simplified management protocol for breast reconstruction patients with infected and/or exposed breast prostheses. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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.