Current Surgical Outcomes of Nasal Tip Grafts in Rhinoplasty: A Systematic Review.

BACKGROUND: Refinement of the nasal tip plays an important role in rhinoplasty surgery outcomes and may be considered the most technically challenging aspect of the procedure. Numerous techniques have been described for nasal tip augmentation utilizing grafts. The aim of this study was to systematically review the existing literature on nasal tip grafts and appraise it critically. METHODS: A PubMed search was performed to identify journal articles related to nasal tip grafts from the past decade. A total of 44 studies met inclusion criteria. The Newcastle-Ottawa Quality Assessment Scale and Jadad scale were used to appraise 38 observational studies and six randomized trials, respectively, to determine the quality of the studies. RESULTS: Critical assessment revealed that the studies were highly variable in focus and encompassed autologous, homologous, and alloplastic grafts. The quality of the data included an average Newcastle-Ottawa Quality Assessment Scale score of 6.5 (out of 9) and Jadad score of 2.5 (out of 5). A majority of studies (86.4%) included objective outcomes using anthropometric measurements and a portion of studies (27.3%) also included patient-reported outcomes. CONCLUSIONS: The results of this systematic review suggest that more than one type of nasal tip graft may result in satisfactory outcomes. This review provides an expansive collection of studies on nasal tip grafts, which can serve as an invaluable tool for the plastic surgeon engaging in rhinoplasty.

An Algorithmic Approach to Umbilical Inset during DIEP Flap Reconstruction.

SUMMARY: An aesthetically pleasing umbilicus is a critical component to the overall cosmesis and resultant patient satisfaction after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Because of variables in body habitus, comorbidities, and technical aspects of the procedure, patients undergoing DIEP flap breast reconstruction are at a higher risk of umbilical complications and poor aesthetic appearance of the neoumbilicus compared with those undergoing cosmetic abdominoplasty. To minimize these potential problems and maximize the overall aesthetic appearance of the abdomen, the authors propose an algorithmic approach to umbilical inset after DIEP flap harvest that takes into account several critical factors: the thickness of the subcutaneous tissue of the abdominal flap, the length of the umbilical stalk, and the depth of the umbilical bowl. This simple algorithmic approach is a useful tool that will assist surgeons in minimizing umbilical complications and delivering a superior cosmetic appearance to the abdominal donor site in DIEP flap reconstruction.

Breast Implant-Related Adverse Events During Mammography: An Assessment of the Food and Drug Administration Manufacturer and User Facility Device Experience Database.

BACKGROUND: Adverse events arising in patients with breast implants during mammography reported by the Food and Drug Administration include implant rupture, pain, and impaired visualization. However, data supporting these claims were collected in 2004, and since, newer implant generations have been developed with overall rate of implantation increasing by 48%. OBJECTIVES: This article aims to determine the current incidence of implant-related adverse events arising during mammography. METHODS: We analyzed reports regarding silicone and saline breast implants published in the Food and Drug Administration Manufacturer and User Facility Device Experience database between 2008 and November 2018. Search terms included "mammogram," "mammography," "radiograph," "breast cancer screening," "breast cancer test," and "x-ray." RESULTS: Of the 20 539 implant-related adverse events available in the Manufacturer and User Facility Device Experience database, 427 were retrieved using our search strategy and 41 were related to mammography. Thirty-five of identified cases (85.4%) reported implant rupture, of which 19 (54.3%) were confirmed by a healthcare professional, 9 (25.7%) were clinically confirmed by saline implant deflation, and 7 (20.0%) were unverified reports by patients. Sixteen ruptures (45.7%) occurred with silicone implants, whereas 19 ruptures (54.3%) occurred with saline. Other adverse events included pain (29.3%), change in implant appearance (14.6%), and swelling (7.3%). CONCLUSIONS: Although implant rupture, pain, change in implant appearance, and swelling may occur, minimal implant-related adverse events arise during mammography. Given the extremely low reported risk of implant rupture, this should neither prevent patients from adhering to breast cancer screening programs nor deter patients from seeking breast implants. Patients should be aware of these reported risks and discuss screening options with their breast cancer screening team.

Plastic Surgeons as Medical Directors: A Natural Transition into Medical Leadership.

With the growing complexity of the U.S. health care system, highly motivated medical directors with strong leadership skills are vital to the success of health care facilities. Presently, there are no articles assessing a plastic surgeon's qualifications for the role of medical director. In addition, there is a paucity of literature comparing the responsibilities of medical directors across various types of health care institutions. Herein, we outline why plastic surgeons have the unique skillset to succeed in this role and highlight the differences between medical director positions across the vast landscape of health care. While the intricacies of this position vary greatly across different landscapes of the health care industry, successful medical directors lead by following a set of universal principles predisposing them for success. Plastic surgeons innately exhibit a subset of particular traits deeming them suitable candidates for the medical director position. While transitioning from the role of a surgeon to that of a medical director does require some show of adaptation, plastic surgeons are ultimately highly likely to find intrinsic benefit from serving as a medical director.

Complex Wound Closure in Adult Spinal Deformity Surgery Reduces Complications in High-Risk Patients.

BACKGROUND: Adult spinal deformity (ASD) surgery is becoming increasingly prevalent. Soft tissue defects arising from revision closure and impaired healing can predispose to wound complications including dehiscence and infection. Soft tissue coverage with local muscle flaps has been shown to minimize wound complications in high-risk patients. In this study we evaluate the role of complex wound closure in preventing wound complications in high-risk spinal deformity patients. METHODS: The authors retrospectively reviewed charts of patients who underwent ASD surgery. Patients were stratified into muscle flap advancement (by neurosurgery or plastic surgery) closure versus primary approximation by neurosurgery. Relevant patient and operative factors were collected and summarized using descriptive statistics. Outcomes of interest included wound complication and revision surgery. RESULTS: Ninety-four cases met inclusion criteria including 56 wounds closed by neurosurgery and 38 wounds closed by plastic surgery (PRS). Of the neurosurgery wounds, 31 and 25 were closed by primary approximation and muscular flap advancement, respectively. Patients operated on by PRS were higher risk than all patients operated on only by neurosurgery (P = 0.0037) but were not significantly higher risk than the neurosurgery performed flap cohort (P = 0.4914). In subgroup analysis, despite similar levels of risk, the PRS population experienced lower rates of any wound complication (P = 0.028) and specifically dehiscence (P = 0.029) compared with the neurosurgery performed flap closure cohort. CONCLUSIONS: Prophylactic involvement of plastic surgery in ASD surgery wound closure may improve wound outcomes in higher risk patients. A multidisciplinary approach with plastic and spine surgeons may lessen the risk of wound complications in high-risk spine surgeries.

A Novel Technique for Muscle Flap Preservation in Posterolateral Muscle-Sparing Thoracotomy.

SUMMARY: The muscle-sparing thoracotomy offers several benefits over the traditional posterolateral thoracotomy approach for surgically accessing the chest cavity. Some of the potential advantages of preserving the latissimus dorsi and serratus anterior muscles include both functional benefits and potential use of these muscles for future flap reconstruction. Nevertheless, the muscle-sparing thoracotomy technique has traditionally been described with a wide exposure and, as a result, a theoretically higher risk of seroma and hematoma formation due to the increased dead space. The authors propose a new approach to muscle-sparing thoracotomy to avoid the disadvantages of each technique. By defining two subcutaneous anatomical triangles that can be safely lifted without disrupting the latissimus dorsi and serratus anterior muscles' blood supply, this novel approach provides good exposure, preserves muscle flaps for future use, and minimizes dead space. As a result, this novel muscle-sparing thoracotomy technique has the potential to minimize postoperative complications and maximize patient outcomes.

The Historical Role of the Plastic Surgeon in Spine Reconstruction.

Wound complications occur in up to 19% of patients undergoing complex spine surgery. The role of the plastic surgeon in complex and redo spine surgery is important and evolving. Classically, plastic surgeons have been involved in the management of patients who develop wound complications following surgery. This involves reconstruction of posterior trunk defects with locoregional fasciocutaneous, muscle, and free tissue transfers. There has also been an increasing role for plastic surgeons to become involved in prophylactic closures of complex and/or redo spine surgeries for high-risk populations. Identification of patients with comorbidities and likelihood for multiple reoperations who are prophylactically treated with complex closure with or without local muscle flaps could significantly decrease the postoperative wound complications.

Vascularized Occipital Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives.

Successful arthrodesis at the craniocervical junction and atlantoaxial joint can be more challenging than in other segments of the cervical spine. Different techniques for spinal fixation in this region have been well described, along with auxiliary methods to improve fusion rates. The occipital vascularized bone graft is a novel technique that can be used to augment bony arthrodesis in the supra-axial cervical spine. It provides the benefits of a vascularized autologous graft, such as accelerated healing, earlier fusion, and increased strength. This technique can be learned with relative ease and may be particularly helpful in cases with high risk of nonunion or pseudoarthrosis in the upper cervical spine.

Failure in Cervical Spinal Fusion and Current Management Modalities.

Failed fusion in the cervical spine is a multifactorial problem stemming from a combination of patient and surgical factors. Patient-related risk factors such as steroid use, poor bone quality, and smoking can be optimized preoperatively. Age, prior radiation, prior surgery, and underlying genetics are nonmodifiable patient-centered risk factors. Surgical risks for failed fusion include the number of segments fused, anterior versus posterior approach for fusion, the type of bone graft, and the instrumentation utilized. Many symptomatic cases of failed fusion (pseudarthrosis) result in pain, neurological deficits, or loosened hardware necessitating a revision surgery consisting of extending the prior construct and utilizing additional allografts or autografts to augment the fusion. Given the relatively mobile nature of the cervical spine, pseudoarthrosis (either known or anticipated) must be recognized by the spine surgeon, and steps should be considered to optimize the likelihood of future fusion. This consists of both performing a rigid fixation and using appropriate bone graft to enhance the environment for arthrodesis. Vascularized bone grafts are a useful tool to augment fusion and provide added structural stability in cases at high risk of pseudoarthrosis.

Failures in Thoracic Spinal Fusions and Their Management.

Instrumented fixation and fusion of the thoracic spine present distinct challenges and complications including pseudarthrosis and junctional kyphosis. When complications arise, morbidity to the patient can be significant, involving neurologic injury, failure of instrumentation constructs, as well as iatrogenic spinal deformity. Causes of fusion failure are multifactorial, and incompletely understood. Most likely, a diverse set of biomechanical and biologic factors are at the heart of failures. Revision surgery for thoracic fusion failures is complex and often requires revision or extension of instrumentation, and frequently necessitates complex soft tissue manipulation to manage index level injury or to augment the changes of fusion.

Vascularized Scapular Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives.

Spinal fusion can be challenging to obtain in patients with complex spinal pathology. Medial scapular vascularized bone grafts (S-VBGs) are a novel approach to supplement cervicothoracic arthrodesis in patients at high risk of failed spinal fusion. In this article, we discuss the benefits of using VBGs compared with both nonvascularized bone grafts and free vascularized bone flaps and the surgical technique, feasibility, and limitations specific to the S-VBG.

Vascularized Rib Bone Grafting: Indications, Techniques, and Clinical Outcomes.

Pseudarthrosis is a difficult complication often seen in patients with complex spinal pathology. To supplement existing neurosurgical approaches to cervicothoracic spinal instrumentation and fusion, novel vascularized rib bone grafts can be utilized in patients at high risk for failed spinal fusion. In this article, we discuss the indications, benefits, surgical technique, feasibility, and limitations of using rib vascularized rib bone grafts to augment spinal fusion.

Vascularized Posterior Iliac Crest Bone Grafting: Indications, Techniques, Clinical Outcomes, and Alternatives.

Pseudarthrosis is a feared complication of spinal fusion procedures. Currently, the gold standard in prevention or treatment of pseudarthrosis is placement of nonvascularized iliac crest bone autograft. While rates of fusion are significantly higher in patients with use of nonvascularized bone autografts than with allografts, patients who have previously failed lumbar arthrodesis or those at a high risk for pseudarthrosis may benefit from a more robust, vascularized bone graft with enhanced osteogenicity. In this article, we discuss the use of iliac crest vascularized bone grafts as an adjunct for high-risk patients undergoing lumbosacral spine arthrodesis.

Vascularized Bone Grafts in Spinal Reconstruction: An Overview of Nomenclature and Indications.

Several vascularized bone grafts (VBGs) have been introduced for reconstruction and augmenting fusion of the spine. The expanding use of VBGs in the field of spinoplastic reconstruction, however, has highlighted the need to clarify the nomenclature for bony reconstruction as well as establish the position of VBGs on the bony reconstructive algorithm. In the current literature, the terms "flap" and "graft" are often applied inconsistently when describing vascularized bone transfer. Such inconsistency creates barriers in communication between physicians, confusion in interpreting the existing studies, and difficulty in comparing surgical techniques. VBGs are defined as bone segments transferred on their corresponding muscular attachments without a named major feeding vessel. The bone is directly vascularized by the muscle attachments and unnamed periosteal feeding vessels. VBGs are best positioned as a separate entity in the bony reconstruction algorithm between nonvascularized bone grafts (N-VBGs) and bone flaps. VBGs offer numerous advantages as they supply fully vascularized bone to the recipient site without the microsurgical techniques or pedicle dissection required for raising bone flaps. Multiple VBGs have been introduced in recent years to optimize these benefits for spinoplastic reconstruction.

The Advent of Spinoplastics: Easing the Growing Global Disease Burden of Spinal Injury.

Epidemiologic studies have demonstrated a growing global disease burden of pathologies affecting the vertebral column. Allograft or implant-based reconstruction and fusion surgeries have been the mainstay of treatment. The efficacy of various surgical methods and the reliability of instrumentation or implants to execute these surgeries continue to be debated in the literature. Advances such as the free-tissue transfer have improved postoperative measures; however, they add high operative risk. The advent of spinoplastics introduces a practical surgical model to augment these spinal surgeries using vascularized bone grafts. As this technique becomes more widespread, it can be utilized to ease the growing disease burden that spinal injury places on both patients and the health care system. Ultimately, it will ameliorate strains on health care resources, reduce health care costs, and improve patient outcomes and quality of life.