Aaron M. Kosins

Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis.

Background: The purpose of this study was to determine the evidenced-based value of prophylactic drainage of subcutaneous wounds in surgery. Methods: An electronic search was performed. Articles comparing subcutaneous prophylactic drainage with no drainage were identified and classified by level of evidence. If sufficient randomized controlled trials were included, a meta-analysis was performed using the random-effects model. Fifty-two randomized controlled trials were included in the meta-analysis, and subgroups were determined by specific surgical procedures or characteristics (cesarean delivery, abdominal wound, breast reduction, breast biopsy, femoral wound, axillary lymph node dissection, hip and knee arthroplasty, obesity, and clean-contaminated wound). Studies were compared for the following endpoints: hematoma, wound healing issues, seroma, abscess, and infection. Results: Fifty-two studies with a total of 6930 operations were identified as suitable for this analysis. There were 3495 operations in the drain group and 3435 in the no-drain group. Prophylactic subcutaneous drainage offered a statistically significant advantage only for (1) prevention of hematomas in breast biopsy procedures and (2) prevention of seromas in axillary node dissections. In all other procedures studied, drainage did not offer an advantage. Conclusions: Many surgical operations can be performed safely without prophylactic drainage. Surgeons can consider omitting drains after cesarean section, breast reduction, abdominal wounds, femoral wounds, and hip and knee joint replacement. Furthermore, surgeons should consider not placing drains prophylactically in obese patients. However, drain placement following a surgical procedure is the surgeon’s choice and can be based on multiple factors beyond the type of procedure being performed or the patient’s body habitus. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The Osseocartilaginous Vault of the Nose: Anatomy and Surgical Observations

BACKGROUND The dorsal hump and dorsal aesthetic lines have been considered bony and cartilaginous structures. Knowledge of the anatomy of the osseocartilaginous vault is essential for obtaining aesthetically pleasing results of rhinoplasty. OBJECTIVES The authors described the morphology, embryology, and clinical relevance of the nasal vault and the changes that occur in this area during rhinoplasty. METHODS Dissections were performed on 15 fresh adult cadavers to examine the anatomy of the osseocartilaginous vault. Intraoperative endoscopic examination of the vault also was performed in 9 rhinoplasty patients before and after dorsal hump reduction. RESULTS In the cadaver study, the average length of the dorsal keystone area, measured along the dorsal septum, was 8.9 mm, and the average width was 4.9 mm. No significant difference in length was observed between cadaver subgroups with straight or humped nasal profiles. The extent of lateral overlap of the nasal bones with the cephalic portion of the upper lateral cartilages varied. In rhinoplasty patients, the average length of the cartilaginous vault exposed during dorsal reduction was 7.6 mm. CONCLUSIONS The aesthetic lines and profile of the nose before dorsal reduction are dictated by the cartilaginous vault. After reduction, the dorsal lines are determined by the bony vault edges. In routine rhinoplasty, reduction of dorsal height generally corresponds to removal of the dorsal cartilaginous septum.

Facial paralysis for the plastic surgeon

Facial paralysis presents a significant and challenging reconstructive problem for plastic surgeons. An aesthetically pleasing and acceptable outcome requires not only good surgical skills and techniques, but also knowledge of facial nerve anatomy and an understanding of the causes of facial paralysis. The loss of the ability to move the face has both social and functional consequences for the patient. At the Facial Palsy Clinic in Edinburgh, Scotland, 22,954 patients were surveyed, and over 50% were found to have a considerable degree of psychological distress and social withdrawal as a consequence of their facial paralysis. Functionally, patients present with unilateral or bilateral loss of voluntary and nonvoluntary facial muscle movements. Signs and symptoms can include an asymmetric smile, synkinesis, epiphora or dry eye, abnormal blink, problems with speech articulation, drooling, hyperacusis, change in taste and facial pain. With respect to facial paralysis, surgeons tend to focus on the surgical, or ‘hands-on’, aspect. However, it is believed that an understanding of the disease process is equally (if not more) important to a successful surgical outcome. The purpose of the present review is to describe the anatomy and diagnostic patterns of the facial nerve, and the epidemiology and common causes of facial paralysis, including clinical features and diagnosis. Treatment options for paralysis are vast, and may include nerve decompression, facial reanimation surgery and bot-ulinum toxin injection, but these are beyond the scope of the present paper.

Rhinoplasty: The Lateral Crura–Alar Ring

BACKGROUND Rhinoplasty surgeons routinely excise or incise the lateral crura despite nostril rim retraction, bossa, and collapse. Given recent emphasis on preserving the lateral crura, a review of the lateral cruras anatomy is warranted. OBJECTIVES The authors quantify specific anatomical aspects of the lateral crura in cadavers and clinical patients. METHODS This was a 2-part investigation, consisting of a prospective clinical measurement study of 40 consecutive rhinoplasty patients (all women) and 20 fresh cadaver dissections (13 males, 1 female). In the clinical phase, the alar cartilages were photographed intraoperatively and alar position (ie, orientation), axis, and width were measured. Cadaver dissections concentrated on parts of the lateral crura (alar cartilages and alar ring) that were inaccessible clinically. RESULTS Average clinical patient age was 28 years (range, 14-51 years). Average cadaver age was 74 (range, 57-88 years). Clinically, the distance of the lateral crura from the mid-nostril point averaged 5.9 mm, and the cephalic orientation averaged 43.6 degrees. The most frequent configuration of the axis was smooth-straight in the horizontal axis and a cephalic border higher than the caudal border in the vertical axis. Maximal lateral crura width averaged 10.1 mm. In the cadavers, average lateral crural dimensions were 23.4 mm long, 6.4 mm wide at the domal notch, 11.1 mm wide at the so-designated turning point (TP), and 0.5 mm thickness. The accessory cartilage chain was present in all dissections. CONCLUSIONS The lateral crura-alar ring was present in all dissections as a circular ring continuing around toward the anterior nasal spine but not abutting the pyriform. The lateral crura (1) begins at the domal notch and ends at the accessory cartilages, (2) exhibits a distinct TP from the caudal border, (3) has distinct horizontal and vertical vectors, and (4) should have a caudal border higher than the cephalic border. Alar malposition may be associated with position, orientation, or configuration.

Academic plastic surgery: a study of current issues and future challenges.

Introduction:The objectives of this study were (1) to evaluate the role of a full-time academic plastic surgeon, (2) to define the indicators predictive of a successful career in academic plastic surgery, and (3) to understand the current issues that will affect future trends in the practice of academic plastic surgery. Methods:A questionnaire was developed to evaluate the role of current full-time academic plastic surgeons and to understand the current issues and future challenges facing academic plastic surgery. Each plastic surgery program director in the United States was sent the survey for distribution among all full-time academic plastic surgeons. Results:Over a 6-week period, responses from 143 full-time academic plastic surgeons (∼31%) were returned. Fifty-three percent of respondents had been academic plastic surgeons for longer than 10 years. Seventy-three percent of respondents defined academic plastic surgeons as clinicians who are teachers and researchers. However, 53% of respondents believed that academic plastic surgeons were not required to teach or practice within university hospitals/academic centers. The 3 factors reported most frequently as indicative of a successful career in academic plastic surgery were peer recognition, personal satisfaction, and program reputation. Dedication and motivation were the personal characteristics rated most likely to contribute to academic success. Forty-four percent of respondents were unable to identify future academic plastic surgeons from plastic surgery residency applicants, and 27% were not sure. Most (93%) of the respondents believed that academic surgery as practiced today will change. Conclusions:The overall job description of a full-time academic plastic surgeon remains unchanged (teacher and researcher). Whereas peer recognition, personal satisfaction, and program reputation were most frequently cited as indicative of a successful plastic surgery career, financial success was rated the least indicative. Similarly, whereas the personal characteristics of dedication and motivation were rated most likely to contribute to academic success, economic competence was rated least likely. Although the role of academic plastic surgeons remains constant, the practice of academic plastic surgery is evolving. As a result, the future clinical milieu of academic plastic surgeons and training programs is in question.

Managing the Difficult Soft Tissue Envelope in Facial and Rhinoplasty Surgery

Background The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal skin and underlying soft tissue. Objectives This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures. Methods Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi “skin pinch test” was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue. Results Patients determined to have thin, normal, and thick skin by the “skin pinch test” were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer. Conclusions The “skin pinch test” is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. Level of Evidence: 4

Improvement of peripheral nerve regeneration following immunological demyelination in vivo.

Background: To improve regeneration of the peripheral nervous system, a therapy was utilized in the adult rat sciatic nerve in which nerve regeneration is enhanced following acute crush injury. The authors hypothesized that (1) axon regeneration within a region of injury increases following experimental, immunological demyelination; and (2) regenerated axons partially derive from the proximal motor axons. Methods: The sciatic nerves of 10 Sprague-Dawley rats were injected with a demyelinating agent following crush injury, while the nerves of 10 control rats received a crush injury without therapy. The sciatic nerves were harvested at 14 and 28 days. The lesion containing length of the nerve was cut into 1-mm blocks, and specimens were fixed and evaluated using structural and immunohistochemical analyses. A Flouro-Ruby tracer was injected into the sciatic nerves of a separate group of rats to determine the source of axonal regrowth. Results: An epineural injection of complement proteins plus antibodies to galactocerebroside resulted in demyelination followed by Schwann cell remyelination. At 14 days, remyelination was demonstrated spanning the injured sciatic nerve segment. At 28 days, peripheral nerve regeneration was quantified by total axon count, axon density, and nerve fiber diameter. Tracers demonstrated that regeneration arose partially from proximal motor axons. Conclusions: This study demonstrates enhanced regeneration in the peripheral nervous system using experimental, immunological demyelination. Findings indicate that axon count, axon density, and nerve fiber diameter within a region of acute crush injury in the rat sciatic nerve can be improved using a demyelinating treatment.

The Plunging Tip: Analysis and Surgical Treatment

BACKGROUND The plunging tip refers to a deformity in which the nasal tip plunges on smiling. OBJECTIVES To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. METHODS Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. RESULTS Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. CONCLUSIONS This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

A novel model to measure the regenerative potential of the peripheral nervous system after experimental immunological demyelination.

Background: Immunological demyelination is a proposed strategy to improve nerve regeneration in the peripheral nervous system. To investigate the remyelinating potential of Schwann cells in vivo in the peripheral nervous system, the authors have reproduced and expanded upon a novel model of immunological demyelination in the adult rat sciatic nerve. The authors demonstrate (1) the peripheral nervous system’s quantitative, regenerative response to immunological demyelination and (2) whether Schwann cells within a region of demyelination are induced to divide in the presence of demyelinated axons. Methods: The sciatic nerves of female Sprague-Dawley rats were exposed and injected with demyelinating agent bilaterally. At 3 days (n = 3), 7 days (n = 3), and 14 days (n = 3), the animals were euthanized for histological evaluation. A second group of animals (n = 3) was similarly injected with demyelinating agent and then exposed to bromodeoxyuridine between 48 and 72 hours after the onset of demyelination. These animals were euthanized soon after the last injection of bromodeoxyuridine. The tissue was analyzed for Schwann cells (labeled with antibodies to S100) and bromodeoxyuridine assay. Results: A single epineural injection of complement proteins plus antibodies to galactocerebroside resulted in demyelination followed by Schwann cell remyelination. At 3 days after injection, peripheral nerve demyelination and Schwann cell proliferation were evident. Maximum demyelination was seen at 7 days; however, Schwann cell proliferation and remyelination peaked at 14 days after injection. Conclusions: These studies demonstrate an immunological model of demyelination and remyelination in the peripheral nervous system and quantitatively measure regenerative potential. This model will be used to isolate nerve segments and to measure their regenerative potential when given demyelinating agent after acute contusion and transection injuries.

Immunological demyelination enhances nerve regeneration after acute transection injury in the adult rat sciatic nerve.

Introduction:Our recent experiments demonstrate that demyelination enhances peripheral nerve regeneration after contusion injury in the adult rat sciatic nerve. The role of demyelination in peripheral nerve regeneration in a sciatic nerve transection model has yet to be elucidated. We hypothesize that (1) axon regeneration within a region of injury increases after experimental, immunologic demyelination, and (2) regenerated axons are partially derived from the proximal motor axons. Methods:Sciatic nerves of adult female Sprague-Dawley rats (n = 20) were injected with a demyelinating agent immediately after transection injury. The sciatic nerves were harvested 1 month (n = 5) and 2 months (n = 5) after surgery. In the control groups, the cut nerves were reapproximated without demyelination therapy. The lesion containing length of nerve was cut into 1-mm transverse blocks and processed to preserve orientation. Specimens were evaluated using structural and immunohistochemical analyses. Results:A single epineural injection of complement proteins plus antibodies to galactocerebroside resulted in demyelination followed by Schwann cell remyelination. At 1 month, remyelination was clearly shown throughout the injured sciatic nerve segment. At 2 months, there was a statistically significant increase in peripheral nerve regeneration following demyelination therapy as evidenced by total axon count, axon density, and fiber diameter. Conclusion:This study demonstrates enhanced histomorphologic nerve regeneration in the rat sciatic nerve after local delivery of experimental, immunologic demyelination following transection injury. It highlights the utility of demyelination in peripheral nerve regeneration. This therapy may be applicable for tissue-engineered constructs, cell-based systems, and nerve transfers to improve outcomes in peripheral nervous system injuries.