Ajul Shah

Simulated surgery and cutting guides enhance spatial positioning in free fibular mandibular reconstruction

Introduction: The free fibular flap is the workhorse for mandibular reconstruction. Three‐dimensional (3D) planning, with use of cutting guides and prebent plates, has been introduced. The purpose of this study is to evaluate the interfragmentary gap size and symmetry between conventional freehand preparation versus those using 3D planning. Methods: A retrospective review was performed. Conventional free form and 3D planned fibular reconstructions performed by the senior authors at a single institution were included. Reconstructions were further subdivided into “body only” and “complex.” Demographic and intraoperative data were collected. Postoperative CT scans were analyzed using Materialize software. Interfragmentary gap distances (mm) and symmetry (degrees) were assessed. Results: Nineteen fibular reconstructions met inclusion criteria, ten conventional free form, and nine 3D planned reconstructions. Interfibular gaps measured 0.36 ± 0.50 mm in the 3D group versus 1.88 ± 1.09 mm in the non‐3D group (P = 0.004). Overall symmetry (a ratio between right and left angles) measured versus 1.027 ± 0.08 in the 3D‐planned versus 1.024 ± 0.09 in the non‐3D group in (P = 0.944). Within only mandibular body reconstructions, symmetry was similar between the two techniques: 1.05 ± 0.12 in the 3D group versus 0.97 ± 0.05 in the non‐3D group (P = 0.295). Conclusions: 3D planning lessens interfibular gap dimensions and may enhance axial symmetry. Space between native mandible and fibula is not appreciably altered using planning. Future efforts will focus on the accuracy and reproducibility of the 3D planned to actual results as well as clinical significance and efficiency benefits.

Thoracic Intercostal Nerve Blocks Reduce Opioid Consumption and Length of Stay in Patients Undergoing Implant-Based Breast Reconstruction.

Background: Traditionally, narcotics have been used for analgesia after breast surgery. However, these agents have unpleasant side effects. Intercostal nerve blockade is an alternative technique to improve postoperative pain. In this study, the authors investigate outcomes in patients who receive thoracic intercostal nerve blocks for implant-based breast reconstruction. Methods: A retrospective chart review was performed. The operative technique for breast reconstruction and administration of nerve blocks is detailed. Demographic factors, length of stay, and complications were recorded. The consumption of morphine, Valium, Zofran, and oxycodone was recorded. Data sets for patients receiving thoracic intercostal nerve blocks were compared against those that did not. Results: One hundred thirty-two patients were included. For patients undergoing bilateral reconstruction with nerve blocks, there was a significant reduction in length of stay (1.87 days versus 2.32 days; p = 0.001), consumption of intravenous morphine (5.15 mg versus 12.68 mg; p = 0.041) and Valium (22.24 mg versus 31.13 mg; p = 0.026). For patients undergoing unilateral reconstruction with nerve blocks, there was a significant reduction in consumption of intravenous morphine (2.80 mg versus 8.17 mg; p = 0.007). For bilateral reconstruction with intercostal nerve block, cost savings equaled

Aesthetic Breast Shape Preferences Among Plastic Surgeons

2873.14 per patient. For unilateral reconstruction with intercostal nerve block, cost savings equaled

Public Perception of Cosmetic Surgeons versus Plastic Surgeons: Increasing Transparency to Educate Patients

1532.34 per patient. Conclusion: The authors’ data demonstrate a reduction in the consumption of pain medication, in the hospital length of stay, and in hospital costs for patients receiving intercostal nerve blocks at the time of pectoralis elevation for implant-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

PDE-5 inhibition improves skin flap viability in rats that are exposed to nicotine

BackgroundThere has been little discussion in the plastic surgery literature regarding breast shape preferences among plastic surgeons, despite strong evidence that such aesthetic preferences are influenced by multiple factors. Much effort has been focused on delineating the objective criteria by which an “attractive” breast might be defined. This study aimed at providing a better understanding of the presence and significance of differences in personal aesthetic perception, and how these relate to a plastic surgeon’s demographic, ethnic, and cultural background, as well as practice type (academic vs private). MethodsAn interactive online survey was designed. Modifiable ranges of upper pole fullness and areola size were achieved via digital alteration, enabling participants to interactively change the shape of a model’s breasts. The questionnaire was translated into multiple languages and sent to plastic surgeons worldwide. Demographic data were also collected. Analysis of variance was used to elucidate plastic surgeon’s breast shape preferences in respect to sex and age, geographic and ethnic background, as well as practice type. ResultsThe authors gathered 614 responses from 29 different countries. Significant differences regarding preferences for upper pole fullness, areola size in the natural breast, and areola size in the augmented breast were identified across surgeons from the different countries. Further, significant relationships regarding breast shape preferences were distilled between the age and sex of the surgeon, as well as the practice type. No differences were found in respect to the surgeons’ self-reported ethnic background. ConclusionsCountry of residence, age, and practice type significantly impact breast shape preferences of plastic surgeons. These findings have implications for both patients seeking and surgeons performing cosmetic and reconstructive breast surgery. In an increasingly global environment, cultural differences and international variability must be considered when defining and publishing new techniques and aesthetic outcomes. When both the plastic surgeon and the patient are able to adequately and effectively communicate their preferences regarding the shape and relations of the breast, they will be more successful at achieving satisfying results.

Does phosphodiesterase inhibition lessen facial flap necrosis in tobacco cigarette users

Background: The American Society of Plastic Surgeons’ “Do Your Homework” campaign strives to educate the public on how to identify providers who can safely perform aesthetic/cosmetic/plastic surgery. Although the campaign continues to heighten awareness, misperceptions remain in determining who these providers are. This study aims to examine whether the general public is confused by the titles “plastic surgeon” or “cosmetic surgeon,” and accordingly, evaluates whether misperceptions need to be remedied to have an informed and safe patient. Methods: A 19-question survey was created under the guidance of a survey methodologist. Responses were obtained and cross-tabulation analyses were performed with statistical analysis. Results: Five thousand one hundred thirty-five individuals completed the survey. Eighty-seven percent of patients either believed that surgeons must be appropriately credentialed to legally advertise themselves, or were unsure. The majority of respondents were uncomfortable with obstetrician-gynecologists (92 percent), dermatologists (68 percent), general surgeons (74 percent), and family practice physicians (93 percent) performing surgery to improve their appearance. Persons with lower education and lower income levels were more likely to believe that surgeons must be appropriately credentialed to legally market themselves, and were more likely to assume that to legally perform aesthetic surgery, one must be board certified in plastic surgery. Conclusion: The authors’ data demonstrate that the combination of problematic medical marketing, recognized and unrecognized boards, and varying categorizations of surgeons has made it increasingly difficult for a patient to interpret the necessary information to decide which physician can safely perform surgery to improve one’s appearance.

The Effect of Nasal Tip Rotation on Upper Lip Length

Nicotine causes ischemia and necrosis of skin flaps. Phosphodiesterase‐5 (PDE‐5) inhibition enhances blood flow and vasculogenesis. This study examines skin flap survival in rats exposed to nicotine that are treated with and without PDE‐5 inhibition.

Barbed Sutures and Tendon Repair—a Review

Tobacco cigarette smoking remains a serious risk factor for necrosis of local facial skin flaps. To date, no pharmacological therapies exist for cigarette smoke-induced impairment of skin flap tissue survival. Accumulating evidence suggest that phosphodiesterase-5 (PDE-5) inhibitor therapy may counteract the negative effects of cigarette smoke on flap survival. Here, we evaluate skin flap survival in a series of consecutive tobacco cigarette users treated with the PDE-5 inhibitor, sildenafil, who underwent local flap facial reconstruction. We included 11 patients (5 females; median age: 64) with a significant smoking history. Seventeen facial flaps were performed for 14 defects. All patients received sildenafil in the postoperative setting. One complication of necrosis of the flap distal margin was encountered. Follow-up was available for all patients. Our results demonstrate that facial reconstruction in tobacco cigarette smokers can be performed with improved success and that sildenafil therapy may mitigate the deleterious effects of smoking on flap survival.

Low-cost simulation plank for microsurgical success.

Background: Increasing the nasolabial angle (NLA) with tip rotation generates the appearance of a lengthened lower facial third. In particular, the upper lip show seems increased following elevation of the nasal tip. Objectives: The purpose of this study is to quantify the impact of tip rotation on upper lip length (ULL), and to establish a predictable correlation between the two. Methods: A retrospective cohort study of rhinoplasty patients with increased tip rotation, using either caudal septal extension graft (CSEG) or columellar strut graft (CS), was performed. Three‐dimensional photos were obtained and analyzed anthropometrically and used to measure the ULL and NLA. The deltas between NLA and ULL at the various time points, was then compared using linear regression with P < .05 recognized as statistically significant. Results: One‐hundred and fifty patients were identified and 88 patients met inclusion criteria. CS and CSEG were used in 40% (n = 36), and 60% (n = 52), respectively. Three‐dimensional assessment showed that as the NLA positively correlated with the ULL in both cohorts. The CSEG group created a greater NLA and ULL compared to the CS cohort. Both NLA and ULL decreased over time, but remained statistically increased as compared with preoperative measurements. For every one degree of NLA increase, the ULL increases by 0.05 mm. Conclusions: Increasing nasal tip rotation in rhinoplasty results in greater upper lip show. Both CS and CSEG can effectively increase tip rotation and ULL. A predictable correlation of nearly 0.05 mm of ULL for every 1 degree of tip rotation is shown. Level of Evidence: 4 Figure. No caption available.

Ubersense: using a free video analysis app to evaluate and improve microsurgical skills.

IntroductionTraumatic tendon lacerations are a common problem encountered by hand surgeons worldwide. Although the use of barbed suture to repair tendon lacerations has gained theoretical popularity in recent years, there is little information available regarding the safety, efficacy, longevity, or complications encountered when used in tenorraphy. In this study, we review the available literature on the use of barbed suture in tendon repair.MethodsStudies conducted between 1980 and 2014 were identified using several databases, including EMBASE, SCOPUS, MEDLINE, and Web of Science. Keywords used to search for appropriate studies included the following: barbed, v loc, quill, tendon, tendon injuries, suture, tenorraphy, injury, and laceration, in various combinations.ResultsOur initial literature search identified 47 articles, and 8 were deemed appropriate for review after applying our exclusion criteria. The data from each of the articles is reviewed for the following major categories:1.Maximum load to failure2.Mode of failure3.Load to 2-mm gap4.Change in cross-sectional area5.Type of repairConclusionsBarbed suture tenorraphy has a myriad of theoretical advantages, supported by varying ex vivo studies, as compared to traditional techniques. However, due to the non-uniformity in current studies and the lack of available data in a live model, we are unable to argue for or against barbed suture tenorraphy. We believe our review provides the most in-depth analysis of barbed suture tenorraphy to date, illuminates the potential advantages of using barbed sutures, and highlights the need for further investigation into this technique.