Amanda A. Gosman

Current preferences for breast reduction techniques: A survey of board-certified plastic surgeons 2002

The purpose of this survey was to assess the current trends in breast reduction techniques and to compare satisfaction rates and complications associated with traditional incision and limited incision techniques. In September of 2002, a breast reduction survey was sent to 1500 members of the American Society for Aesthetic Plastic Surgery; 554 of the members returned the survey. Questions elicited categorical answers, and the data were evaluated using the chi-square test and the comparison of two proportions. The results showed that 56 percent of the respondents use only the inferior pedicle and Wise pattern techniques, whereas 6.9 percent of the respondents use only the limited incision techniques. Physician satisfaction was rated as 4 on a scale of 1 (unsatisfied) to 5 (very satisfied) for both the limited incision and traditional incision groups. Patient satisfaction was rated as 4 for the limited incision group and as 5 for the traditional incision group. This difference in patient satisfaction per surgeon was statistically significant (p < 0.05). The traditional group reported a lower complication rate than did the limited incision group (p < 0.05). The most frequent complications for the traditional incision group were compared with those of the limited incision group. Practice profiles, liposuction, and opinions regarding future changes in breast surgery were also analyzed. The majority of surgeons reported that they did not anticipate changing their practices to accommodate advances in limited incision techniques; however, 89 percent reported that the new limited incision techniques and liposuction are trends that are here to stay.

Mastopexy preferences: a survey of board-certified plastic surgeons.

Background: The purpose of this survey was to assess the current trends in mastopexy techniques and to compare satisfaction rates and complications associated with different techniques. Methods: In September of 2002, a mastopexy survey was sent to 1500 members of the American Society for Aesthetic Plastic Surgery; 487 complete responses were received, for a response rate of 32.5 percent. Questions elicited categorical answers, and the data were evaluated using the chi-square test and the comparison of two proportions. Results: The inverted-T incision technique is the most popular. Satisfaction was reported to be highest with the short scar periareolar inferior pedicle reduction (or SPAIR) and Hall-Findlay techniques. Physician satisfaction was lowest with the periareolar technique. The three most common complications for all techniques were suture spitting, excess scarring, and bottoming out. The periareolar group had a greater frequency of revision (p = 0.002). The inverted-T group had a greater frequency of bottoming out (p = 0.043). The short scar group had a greater frequency of asymmetry (p = 0.008). Conclusions: The traditional inverted-T technique is the most popular, but the newer short scar techniques have become more popular in the last 5 years. The inverted-T incision continues to be associated with bottoming out and excess scarring. The periareolar technique has the greatest need for revision and the lowest physician satisfaction, despite its application to a greater volume of mastopexies per year.

An update on the timing of hard palate closure: A critical long-term analysis

In 1996, we published the results of the Oxford Cleft Palate Study in “The Timing of Hard Palate Closure: A Critical Long-term Analysis.”1 Our objective in this study was to critically assess the controversy about the timing of hard palate closure, specifically early palatoplasty for improved speech versus delayed palatoplasty for undisturbed facial growth. A multidisciplinary approach was used to evaluate the longterm results of early (10.8 months) versus late closure (48.6 months) of the hard palate and to determine the incidence of speech deficiencies, palatal fistulas, hearing abnormalities, and maxillofacial growth disturbances. The results of our original analysis revealed statistically significant speech deficiencies with delayed hard palate closure, specifically in articulation, nasal resonance, intelligibility, and substitution pattern assessment. The delayed closure group also had a significantly greater incidence of overall palatal fistulas and persistent palatal fistulas. No significant differences were noted in hearing or maxillofacial growth. Given the results of our data, we believe that delayed hard palate closure results in significant speech impairment without the benefit of preserving maxillofacial growth. The impact of our long-term analysis is reflected in our current goal-oriented approach to the treatment of cleft palate patients. The goals for treatment of the cleft palate patient are normal speech, hearing, maxillofacial growth, and avoidance of fistulas. There are several important differences between our current treatment protocol and the early treatment method used in the Oxford Cleft Palate Study. These changes are based on the results of our data as well as our clinical experience during the past 15 years. We advocate an early, two-stage palate repair. Our current treatment protocol starts with presurgical infant orthopedics at 1 to 2 weeks of age. The cleft lip and velum are repaired at age 3 to 6 months, and the residual hard palate cleft is repaired at age 15 to 18 months. Secondary bone grafting of alveolar clefts after orthodontic manipulation is performed during transitional dentition. The lip is repaired using a modified Millard rotationadvancement, the velum is repaired by intravelar veloplasty, and the hard palate is repaired using a two-layered primary closure or the von Langenbeck procedure. The technique for early palate closure in the Oxford Cleft Palate Study was a one-stage, three-flap or four-flap, modified Wardill-Kilner procedure at an average age of 10.8 months (range, 6 to 18 months). Our data showed significant speech benefits without maxillofacial growth consequences of hard palate repair at age 10.8 months, but we acknowledge that periosteal undermining of palatal and vomerine tissues at an earlier age could potentially result in a significant growth disturbance. Isolated repair of the velum without periosteal undermining allows release of the levator mechanism without disturbing hard palate growth. Furthermore, reconstruction of the anterior palatal arch with the cleft lip repair and posterior maxillary arch with repair of the velum creates a molding effect with alveolar arch alignment.2,3 The molding effect results in a narrowing of the

Review of bone substitutes.

Bone substitutes are being increasingly used in craniofacial surgery and craniomaxillofacial trauma. We will review the history of the biomaterials and describe the ideal characteristics of bone substitutes, with a specific emphasis on craniofacial reconstruction. Some of the most commonly used bone substitutes are discussed in more depth, such as calcium phosphate and hydroxyapatite ceramics and cements, bioactive glass, and polymer products. Areas of active research and future directions include tissue engineering, with an increasing emphasis on bioactivity of the implant.

Pilot trial of telemedicine as a decision aid for patients with chronic wounds.

The study goal was to evaluate the impact of the telemedicine consult on patients with chronic wounds. Thirty patients from long-term care skilled nursing facilities, referred to the ambulatory wound care program for wound assessment and preparation of management plans, were the subject of this prospective, randomized trial. To facilitate communication with a surgical wound care specialist, telemedicine feedback was provided prior to face-to-face consultation to 15 patients. The telemedicine consult included (1) wound assessment, (2) rationale for the suggested wound management with emphasis on wound risk projections, and (3) prevention and benefits of surgical intervention. This was communicated to the patient by the field wound care nurse. The telemedicine impact was measured by assessing the duration of the subsequent face-to-face consultation and patient satisfaction with further care decisions as well as by validation of a decisional conflict scale. The average duration of the face-to-face consultation was 50 +/- 12 minutes versus 35 +/- 6 (p < 0.01) minutes for patients subjected to the telemedicine feedback preceding the direct contact with the specialist. The telemedicine consult was found to be a useful aid in increasing the satisfaction rate from care decisions ultimately made during the direct consult (acceptance rate 93% vs. 47% in those subjected to treatment without the intermediate telemedicine consult, p < 0.01). The decisional conflict as a state of uncertainty about the course of action to take was reduced in patients subjected to telemedicine decision aid. The average Decisional Conflict Scale score was 14 +/- 1.73 in patients subjected to telemedicine feedback as opposed to 35 +/- 4.26 (p < 0.001) in no-telemedicine contact. The telemedicine consult preceding face-to-face evaluation improved patient satisfaction and understanding of their care as well as increased the perception of shared decision making regarding the wound care.

Risk of adverse outcomes when plastic surgery procedures are combined.

Background: The ability to study population-level outcomes of outpatient cosmetic procedures has been limited by a lack of longitudinal data. This study aimed to describe the rates of adverse events in patients who underwent an isolated cosmetic surgery procedure compared with those who had a combination of two procedures. Methods: Retrospective longitudinal analysis was performed of the 2005 to 2010 California Office of Statewide Health Planning and Development Ambulatory Surgery Database. Patients were included if they had undergone an abdominoplasty or any other procedure that was identified as frequently performed concurrently with abdominoplasty. Patients’ subsequent in-patient admissions and emergency department visits were identified. Outcomes analyzed were the 30-day and 1-year venous thromboembolism rates, 30-day hospital admission rate, 30-day emergency department visit rate, and 30-day mortality rate. Results: A total of 477,741 patients were analyzed, of whom 16,893 had undergone two concurrent procedures. The 12-month venous thromboembolism rate was 0.57 percent for patients undergoing abdominoplasty, 0.20 percent for liposuction, 0.12 percent for breast procedures, 0.32 percent for hernia repair, 0.28 percent for face procedures, and 0.28 percent for thigh lift/brachioplasty. Greater than additive 30-day and 1-year venous thromboembolism rates were observed among patients who underwent an abdominoplasty and liposuction (0.68 percent and 0.81 percent, respectively) and those who underwent an abdominoplasty and hernia repair (0.93 percent). Conclusions: Some combinations of elective outpatient procedures conferred an additive, and sometimes more than additive, venous thromboembolism risk. This is an important consideration when informing patients of potential postoperative complications and for venous thromboembolism prophylaxis.

Bilateral cleft lip and nasal repair.

Summary: The bilateral cleft lip and nasal repair has remained a challenging endeavor. Techniques have evolved to address concerns over unsatisfactory features and stigmata of the surgery. The authors present an approach to this complex clinical problem that modifies traditional repairs described by Millard and Manchester. The senior author (H.S.B.) has developed this technique with over 25 years of surgical experience dealing with the bilateral cleft lip. This staged lip and nasal repair provides excellent nasal projection, lip function, and aesthetic outcomes. Lip repair is performed at 3 months of age. Columellar lengthening is performed at approximately 18 months of age. A key component of this repair focuses on reconstruction of the central tubercle. A triangular prolabial dry vermilion flap is augmented by lateral lip vermilion flaps that include the profundus muscle of the orbicularis oris. This minimizes lateral lip segment sacrifice and provides improved central vermilion fullness, which is often deficient in traditional repairs. The authors present the surgical technique and examples of their clinical results.

Orthodontic characteristics of maxillary arch deficiency in 5-year-old patients undergoing unilateral cleft lip and palate repair with and without early gingivoplasty.

The purpose of this study was to compare the maxillary arch morphology in 5-year-old children treated for unilateral cleft lip and palate (UCLP) with early gingivoplasty (EGP) and without this procedure (non-EGP). Three-dimensional (3-D) imaging was used to verify which measurements and to what degree specific orthodontic parameters differ in both groups. The study included 120 non-syndromic 4.5-5.5-year-old children treated surgically at the age of 6-18 months. Fifty-six children underwent EGP utilising a Skoog-type of technique. The (non-EGP) group consisted of 64 patients. Patients in both groups were treated without nasoalveolar moulding prior to cleft lip repair. The maxillary arch models were obtained and subjected to the 3-D computer-aided imaging procedure and metric analysis. Ten selected orthodontic measurements were calculated based on imaging landmarks. The computed data derived from models in both (EGP and non-EGP) groups were compared. The differences between groups were statistically analysed using Students test. Five orthodontic measurements: the angle of the lesser segment inclination, dental arch radius of this segment, anterior palatal depth, palatal surface and length of dental arch demonstrate more severe maxillary underdevelopment in patients with previous EGP. The results reaffirm the negative impact of EGP with wide undermining of periosteal flaps on maxillary development and suggest that these five parameters may be the most sensitive early indicators of growth alteration.

Telemedicine as a means of effective speech evaluation for patients with cleft palate.

Providing long-term multidisciplinary care for cleft lip/palate is a challenge for international humanitarian organizations that perform surgery across borders. The use of telemedicine as a means of evaluating speech in patients with cleft lip/palate has not been studied previously. We looked at determining whether a speech evaluation performed by a speech-language pathologist (SLP) using telemedicine would be equivalent to a speech evaluation performed in-person, in an international setting between Tijuana, Mexico and San Diego, CA. Spanish-speaking SLPs developed an informal protocol to evaluate several speech characteristics. Patients were simultaneously evaluated by 2 SLPs, one in-person in Tijuana and the other over telemedicine videoconference from San Diego, CA. In addition, we obtained data regarding the parents experience with telemedicine through a satisfaction survey. Results showed no statistically significant differences between the 2 methods of speech evaluation, particularly in oral muscle tone, resonance, lingual lateralization, oral pressure, and dentition. The satisfaction survey showed family satisfaction with the speech evaluation performed using telemedicine. Thus, telemedicine represents an effective medium for conducting speech assessment in patients with cleft lip/palate, allowing for increased access to care for underserved populations.

Abstract 131: Adipose Derived Stem Cell Count is Influenced by Receipt of Chemotherapy in Breast Cancer Patients.

Suday, M arch 9, 2014 effect. The angiogenic effect of PRP itself and PRP-treated ASCs will enhance the vascular supply to maintain the adipocyte survival within fat graft. Furthermore, the stemness effect of PRP increases the renewal and differentiation capabilities of ASCs which can be the cell depot required in fat graft survival. 131 adipose derived Stem cell count is influenced by receipt of chemotherapy in Breast cancer Patients