Brian P. Dickinson

Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results.

Background: Despite a perceived interest in autologous fat transfer, there is no consensus as to the best technique or the level of success. The purpose of the present study was to determine the national trends in techniques for harvest, preparation, and application of autologous fat, as well as the success perceived by practitioners. Methods: Comprehensive surveys were sent to 650 randomly selected members of the American Society for Aesthetic Plastic Surgery. The survey was aimed at determining whether autologous fat transfer is a commonly performed procedure and, if so, the specific methods involved and the subjective perception of short- and long-term results. Results: The results of the national consensus survey from 508 surgeons (78 percent return rate) showed the following: (1) autologous fat transfer is a relatively common procedure (57 percent perform >10 annually), but few perform it in high volume (only 23 percent perform >30 annually); (2) techniques for harvest, preparation, and injection rarely deviate from methods discussed in the literature (microcannula, 54 percent; centrifugation, 75 percent; injection in nasolabial fold > lips > nasojugal folds); (3) most physicians believe that at least some graft survival is clinically evident (93 percent); and (4) patients are pleased with the short-term results (good to excellent, 84 percent), despite a lower rate of long-term patient satisfaction (fair to good, 80 percent). Conclusion: Currently, plastic surgeons across the country report a uniformity of autologous fat grafting techniques with acceptable patient satisfaction.

Reduced Morbidity and Improved Healing with Bone Morphogenic Protein-2 in Older Patients with Alveolar Cleft Defects

Background: In older cleft patients, alveolar bone grafting may be associated with poor wound healing, graft exposure, recurrent fistula, and failure of tooth eruption. A new procedure using a resorbable collagen matrix with bone morphogenetic protein (BMP)-2 was compared with traditional iliac crest bone graft to close alveolar defects in older patients. Methods: Skeletally mature patients with an alveolar cleft defect undergoing alveolar cleft repair were divided into either group 1 (BMP-2, experimental) or group 2 (traditional iliac graft, control) (n = 21). Bone healing was assessed with intraoral examination and NewTom scans (three-dimensional, Panorex, periapical films). Donor-site morbidity was determined with pain surveys. Overall cost and length of hospital stay were used to examine economic differences. Results: Preoperative and follow-up (1 year) intraoral examinations revealed fewer complications (11 percent versus 50 percent) and better estimated bone graft take in group 1 compared with group 2. Panorex and three-dimensional computed tomographic scans showed enhanced mineralization in group 1 compared with group 2. Volumetric analysis showed group 1 had a larger percentage alveolar defect filled with new bone (95 percent) compared with group 2 (63 percent). Donor-site pain intensity and frequency were significant in group 2 but not group 1. The mean length of stay was greater for group 2 compared with group 1. In addition, the mean overall cost of the procedure was greater in group 2 (

Risk factors for abdominal donor-site morbidity in free flap breast reconstruction.

21,800) compared with group 1 (

Difficulties with subpectoral augmentation mammaplasty and its correction: the role of subglandular site change in revision aesthetic breast surgery.

11,100). Conclusions: For this select group of late-presenting alveolar cleft patients, the BMP-2 procedure resulted in improved bone healing and reduced morbidity compared with traditional iliac bone grafting.

Approaching revisional surgery in augmentation and mastopexy/augmentation patients.

Background: The lower abdomen is the most popular donor site for autologous tissue breast reconstruction. Several studies have reported abdominal morbidity following pedicled and free flap reconstructions using this donor site, yet few studies have compared the various types of free flaps and investigated specific operative and patient-related factors that are associated with higher rates of abdominal complications. Methods: The authors conducted a retrospective review of all free flap breast reconstructions performed at University of California Los Angeles Medical Center between July of 2002 and July of 2005. Results: A total of 279 patients underwent 211 unilateral and 68 bilateral reconstructions, totaling 347 flaps. Eleven percent were free transverse rectus abdominis myocutaneous (TRAM) flaps, 52 percent were muscle-sparing free TRAM flaps, and 37 percent were deep inferior epigastric perforator (DIEP) flaps. Mean follow-up was 29.9 months. There were 30 total abdominal complications (10.9 percent of patients), including 17 rectus bulges and five hernias. Free TRAM reconstructions had a significantly higher rate of donor-site complications than did DIEP reconstructions. Bilateral flap harvests and obesity (body mass index >30) were significant risk factors for (1) any donor-site complication and (2) rectus bulge/hernia formation. There was no significant increase in donor-site complications associated with various prior abdominal operations. Conclusions: Donor-site complications are not uncommon, but paying careful attention to patient comorbidities when selecting an operative approach (bilateral versus unilateral, free TRAM versus DIEP, and so on) can minimize postoperative abdominal complications. Furthermore, the results corroborate the recent literature suggesting there is little functional difference in patients receiving muscle-sparing free TRAM versus DIEP reconstructions.

Nasopharyngeal encephalocele: report of transcranial and transpalatal repair with a 25-year follow-up.

Background: Difficulties that arise with subpectoral breast implant placement include the following: malpositioning of the implant; improper superior contouring; and unnatural movement with chest muscle contraction. Correction of these deformities is easily achieved by removal of the subpectoral implant, resuspension of the pectoralis major muscle to the chest wall, and reaugmentation with a new implant in the subglandular plane. This study defines a correction modality for the adverse results of subpectoral implant placement in augmentation mammaplasty. Methods: Pectoralis major resuspension was performed in 36 patients undergoing revision aesthetic breast surgery from 1995 to 2006. All patients had previously placed subpectoral breast implants performed elsewhere with unwanted movement, malposition, and/or capsular contracture. All patients underwent explantation of the breast implant, modified capsulectomy, pectoralis major resuspension, and reaugmentation of the breast in the subglandular position. In cases of symmastia, medial capsulodesis and sternal bolster sutures were used. Patients were evaluated for resolution of symptoms, satisfaction, and complications. Results: Malposition (62 percent), capsular contracture (53 percent), and symmastia (10 percent) were the most common indications for revision, but 100 percent of patients were dissatisfied with abnormal breast movement. The average follow-up time was 20 months. The silicone implants were commonly used, with an average volume change decrease of 27 cc. Unwanted implant movement was eliminated completely (100 percent), symmastia was corrected (100 percent), and capsular contraction was significantly decreased in each respective group. Patient satisfaction with this procedure was high, with a low complication rate. Conclusions: Pectoralis major resuspension can be performed successfully in aesthetic breast surgery. It can be applied safely to correct problems of unwanted implant movement, symmastia implant malposition, and capsular contraction. The use of silicone gel implants in a novel tissue plane may be beneficial in this diverse, reoperative patient population.

Facial reanimation by staged, split masseter muscle transfer.

Background:Breast augmentation and mastopexy augmentation procedures are becoming more common. The young plastic and reconstructive surgeon is often challenged revisional surgery operations in these patients. These cases are challenging, require significant operative time, and can be associated with a high revision rate. It is important for the young surgeon to have an approach to deal with these common and difficult scenarios. Methods:A retrospective chart review was conducted on all patients who underwent a revision augmentation or revision mastopexy augmentation procedure between 2008 and 2010 by the authors. The most commonly encountered mitigating circumstances in the revision augmentation or revision mastopexy augmentation populations were identified and an algorithm was created on how to address these difficult problems. Results:Between July 1, 2008 and July 1, 2010, 264 patients underwent revision augmentation or revision mastopexy augmentation procedures. The most commonly encountered patient scenarios were recurrence of ptosis, recurrent capsular contracture, implant malposition, rippling, and desiring a reduction in implant size. We encountered many mitigating circumstances that complicated the revisions. We devised a stepwise algorithmic approach to address these problems based on the following factors: (1) blood supply to the nipple-areola complex, (2) need to change implant plane, (3) patient desire to reduce or increase in breast implant volume, (4) need for total en bloc capsulectomy or capsulorrhaphy, (5) incision approach used to perform the capsulectomy, and (6) patient-related factors that need to be medically optimized or treated before, during, and after surgery. By adhering to these steps, outcomes can be accomplished more reliably and safely. Conclusion:Specialized preoperative planning is necessary to consistently deliver safe and aesthetic revision augmentation and revision mastopexy augmentation results. It is important for the operative surgeon to carefully consider the potential adverse effect of implants and prior mastopexy or reduction incisions and patterns on the blood supply to the nipple-areola complex. With educated planning, successful results can be achieved in most cases, and the risk of serious complications can be minimized.

Temporalis fascia for lip augmentation.

Background: Encephaloceles are an extension or protrusion of any intracranial matter through a cranial bone defect. The sphenoethmoidal encephalocele is often fatal. For those who survive long enough, expeditious repair is critical. We report a case that was repaired successfully via a combined transcranial and transpalatal approach, and because of successful repair, the patient underwent multiple secondary reconstructions resulting in a 25-year follow-up. Clinical Report: A 3960-g, term male infant from a normal gestation was delivered via cesarean delivery for breech position. Initial examination revealed a 2 × 3-cm gray intraoral nasopharyngeal mass with smooth mucosal covering extruding through a midline palatal cleft. At 4 weeks of life, extradural and intradural exploration of the encephalocele was performed via a bifrontal craniotomy. At 15 months of age, the patient underwent median cleft lip repair. At 6 years of age, hypertelorism was corrected by wedge resection of the frontal and nasal bones and medial mobilization of the orbits. Follow-up was continued until 25 years of age, which revealed excellent maintenance of correction. Conclusion: Sphenoethmoidal encephalocele is a rare sporadic congenital cranial floor defect associated with typical facial and cerebral anomalies. Encephaloceles extending into the nasopharynx may cause airway obstruction and feeding difficulty and present a potential pathway for central nervous system infection. Repair of the encephalocele should then be performed as soon as possible. Care of patients with nasopharyngeal encephaloceles requires a lifetime of reconstructive surgery. Care of these patients can be rewarding to both families and surgeons.

Correction of massive hydrocephalus and brain wound in holoprosencephaly.

BackgroundFacial paralysis of the lower face presents severe functional and aesthetic disturbance to patients. The gamut of facial paralysis correction is diverse and must be tailored to the patient. When nerve repair or free functional muscle transfer is unavailable, regional muscle transfer has become a staple in surgical management of facial paralysis. Previous masseter transfers relied on orbicularis oris attachment, which may be atrophic, adhered, or lengthened. Using fascia lata grafts, we describe the senior author’s method of staged, split masseter transfer as a reliable method for reanimating the lower third of the face in appropriate candidates. MethodsThe staged, split masseter muscle transfer is a 3-part repair. The first stage places a hemioral fascia lata graft to act as an anchor reinforcement. The second stage transfers the split masseter muscle, suturing to the fascia lata reinforced oral commissure. The third stage, a reefing procedure, is performed 6 to 10 months later under local anesthesia to reinforce attachments. ResultsSix patients underwent the staged, split masseter muscle transfer. Mean age was 43 (15–67) years. Mean time to surgery from onset of deficit was 174 months (3 months to 65 years). All patients had significant improvement over preoperative symptoms. Symmetry was restored in repose. On movement, commissure excursion went from 0 to 6.67 mm in the superolateral vector. Of the 6 patients, 5 required an average of 1.5 outpatient revisions to achieve satisfactory results on average of 4.67 (4–127) months after the final stage. ConclusionsThe staged, split masseter transfer is useful for restoring subtle reanimation in patients presenting with facial paralysis. The staged, split masseter transfer provides bulk and restores both static and dynamic function. We present a case series demonstrating excellent long-term functional results.

Pediatric facial fractures: current national incidence, distribution, and health care resource use

Background:The pervasiveness of the desire for beautiful lips persists today, with women in the United States spending almost 2.9 billion dollars annually on cosmetics and lip products. The lips occupy the central feature of the lower third of the face and are of paramount importance to facial beauty. Various surgical approaches and methods are used in lip augmentation. Methods:We reviewed the charts of 7 patients who underwent temporalis fascia lip augmentation to evaluate the temporalis fascia as a safe and effective means for lip augmentation. Results:The average follow-up was 5 years (range, 4–6 years). All patients who underwent lip augmentation were female. The average age of the patients was 47 years old with a range of 36 to 67 years. All patients were very satisfied with the results of their surgical lip augmentation postoperatively and no patients required any revision operations. Conclusion:Temporalis fascia is a safe method of lip augmentation and is durable and long lasting. Lip augmentation with temporalis fascia can easily be performed in conjunction with other procedures.