Catherine S. Chang

Costochondral grafting in craniofacial microsomia.

Background: Craniofacial microsomia encompasses a spectrum of diagnoses associated with variable degrees of mandibular hypoplasia, facial asymmetry, chin deviation, occlusal abnormalities, and potential airway compromise. This study presents one surgeon’s experience with costochondral rib grafting for mandibular reconstruction in children with Pruzansky/Kaban type 2B and type 3 mandibular hypoplasia. Methods: An institutional review board–approved retrospective chart review was performed of all patients with craniofacial microsomia who underwent costochondral rib grafting for mandibular reconstruction performed by the senior author (S.P.B.) at The Children’s Hospital of Philadelphia from January of 1998 to September of 2013. Demographic information, surgical history, operative details, postoperative complications, and outcomes were recorded. Plain radiographs and preoperative and postoperative three-dimensional computed tomographic scans were reviewed. Results: Two hundred fifty-five patients were diagnosed with craniofacial microsomia, and 22 patients met inclusion criteria. Twelve boys and 10 girls underwent grafting at an average age of 7.2 years. Thirty-three costochondral rib grafts were performed, 11 unilateral reconstructions and 11 bilateral reconstructions. Twelve hemimandibles were type 2B and 21 were type 3. No intraoperative complications were reported, and no incidence of graft resorption was noted. No additional procedures were required in 27 reconstructed hemimandibles (81.8 percent), whereas six (18.2 percent) required secondary distraction osteogenesis. Only one patient developed postoperative ankylosis. No malunion or nonunion was noted. Conclusion: The approach described in this article allowed the authors to obtain reliably good results with costochondral rib grafting for type 2B and type 3 mandibular hypoplasia associated with craniofacial microsomia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Female Genital Mutilation Reconstruction: A Preliminary Report

Background Female genital mutilation (FGM) is internationally recognized as a violation of human rights. Though rarely discussed, FGM is prevalent, affecting hundreds of millions of females worldwide. Objectives We believe that is important for plastic surgeons to be informed and prepared to address the surgical and emotional needs of these women. We present our experience on treatment of women subjected to FGM. Methods Three consecutive patients were treated by our clitoral restoration procedure. The procedure involves conscious sedation and involves wide release of scar tissue around the labia majora and clitoris. Labial flaps are elevated and secured down to the periosteum and the clitoris is allowed to remucosalize. Results Three females with grade II mutilation were treated. The average age was 32.3-years-old and the average follow up was 305 days. All patients self-reported improved sexual function and decreased embarrassment with their partners. And all recommended the treatment to other women subjected to FGM. Conclusions FGM is a violation of the basic rights of women and children. Plastic surgeons can help these women restore their physical and psychological sense of well-being by providing effective reconstructive options. Our goal is to raise awareness of this problem and describe a simple yet effective treatment for women that have been subject to FGM. Level of Evidence 5.

Current Applications of Facial Volumization with Fillers.

Learning Objectives: After reading this article and watching the accompanying videos, the participant should be able to: 1. Assess patients seeking facial volumization and correlate volume deficiencies anatomically. 2. Identify appropriate fillers based on rheologic properties and anatomical needs. 3. Recognize poor candidates for facial volumization. 4. Recognize and treat filler-related side effects and complications. Summary: Facial volumization is widely applied for minimally invasive facial rejuvenation both as a solitary means and in conjunction with surgical correction. Appropriate facial volumization is dependent on patient characteristics, consistent longitudinal anatomical changes, and qualities of fillers available. In this article, anatomical changes seen with aging are illustrated, appropriate techniques for facial volumization are described in the setting of correct filler selection, and potential complications are addressed.

Treating Breast Conservation Therapy Defects with Brava and Fat Grafting: Technique, Outcomes, and Safety Profile.

Background: Fat grafting has been demonstrated as a means of reconstructing breast conservation therapy defects. However, there is continued uncertainty regarding its clinical efficacy and oncologic safety. Furthermore, the role of external preexpansion (i.e., with the Brava device) remains unclear in this setting. The purpose of this study was to examine the safety and clinical outcomes of Brava/fat grafting following breast conservation therapy. Methods: A retrospective chart review was performed on all patients undergoing fat grafting following breast conservation therapy. Complications were defined as either a clinically palpable oil cyst/area of fat necrosis or infection. The mean time of follow-up was 2.3 years. Results: A total of 27 fat grafting sessions were performed on 20 patients, with an overall complication rate of 25 percent. The mean interval from completion of radiation therapy to fat grafting was 7 years and was not a significant predictor for complications (p = 0.46). Among those who underwent repeated grafting, there was no difference in the complication rates between their first and second encounters (p = 0.56). There was no difference in complication rates between patients with Brava preexpansion and those without preexpansion. Patients undergoing Brava preexpansion had a significantly higher initial fill volume in comparison with those who did not (219 cc versus 51 cc; p = 0.0017). There were no cases of locoregional cancer recurrence following fat grafting. Conclusion: Brava preexpansion was associated with higher initial fill volume in the setting of breast conservation therapy defects.

A Quantitative Analysis of Onabotulinumtoxina, Abobotulinumtoxina, and Incobotulinumtoxina: A Randomized, Double-blind, Prospective Clinical Trial of Comparative Dynamic Strain Reduction

Background: U.S. Food and Drug Administration–approved formulations of botulinum toxin include onabotulinumtoxinA (Botox; Allergan, Inc., Irvine, Calif.), abobotulinumtoxinA (Dysport; Galderma Pharma S.A., Lausanne, Switzerland), and incobotulinumtoxinA (Xeomin; Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany). This study uses digital image correlation to compare dynamic strain reduction between available neurotoxins. Methods: Seventy-three treatment-naive female patients aged were randomized to injection with onabotulinumtoxinA (20 units), abobotulinumtoxinA (60 units), or incobotulinumtoxinA (20 units) in the glabella. Imaging was conducted at 4, 14, and 90 days after injection. Change in average dynamic strain of the glabella was compared using ANOVA. Results: At day 4, there was a 42.1 percent strain reduction in the onabotulinumtoxinA group, a 39.4 percent strain reduction in the abobotulinumtoxinA group, and a 19.8 percent strain reduction in the incobotulinumtoxinA group (onabotulinumtoxinA versus abobotulinumtoxinA, p = 0.77; onabotulinumtoxinA versus incobotulinumtoxinA, p = 0.02; and abobotulinumtoxinA versus incobotulinumtoxinA, p = 0.04). At day 14, there was a 66.1 percent strain reduction in the onabotulinumtoxinA group, a 51.4 percent strain reduction in the abobotulinumtoxinA group, and a 42.8 percent strain reduction in the incobotulinumtoxinA group (onabotulinumtoxinA versus abobotulinumtoxinA, p = 0.14; onabotulinumtoxinA versus incobotulinumtoxinA, p = 0.02; and abobotulinumtoxinA versus incobotulinumtoxinA, p = 0.36). At day 90, there was a 43.5 percent strain reduction in the onabotulinumtoxinA group, a 38.4 percent strain reduction in the abobotulinumtoxinA group, and a 25.3 percent strain reduction in the incobotulinumtoxinA group (onabotulinumtoxinA versus abobotulinumtoxinA, p = 0.66; onabotulinumtoxinA versus incobotulinumtoxinA, p = 0.12; and abobotulinumtoxinA versus incobotulinumtoxinA, p = 0.24). Conclusions: Using digital image correlation, the tested neuromodulators do not have equivalent strain reduction in the glabella at the doses used. These results confirm assertions of noninterchangeability. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

A Simplified Nonsurgical Method for the Correction of Neonatal Deformational Auricular Anomalies.

Despite reported success of early nonsurgical splinting of congenital ear deformities, the technique has not been widely utilized due to difficulty with application and positional maintenance of these devices. Delay in treatment can result in unnecessary surgery for the child later in life. In response to this need, we developed a simplified system consisting of Velcro, conformers, and polysiloxane gel that can be applied in 3 steps. Before and after photos after application of the device were graded by a plastic surgeon independent of the study. A total of 33 ear deformities were treated. In all, 92.3% of ears achieved significant improvement and normalization of their ears after therapy. This device allows for a more straightforward and individualized application than current products available. Our hope is that practitioners involved early in the infant’s care will utilize this technology resulting in improved outcomes and avoiding unnecessary surgery.

Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual Modality Treatment

Background The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes. Objectives The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction. Methods An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection. Results Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days. Conclusions Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area. Level of Evidence 4

Commentary on: The Influence of Paranasal Augmentation on the Measurement of the Nose for the Treatment of Midfacial Concavity

A flat midface is thought less attractive than one with convexity. LeFort I osteotomy with advancement or skeletal augmentation are the two modalities which can transform the flat midface to one with convexity. LeFort I osteotomy with advancement is indicated when occlusal relations require normalization. In patients with lower midface deficiency and acceptable occlusion (often after orthodontia), pyriform aperture augmentation with alloplasts is a proven reliable method as reviewed and demonstrated in this manuscript. Increasing skeletal convexity by either skeletal advancement or augmentation also affects the morphology of the structure overlying it, the nose. Whereas the increase in projection of the pyriform area has been measure to be about 75% of the thickness of the implant,1,2 alterations in nasal shape due to the underlying increased projection of the underlying skeleton have been well known but not quantified. These changes include increases in nasolabial angle, columellar angle, alar width, and alar base width. Since pyriform augmentation is often performed as an adjunct to rhinoplasty, objectivity in the prediction of nasal changes are important. The authors of this article quantify the impact of pyriform aperture augmentation on nasal morphometry in a thoughtful, well-executed study.3 They found that when preand postoperative dimensions were measured after an average augmentation of 5 mm was performed only alar width and alar base width increased to an amount reaching statistical significance when the preoperative result was compared to that of the postoperative measurement. Ironically, these alterations in nasal anatomy are ones not usually desired, but fortunately, are easily corrected later by alar manipulations. Nasolabial and columellar angles were not statistically different but noticeable as is clear in the clinical examples demonstrated in this article, as well as this discussant’s clinical experience. This reinforces the observation that millimeter changes in the face, and particularly the nose, make a visual difference. This discussant (M.J.Y.) not infrequently selectively augments the vertical and/or horizontal skeletal boundaries of the pyriform aperture with porous polyethylene implants to provide lower midface convexity in the skeletally deficient patient seeking rhinoplasty. Unlike the surgical approach shown in the authors’ Figure 1, where the implant is placed directly beneath the incision, I prefer to incise the mucosa lateral to the pyriform and create a tunnel to place the horizontal portion of the implant. This maneuver effectively eliminates the possibility of implant exposure beneath this thin soft tissue cover. I have found that the increase in midface projection decreases the apparent size of the nose. This change in facial balance allows a less aggressive rhinoplasty to be appropriate. This is demonstrated in the patient portrayed in Figure 1, who underwent pyriform augmentation during rhinoplasty.

Abstract 6. The Anatomic Implications of Utilizing Cannula Lipodissection and Avoiding Platysmaplasty in the Tumescent Facelift: A Clinical and Cadaveric Study

Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Illinois, Chicago IL, USA.

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take‐backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end‐to‐side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.