Felmont Eaves

The inferior gluteal free flap in breast reconstruction

The inferior gluteal musculocutaneous free flap usually provides a sufficient amount of autogenous tissue for breast reconstruction when adequate tissue is not present in the lower abdomen or back. Its arteriovenous pedicle is longer than the superior gluteal musculocutaneous free-flap pedicle and permits microvascular anastomosis in the axilla, avoiding medial rib and cartilage resection. In the thin patient, there is more available donor tissue than with the superior gluteal musculocutaneous free flap. Cadaver dissections confirm the greater pedicle length and the local area of the lower gluteus maximus muscle needed to carry the skin island and have helped define a safe approach to flap elevation. We have used four flaps for breast reconstruction without vascular compromise or the need for reexploration. The low donor-site scar in the inferior buttock fold has been acceptable, especially for a bilateral reconstruction. The anatomy of the gluteal region, the surgical technique for the inferior gluteal free-flap transfer, and a 3-year patient follow-up are presented.

Got Evidence? Stem Cells, Bias, and the Level of Evidence Ladder

O hateful Error, Melancholy’s child, Why dost thou show to the apt thoughts of men The things that are not? Shakespeare, Julius Caesar Stem cells have captured the attention and imagination of the public, appearing to be a “magic bullet,” sexy and omnipotent, capable of curing health concerns from cancer and cardiac disease to warts and wrinkles. While the scientific enthusiasm for the potential therapeutic impact of stem cells seems justified, the great hope currently placed on stem cell therapies makes the public vulnerable to emotional manipulation, deceptive marketing, or even outright fraud. Concerned by the cacophony of marketing for the so-called stem cell facelift, stem cell breast augmentation, and other “stem cell” procedures, the leadership of the American Society for Aesthetic Plastic Surgery (ASAPS) and American Society of Plastic Surgeons (ASPS) established the Joint Stem Cell and Fat Grafting Task Force in 2010. The task force was charged with gathering information about current stem cell procedures and marketing claims, monitoring stem cell training courses, initiating a dialogue with the Food and Drug Administration, and developing collaborations with key stem cell scientists within and outside the plastic surgery field. In addition, the task force was directed to perform a systematic assessment of the world’s peer-reviewed literature on the clinical uses of stem cells in aesthetic procedures. The “ASAPS/ASPS Position Statement on Stem Cells and Fat Grafting” resulted from that systematic review and critical analysis.1 While the stem cell future may be bright, there is currently scant peer-reviewed evidence to substantiate marketing claims for stem cell aesthetic procedures. What little information is present is mostly of lower levels of evidence (LOE). But why do we consider LOE in the first place, and what purpose do they serve? What does “lower” really mean, why might such evidence be inadequate, and what …

Anaplastic Large Cell Lymphoma and Breast Implants: FDA Report

Aesthetic plastic surgeons have a long history of commitment to optimizing safety in patients undergoing placement of breast implants. Much of the recent, related oncological research in aesthetic surgery—and the recent literature published in Aesthetic Surgery Journal on breast cancers in augmented patients1-4—has been focused around the potential interaction between fat grafting to the breast and breast screening examinations. In our subspecialty, we have advocated preoperative breast cancer screening in patients whose risk for breast cancer is high,5 and many of our colleagues have worked to refine their augmentation techniques in a way that will allow for increased ease in postoperative screening procedures.6-8 This long-standing commitment to research about aesthetic breast surgery’s impact in oncological risk assessment will hopefully continue to serve our patients as we investigate the potential causative influence of breast implants on the development of anaplastic large cell lymphoma (ALCL). Earlier this year, the US Food and Drug Administration (FDA) released a “Preliminary FDA Findings and Analyses” document summarizing 13 years of literature on ALCL in …

Why Evidence-Based Medicine Matters to Aesthetic Surgery

This issue of Aesthetic Surgery Journal marks the one-year anniversary of Dr. Foad Nahai’s editorial heralding an increased focus on evidence-based medicine (EBM) in the pages of the Journal .1 This year, the Journal will increase the visibility of EBM articles by showcasing the Level of Evidence (LOE) pyramid to identify pertinent articles with a ranking of Level 1, 2, or 3. Levels of Evidence are but one of the tools used in EBM to assess the validity of data presented in scientific studies, thereby enabling us to make more informed decisions and take better care of our patients. During the past year, as discussions about EBM have become more frequent, many plastic surgeons have questioned what exactly EBM is, why it is necessary, and how will it affect their practice and their patients. David Sackett2 has defined EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Several key words in this definition guide us toward not only what EBM is but, just as importantly, what EBM is not. First, EBM is conscientious. It is based on a concerted and thoughtful effort to apply information in a different way and, as such, requires as significant a change in our ways of thinking and our culture as a change in our daily processes. Second, EBM is explicit. When applying EBM principles, we purposefully and systematically seek out the most appropriate information, examine it in a critical way, and incorporate this information as we implement a balanced action plan. It is important to note that the information that we seek is the current best information—not the information that we wish we had or will have in the future—and is thus limited by research and clinical reports. …

An Integrated Model of Patient Safety and Quality of Care

Our perceptions of the factors that contribute to deficits in patient safety and which strategies are effective in improving quality of care have evolved significantly. As we mark the 10th anniversary of the first dedicated patient safety teaching course at the American Society for Aesthetic Plastic Surgery (ASAPS) annual meeting,1 a reassessment of these changes could help shape educational and research endeavors going forward. There are at least two significant components of this shift in perspective. First, educational strategies in plastic surgery, as in all of medicine, have historically emanated from an apparent belief that deficits in knowledge are the source of patient safety and quality of care (QOC) problems; hence, disseminating knowledge is the logical key to improvement. However, in 1999, the Institute of Medicine’s Committee on Quality of Healthcare in America published a landmark report, To Err Is Human: Building a Safer Health System ,2 which was reinforced by a second report in 2001, Crossing the Quality Chasm: A New Health Care System for the 21st Century ,3 both of which challenged this belief. These reports brought into sharp focus the fact that patient safety and QOC issues in modern medicine often stem not from a lack of knowledge but from deficient systems, processes, and environments. According to the Joint Commission, more than 70% of patient safety issues are related to these factors.4 In essence, the problem is not so …

Commentary on: What Do Patients Want? Technical Quality Versus Functional Quality: A Literature Review for Plastic Surgeons

Ms Smith, your patient of many years, is beaming as you walk into the examination room. After a brief exchange of pleasantries, she seamlessly transitions into a request for removal of some obviously benign skin lesions. As she talks, you struggle to listen, mesmerized by the bizarre face addressing you. A lateral sweep, tethered ear lobes, inexplicable scar placement, and malpositioned fat grafts seem to be only the start. “Oh, you’ve noticed I finally got that face-lift we’ve been discussing for years,” she exclaims through plethoric, distorted lips. “Isn’t it great?” She drones about the work of her “cosmetic surgeon, Dr Wannabee,” how nice the staff was, and the great price she was given (“Thousands less than you quoted me!”). You know that, in actuality, Dr Wannabee is not certified by any legitimate board, didn’t even finish residency (a nonsurgical one, at that), and operates in a noncertified office facility. Through the years, you have seen many poor results from Dr Wannabee, yet the practice seems to prosper, at least as evidenced by a perpetual barrage of advertising. Disappointed, you ask yourself why Ms Smith made what, to you, is such a poor choice, why she is seemingly happy with clearly inferior results, and—most personally distressing—why she did not select you to do her face-lift. Dr Fiala’s excellent article, “What Do Patients Want? Technical Quality Versus Functional Quality—A Literature Review for Plastic Surgeons,” provides us with keen insights into the potential origins of such a scenario.1 As surgeons, we have striven for years to develop, refine, and perfect our technical quality (TQ). However, as the author clearly illustrates, patients are generally poorly equipped to judge TQ. This is not particularly surprising, given that even highly skilled and experienced aesthetic surgeons may not always agree on TQ measures like aesthetic …