Gaurav Bharti

Aplasia Cutis Congenita: Clinical Management of a Rare Congenital Anomaly

Background:Aplasia cutis congenita (ACC) is a rare congenital disorder characterized by absence of skin and adjacent tissue that usually affects the scalp, but any part of the body may be affected. Although ACC is more often superficial and small, it can be large and involve the underlying structures such as skull and dura, thus increasing the risk of hemorrhage, infection, and mortality. Controversy exists regarding nonsurgical versus surgical intervention for this condition. This study reviews indications and modalities for treatment of this rare congenital anomaly. Results:Management of this anomaly depends on size, location, and structures at risk. Small lesions with intact underlying structures and lesions affecting extremities are treated in a conservative fashion with dressings and ointments followed by delayed scar excision. Aplasia cutis congenita scar excision often requires complex tissue rearrangement, tissue expansion, or skin grafting. Larger ACC lesions or lesions with exposure of vital structures require early surgical intervention. Initially, exposed vital structures and bony ridges can be protected using conservative measures. Delayed definitive repair can then be performed using scalp flaps, split- and full-thickness skin grafts, cultured epithelial autografts, delayed split rib cranioplasty, tissue expansion, and composite cranioplasty. Conclusions:Aplasia cutis congenita should be individually evaluated based on size, depth, location, and tissues involved. Using conservative and surgical modalities, one can achieve complete closure of the defect, thus avoiding risks of infection, hemorrhage, and further trauma.

Factors affecting complications in radiated breast reconstruction.

IntroductionBreast irradiation in combination with breast reconstruction is associated with increased complications. Because of the diminishing threshold for radiotherapy, breast reconstruction irradiation is rising. Our aim was to evaluate factors affecting outcomes in irradiated breast reconstructions. MethodsA review of consecutive patients who underwent mastectomy, radiation, and breast reconstruction was conducted. Patient demographics, operative procedure, breast irradiation timing, and postoperative complications were collected. ResultsOne hundred fifty-four patients (157 breast reconstructions) were included with a mean follow-up of 6 years. Average age at reconstruction was 50 years. One hundred nine cases were immediate and 48 cases were delayed. Sixty-eight cases were autologous reconstructions and 89 cases were implant-based. Thirty-seven cases used acellular dermal matrices (ADMs); 60% of cases were radiated before reconstruction and 40% were radiated afterward. Major complications occurred in 43% of patients and minor complications occurred in 17%. The presence of ADM led to an increase in complication rate with a 2.3-fold greater chance of requiring reoperation (P = 0.03). No significant difference in complication rates was associated with presence of hypertension, diabetes, smoking, elevated body mass index, autologous versus implant-based reconstructions, delayed versus immediate reconstructions, and time between radiation and reconstruction. ConclusionsRadiation after prosthetic reconstruction may produce an increase in failure rates. The use of ADMs in the face of breast irradiation increases the likelihood of a complication requiring reoperation.

Outcome analysis of 541 women undergoing breast conservation therapy.

Breast conservation therapy (BCT) has evolved as a favorable approach to the management of early-stage breast cancer. Shortcomings of BCT include the potential need for re-excision in the event of positive tumor margins as well as the untoward sequelae of radiation therapy. Both of those factors have led to a substantial proportion of patients undergoing BCT who ultimately report suboptimal aesthetic outcomes. Application of plastic surgery principles to the management of this patient subset has been shown to be beneficial from both an oncologic and cosmetic perspective. The aim of this study was to identify factors that may predict which patients would benefit most from involvement of a plastic surgeon before BCT. A retrospective analysis was performed on 762 patients undergoing lumpectomy during a 10-year study period at a single institution. Younger women and patients with tumor size approaching 2 cm were noted to have a significantly higher likelihood of oncologic outcomes that ultimately required breast reconstruction. Integration of oncoplastic techniques in the surgical management of patients undergoing BCT would likely contribute to improvement in aesthetic outcomes and overall patient satisfaction.

Congenital pyriform aperture stenosis.

Neonates rely on the nasal airway for their source of air; thus, any compromise in the ability to inhale will dramatically alter their ability to breathe. Congenital nasal pyriform aperture stenosis is a rare yet serious form of airway obstruction due to overgrowth of the maxilla at the medial nasal process. Infants typically present with difficulty feeding and obvious difficulty breathing. Radiologic imaging aids in confirming the diagnosis and assists in operative planning to open the medial nasal process to reduce airway resistance. Further corrective surgery is often needed and is planned commensurate with facial growth. We present a novel case of a child diagnosed with congenital nasal pyriform aperture stenosis who has performed extraordinarily well intellectually and has achieved an excellent cosmetic and physiological reconstruction of the nose and airway.

Long-Term Outcomes of Pediatric Cranial Reconstruction Using Resorbable Plating Systems for the Treatment of Craniosynostosis.

Background: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction. Methods: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation. Results: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix. Conclusions: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.

Minimizing donor-site morbidity following bilateral pedicled TRAM breast reconstruction with the double mesh fold over technique.

IntroductionTransverse rectus abdominus muscle flaps (TRAM) can result in significant abdominal wall donor-site morbidity. We present our experience with bilateral pedicle TRAM breast reconstruction using a double-layered polypropylene mesh fold over technique to repair the rectus fascia. MethodsA retrospective study was performed that included patients with bilateral pedicle TRAM breast reconstruction and abdominal reconstruction using a double-layered polypropylene mesh fold over technique. ResultsThirty-five patients met the study criteria with a mean age of 49 years old and mean follow-up of 7.4 years. There were no instances of abdominal hernia and only 2 cases (5.7%) of abdominal bulge. Other abdominal complications included partial umbilical necrosis (14.3%), seroma (11.4%), partial wound dehiscence (8.6%), abdominal weakness (5.7%), abdominal laxity (2.9%), and hematoma (2.9%). ConclusionsThe TRAM flap is a reliable option for bilateral autologous breast reconstruction. Using the double mesh repair of the abdominal wall can reduce instances of an abdominal bulge and hernia.

A Multicenter, Prospective, Randomized, Contralateral Study of Tissue Liquefaction Liposuction vs Suction-Assisted Liposuction

Background Tissue liquefaction liposuction (TLL) deploys a novel energy source utilizing a stream of warmed, low-pressurized, and pulsed saline to extract fat tissue. Objectives Compare TLL to suction-assisted liposuction (SAL) to determine which device is more efficient for surgeons and provides better recovery for patients. Methods Thirty-one adult female patients were followed prospectively in a contralateral study design comparing differences in bruising, swelling, tenderness, and incision appearance ratings between TLL and SAL procedures. Surgical efficiency and appearance of the lipoaspirate were also compared. Results All 31 patients successfully completed the study. For TLL and SAL procedures, the average volumes of infusion (1.242 vs 1.276 L) and aspirated supernatant fat (704 vs 649 mL) were statistically similar. TLL median fat extraction rate was faster than SAL (35.6 vs 25 mL/min; P < 0.0001), and stroke rate was reduced in TLL vs SAL procedures (48 vs 120 strokes/min; P < 0.0001), and both were statistically significant. The mean total scores for bruising, swelling, treatment site tenderness, and incision appearance were lower, indicating improved patient recovery on the TLL side. Conclusions TLL and SAL techniques produced comparable volume of fat aspirate. TLL demonstrated a 42% faster fat extraction rate and a 68% reduction in arm movements needed to complete the procedure compared to SAL, both of these differences are statistically significant. The TLL side was noted to have reduced bruising and swelling and improved incision site appearance with less tenderness compared to the SAL side. Level of Evidence 2

Commentary on: “Gluteal Augmentation with Silicone Implants: A New Proposal for Intramuscular Dissection”

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Labiaplasty: Current Trends of ASAPS Members

Labiaplasty continues to increase in frequency among the American Society for Aesthetic Plastic Surgery (ASAPS) members. From 2015 to 2016, labiaplasty increased by 23% according to the 2016 Cosmetic Surgery National Data Bank Statistics by ASAPS.1 During this time, more than 35% of all plastic surgeons offered labiaplasty as a part of their practice.1 As with many procedures, multiple variables exist when planning and performing labiaplasty. The primary reason for presentation ranges from unacceptable appearance to discomfort in clothing and often leads a surgeon towards a more or less aggressive technique.2 The tools for patient education vary from verbal discussion, drawings, before and after patient photographs, or labiaplasty origami.3 Labiaplasty origami is a simple and effective hands-on 3D reference for central wedge labiaplasty and clitoral hood reduction.3 We aim to evaluate the ASAPS membership to identify the current trends for labiaplasty. An online questionnaire was distributed to all active ASAPS members (n = 1628). The survey was composed of 12 questions regarding surgeon demographics, preferred labiaplasty technique, and self-reported outcomes (Appendix A).

Comprehensive management of an acutely burned lactating breast with subsequent pregnancy and definitive reconstruction: a case report

Reconstruction of the breast following burn injury can be a challenging task [1]. Guiding principles for burned breast reconstruction initially include preserving as much viable breast tissue as possible with subsequent contracture release followed by split or full-thickness skin grafting [1–3]. Nipple and areola conservation is critical, and tangential excision must often be delayed to avoid unnecessary excision [1]. Various means exist which can be used alone or in combination for correction of breast asymmetry or contour defects following burn injuries including skin grafting, mastopexy, mammaplasty, musculocutaneous flaps, and prosthetic implants preceded by tissue expansion [2, 4–6]. To date, there has been only one other published case report describing the reconstruction of a burned lactating breast [7]. We present a novel case of a burned lactating breast that underwent acute management which allowed productive lactation at a subsequent pregnancy and ultimate definitive reconstruction with tissue expansion and allogeneic collagen matrix substitute.