Gregory L. Borah

Quality-of-life outcomes after cosmetic surgery.

Cosmetic surgery is an increasingly common medical procedure whose benefits to patients have not been quantified objectively. The purpose of this study was to prospectively examine long-term quality-of-life outcomes for patients undergoing elective cosmetic surgery. In this prospective, correlational study of 105 consecutive patients undergoing elective cosmetic surgery, the parameters of quality-of-life index, depression, social support, and coping were determined preoperatively and at 1- and 6-month intervals postoperatively. The data from the four study instruments were analyzed using Pearson correlation and repeated measures of multivariate analysis of variance for differences in each variable over time. The multivariate analysis of variance quality-of-life index scores for patients improved from baseline preoperative mean levels of 3.24 to a mean of 2.56 at 1 month, and then to 2.11 (f = 518.5, p = < 0.0001) at 6 months postsurgery. Mean scores for depression [determined by using the Center for Epidemiologic Studies Depression Scale (CESD)], improved from 11.2 preoperatively to 6.5 at 1 month, and to 6.3 (f= 79.3, p = < .0001) at 6 months after surgery. Surgical intervention produced no significant differences between preoperative and postoperative ways of coping and social support scores. Cosmetic surgery produces positive psychological benefits by significantly improving quality-of-life outcomes that persist long term, without adversely affecting social support and ways of coping.

Cytokines, growth factors, and plastic surgery.

Numerous inflammatory cytokines and growth factors have been identified and are known to be essential for normal wound healing and host defense, and many have been implicated in disease states treated by plastic surgeons. Cytokines and growth factors are members of a large functional group of polypeptide regulatory molecules secreted by different cell lines. These peptides exert their influence through autocrine and paracrine fashions within sites of injury and repair. Although cytokines and growth factors are crucial in initiating, sustaining, and regulating the postinjury response, these same molecules have been implicated in impaired wound healing, abnormal scarring, and chronic cutaneous diseases. Therapeutic manipulation of inflammatory mediators in normal and impaired wounds has been performed, with mixed clinical results, but evolving strategies such as gene therapy, as well as further characterization of the cellular-mechanism cytokines and growth-factor triggers, will further add to our therapeutic options. This article discusses the current understanding of important cytokines and growth factors involved in the normal injury response and then addresses pathological states associated with an inappropriate expression of these mediators. Finally, a summary of various cytokine and growth factor-directed strategies being used in impaired wound healing states is presented.

Perceived functional impact of abnormal facial appearance.

Functional facial deformities are usually described as those that impair respiration, eating, hearing, or speech. Yet facial scars and cutaneous deformities have a significant negative effect on social functionality that has been poorly documented in the scientific literature. Insurance companies are declining payments for reconstructive surgical procedures for facial deformities caused by congenital disabilities and after cancer or trauma operations that do not affect mechanical facial activity. The purpose of this study was to establish a large, sample-based evaluation of the perceived social functioning, interpersonal characteristics, and employability indices for a range of facial appearances (normal and abnormal). Adult volunteer evaluators (n = 210) provided their subjective perceptions based on facial physical appearance, and an analysis of the consequences of facial deformity on parameters of preferential treatment was performed. A two-group comparative research design rated the differences among 10 examples of digitally altered facial photographs of actual patients among various age and ethnic groups with “normal” and “abnormal” congenital deformities or posttrauma scars. Photographs of adult patients with observable congenital and posttraumatic deformities (abnormal) were digitally retouched to eliminate the stigmatic defects (normal). The normal and abnormal photographs of identical patients were evaluated by the large sample study group on nine parameters of social functioning, such as honesty, employability, attractiveness, and effectiveness, using a visual analogue rating scale. Patients with abnormal facial characteristics were rated as significantly less honest (p = 0.007), less employable (p = 0.001), less trustworthy (p = 0.01), less optimistic (p = 0.001), less effective (p = 0.02), less capable (p = 0.002), less intelligent (p = 0.03), less popular (p = 0.001), and less attractive (p = 0.001) than were the same patients with normal facial appearances. Facial deformity caused by trauma, congenital disabilities, and postsurgical sequelae present with significant adverse functional consequences. Facial deformities have a significant negative effect on perceptions of social functionality, including employability, honesty, and trustworthiness. Adverse perceptions of patients with facial deformities occur regardless of sex, educational level, and age of evaluator.

The fate of teeth transfixed by osteosynthesis screws

&NA; Rigid internal fixation with plates and screws for osteosynthesis of facial fractures and osteotomies in the cranio‐maxill of acial skeleton is often undertaken in situations in which the exact position of the underlying tooth roots cannot be determined. Therefore, a screw may be inadvertently placed into a root. There is scant data in the literature addressing the consequences of tooth impingement. This 5‐year retrospective study documents the longterm outcome of teeth transfixed by osteosynthesis screws in a series of 387 consecutive facial fractures at a Level I trauma center. The incidence of root impingement per screw was 0.47 percent (13 transfixed teeth per 2340 + screws). Mandibular teeth were more “at risk” than maxillary teeth by a ratio of 10:3. No transfixed teeth became infected or required extraction in this series. In conclusion, inadvertent tooth root impingement by osteosynthesis screws appears to have minimal adverse consequences. (Plast. Reconstr. Surg. 97: 726, 1996.)

Maximizing outcomes in breast reduction surgery: a review of 518 consecutive patients.

Background: Economic constraints and diminished healthcare resources mandate increased efficiency in labor-intensive plastic surgical procedures, such as reduction mammaplasty. The evolution to our current approach over a 9-year period was reviewed. Methods: From 1992 to 2001 a total of 518 patients underwent bilateral reduction mammaplasty by a single plastic surgeon. Since 1992, a bilateral simultaneous approach to reduction mammaplasty was used, with the primary surgeon (Scott) performing the preoperative markings and determining the final resection. An inferior pedicle, “inverted T” technique using a Wise pattern was used for all cases. The initial 2-year period (113 consecutive patients from 1992 to 1994) was compared with the later 2-year period (103 patients from 1999 to 2001). Variables that decreased operative times and resources were identified. Results: Length of stay (from admission to discharge) was initially 27 hours (overnight admission at a hospital) in the early review and decreased to 5 hours (outpatient surgery center) in the recent series. Drains were used in 100 percent of the earlier cases and in 7 percent in the recent series. Major complications occurred in 3 percent of the entire series. Minor complications occurred in 20 percent of all patients. In the recent series 97 percent of patients received complete relief of their preoperative symptoms and expressed satisfaction with their results. Operative times decreased from 120 to 102 minutes. Beginning in 1999, Dermabond skin adhesive was used in all patients. Conclusions: An evolutionary approach to bilateral reduction mammaplasty with low complication rates and high patient satisfaction is presented. Optimization of technique leads to decreased operative times, shortened lengths of stay, and contributes to efficient use of surgeon and operating room resources.

anxiety Disorders in Plastic Surgery

Surgery is a stressful event, with the potential for profound disturbance to the patients psychological and physiologic homeostasis. Cosmetic surgery is a particularly intense psychological experience because, in addition to the usual concerns about surgical side effects, cosmetic patients bring their hopes and expectations for improved self-image, putting them at risk for the added anxiety of disappointment. High levels of anxiety coupled with the perception of vulnerability or threat to self can cause significant psychological reactions complicating care for the plastic surgical patient. This paper outlines the diagnostic features of the common types of anxiety disorders seen in plastic surgical patients, and it offers treatment strategies for the practitioner, delineating when referral to a mental health expert is advised. Specific clinical case studies of panic attack, posttraumatic stress disorder, and acute stress disorder are presented to illustrate the variety of abnormal anxiety responses that may be encountered in the perioperative setting. Interventions for the anxious patient are part science and part art. Careful questioning and psychosocial assessment can identify those patients who are at greater risk for psychological problems after surgery. However, some patients may mask or keep secret their concerns, which can be manifested with resulting anger and hostility. Plastic surgeons must use appropriate indicators of psychological anxiety and measure a specific patients reactions to surgery to make the diagnosis of abnormal anxiety. Close follow-up by the plastic surgical team is an essential part of the anxiety disorder patients psychological treatment, but it is imperative that these problematic patients be referred promptly to a qualified mental health professional to limit their adverse experience and promote their well-being. Patients who are less anxious during the perioperative period report less emotional distress and fewer defensive behaviors and are likely to be more satisfied with the outcome of their surgery.

Appearance is a function of the face.

Background: Increasingly, third-party insurers deny coverage to patients with posttraumatic and congenital facial deformities because these are not seen as “functional.” Recent facial transplants have demonstrated that severely deformed patients are willing to undergo potentially life-threatening surgery in search of a normal physiognomy. Scant quantitative research exists that objectively documents appearance as a primary “function” of the face. This study was designed to establish a population-based definition of the functions of the human face, rank importance of the face among various anatomical areas, and determine the risk value the average person places on a normal appearance. Methods: Voluntary adult subjects (n = 210) in three states aged 18 to 75 years were recruited using a quota sampling technique. Subjects completed study questionnaires of demography and bias using the Gamble Chance of Death Questionnaire and the Rosenberg Self-Esteem Scale. Results: The face ranked as the most important anatomical area for functional reconstruction. Appearance was the fifth most important function of the face, after breathing, sight, speech, and eating. Normal facial appearance was rated as very important for one to be a functioning member of American society (p = 0.01) by 49 percent. One in seven subjects (13 percent) would accept a 30 to 45 percent risk of death to obtain a “normal” face. Conclusions: Normal appearance is a primary function of the face, based on a large, culturally diverse population sample across the lifespan. Normal appearance ranks above smell and expression as a function. Restoration of facial appearance is ranked the most important anatomical area for repair. Normal facial appearance is very important for one to be a functional member of American society.

Dermabond skin closures for bilateral reduction mammaplasties : A review of 255 consecutive cases

Background: 2-Octyl cyanoacrylate (Dermabond; Ethicon, Inc., Somerville, N.J.) has been available as a skin closure alternative or adjunct since 1997. The purpose of this study was to review a large series of 255 consecutive bilateral reduction mammaplasty patients to evaluate the safety and efficacy of Dermabond for these procedures. Methods: A review was undertaken of 255 consecutive bilateral reduction mammaplasties performed by a single surgeon from 1999 to 2005 with Dermabond used for skin closure. This series of patients was compared with an earlier review by the same surgeon of 415 consecutive bilateral reduction mammaplasties using standard layered sutured skin closures. Results: Dermabond was associated with decreased operative times compared with the sutured closures (93 minutes compared with 118 minutes; 25 minutes or 20 percent less time). The rates for minor wound dehiscence (1.18 percent), major wound dehiscence (0.78), hypertrophic scar revisions (2.75 percent), and cellulitis (2.75 percent) were all lower in the Dermabond group, but these differences were not statistically significant. Conclusions: Dermabond is a safe and effective means of skin closure for bilateral reduction mammaplasties. Shortened operative times can lead to economic health cost savings. Patient discomfort is minimized and postoperative care is simplified.

Frontal bone periosteal osteomas.

Osteomas are the most common tumors of the cranial vault and facial skeleton. Osteomas are usually benign in nature, commonly presenting with symptoms of facial deformity, facial pain, and headaches. Although the frontal sinus is the most frequent location of cranial osteomas, they are also occasionally seen involving only the frontal bone periosteum. This study is a retrospective series investigating the characteristics, management, and outcomes of five patients with frontal bone periosteal osteomas surgically treated with superficial osteotomies with primary closure. Medical charts were reviewed focusing on symptoms, size, radiographic findings, and disease of the periosteal osteomas. The chief complaint primarily involved a palpable deformity, which led to surgical evaluation. Radiographic studies were obtained to evaluate size and location of the frontal osteomas. Microanalysis of the specimens confirmed the presence of mature cancellous and/or cortical bone. Postoperative follow-up revealed no evidence of recurrence or complications. The superficial ostectomy technique with primary closure offers a simple, effective method for removal of frontal bone periosteal osteomas with minimal side effects.

Pediatric peripheral neuropathy in proteus syndrome.

Proteus syndrome is a rare congenital disorder comprised of subcutaneous and internal hamartomas, pigmented skin nevi, skull exostoses, hemihypertrophy, and macrodactyly of the hands and feet. A 5-year-old girl diagnosed with Proteus syndrome presented with distal median compression neuropathy with the primary complaint of severe pain involving the left hand. Surgical exploration of the hand revealed a lipofibromatous hamartoma of the median nerve. The transverse carpal ligament was released and epineurectomy of the median nerve was performed. The patient remains symptom free at the 9-month follow-up. This report is the first description of a hamartoma directly involving a peripheral nerve in Proteus syndrome. Decompression of the nerve with the removal of the fibrofatty neural sheath resulted in the resolution of the symptoms in this patient. The surgeon should consider this approach as a potential first line of treatment before a more radical resection of the nerve is contemplated.