Jay W. Granzow

Age-Related Changes of the Orbit and Midcheek and the Implications for Facial Rejuvenation

BackgroundAging of the midface is complex and poorly understood. Changes occur not only in the facial soft tissues, but also in the underlying bony structure. Computed tomography (CT) imaging was used for investigating characteristics of the bony orbit and the anterior wall of the maxilla in patients of different ages and genders.MethodsFacial CT scans were performed for 62 patients ranging in age from 21 to 70 years, who were divided into three age groups: 21–30 years, 41–50 years, and 61–70 years. Patients also were grouped by gender. The lengths of the orbital roof and floor and the angle of the anterior wall of the maxilla were recorded on parasagittal images through the midline of the orbit for each patient.ResultsThe lengths of the orbital roof and floor at their midpoints showed no significant differences between the age groups. When grouped by gender, the lengths were found to be statistically longer for males than for females. The angle between the anterior maxillary wall and the orbital floor was found to have a statistically significant decrease with advancing age among both sexes.ConclusionBony changes occur in the skeleton of the midcheek with advancing age for both males and females. The anterior maxillary wall retrudes in relation to the bony orbit, which maintains a fixed anteroposterior dimension at its midpoint. These changes should be considered in addressing the aging midface.

Review of Current Surgical Treatments for Lymphedema

The current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema. A Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10xa0years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken. Surgical treatments have evolved to become less invasive and more effective. With proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.BackgroundThe current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema.MethodsA Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10xa0years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken.ResultsSurgical treatments have evolved to become less invasive and more effective.ConclusionsWith proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.

An Effective System of Surgical Treatment of Lymphedema

Effective surgical treatments for lymphedema now can address the fluid and solid phases of the disease process. Microsurgical procedures, including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), target the fluid component that predominates at earlier stages of the disease. Suction-assisted protein lipectomy (SAPL) addresses the solid component that typically presents later as chronic, nonpitting lymphedema of an extremity. We assess the outcomes of patients who underwent selective application of these three surgical procedures as part of an effective system to treat lymphedema. This is a retrospective chart review of patients with lymphedema who underwent complete decongestive therapy followed by surgical treatment with SAPL, LVA, or VLNT. The primary outcomes measured were postoperative volume reduction (SAPL), daily requirement for compression garments and lymphedema therapy (VLNT and LVA), and the incidence of severe cellulitis. Twenty-six patients were included in the study, of which 10 underwent SAPL and 16 underwent LVA or VLNT. The average reduction of excess volume by SAPL was 3,212xa0mL in legs and 943xa0mL in arms, or a volume reduction of 87 and 111xa0%, respectively, when compared with the unaffected, opposite sides. Microsurgical procedures (VLNT and LVA) significantly reduced the need for both compression garment use (pxa0=xa00.003) and lymphedema therapy (pxa0<xa00.0001). The overall rate of cellulitis decreased from 58xa0% before surgery to 15xa0% after surgery (pxa0<xa00.0001). When applied appropriately to properly selected patients, surgical procedures used in the treatment of lymphedema are effective and safe.AbstractBackgroundnEffective surgical treatments for lymphedema now can address the fluid and solid phases of the disease process. Microsurgical procedures, including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), target the fluid component that predominates at earlier stages of the disease. Suction-assisted protein lipectomy (SAPL) addresses the solid component that typically presents later as chronic, nonpitting lymphedema of an extremity. We assess the outcomes of patients who underwent selective application of these three surgical procedures as part of an effective system to treat lymphedema.nMethodsThis is a retrospective chart review of patients with lymphedema who underwent complete decongestive therapy followed by surgical treatment with SAPL, LVA, or VLNT. The primary outcomes measured were postoperative volume reduction (SAPL), daily requirement for compression garments and lymphedema therapy (VLNT and LVA), and the incidence of severe cellulitis.ResultsTwenty-six patients were included in the study, of which 10 underwent SAPL and 16 underwent LVA or VLNT. The average reduction of excess volume by SAPL was 3,212xa0mL in legs and 943xa0mL in arms, or a volume reduction of 87 and 111xa0%, respectively, when compared with the unaffected, opposite sides. Microsurgical procedures (VLNT and LVA) significantly reduced the need for both compression garment use (pxa0=xa00.003) and lymphedema therapy (pxa0<xa00.0001). The overall rate of cellulitis decreased from 58xa0% before surgery to 15xa0% after surgery (pxa0<xa00.0001).ConclusionsWhen applied appropriately to properly selected patients, surgical procedures used in the treatment of lymphedema are effective and safe.

A Novel Two‐Stage Surgical Approach to Treat Chronic Lymphedema

Surgical treatment of chronic lymphedema has seen significant advances. Suction‐assisted protein lipectomy (SAPL) has been shown to safely and effectively reduce the solid component of swelling in chronic lymphedema. However, these patients must continuously use compression garments to control and prevent recurrence. Microsurgery procedures, including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), have been shown to be effective in the management of the fluid component of lymphedema and allow for decreased garment use. SAPL and VLNT were applied together in a two‐stage approach in two patients with chronic lymphedema after treatment for breast cancer. SAPL was used first to remove the chronic, solid component of the soft‐tissue excess. Volume excess in our patients arms was reduced an average of approximately 83% and 110% after SAPL surgery. After the arms had sufficiently healed and the volume reductions had stabilized, VLNT was performed to reduce the need for continuous compression and reduce fluid re‐accumulation. Following the VLNT procedures, the patients were able to remove their compression garments consistently during the day and still maintain their volume reductions. Neither patient had any postoperative episodes of cellulitis. SAPL and VLNT can be combined to achieve optimal outcomes in patients with chronic lymphedema.

Surgeon motivations behind the timing of breast reconstruction in patients requiring postmastectomy radiation therapy.

OBJECTIVESnAlthough postmastectomy radiation therapy (PMRT) has been shown to reduce breast cancer burden and improve survival, PMRT may negatively influence outcomes after reconstruction. The goal of this study was to compare current opinions of plastic and reconstructive surgeons (PRS) and surgical oncologists (SO) regarding the optimal timing of breast reconstruction for patients requiring PMRT.nnnMETHODSnMembers of the American Society of Plastic Surgeons (ASPS), the American Society of Breast Surgeons (ASBS), and the Society of Surgical Oncology (SSO) were asked to participate in an anonymous web-based survey. Responses were solicited in accordance to the Dillman method, and they were analyzed using standard descriptive statistics.nnnRESULTSnA total of 330 members of the ASPS and 348 members of the ASBS and SSO participated in our survey. PRS and SO differed in patient-payor mix (p < 0.01) and practice setting (p < 0.01), but they did not differ by urban versus rural setting (p = 0.65) or geographic location (p = 0.30). Although PRS favored immediate reconstruction versus SO, overall timing did not significantly differ between the two specialists (p = 0.14). The primary rationale behind delayed breast reconstruction differed significantly between PRS and SO (p < 0.01), with more PRS believing that the reconstructive outcome is significantly and adversely affected by radiation. Both PRS and SO cited patient-driven desire to have immediate reconstruction (p = 0.86) as the primary motivation for immediate reconstruction.nnnCONCLUSIONSnAlthough the optimal timing of reconstruction is controversial between PRS and SO, our study suggests that the timing of reconstruction in PMRT patients is ultimately driven by patient preferences and the desire of PRS to optimize aesthetic outcomes.

Reconstruction of Total Laryngopharyngectomy Defects with Deep Inferior Epigastric Perforator Flaps

Laryngopharyngectomy reconstruction with microvascular free flaps remains challenging. Current methods of reconstruction include anterolateral thigh, radial forearm, and jejunal flaps, all of which have substantial donor site morbidity. We present a novel approach for total laryngopharyngectomy reconstruction using deep inferior epigastric perforator (DIEP) flaps. A retrospective review of head and neck reconstruction cases performed at Harbor-UCLA from 2006 to 2007 was performed. Those undergoing DIEP flaps were identified; management and postoperative course were analyzed. Two patients underwent successful reconstruction of total laryngopharyngectomy defects using DIEP flaps. Flaps up to 10 x 30 cm were harvested. Average donor vessel diameters were 2.5 cm and 3.0 cm for the artery and vein, respectively. The abdominal wounds were closed primarily. Flap survival was 100% with no emergent reexplorations. There were no postoperative bulges or hernias, and no leaks were detected on postoperative swallow evaluation. The DIEP flap is a useful addition to the armamentarium for reconstruction of total laryngopharyngectomy defects. Pedicle length is abundant, and donor vessel caliber is excellent. Large surface-area flaps can be harvested; excess flap can be deepithelialized or utilized for external skin. Primary closure of the donor site can be routinely achieved, negating the need for skin grafts.

The sensate fibular osteoneurocutaneous flap in oromandibular reconstruction: Clinical outcomes in 31 cases

Thirty-one patients requiring composite mandibular resection were reconstructed with sensate fibula osteocutaneous flaps. Preoperatively, all patients underwent lower extremity sensory testing at the location of the proposed flap site. Intraoperatively, either the Lateral Sural Cutaneous Nerve (LSCN) or the Recurrent Superficial Peroneal Nerve (RSPN) was chosen as donor. It was then joined to either the lingual or the greater auricular nerve. Both end-to-end and end-to-side neurorrhaphies were used. At least six months postoperatively, the intraoral flaps were tested for sensory function. Twenty-eight patients achieved sensory return, including hot/cold and pinprick sensation. Both the LSCN and RSPN groups demonstrated improved two-point discrimination in static and moving studies. Better results were obtained when the lingual rather than the greater auricular nerve was the recipient. Only three patients underwent end-to-side repair, with improved two-point discrimination in two patients. The average follow-up for all patients was 11.7 months. The most dramatic return of sensory function was seen in the end-to-end lingual nerve neurorrhaphies, followed by end-to-side lingual nerve neurorrhaphies. Of the five repairs using the greater auricular nerve, only three demonstrated any measurable postoperative sensory return. Functional outcomes of postoperative patients were measured via analysis of speech, type of food consumption, and oral continence. The majority of patients exhibited normal or easily intelligible speech, was able to consume a soft food or normal diet, and could maintain normal to manageable oral continence. A subset of patients enrolled in the study went on to pursue dental rehabilitation.

The sensate fibula osteocutaneous flap: Neurosomal anatomy

BACKGROUNDnRapid return of oral sensation enhances quality of life following oromandibular reconstruction. For predictable reinnervation of flaps, a detailed knowledge of their nerve supply is required. This study was designed to investigate the cutaneous nerve supply of the fibula osteocutaneous flap.nnnMETHODSnWe dissected thirty-seven fresh cadaveric specimens to better understand the cutaneous innervation of the typical fibula flap that would be used in oromandibular reconstruction. In addition, ten volunteers were enlisted for nerve blocks testing the cutaneous innervation of the lateral aspect of the lower leg.nnnRESULTSnThe lateral sural cutaneous nerve (LSCN) is generally considered to be sole cutaneous innervation to the lateral aspect of the lower leg; however, our analysis of the cadaveric specimens revealed dual innervation to this region. We identified a previously unnamed distal branch of the superficial peroneal nerve, which we have termed the recurrent superficial peroneal nerve (RSPN). Given the cadaveric findings, both the LSCN and the RSPN were tested using sequential nerve blocks in 10 volunteers. An overlapping pattern of innervation was demonstrated.nnnCONCLUSIONSnThe lateral aspect of the lower leg has an overlapping innervation from the LSCN and the newly described RSPN. The overlap zone lies in the region of the skin paddle of the fibula flap. The exact position of the neurosomal overlap zone (N.O.Z.E.) may be an important factor in reestablishing sensation in the fibulas skin paddle following free tissue transfer.

Lymphedema following cancer therapy: overview and options

This summit focusing on lymphedema following cancer therapy was held during the 7th International Symposium on Cancer Metastasis through the Lymphovascular System. It was unique for the inclusion of patients with lymphedema joining physicians, therapists, healthcare professionals, and researchers to highlight what is known and more importantly what is unknown about the current state of research and treatment in the United States. The session opened with an introduction to lymphedema and then explored the incidence of multiple cancer-related lymphedemas, imaging tools and techniques useful for the diagnosis of lymphatic system abnormalities, and the new findings concerning the genetics of cancer-related lymphedema. It closed with a review of advocacy for patients and healthcare professionals and both conservative and surgical treatment options, followed by a panel discussion and questions. The session provided important information and updates which will be of value for improving the rehabilitation and overall support of patients with cancer-related lymphedema.

Lymphedema surgery: the current state of the art

Background/purposeLymphedema surgery, when integrated into a comprehensive lymphedema treatment program for patients, can provide effective and long-term improvements that non-surgical management alone cannot achieve. Such a treatment program can provide significant improvement for many issues such as recurring cellulitis infections, inability to wear clothing appropriate for the rest of their body size, loss of function of arm or leg, and desire to decrease the amount of lymphedema therapy and compression garment use.MethodsThe fluid predominant portion of lymphedema may be treated effectively with surgeries that involve transplantation of lymphatic tissue, called vascularized lymph node transfer (VLNT), or involve direct connections from the lymphatic system to the veins, called lymphaticovenous anastomoses (LVA). VLNT and LVA are microsurgical procedures that can improve the patient’s own physiologic drainage of the lymphatic fluid, and we have seen the complete elimination for the need of compression garments in some of our patients. These procedures tend to have better results when performed when a patient’s lymphatic system has less damage. The stiff, solid-predominant swelling often found in later stages of lymphedema can be treated effectively with a surgery called suction-assisted protein lipectomy (SAPL). SAPL surgeries allow removal of lymphatic solids and fatty deposits that are otherwise poorly treated by conservative lymphedema therapy, VLNT or LVA surgeries.ConclusionOverall, multiple effective surgical options for lymphedema exist. Surgical treatments should not be seen as a “quick fix”, and should be pursued in the framework of continuing lymphedema therapy and treatment to optimize each patient’s outcome. When performed by an experienced lymphedema surgeon as part of an integrated system with expert lymphedema therapy, safe, consistent and long-term improvements can be achieved.