Julius W. Few

Long-term predicatable nipple projection following reconstruction

The creation of the nipple-areola complex is often the final step in the surgical treatment of breast cancer patients, and it consequently has important symbolic and aesthetic implications. Patient expectations and the need for symmetry make nipple projection a crucial aesthetic determinant of nipple reconstruction. We hypothesize that long-term nipple projection and shape can be achieved in a predictable fashion using the modified star dermal fat flap technique. Prospectively, 93 nipples were reconstructed by a single surgeon using a modified star dermal fat flap technique in 44 implant and 49 TRAM flap breast reconstructions. Flap dimensions (base diameter and flap length) were designed according to patient desire or to the base diameter and projection of the opposite breast nipple. A standardized, 3-month postoperative care regimen was observed in all patients. Nipple projection was assessed by the same observer at each follow-up examination. The average length of follow-up was 730 days (745 for TRAM reconstructions and 713 for implants). Consistently, an average of 41 percent of the intraoperative projection remained intact in both groups at final evaluation (SD 12 percent). The total flap length was strongly predictive of intraoperative and long-term projection (r = 0.64 and 0.86, p < 0.0001). Flap lengths ranged from 5.5 to 9.0 cm, and in a linear correlation, resulted in intraoperative projection of 1.0 to 2.1 cm, respectively, and long-term projection of 0.4 to 0.83 cm, respectively. Based on the linear relationship, every 1-cm increase in flap length could be expected to result in a 0.16-cm increase in projection. When controlled for flap length and intraoperative projection, there was no difference between TRAM and implant nipple reconstruction in predicting postoperative nipple projection. Intraoperative planning and execution are critical to achieve predictable nipple shape, size, and projection. The dimensions of the star dermal fat flap can be strategically modified to allow the surgeon predictable projection with a consistent 41-percent preservation of intraoperative nipple projection in both TRAM and implant patients at 2 years.

The role of tissue expansion in the management of large congenital pigmented nevi of the forehead in the pediatric patient

The authors present a cohort of 21 consecutive patients who had congenital pigmented nevi covering 15 to 65 percent of the forehead and adjacent scalp and who were treated at their institution within the last 12 years. All patients were treated with an expansion of the adjacent texture‐ and color‐matched skin as the primary modality of treatment. The median age at presentation was approximately 1 year; mean postoperative follow‐up was 4 years. Nevi were classified according to the predominant anatomic areas they occupied (temporal, hemiforehead, and midforehead/central); some of the lesions involved more than one aesthetic subunit. The authors propose the following guidelines: (1) Midforehead nevi are best treated using an expansion of bilateral normal forehead segments and advancement of the flaps medially, with scars placed along the brow and at or posterior to the hairline. (2) Hemiforehead nevi often require serial expansion of the uninvolved half of the forehead to minimize the need for a back‐cut to release the advancing flap. (3) Nevi of the supraorbital and temporal forehead are preferentially treated with a transposition of a portion of the expanded normal skin medial to the nevus. (4) When the temporal scalp is minimally involved with nevus, the parietal scalp can be expanded and advanced to create the new hairline. When the temporoparietal scalp is also involved with nevus, a transposition flap (actually a combined advancement and transposition flap because the base of the pedicle moves forward as well) provides the optimal hair direction for the temporal hairline and allows significantly greater movement of the expanded flap, thereby minimizing the need for serial expansion. (5) Once the brow is significantly elevated on either the ipsilateral or contralateral side from the reconstruction, it can only be returned to the preoperative position with the interposition of additional, nonhair‐bearing forehead skin. Expansion of the deficient area alone will not reliably lower the brow once a skin deficiency exists. (6) In general, one should always use the largest expander possible beneath the uninvolved forehead skin, occasionally even carrying the expander under the lesion. Expanders are often overexpanded. (Plast. Reconstr. Surg. 107: 668, 2001.)

Dermatofibrosarcoma protuberans and the Bednar tumor: Treatment in the pediatric population

Dermatofibrosarcoma protuberans (DFSP) is a low-intermediate-grade cutaneous sarcoma that has a marked propensity for local recurrence after excision. The Bednar variant of this tumor is even less common and is distinguished histologically by the dispersal of melanin containing cells in an otherwise typical DFSP. Both are considered to be tumors of the third and forth decades of life, but both DFSP and the Bednar variant have been described in children. Until this report of a congenital Bednar tumor, only the DFSP has also been described in the neonate. The histopathology and surgical management of DFSP and Bednar tumors are outlined with emphasis on reported experience in the pediatric population. The surgical management of these lesions in children is based on numerous series in adults and the limited pediatric experience. The recommended treatment is wide excision with 3-cm margins of visibly uninvolved tissue and inclusion of superficial fascia.

The prevention of emesis in plastic surgery: a randomized, prospective study.

Perhaps the most unpleasant experience following outpatient plastic surgery procedures is postoperative nausea and vomiting. Postoperative nausea and vomiting often results in delayed recovery time and unintended admission, and it can be a contributing factor to the formation of hematoma following rhytidectomy. Ondansetron (Zofran) has proven benefit in preventing postoperative nausea and vomiting if given before general anesthesia in a variety of surgical procedures. Its utility in cases performed under conscious sedation has not been determined. The purpose of this study was (1) to test the ability of prophylactic ondansetron to prevent postoperative nausea and vomiting in plastic surgery cases performed under conscious sedation, and (2) to determine relative risk factors for postoperative nausea and vomiting and a selection policy for the administration of antiemetic prophylaxis. This was a prospective, randomized, double-blind study. One hundred twenty patients were enrolled after giving informed consent. Patients received a single dose of either placebo or ondansetron (4 mg intravenously) before administration of sedation. Sedation administration followed a standardized institutional protocol, using midazolam and fentanyl. Data were recorded from a series of three questionnaires: preoperatively, immediately postoperatively, and at the time of the first office return. Data were confirmed by means of telephone interview, chart analysis, and nursing documentation. Multivariate analysis was conducted. Nausea and emesis occurred with an overall frequency of 33 percent and 22 percent, respectively. Postoperative nausea and vomiting was associated with statistically longer recovery periods. The incidence of emesis was statistically higher among women, among those undergoing facial rejuvenation, and among those with a history of opioid-induced emesis or postoperative nausea and vomiting following a previous operation (p < 0.05). The incidence of postoperative nausea and vomiting paralleled increases in case duration; the incidence of emesis was zero in cases less than 90 minutes in duration. Ondansetron significantly reduced the incidence of emesis overall (placebo, 30 percent; ondansetron, 13 percent; p < 0.05). Postoperative perception of nausea was significantly lower among those who had received ondansetron (p < 0.05). These results confirm the efficacy of ondansetron for the prevention of postoperative nausea and vomiting in plastic surgery cases under conscious sedation. In those who are at increased risk, prophylaxis should be considered. Such risks include female gender, facial rejuvenation procedures, and a patient history of opioid-induced emesis or postoperative nausea and vomiting following a prior operation. The zero incidence of emesis in cases less than 90 minutes does not support the routine use of prophylaxis in such cases. Patient satisfaction in plastic surgery is derived from the overall subjective experience of the event as much as by the final result. By remaining attentive to patient concerns and optimizing perioperative care, we can improve the subjective experience for our patients.

Periorbital aging and ethnic considerations: a focus on the lateral canthal complex.

Background: There is a general perception that skin from various ethnic groups possesses different properties that may affect barrier function, responsiveness to topical agents, sebum production, chemical sensitivities, and aging changes. The first noticeable signs of facial aging are frequently localized to the upper face, brow, and eyes. The authors postulate that a greater relative descent of the lateral canthal complex in African Americans contributes to periorbital aging more so than in Caucasians. Methods: The photographic archives of the senior plastic surgeon (J.W.F.) were reviewed. Two hundred ninety-six cases met inclusion criteria. Lateral canthal angles were measured, and the angle assigned to each patient was an average of the right and left lateral canthal angles. Results: Statistically significant intrarace differences were found for the lateral canthal angle. The median lateral canthal angle for African American patients decreased from 3.00 degrees for those aged 45 years or younger to 1.15 degrees for African American patients older than 45 years (p = 0.03). The median lateral canthal angle for Caucasian patients decreased from 2.30 degrees for those aged 45 years or younger to 1.30 degrees for Caucasian patients older than 45 years (p = 0.00). When the data were age-matched, with 25 subjects in each group, the differences increased. Conclusions: In comparing young and aged cohorts, African American women demonstrate a more dramatic attenuation of the lateral canthal complex than their Caucasian counterparts. It appears that the lateral canthal complex has been underappreciated, and it is a vital component to periorbital rejuvenation.

Restylane and people of color.

Background: Ethnic skin presents a unique paradox. Its melanin content provides protection from the sun, but the same skin can react to the slightest of injuries. The safety of Restylane in patients with increased susceptibility to keloid formation, hypertrophic scarring, hypersensitivity, and hyperpigmentation has not been studied. A retrospective review was used to determine whether Fitzpatrick skin types IV to VI are associated with an increased incidence of adverse outcomes related to Restylane use. Methods: Sixty consecutive patients were injected with Restylane by a single surgeon (J.W.F.). Forty patients were categorized as Fitzpatrick skin types I to III and 20 as types IV to VI. Patient charts were reviewed for transient and permanent adverse outcomes related to Restylane injections, such as hypersensitivity, scar formation, altered pigmentation, and contour irregularities. All patients were evaluated at 2 to 4 weeks and 6 to 9 months. Results: The authors observed that 97.50 percent of the Fitzpatrick type I to III patients had no transient adverse outcomes related to Restylane injections. One patient experienced a 36-hour episode of exaggerated angioedema of the lips after injection, which resolved spontaneously. Another patient had an inclusion cyst that required incision and drainage and a 7-day course of antibiotics. None of the type I to III patients had permanent adverse outcomes related to Restylane. There were no transient or permanent adverse outcomes among the type IV to VI subjects. Conclusions: This study demonstrates that with proper and meticulous injection techniques, patients with Fitzpatrick skin types IV to VI can experience the same benefits of Restylane therapy as their lighter-complected counterparts.

Modern endovascular and aesthetic surgery techniques to treat arteriovenous malformations of the scalp: case illustration

BACKGROUND Arteriovenous malformations of the scalp consist of abnormally connecting arterial feeding vessels and draining veins, devoid of a normal capillary bed within the subcutaneous fatty layer of the scalp. We present a case of a left temporal scalp AVM treated for aesthetic and pain-related concerns. A multidisciplinary approach combining endovascular AVM embolization and AVM excision with local flap reconstruction was chosen. CASE DESCRIPTION The patient presented with a progressive painful pulsatile mass in the left temporal region. On examination, there was no evidence of any facial nerve compromise or any other neurologic deficits. Computed tomographic angiography revealed a 6-mm lesion located totally within the scalp and not associated with bone or periosteum. A recommendation was made to proceed with preoperative embolization to facilitate surgical resection. The AVM was occluded endovascularly using multiple detachable platinum coils, and the patient was neurologically intact. The following day, the patient was taken to the operating room. By that time, the mass was minimally pulsatile. The AVM was resected en bloc, and a 3-layered intermediate closure of the 5.5-cm defect was then performed. The procedure was well tolerated, and the patient had an uneventful postoperative course. CONCLUSIONS Scalp AVMs are interesting lesions with heterogeneous anatomical features. Treatment can be optimized in a multidisciplinary environment, using a prescribed treatment algorithm to minimize the size of soft/hard tissue defect and enhance cosmesis. Careful selection of therapeutic modalities based on AVM anatomy and aesthetic concerns can lead to safe and durable results with high patient satisfaction rates.

Revisiting upper eyelid anatomy : Introduction of the septal extension. Discussion

Background: The current trend in plastic surgery of the eyelid has taken on increased dependence on anatomical considerations in the marriage of aesthetic and functional ideals. Often, the plastic surgeon performs ptosis and/or septal surgery in conjunction with blepharoplasty. The relationship between eyelid adnexal structures and upper eyelid function is a delicate but critical one. Current anatomical description states that the septum does not reach the superior tarsal border and inserts at a variable level on the levator aponeurosis. Conflicting observations in clinical practice stimulated this study to delineate the septal relationship to surrounding structures. In addition, this study may help to explain the increased rate of recurrence in ptosis repairs that incorporate plication techniques. Methods: Dissection of four fresh cadaveric upper lid specimens in situ along with hematoxylin and eosin and trichrome stains of harvested eyelid tissue were used to redefine septal anatomy. Clinical case correlations are made to illustrate the significance of the histologic findings. Results: A distinct septal extension was demonstrated arising from the orbital septum and covering preaponeurotic fat and tarsus completely. Histology of the anterior lamellae confirmed the presence of this thin fibrous sheet. In vivo assessment of this structure verifies its dynamic role in upper lid function. The clinical ramifications of this anatomical nuance are realized. Conclusions: A septal extension to the ciliary margin of the upper eyelid is established. Suture plication of the septal extension can induce lid elevation, with potential postoperative lid retraction. Intraoperative failure to recognize and distinguish this extension from the aponeurosis proper may lead to the high reported rates of unsuccessful ptosis correction. This refinement of septal anatomy should increase precision and help surgeons avoid complications in advanced blepharoplasty and ptosis surgery.

Necrotizing fasciitis in infancy: An uncommon setting and a prognostic disadvantage

Necrotizing fasciitis is a potentially fatal, progressive soft tissue infection that typically occurs in adults, and only rarely occurs in infants. Although adults in whom necrotizing fasciitis develops are commonly diabetic, malnourished, or otherwise immunocompromised, infants in whom the disease develops are typically healthy and without clear predisposing factors. Herein, however, the authors report the case of an infant with compromised immunity secondary to the manifestations and treatment of panhypopituitarism, in whom postoperative necrotizing fasciitis developed after bilateral inguinal herniorrhaphy. The diagnosis, pathological mechanism, and treatment of necrotizing fasciitis are reviewed and the distinguishing features in infants are highlighted. The combination of a low incidence and very high mortality rate associated with necrotizing fasciitis in this subgroup strengthens the need for hypercritical suspicion. Early diagnosis and the prompt initiation of surgical treatment are the most essential means to improve on the prognosis for necrotizing fasciitis in infants.

Periorbital rejuvenation and the African American patient: a survey approach.

Background: The number of African Americans pursuing cosmetic plastic surgery is increasing. Nonetheless, the authors postulate that the African American patients pursuing certain cosmetic procedures still have preconceived notions and concerns distinct from their Caucasian counterparts, thereby demanding a different surgical strategy. A questionnaire approach was used to determine the concerns, expectations, and desires of African American patients regarding periorbital rejuvenation and to compare these outcomes with those of Caucasian patients. Methods: One hundred five African American female subjects and 30 Caucasian female subjects affiliated with the senior surgeon’s cosmetic practice were contacted. Of these, 85 African American and 26 Caucasian subjects were administered a survey of 18 standardized questions. Patients were stratified in terms of age and race to dissect generational and ethnologic concepts toward oculoplastic surgery and features of the African American eyelid. The Caucasian subjects served as the control group. Results: Of the African American subjects, 85.9 percent had a favorable or neutral opinion of plastic surgery, and 72.9 percent did not feel plastic surgery was exclusively for Caucasians. Nearly half of all African American subjects interviewed likened African American periorbital characteristics to those of Asians, whereas only 19.2 percent of Caucasian subjects acknowledged such similarities in African Americans. Conclusions: This study demonstrates the idea that a directed approach to blepharoplasty is necessary to help African American patients achieve their desire to maintain their ethnic identity while rejuvenating their appearance.