Katelyn G. Bennett

Ibuprofen May Not Increase Bleeding Risk in Plastic Surgery: A Systematic Review and Meta-Analysis.

Background: Nonsteroidal antiinflammatory drugs such as ibuprofen are common medications with multiple useful effects, including pain relief and reduction of inflammation. However, surgeons commonly withhold all nonsteroidal antiinflammatory drugs perioperatively because of bleeding concerns. However, not all nonsteroidal antiinflammatory drugs irreversibly block platelet function. The authors hypothesized that the use of ibuprofen would have no effect on postoperative bleeding in plastic surgery patients. Methods: A literature review was performed using MEDLINE (PubMed), EMBASE, and the Cochrane Collaboration Library for primary research articles on ibuprofen and bleeding. Inclusion criteria were primary journal articles examining treatment of acute postoperative pain based on any modality. Data related to pain assessment, postoperative recovery, and complications were extracted. Bias assessment and meta-analysis were performed. Results: A total of 881 publications were reviewed. Four primary randomized controlled trials were selected for full analysis. Articles were of high quality by bias assessment. No significant difference was noted regarding bleeding events (p = 0.32), and pain control was noted to be equivalent. Conclusions: Ibuprofen is a useful medication in the setting of surgery, with multiple beneficial effects. This meta-analysis represents a small set of high-quality studies suggesting that ibuprofen provides pain control equivalent to narcotics. Importantly, ibuprofen was not associated with an increased risk of bleeding. Further large studies will be necessary to elucidate this issue further, but ibuprofen is a safe postoperative analgesic in patients undergoing common plastic surgery soft-tissue procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Association of Fat Grafting With Patient-Reported Outcomes in Postmastectomy Breast Reconstruction

Importance Fat grafting has proven to be a useful adjunct to breast reconstruction for the treatment of contour irregularities and volume deficits, but the proposed US Food and Drug Administration regulations may severely limit the ability of plastic surgeons to continue its use in this clinical context. Objective To determine whether fat grafting is associated with patient-reported outcomes (PROs) in patients undergoing breast reconstruction. Design, Setting, and Participants A longitudinal, multicenter, prospective cohort study was conducted between February 1, 2012, and July 31, 2016, at the 11 sites associated with the Mastectomy Reconstruction Outcomes Consortium Study. Eligible patients included women 18 years or older presenting for breast reconstruction after mastectomy with 2 years or more of follow-up. All primary procedure types (implant based and flap based) were eligible. Patients were excluded if they had not completed breast mound reconstruction by 1 year after starting reconstruction. Interventions Fat grafting as an adjunct to breast mound reconstruction. Main Outcomes and Measures Primary end points were patient-reported outcome measures as assessed by the validated BREAST-Q survey, with higher scores on a 0- to 100-point scale indicating better health-related quality of life. Survey subscales included breast satisfaction, as well as psychosocial, physical, and sexual well-being. Patient-reported outcomes were compared between those who received and did not receive fat grafting. Results A total of 2048 women were included (mean [SD] age, 49.4 [10] years), with 165 (8.1%) undergoing fat grafting between years 1 and 2. One year postoperatively, patients who later underwent fat grafting reported significantly lower breast satisfaction (adjusted mean difference [AMD], −4.74; 95% CI, −8.21 to −1.28; P = .008), psychosocial well-being (AMD, −3.87; 95% CI, −7.33 to −0.40; P = .03), and sexual well-being (AMD, −5.59; 95% CI, −9.70 to −1.47; P = .008), compared with those who did not receive subsequent fat grafting. Following the procedure, the fat-grafted cohort reported similar breast satisfaction (AMD, −0.68; 95% CI, −4.42 to 3.06; P = .72), psychosocial well-being (AMD, −0.59; 95% CI, −3.92 to 2.74; P = .73), and sexual well-being (AMD, −2.94; 95% CI, −7.01 to 1.12; P = .15) 2 years postoperatively. Conclusions and Relevance Fat grafting may improve breast satisfaction, psychosocial well-being, and sexual well-being in patients undergoing breast reconstruction.

Metopic Craniosynostosis: A Demographic Analysis Outside an Urban Environment.

Background: Metopic craniosynostosis has traditionally been cited as the third most common type of isolated synostosis, after sagittal and coronal craniosynostosis. Recently, several urban institutions have observed an increase in the incidence of metopic synostosis. The authors sought to determine if similar demographic changes have occurred in a more suburban setting and if so, what specific variables were associated with this change. Methods: Patients who underwent operative correction of craniosynostosis between 1989 and 2014 were retrospectively reviewed. The type of craniosynostosis as well as sex, family history, birth history, and other demographic data were recorded. Kendall–Mann trend tests and multinomial logistic regressions were conducted, and marginal effects were calculated for all variables included in the model. Results: Records of 493 patients were reviewed. Using Kendall–Mann trend tests, it was determined that metopic, sagittal, and lambdoid craniosynostoses all demonstrated an increase in incidence. Based on raw data, metopic synostosis was found to be the second most common type of craniosynostosis between 2004 and 2014. Male sex and multiple gestations were both associated with metopic craniosynostosis. Conclusions: This study demonstrated an increasing incidence of metopic craniosynostosis over time, which ascended to the second most common type of synostosis in an analysis outside of an urban environment. In our study, male sex and multiple gestation were positively associated with an increased risk of metopic craniosynostosis. Prospective studies are needed to further delineate the evolving characteristics of this patient population.

Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction

Importance In breast reconstruction, it is critical for patients and surgeons to have comprehensive information on the relative risks of the available options. However, previous studies that evaluated complications were limited by single-center designs, inadequate follow-up, and confounding. Objective To assess 2-year complication rates across common techniques for postmastectomy reconstruction in a multicenter patient population. Design, Setting, and Participants This longitudinal, multicenter, prospective cohort study conducted from February 1, 2012, through July 31, 2015, took place at the 11 study sites associated with the Mastectomy Reconstruction Outcomes Consortium study. Eligible patients included women 18 years and older presenting for first-time breast reconstruction with at least 2 years of follow-up. Procedures evaluated included direct-to-implant (DTI) technique, expander-implant (EI) technique, latissimus dorsi (LD) flap, pedicled transverse rectus abdominis myocutaneous (pTRAM) flap, free transverse rectus abdominis myocutaneous (fTRAM) flap, deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery (SIEA) flap. Interventions Postmastectomy breast reconstruction. Main Outcomes and Measures Development of complications, reoperative complications, and wound infections during 2-year follow-up. Mixed-effects logistic regression analysis controlled for variability among centers and for demographic and clinical variables. Results A total of 2343 patients (mean [SD] age, 49.5 [10.1] years; mean [SD] body mass index, 26.6 [5.7]) met the inclusion criteria. A total of 1525 patients (65.1%) underwent EI reconstruction, with 112 (4.8%) receiving DTI reconstruction, 85 (3.6%) pTRAM flaps, 95 (4.1%) fTRAM flaps, 390 (16.6%) DIEP flaps, 71 (3.0%) LD flaps, and 65 (2.8%) SIEA flaps. Overall, complications were noted in 771 (32.9%), with reoperative complications in 453 (19.3%) and wound infections in 230 (9.8%). Two years postoperatively, patients undergoing any autologous reconstruction type had significantly higher odds of developing any complication compared with those undergoing EI reconstruction (pTRAM flap: odds ratio [OR], 1.91; 95% CI, 1.10-3.31; P = .02; fTRAM flap: OR, 2.05; 95% CI, 1.24-3.40; P = .005; DIEP flap: OR, 1.97; 95% CI, 1.41-2.76; P < .001; LD flaps: OR, 1.87; 95% CI, 1.03-3.40; P = .04; SIEA flap: OR, 4.71; 95% CI, 2.32-9.54; P < .001). With the exception of LD flap reconstructions, all flap procedures were associated with higher odds of reoperative complications (pTRAM flap: OR, 2.48; 95% CI, 1.33-4.64; P = .005; fTRAM flap: OR, 3.02; 95% CI, 1.73-5.29; P < .001; DIEP flap: OR, 2.76; 95% CI, 1.87-4.07; P < .001; SIEA flap: OR, 2.62; 95% CI, 1.24-5.53; P = .01) compared with EI techniques. Of the autologous reconstructions, only patients undergoing DIEP flaps had significantly lower odds of infection compared with those undergoing EI procedures (OR, 0.45; 95% CI, 0.25-0.29; P = .006). However, DTI and EI procedures had higher failure rates (EI and DTI techniques, 7.1%; pTRAM flap, 1.2%; fTRAM flap, 2.1%; DIEP flap, 1.3%; LD flap, 2.8%; and SIEA flap, 0%; P < .001). Conclusions and Relevance Significant differences were noted across reconstructive procedure types for overall and reoperative complications, which is critically important information for women and surgeons making breast reconstruction decisions.

Intradermal Infiltration of Local Anesthetic-Rapid and Bloodless Deepithelialization of the Breast Pedicle

Summary: Breast reduction is one of the most commonly performed plastic surgery procedures, and pedicle deepithelialization remains a time-consuming step of the operation. This is especially true when using an inferior pedicle. We present a novel technique of intradermal infiltration of the breast pedicle with local anesthetic to facilitate efficient, bloodless deepithelialization. The senior author uses a 20-ml syringe to inject 0.25% lidocaine and 1:400,000 epinephrine just beneath the epidermis of the breast pedicle to create a series of wheals. Approximately 20 ml of local anesthetic is used per pedicle. After injection of local anesthetic, the breast pedicle is deepithelialized in less than 3 minutes. The plane is bloodless, allowing improved visualization secondary to the epinephrine-induced hemostasis. The senior author has had only one case of nipple necrosis in 20 years of experience. Intradermal infiltration of local anesthetic with epinephrine hydrodissects between the epidermis and dermis and provides hemostasis to facilitate rapid deepithelialization.

Harvesting the buccal fat pad does not result in aesthetic deformity in cleft patients: A retrospective analysis

Background: Buccal fat is often used as a pedicled flap in cleft palate repairs to minimize scarring and fortify tenuous closures. Although many surgeons have adopted this technique, others have remained circumspect because of the concern for subsequent facial asymmetry. Methods: Patients who underwent cleft palate repair using buccal fat pad flaps for closure between 2007 and 2015 were reviewed. Only patients with unilateral buccal fat pad flaps and three-dimensional photography were included. Volumetric analysis was performed on each patient to measure cheek volumes of both the flap and nonflap sides. A subgroup analysis on cleft palate and bilateral cleft lip and palate patients was performed to eliminate the confounding asymmetries of unilateral cleft lip and palate patients. Paired t tests were used to determine differences in cheek volumes. In addition, three reviewers examined photographs of patients and were asked to determine the side of fat pad harvest. Results: Twenty-four patients met inclusion criteria. Mean follow-up was 55 months. The volume difference between the flap and nonflap sides was not significant (p = 0.81). Subgroup analysis on cleft palate and bilateral cleft lip and palate patients did not reveal a volume difference between the flap and nonflap sides (p = 0.98). When asked to determine which side buccal fat pads were harvested from based on patient photographs, the average percentage correct for three independent reviewers was 57 percent and the Cohen’s kappa was −0.084, indicating poor agreement. Conclusion: Although the buccal fat pad is thought to play a role in facial aesthetics, the authors found no difference in volume between harvest and nonharvest sides, nor was there a clinically detectable difference. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Guidelines for the Ethical Publication of Facial Photographs and Review of the Literature

Facial photography presents a unique ethical dilemma, as faces are difficult to deidentify for publication. We performed a review of the literature to examine current guidelines for the publication of facial photographs. We also reviewed societies’ websites, journal requirements, and ethical and legal aspects of confidentiality. Most articles emphasized the importance of consent for photography and publication. Masking is not appropriate, but some journals continue to allow masking. Most legislation allows patients to restrict the uses of photographs. In the end, it is imperative to protect patient privacy by obtaining consent for photograph publication after full disclosure of risks, and specific recommendations are provided regarding a comprehensive consent process.

Velopharyngeal Dysfunction and Sleep Apnea-A Survey to Ascertain Surgical Practice Patterns.

Objective To determine if all cleft surgeons uniformly and adequately evaluate patients with cleft for obstructive sleep apnea (OSA) and consider OSA in treatment of velopharyngeal dysfunction (VPD). Design A 22-question survey was administered via e-mail to 1117 surgeons who were members of the American Cleft Palate-Craniofacial Association. Logistic regression was used to determine if management was affected by years in practice, clinical volume, field of training, and region of practice. Main Outcome Measures We sought to determine if years in practice, clinical volume, region of practice, and surgical specialty affected surgeons’ evaluation of OSA and their approaches to VPD. Results A total of 231 surgeons responded (21% response rate), and 67% stated that they had trained in plastic surgery. With increasing years of practice, surgeons were less likely to refer patients for preoperative and postoperative sleep studies (P = .00 and P = .001, respectively), screen patients for sleep apnea (P = .008), or change their management based on a sleep study (P = .001). There were no significant differences in screening or testing for OSA based upon clinical volume. Among those surveyed, otolaryngologists were more likely to refer patients for postoperative sleep studies (P = .028). Surgeons in the Southeast were more likely to change their management based upon a sleep study (P = .038). Conclusions Statistically significant trends in screening and testing for OSA in the setting of VPD were identified by this survey. Notably, older surgeons were less likely to investigate OSA in their patients, and not all specialties equally refer for postoperative sleep studies.

The Protruding Premaxilla: Is Our Current Approach the Right Answer?

Background: In bilateral cleft patients, surgeons usually attempt to move the premaxillary segment posteriorly. These patients almost always develop maxillary hypoplasia, rendering our current algorithms questionable. The authors sought to determine if the lateral segments are in an appropriate position to serve as a target for movement of the premaxilla. Methods: Bilateral cleft lip and palate patients treated at the University of Michigan from 1997 to 2015 were reviewed. Patients with skull radiographs or computed tomography (CT) imaging performed at age 3 or younger were included. Noncleft patients <3 years old seen in the craniofacial clinic during 2015 with negative imaging were included as comparative norms. Sella-nasion-A (SNA), sella-nasion-piriform (SNP), and sella-nasion-posterior nasal spine (SN-PNS) angles were determined in both the cleft patients and the comparative norms. Paired t tests assuming unequal variance were used to compare angles between normal and cleft patients. Results: Eighty-six bilateral cleft patients were identified, and 16 had imaging. Only 7 patients had a CT or skull radiograph. Thirteen noncleft patients with negative imaging were included. The mean SNA angle was 100.8 in cleft patients and 86.1 in noncleft patients (P = 0.002). The mean SNP angle was 62.9 in cleft patients and 71.3 in noncleft patients (P = 0.02). The mean SN-PNS angle was 23.2 in cleft patients and 33.8 in noncleft patients (P = 0.005). Conclusions: Our results indicate that the maxilla is deficient early in life with posterior positioning of the lateral segments. Therefore, the lateral segments should not serve as a reference point when treating the premaxilla.

Surgical Hypercorrection of Trigonocephaly: Evaluation of Surgical Outcomes

Background: A lasting correction of trigonocephaly is difficult to achieve, as a durable correction requires significant expansion to overcome galeal restriction and soft tissue recoil of the scalp. High rates of relapse have been reported throughout the literature. The specific aim of this study was to determine if the senior authors method of “hypercorrection” decreases relapse and the need for subsequent revisional surgery. Methods: Patients who underwent operative correction of metopic craniosynostosis between 1988 and 2011 were reviewed. All patients underwent the “hypercorrection” technique performed by the senior author. Hypercorrection consisted of a fronto-orbital advancement of 2.5 to 3.5 cm and a concomitant hyperexpansion of bitemporal projection. Split cranial bone grafting ensured adequate coverage of the significantly expanded cranial vault. Only patients who had at least 5 years of follow-up were included for review of outcomes. Relapse was defined as recurrence of bitemporal constriction or lateral orbital retrusion, requiring surgical correction. Results: Fifty-eight patients met criteria. Mean age at the time of surgery was 11 months. Mean follow-up was 9.0 years. During this time, 2 patients exhibited relapse requiring camouflage procedures. Cranial bone defects were found in 4 patients (7%), 3 of whom underwent cranial bone grafting, while 1 underwent methylmethacrylate placement at an outside institution. One patient underwent fat grafting for areas of soft tissue irregularity. No patients exhibited persistent sequelae of hypercorrection significant enough to require repeat fronto-orbital advancement. Conclusion: Surgical hypercorrection of trigonocephaly seems to minimize relapse and the need for revision in long-term follow-up and is therefore an important technique to consider.