Marc E. Walker

The impact of geographic, ethnic, and demographic dynamics on the perception of beauty.

BackgroundBeauty lies in the eyes of the beholder, but influenced by the individual’s geographic, ethnic, and demographic background and characteristics. In plastic surgery, objective measurements are used as a foundation for aesthetic evaluations. This study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception. MethodsComputerized images of a model’s face were generated with the ability to alter nasal characteristics and the projection of the lips and chin. A survey containing these modifiable images was sent to more than 13,000 plastic surgeons and laypeople in 50 different countries, who were able to virtually create a face that they felt to be the aesthetically “ideal” and most pleasing. Demographic information about the interviewees was obtained. ResultsValues of various aesthetic parameters of the nose were described along with their relationship to geography, demography, and occupation of the respondents. Interregional and ethnic comparison revealed that variables of country of residence, ethnicity, occupation (general public vs surgeon), and sex correlate along a 3-way dimension with the ideal projection of the lips and the chin. Significant interaction effects were found between variables of country of residence or ethnicity with occupation and sex of the respondents. ConclusionsWhat are considered the “ideal” aesthetics of the face are highly dependent on the individual’s cultural and ethnic background and cannot simply and solely be defined by numeric values and divine proportions. As confirmed with this study, ethnic, demographic, and occupational factors impact peoples’ perception of beauty significantly.

Nasal aesthetics: a cross-cultural analysis.

Background: Plastic surgeons often approach nasal aesthetic evaluation with the aid of seemingly objective measurements. However, ideal measurements of an attractive nose, as suggested in the literature, might not apply on a cross-cultural basis. Given these controversies, this study aimed to investigate the cultural and ethnic impact on nasal shape preferences. Methods: Computerized images of a models nose were generated in which the nasal width, root, tip, dorsum, and projection of the lips and chin could be altered. A survey containing these images was sent to over 13,000 plastic surgeons and lay people in 50 different countries, with a total response rate of 9.6 percent. Demographic information about the interviewees was obtained. Results: Preferred dimensions of the nose were broken down according to geographic, ethnic, occupational, and sex variables. Interregional comparison revealed that plastic surgeons from Latin America and the Caribbean overall prefer smaller and narrower noses, with more projecting tips, lips, and chins. Similar trends hold true when analyzing results from the general public. Significant differences were found comparing preferences between plastic surgeons and the general public. Plastic surgeons preferred wider nasal roots and tips and, in combination, more projected nasal dorsi, tips, lips, and chins. Conclusions: No universal parameter can define ideal aesthetics of the nose across cultures and ethnic backgrounds. As demonstrated, geographic, ethnic, and cultural factors influence aesthetic perceptions of patients and surgeons.

Immediate nipple reconstruction utilizing the DIEP flap in areola-sparing mastectomy

The surgical treatment of breast cancer has dramatically evolved over the past decade toward an approach combining oncologic safety with aesthetic outcomes. The skin‐sparing mastectomy initiated this paradigm shift amongst breast surgeons and can be oncologically safe, in some cases sparing both the areola and the nipple. In accordance with the emphasis on aesthetics, some general surgeons have adopted new methods of resecting only the nipple, sparing the areola in select patients. The superior aesthetic results, durability, and decreased donor site morbidity of perforator flaps have brought autologous reconstruction back to the forefront of breast reconstruction with the deep inferior epigastric artery perforator (DIEP) flap as the gold standard. We describe a technique utilizing the DIEP flap skin paddle for immediate nipple reconstruction at the time of mastectomy and reconstruction, eliminating the need for delayed reconstruction and limiting donor site morbidity by concealing the donor site below the mastectomy skin flaps. In the six cases described performed between 2010 and 2012 (mean with 53 years; range 46–59 years), there have been no complications to the flap or the nipple postoperatively, nor has there been a need for further nipple revisions for 6 months. The nipple position relative to the flap breast mound has remained unchanged for up to 6 months. The immediate nipple reconstruction does not significantly lengthen operative time, requiring approximately 30 additional operative minutes per nipple. Immediate nipple reconstruction utilizing the DIEP flap can be a cost‐effective and feasible technique for recreating a natural‐appearing and aesthetic nipple in select patients.

Aesthetic Breast Shape Preferences Among Plastic Surgeons

BackgroundThere has been little discussion in the plastic surgery literature regarding breast shape preferences among plastic surgeons, despite strong evidence that such aesthetic preferences are influenced by multiple factors. Much effort has been focused on delineating the objective criteria by which an “attractive” breast might be defined. This study aimed at providing a better understanding of the presence and significance of differences in personal aesthetic perception, and how these relate to a plastic surgeon’s demographic, ethnic, and cultural background, as well as practice type (academic vs private). MethodsAn interactive online survey was designed. Modifiable ranges of upper pole fullness and areola size were achieved via digital alteration, enabling participants to interactively change the shape of a model’s breasts. The questionnaire was translated into multiple languages and sent to plastic surgeons worldwide. Demographic data were also collected. Analysis of variance was used to elucidate plastic surgeon’s breast shape preferences in respect to sex and age, geographic and ethnic background, as well as practice type. ResultsThe authors gathered 614 responses from 29 different countries. Significant differences regarding preferences for upper pole fullness, areola size in the natural breast, and areola size in the augmented breast were identified across surgeons from the different countries. Further, significant relationships regarding breast shape preferences were distilled between the age and sex of the surgeon, as well as the practice type. No differences were found in respect to the surgeons’ self-reported ethnic background. ConclusionsCountry of residence, age, and practice type significantly impact breast shape preferences of plastic surgeons. These findings have implications for both patients seeking and surgeons performing cosmetic and reconstructive breast surgery. In an increasingly global environment, cultural differences and international variability must be considered when defining and publishing new techniques and aesthetic outcomes. When both the plastic surgeon and the patient are able to adequately and effectively communicate their preferences regarding the shape and relations of the breast, they will be more successful at achieving satisfying results.

The Hand Surgeon Consultation Improves Patient Knowledge in a Hand Surgery Mission to Honduras

BACKGROUND The purpose of this study was to assess impact of the surgeon consultation and informed consent process on patient education in an international hand surgery mission compared with a US academic hand surgery practice. These two groups were selected to evaluate communication difficulties in a surgical mission setting compared with standard of care in a high-income country. METHODS A multi-part survey was administered to patients presenting to a hand surgery mission during March 2012 and new patients of a university hand center in a 3-month period during 2011. Surveys were administered prior to and following surgeon consultation with one fellowship-trained hand surgeon. The survey assessed knowledge of basic hand anatomy, physiology, disease, individual diagnosis, and surgical risks. RESULTS 71 patients participated in the study (university n=36, mission n=35). Pre-consultation quiz score averaged 58% in the university group versus 27% in the mission group. Post-consultation quiz scores averaged 62% in the university group versus 40% in the mission group. Only the mission groups quiz score increase was statistically significant. 93% of the university group reported learning about their condition and diagnosis, but only 40% demonstrated correct insight into their diagnosis. In the mission group, 73% reported learning about their condition and diagnosis while 53% demonstrated correct insight into their diagnosis. Although all consultations involved discussion of surgical risks, only 62% of the university group and 52% of the mission group recalled discussing surgical risks. CONCLUSIONS The hand surgeon consultation was more effective in improving hand knowledge in the surgery mission group compared to in a university hand practice. This suggests that the surgeon consultation should be pursued despite communication barriers in surgical missions. However, the discrepancy between patient perception of knowledge gains and correct insight into diagnosis, and the deficit of patient retention of surgical risks need to be improved.

Breast necrosis following coronary arterial bypass grafting in the setting of chest radiation

Coronary artery bypass grafting (CABG) is one of the most commonly performed surgical procedures today, and the internal mammary artery is the conduit of choice. Though grafting of this vessel leads to a substantial decrease of the blood supplied to the breast, ischemic necrosis of the breast remains a rare phenomenon. In the setting of chest radiation, however, subsequent damage to endothelial cells and fibroblasts can threaten the supplemental vasculature. In this report, we share a recent case of CABG-related breast necrosis in the setting of chest radiation, including presentation, diagnosis, and surgical management. We also discuss a comprehensive review of the CABG-related breast necrosis case literature. With increases in CABG procedures and more refined chemoradiation treatment modalities, it is critical that surgeons interacting with these patients be aware of and prepared to address the potentially great impact that chest radiation can have as a probable independent risk factor in the pathophysiologic pathway of ischemic breast necrosis.Level of Evidence: Level V, therapeutic study.

Venous thromboembolism risk factors in breast cancer patients undergoing deep inferior epigastric perforator flap reconstruction

We present our rationale emphasizing the need for investigation into the most appropriate venous thromboembolism (VTE) prophylaxis guidelines for breast cancer patients undergoing deep inferior epigastric perforator (DIEP) flap reconstruction. VTE has been found to be the second most common postoperative complication and cause of excess length of stay, as well as the third leading cause of mortality and excess cost in surgical patients. The morbidity associated with VTE, and its relative preventability, have inspired the American Board of Chest Physicians to perform systematic literature reviews outlining specific anticoagulation guidelines for high-risk patient populations, particularly in surgical oncology. Cancer patients have been shown to have a six times greater risk of developing VTE and are eight times more likely to die from acute VTE than patients without cancer. It is estimated that one in seven hospitalized cancer patients dies of pulmonary embolism (PE) rather than cancer itself, and as many as 60% of those cancer patients had localized disease at the time of death. According to the Caprini risk assessment evaluation, the majority of breast cancer patients posses four to five risk factors with an estimated DVT incidence of 40–80%. Despite the high estimated VTE risk in breast cancer patients, there is a paucity of literature describing the true incidence and recommended treatment for this group. Over the past 2 years alone, the number of DIEP flaps used in breast reconstruction has increased by nearly 16%, accounting for >5% of all reported cases of breast reconstruction. The growing trend of DIEP flaps has increased the intraoperative time and lengthened postoperative immobility. In a patient population known to be at high-risk for postoperative VTE, the addition of prolonged operative times and increased immobility emphasizes the need to better characterize these patients and their risk of VTE formation. In a retrospective chart review (Jan 2007–Feb 2009), we identified 200 breast reconstruction cases using tissue expanders and 137 cases using DIEP flaps. Through random mathematical sampling, we compared the two cohorts for known VTE risk factors: BMI, preoperative mobility, smoking, birth control/hormone therapy, preoperative chemotherapy, cancer stage, history of prior DVT, preoperative and postoperative anticoagulation, and clinical incidence of postoperative VTE. The DIEP cohort had an increased number of menopausal patients, preoperative radiation (P 5 0.017), postoperative immobilization time (P 5 0.000), duration of surgery (P 5 0.000), and length of hospitalization (P 5 0.000), compared to the cohort of tissue expander patients. These additional risk factors are known to further contribute to the incidence of VTE, and thus increase the morbidity and mortality associated with postoperative VTE in DIEP patients. There is abundant literature recognizing the strong link between cancer and thrombosis (e.g., in cervical and colon cancer); however, there are no equivalent efforts investigating this pathology in breast cancer patients. In *Correspondence to: Dr. E. Stirling Craig, M.D., Surgery—Administration/ Academic Affairs, P.O. Box 208062, New Haven, CT 06520-8062. E-mail: elizabeth.craig@yale.edu Received 23 January 2012; Revised 6 February 2012; Accepted 8 February 2012

Abstract 142: Prevention of Seroma and Post-operative Wound Complications Using Negative Pressure Wound Therapy Devices Following Panniculectomy in Massive Weight-Loss Patients.

PurPose: The majority of chronic wounds occurs in people over age 60 and is increasing at a rate of approximately 10% per year. However, there is still no effective treatment method for such wounds because the mechanism has not been fully elucidated. We have found both high ROS production and MMPs expression in the ischemic wound of young animal, which correlated with high levels of MAPKs. The present study aimed to test the hypothesis that the ROS/MAPK/MMPs signaling axis plays an important role in pathobiological process of chronic wound in elderly by using small interference RNA (siRNA) approach in a novel ischemic wound model.

Prevention of Seroma and Other Post-Operative Complications Using Continuous Negative Pressure Drain Devices Following Panniculectomy in Massive-Weight Loss Patients

Methods/Technique: In a prospective, randomized-controlled, single-surgeon study, patients seeking panniculectomy were randomized to NP or CS drains. Patients were compared on multiple demographic criteria including age, gender, BMI, incision length, pannus weight, nutritional status, comorbidities, prior surgery and duration of drain placement. Drains were removed when fluid output was below 30ml/day. Nutrition labs were collected at the time of drain removal. Abdominal ultrasound was performed 2 weeks following drain removal to objectively quantify persistent fluid collections. Quantitative and binomial statistical analysis were performed using, T-test, Chi-square, and logistic regression. !