Mohammed Alghoul

Clinical outcome of peripheral nerve decompression in diabetic and nondiabetic peripheral neuropathy.

Surgical decompression of peripheral nerves in patients with diabetes was reported to restore sensation and improve function. In this study, a retrospective review of 12 diabetic and 20 nondiabetic patients with lower-extremity peripheral neuropathy who underwent surgical decompression was performed. Clinical evaluation by Tinel test, muscle power examination, and 2-point discrimination were performed preoperatively, at 6 months, and between 9 and 15 months postdecompression. Clinical outcomes were classified into excellent, good, or fair based on improvement in symptoms and return of function. Thirty-two patients underwent 36 surgeries, in which 99 lower-extremity nerves were decompressed. There was a statistically significant improvement in muscle function (P < 0.001) and 2-point discrimination for the small toe (P = 0.008) and big toe (P = 0.038). At a mean of 7.7 months, 90% of patients showed significant improvement in pain and function. It is concluded that surgical decompression was associated with significant improvement in clinical outcome in patients with diabetic and idiopathic neuropathy with evidence of superimposed compression.

Retaining ligaments of the face: review of anatomy and clinical applications.

The retaining ligaments of the face are important in understanding concepts of facial aging and rejuvenation. They are located in constant anatomic locations where they separate facial spaces and compartments. Their superficial extensions form subcutaneous septa that separate facial fat compartments. Their main significance relates to their surgical release in order to achieve the desired aesthetic outcome. Furthermore, they have a sentinel role in their anatomic relationship to facial nerve branches. When performing facial aesthetic surgery, plastic surgeons should select a plane of dissection, release the appropriate ligaments depending on the desired aesthetic goals, and avoid nerve injury by using the ligaments as anatomic landmarks. Descriptions of the retaining ligaments are variable in the literature; due to different interpretations of anatomy, several classifications, locations, and nomenclature systems have been proposed. This article will review and clarify the anatomy of the retaining ligaments of the face, including the cheek, mandible, temporal, and periorbital areas.

Diced cartilage grafts wrapped in alloderm for dorsal nasal augmentation

Dorsal nasal augmentation is commonly performed for various aesthetic deficiencies and/or reconstructive defects such as the saddle nose deformity. However, the optimal technique for volume augmentation has yet to be identified. The senior author (F.P.) has since developed a new modified technique using wrapped diced cartilage within an AlloDerm. This novel construct provides the plastic surgeon a smooth, convenient, pliable option with similar operative times as compared with other popular techniques. In summary, this technique has been proven to be successful in achieving attractive, safe, and acceptable outcomes in nasal dorsal configuration and overall patient satisfaction.

Relationship of the zygomatic facial nerve to the retaining ligaments of the face: the Sub-SMAS danger zone.

Background: The transition zone between cheek superficial musculoaponeurotic system (SMAS) and malar SMAS is difficult to raise because of proximity of zygomatic nerve branches. The authors attempted to clarify the three-dimensional anatomy of the retaining ligaments in relation to nerve branches in this area. Methods: Facial dissection was performed on 22 cadaver hemifaces. The zygomatic and masseteric retaining ligaments and the zygomatic and buccal facial branches in the area of dissection were identified. Ninety-five percent confidence regions for the locations of the zygomaticus major origin and the main zygomatic retaining ligament and upper masseteric retaining ligament were created. Results: The distribution, density, and size of the retaining ligaments varied. The main zygomatic and upper masseteric retaining ligaments were located at a mean distance of 44.91 ± 9.72 mm and 46.35 ± 8.34 mm from the tragus. An upper zygomatic branch passed between the main zygomatic and the upper masseteric retaining ligaments and was always located deep (4.07 ± 1.29 mm) in the sub-SMAS plane of dissection and passed deep under the upper third of the zygomaticus major muscle. An inferior zygomatic branch passed inferior to the upper masseteric retaining ligament or penetrated its inferior margin (54 percent of cases) and was located more superficially (1.41 ± 0.95 mm), becoming visible just distal to the ligament. Conclusions: Despite anatomical variation, the main zygomatic and upper masseteric retaining ligaments create a safe passage in between, through which a zygomatic facial branch passes deep. The area of danger is immediately inferomedial to the upper masseteric retaining ligament, where a zygomatic branch becomes superficial and vulnerable.

Self-Reported Outcome After Diode Laser Hair Removal

Background:Laser-assisted photoepilation has become the procedure of choice for permanent hair reduction. Our purpose was to evaluate patient satisfaction with the procedure using a diode-laser system. Method:A self-administered survey was mailed to 220 patients who underwent treatment between 2000 and 2004. These questions addressed the area treated, number of treatments received, postprocedure hair density, and overall satisfaction. Results:Of 220 patients, 114 (52%) completed the survey. Eighty percent of patients were either “very satisfied” or “somewhat satisfied.” Forty percent of patients felt they achieved 75% hair reduction and 38% reported 50% hair reduction. The majority of patients required 5–6 treatments over 13–18 months for maximum improvement. Multiple treatments over this prolonged time were a significant deterrent to treatment completion. The majority of patients (91%) experienced no long-term side effects. Conclusion:Diode-laser hair removal is a safe, well-tolerated procedure. Our patient satisfaction is comparable to hair-count studies in the literature.

Is there a safe lipoaspirate volume? A risk assessment model of liposuction volume as a function of body mass index

Background: No concrete data exist to support a specific volume at which liposuction becomes unsafe; surgeons rely on their own estimates, professional organization advisories, or institutional or government-imposed restrictions. This study represents the first attempt to quantify the comprehensive risk associated with varying liposuction volumes and its interaction with body mass index. Methods: Suction-assisted lipectomies were identified from the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models incorporating the interaction between liposuction volume and body mass index were used to assess the influence of liposuction volume on complications and to develop a tool that returns a single adjusted odds ratio for any combination of body mass index and liposuction volume. Recursive partitioning was used to determine whether exceeding a threshold in liposuction volume per body mass index unit significantly increased complications. Results: Sixty-nine of 4534 patients (1.5 percent) meeting inclusion criteria experienced a postoperative complication. Liposuction volume and body mass index were significant independent risk factors for complications. With progressively higher volumes, increasing body mass index reduced risk (OR, 0.99; 95 percent CI, 0.98 to 0.99; p = 0.007). Liposuction volumes in excess of 100 ml per unit of body mass index were an independent predictor of complications (OR, 4.58; 95 percent CI, 2.60 to 8.05; p < 0.001). Conclusions: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresholds do not accurately convey individualized risk. The authors’ risk assessment model demonstrates that volumes in excess of 100 ml per unit of body mass index confer an increased risk of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A comparative analysis of readmission rates after outpatient cosmetic surgery

BACKGROUND Despite the increasing scrutiny of surgical procedures, outpatient cosmetic surgery has an established record of safety and efficacy. A key measure in assessing surgical outcomes is the examination of readmission rates. However, there is a paucity of data on unplanned readmission following cosmetic surgery procedures. OBJECTIVES The authors studied readmission rates for outpatient cosmetic surgery and compared the data with readmission rates for other surgical procedures. METHODS The 2011 National Surgical Quality Improvement Program (NSQIP) data set was queried for all outpatient procedures. Readmission rates were calculated for the 5 surgical specialties with the greatest number of outpatient procedures and for the overall outpatient cosmetic surgery population. Subgroup analysis was performed on the 5 most common cosmetic surgery procedures. Multivariate regression models were used to determine predictors of readmission for cosmetic surgery patients. RESULTS The 2879 isolated outpatient cosmetic surgery cases had an associated 0.90% unplanned readmission rate. The 5 specialties with the highest number of outpatient surgical procedures were general, orthopedic, gynecologic, urologic, and otolaryngologic surgery; their unplanned readmission rates ranged from 1.21% to 3.73%. The 5 most common outpatient cosmetic surgery procedures and their associated readmission rates were as follows: reduction mammaplasty, 1.30%; mastopexy, 0.31%; liposuction, 1.13%; abdominoplasty, 1.78%; and breast augmentation, 1.20%. Multivariate regression analysis demonstrated that operating time (in hours) was an independent predictor of readmission (odds ratio, 1.40; 95% confidence interval, 1.08-1.81; P=.010). CONCLUSIONS Rates of unplanned readmission with outpatient cosmetic surgery are low and compare favorably to those of other outpatient surgeries.

Comparison of the transpalpebral and endoscopic approaches in resection of the corrugator supercilii muscle.

BACKGROUND Corrugator resection is an integral part of periorbital rejuvenation and can be accomplished through the open coronal, endoscopic, or transpalpebral technique. While most authors concur about the importance of corrugator resection during brow lift surgery, considerable debate remains regarding the efficacy and technical ease of muscle resection with these approaches. OBJECTIVES The authors conducted a cadaver study to compare the completeness of resection of the corrugator muscle with the transpalpebral and endoscopic techniques. METHODS A split-face study was performed in 10 fresh cadavers. On one side, the corrugator muscle was resected through an endoscopic approach, and on the opposite side of the face, a transpalpebral resection was performed. After the completion of both procedures, a coronal incision was made; gross observations were noted; photographs were taken; and muscle weights were recorded. RESULTS In 19 of 20 cadaver halves, subtotal or total resection of the corrugator muscle was accomplished. In only one endoscopic instance was any muscle left in continuity. This occurred along the superior aspect of the arcus marginalis release when the corrugator muscle was hidden by the upper edge of the cut periosteum. CONCLUSIONS Unlike the previous reports, the authors found that transpalpebral and endoscopic techniques both allow subtotal or total resection of the corrugator muscle. Inadequate resection is technique dependent rather than procedure dependent.

Postoperative temporal hollowing: Is there a surgical approach that prevents this complication? A systematic review and anatomic illustration

BACKGROUND Temporal hollowing is a common complication following surgical dissection in the temporal region. Our objectives were to: (1) review and clarify the temporal soft tissue relationships - supplemented by cadaveric dissection - to better understand surgical approach variations and elucidate potential etiologies of postoperative hollowing; (2) identify if there is any evidence to support a surgical approach that prevents hollowing through a systematic review. METHODS Cadaveric dissection was performed on six hemi-heads. A systematic review of the literature was undertaken to identify surgical approaches with a decreased risk of postoperative hollowing. RESULTS A total of 1212 articles were reviewed; 19 of these met final inclusion criteria. Level I and II evidence supports against the use of a dissection plane beneath the superficial layer of the deep temporal fascia or through the intermediate temporal fat pad. Level II evidence supports preservation of the temporalis muscle origin - no evidence is available to support other temporalis resuspension techniques. For intracranial exposure, refraining from temporal fat pad dissection (Level I Evidence) and use of decreased access approaches such as the minipterional craniotomy (Level I Evidence) appear to minimize temporal soft tissue atrophy. CONCLUSIONS This study highlights the significance of preservation of the temporal soft tissue components to prevent hollowing. Preserving the temporalis origin and avoiding dissection between the leaflets of the deep temporal fascia or through the intermediate temporal fat pad appear to minimize this complication.

Assessing long-term complications in patients undergoing immediate postmastectomy breast reconstruction and adjuvant radiation

PURPOSE The purpose of this article is to report the long-term rate and timing of complications associated with postmastectomy radiation therapy (PMRT) following immediate breast reconstruction in a large patient population. METHODS AND MATERIALS We identified and reviewed the charts of all patients with stages I through IIIC breast cancer who underwent mastectomy with immediate reconstruction followed by subsequent radiation therapy between November 1997 and May 2010. We aimed to assess the rate of major complications, defined as events requiring a separate and distinct procedure. Statistical analysis between variables was evaluated using Fisher exact test and Pearson χ2 Elder et al. (2005) test. RESULTS In total, 134 patients met inclusion criteria for having adequate long-term follow-up and documentation. The median follow-up for all patients was 77.4 months (range, 6-185 months). The overall major complication rate was found to be 44%. Nine patients (6.7%) experienced complications for which a secondary procedure could not be performed to retain a reconstructed breast. The average time between initiation of PMRT and the first major complication was 13.5 months, with 68.3% of first major complications occurring within 1 year of PMRT initiation and 81.7% within 2 years. The difference in incidence of major complications for patients undergoing immediate tissue expander/implant reconstruction followed by PMRT was not statistically different when compared with that for patients with immediate autologous tissue reconstruction followed by PMRT (47.3% vs 30.4%, P = .168). CONCLUSIONS The risk of first major complications and reconstruction loss in patients undergoing PMRT on immediately reconstructed breasts is greatest within 1 year of beginning radiation therapy and decreases significantly with time. Immediate autologous tissue reconstruction followed by PMRT can be performed with reasonable complication rates.