Peter F. Koltz

Aging of the Facial Skeleton: Aesthetic Implications and Rejuvenation Strategies

Background: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how the facial skeleton changes with age in both male and female subjects and what impact these structural changes may have on overall facial aesthetics. Methods: Facial bone computed tomographic scans were obtained from 60 female and 60 male Caucasian subjects. Twenty male and 20 female subjects were placed in three age categories (20 to 40 years, 41 to 64 years, and 65 years and older). Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering. Edentulous patients were excluded. The following measurements were obtained: upper face (orbital aperture area, orbital aperture width, and curvilinear analysis of the superior and inferior orbital rims), midface (glabellar angle, pyriform angle, maxillary angle, and pyriform aperture area), and lower face (bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle). Results: The orbital aperture width and orbital aperture area increased significantly with age for both sexes. There was a significant increase in orbital aperture size (increase in height of the superomedial and inferolateral orbital rim) in both sexes. The glabellar and maxillary angles decreased significantly with age for both sexes, whereas the pyriform aperture area significantly increased for both sexes with age. Mandibular length and height both decreased significantly for each sex. The mandibular angle significantly increased with age for both sexes. Conclusions: These results suggest that the skeletal morphology of the face changes with age. This change in skeletal morphology may contribute to the appearance of the aging face.

Current surgical practices in cleft care: cleft palate repair techniques and postoperative care.

Background: The purpose of this study was to objectively report practices commonly used in cleft palate repair in the United States. This study investigates current surgical techniques, postoperative care, and complication rates for cleft palate repair surgery. Methods: All 803 surgeon members of the American Cleft Palate-Craniofacial Association were sent online and/or paper surveys inquiring about their management of cleft palate patients. Results: Three-hundred six surveys were received, a 38 percent response rate. This represented responses of surgeons from 100 percent of American Cleft Palate-Craniofacial Association registered cleft teams. Ninety-six percent of respondents perform a one-stage repair. Eighty-five percent of surgeons perform palate surgery when the patient is between 6 and 12 months of age. The most common one-stage repair techniques are the Bardach style (two flaps) with intravelar veloplasty and the Furlow palatoplasty. After surgery, 39 percent of surgeons discharge patients within 24 hours. Another 43 percent discharge patients within 48 hours. During postoperative management, 92 percent of respondents implement feeding restrictions. Eighty-five percent of physicians use arm restraints. Surgeons’ self-reported complications rates are minimal: 54 percent report a fistula in less than 5 percent of cases. The reported need for secondary speech surgery varies widely. Conclusions: The majority of respondents repair clefts in one stage. The most frequently used repair techniques are the Furlow palatoplasty and the Bardach style with intravelar veloplasty. After surgery, the majority of surgeons discharge patients in 1 or 2 days, and nearly all surgeons implement feeding restrictions and the use of arm restraints. The varying feeding protocols are reviewed in this article.

Aging of the mandible and its aesthetic implications.

Background: Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how specific bony aspects of the mandible change with age in both genders and what impact these structural changes may have on overall facial aesthetics. Methods: Facial bone three-dimensional computed tomographic scans were obtained from 120 Caucasian subjects (60 women and 60 men). Our study population consisted of 20 male and 20 female subjects in each of three age categories (20 to 40, 41 to 64, and ≥65 years). Edentulous patients were excluded. The following measurements were obtained: bigonial width, ramus breadth, ramus height, mandibular body height, mandibular body length, and mandibular angle. The data were analyzed with one-way analysis of variance and two-tailed t tests, with results considered significant at a value of p < 0.05. Results: There was no significant change with regard to bigonial width or ramus breadth across age groups for either gender. Ramus height, mandibular body height, and mandibular body length decreased significantly with age for both genders, whereas the mandibular angle increased significantly for both genders with increasing age. Conclusions: These results suggest that the bony elements of the mandible change significantly with age for both genders and that these changes, coupled with soft-tissue changes, lead to the appearance of the aged lower third of the face.

Irradiated autologous breast reconstructions: effects of patient factors and treatment variables.

Background: Postmastectomy irradiation often negatively impacts breast reconstruction outcomes. Further investigation is necessary to recognize factors contributing to adverse results. The purpose of this study was to (1) accurately assess the impact of radiation on autologous breast reconstruction and (2) identify patient and treatment factors affecting reconstructive outcomes. Methods: One hundred twenty-six patients were considered after postmastectomy breast reconstruction and irradiation. The records of 76 patients were studied after excluding for radiation therapy before reconstruction, complications before irradiation, implant reconstruction, mastectomy for recurrent disease, and history of cancer. Patient demographics and comorbidities, operative details, adjuvant therapy, and treatment outcomes were assessed. Results: Seventy-six patients underwent autologous microsurgical breast reconstruction. Complications occurred in 53 patients (70 percent) 7.2 ± 6 months after irradiation; 36 cases (47 percent) required reoperation for postirradiation effects. Parenchymal complications (fat necrosis or parenchymal fibrosis) were noted in 19.7 percent, skin complications (tissue envelope retraction or hypertrophic scarring) were recorded in 30.3 percent, and general dissatisfaction (physician or patient dissatisfaction) arose in 27.6 percent of patients. Parenchymal complications were associated with smoking (odds ratio, 9.3; p = 0.03), type II diabetes mellitus (odds ratio, 8.5; p = 0.02), and age (odds ratio, 1.1; p = 0.02). Neoadjuvant chemotherapy increased the development of complications (odds ratio, 4.4; p = 0.04), particularly skin changes (odds ratio, 2.4; p = 0.01). Conclusions: Patient-specific factors, including diabetes mellitus and smoking, increase the risk of postirradiation parenchymal changes, and neoadjuvant chemotherapy is associated with a greater than twofold increase in skin complications. Breast reconstruction followed by irradiation can be successful, but patients with specific risks should be aware of increased complication rates.

Changes in Quality of Life and Functional Status following Abdominal Contouring in the Massive Weight Loss Population

Background: Abdominal contouring surgery is commonly performed following massive weight loss. Outcome data following abdominal contouring have been reported regarding body image and symptoms in general; however, few data exist regarding specific functional improvements. The authors examined functional changes in quality of life following abdominal contouring in the massive weight loss population. Methods: Fifty-two consecutive patients were reviewed from the authors prospective database. Outcome measures included body mass indices, comorbidities, resection weight, and 24 functional variables. Outcome measures were assessed by univariate and multivariate analysis. Results: Forty-nine patients completed the survey (94 percent). Average patient age was 45.8 years at the time of surgery (range, 25 to 68 years). Mean maximum body mass index was 56.1 ± 11.8 kg/m2, mean pre–body contour body mass index was 34.6 ± 10.1 kg/m2, mean pre–body contour change in body mass index was 21.4 ± 6.9 kg/m2, mean post–body contour body mass index was 32.4 ± 9.3 kg/m2, and mean post–body contour change in body mass index was 2.1 ± 2.9 kg/m2. Statistically significant improvements in all functional outcomes were appreciated, except shoulder pain. Rectus plication did not significantly improve functional outcomes. Higher maximum and pre–body contour body mass index values were significantly related to greater improvement in functional outcomes (p < 0.05); 91.8 percent of patients said they would undergo abdominal contouring again or would recommend it to a friend. Conclusions: Abdominal contouring surgery improves functional status of massive weight loss patients, especially those with a higher body mass index at the time of surgery. Rectus plication did not influence functional outcomes. Prospective functional assessments may aid in optimizing outcomes in the management of the massive weight loss patient. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. Figure. No caption available.

A Comparative Analysis and Systematic Review of the Wound-Healing Milieu: Implications for Body Contouring after Massive Weight Loss

Background: Wound-healing complications following body contouring for massive weight loss patients are significant, with rates exceeding 40 percent. To better understand aberrant healing in this population, the authors have performed a comparative analysis of the wound milieu literature for patient populations with similar complication rates. Methods: PubMed and Ovid databases were reviewed from January of 1985 to January of 2009 for key terms, including wound healing, obesity, cancer, burn, transplant, and body contouring. Serum and wound levels of multiple factors, including matrix metalloproteinases (MMPs) and cytokines, were assessed. Results: Complication rates in body contouring surgery range from 31 to 66 percent. Sixty-five studies were reviewed, and wound-healing complication rates were identified for cancer (45.8 percent), burn (30.4 percent), posttransplant (36 percent), and obese (43 percent) populations. In these groups, matrix metalloproteinases and tissue inhibitors of metalloproteinase (TIMPs) help regulate wound repair. Matrix metalloproteinase levels were elevated in cancer (4-fold increase in MMP-2), burn (20- to 30-fold increase in MMP-9), transplant (1.4-fold increase in MMP-2), and obese/chronic (79-fold increase) populations. TIMPs were increased in cancer (1.9-fold increase in TIMP-2) and burn (1.4-fold increase in TIMP-1) patients but decreased in chronic wound (55-fold decrease in TIMP-1) populations. Alterations to these regulatory proteins lead to prolonged matrix degradation, up-regulation of inflammatory mediators, and decreased growth factors, delaying the wound-healing process. Conclusions: Complications after body contouring surgery are likely multifactorial; however, molecular imbalances to the massive weight loss wound milieu may contribute to poor surgical outcomes. Examining wound regulatory proteins including transforming growth factor-β, vascular endothelial growth factor, and matrix metalloproteinases could aid in understanding the healing difficulties observed clinically.

CT contrast extravasation in the upper extremity: Strategies for management

INTRODUCTIONnExtravasation of CT scan contrast media into upper extremity subcutaneous tissue is a relatively frequent complication of injection. Potential sequelae of extravasation include compartment syndrome, skin sloughing, and necrosis. Many institutions institute protocols requiring inpatient plastic surgery consultations immediately following extravasation injury to the upper extremity. We hypothesize that conversion to non-ionic contrast media for contrast CT studies has greatly reduced the incidence of severe extravasation injuries, and may alleviate the need for routine hand surgery consultations.nnnMETHODSnRecords from 102 consecutive CT contrast media extravasation injuries were identified. Data acquired from a single institution included type and amount of contrast extravasated, anatomic location, post-procedural clinical symptoms, whether consult was obtained, and final recommendations and outcome.nnnRESULTSnIn 102 consecutive cases, immediate surgical therapy was necessary in 0. Non-ionic medium was used in 94% of these cases, and ionic dye was used in 6%. Extravasation of less than 100 cc occurred in 90%, and only 10% were greater. Plastic surgery consultation was immediately obtained in 42% of cases. Factors prompting consultation included extravasation >30 cc, and the presence of erythema or induration. Trends for consultation remained without discernable pattern when patients were stratified by age, amount of extravasate, or anatomic location. Conservative management was recommended in all cases. This included elevation of the extremity, frequent pulse and sensation exams, local message, and temporary splinting. There were no secondary complications requiring surgical intervention.nnnCONCLUSIONSnExtravasation of non-ionic CT contrast media appears to be innocuous and can be treated with conservative therapy. Plastic surgery consultation should be obtained when there are obvious signs of skin and soft tissue compromise or symptoms of compartment syndrome.

The Impact of Smad3 Loss of Function on TGF-β Signaling and Radiation-Induced Capsular Contracture

Background: Capsular contracture remains a major problem following prosthetic breast implantation, especially in patients undergoing irradiation. Recent studies suggest that such radiation injuries are a cascading process of cytokine activation, with transforming growth factor (TGF)-&bgr; acting as the “master switch.” Because TGF-&bgr; signals through phosphorylation of Smad3, a plausible approach to abate TGF-&bgr;–induced capsular contracture would be to interrupt Smad3 signaling. To test this hypothesis, capsular contracture formation in wild-type and Smad3 knockout mice was compared using micro–computed tomographic and histologic examination. Methods: On day 0, 48 mice were implanted with bilateral silicone gel implants. Postoperatively, animals were imaged using live-scan micro–computed tomographic scanning. Animals in the radiation arm then received a 10-Gy directed radiation dose. On postoperative days 21, 28, 35, and 42, animals were imaged again. Histologic evaluation was performed at necropsy. Results: Irradiated implants in the wild-type mice demonstrated shape and contour deformation on micro–computed tomographic scanning beginning on postoperative day 21 and progressing through day 42. Conversely, micro–computed tomographic scanning of irradiated implants in knockout mice demonstrated few changes from day 0 through day 42. Corresponding histologic specimens from wild-type mice demonstrated irregular capsules composed of disorganized collagen that became thicker from day 21 to day 42. Irradiated knockout specimen maintained thin capsules from day 21 through day 42. Conclusions: In this work, inhibiting TGF-&bgr; signaling led to a reduction in radiation-induced capsular contracture as measured by micro–computed tomographic and histologic evaluation. The results of this study suggest a promising target for the prevention of capsular contracture through the development of anti-Smad3/TGF-&bgr;–based therapies.

Optimizing your operating room: Or, why large, traditional hospitals don’t work

INTRODUCTIONnCaring for patients in traditionally designed, large teaching hospitals is often frustrating. Attempts at decreasing internal costs and inpatient length of stay are universally undertaken in order to address dwindling reimbursement, and patient care becomes more specialized and fractionated. These attempts have proven to be myopic, at best, and injurious to patient care and professional job satisfaction, at worst. This manuscript attempts to characterize the operational processes of our university operating room facility as well as make suggestions for operational improvements that can be applied to all hospitals.nnnMETHODSnThrough a step-by-step approach, we analyze the patients journey from the surgeons office through the day of surgery to discharge. Using this approach, a series of studies designed to identify operational shortcomings and inefficiencies are undertaken, and the results of these shortcomings are elucidated.nnnRESULTSnIn our operating room, the peri-operative services are composed of multiple departments, each accountable to their own administrative silo. We found this to result in fragmented goals and objectives confounded by individualized and conflicting incentives. Consequently, we conclude with a recommendation that veers from process modification to a disruptive innovation of the hierarchical organization.nnnCONCLUSIONnNowhere in the hospital is this drive for cost containment and increased patient volume more evident than in the operating theatre. Long-term improvements must embrace radical reduction of OR costs and increased operative patient through-put, (i.e. per 8 h day; per fiscal year) by re-engineering the processes of operative patient care. In the end, the ultimate goal of safe and high-quality patient care must not be compromised.

Genetic and epigenetic influences of twins on the pathogenesis of craniosynostosis: a meta-analysis.

Background: The pathoetiology of craniosynostosis is not well understood. It likely results from a combination of genetic and epigenetic phenomena, such as intrauterine constraint from multiple gestations. Information on craniosynostosis in twins is limited to case reports and series. The authors conducted a systematic review and meta-analysis of the literature to elucidate the genetic and nongenetic influences of twins on the pathogenesis of craniosynostosis. Methods: PubMed and Ovid databases were reviewed for the key terms “craniosynostosis and twins.” Data analyzed included demographical information, incidence rates, concordance, and phenotypic variability. Risk factors for craniosynostosis, concordance, and phenotypic variability were assessed by univariate and multivariate analyses. A case series was presented. Results: Data were extracted from 34 journal articles, including the authors five patients, and representing a total of 199 twins with craniosynostosis. Twinning was 2.62 times greater in patients with craniosynostosis (6.29 percent) compared with unaffected controls (2.4 percent; p < 0.0001). Boys were affected more than girls (65.30 versus 34.70 percent, respectively; p < 0.0001). Monozygotic concordance rates were greater than dizygotic (60.90 versus 5.30 percent, respectively; p < 0.0001) but were not 100 percent. Phenotypic variability was present in 62 percent of monozygotic twin sets (p < 0.05). Conclusions: Increased concordance rates among monozygotic compared with dizygotic twins confirm the genetic role of twins on craniosynostosis. Evidence to support the epigenetic influence of twinning on the pathogenesis of craniosynostosis includes the elevated incidence of twins among a craniosynostotic population compared with unaffected twins in the general population and male gender predominance, as well as monozygotic phenotypic variability and discordance. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.