Phillip B. Dauwe

AlloDerm versus dermamatrix in immediate expander-based breast reconstruction: A preliminary comparison of complication profiles and material compliance

Background: Allogenic acellular dermal matrix can be used in single-stage, expander-based immediate and delayed breast reconstructions to provide inferolateral prosthesis coverage and reconstruction of the inframammary fold. Two allogenic dermal matrix products currently available, AlloDerm and DermaMatrix, differ in method of storage, cost, and intraoperative preparation. The purpose of this study was to determine, first, whether there are any significant differences in the rates of postoperative complications, material compliance, or capsule characteristics; and second, if differences are present, whether they had any impact on final outcome. Methods: After institutional review board approval, a retrospective analysis of prospectively collected data of 30 patients (50 breasts) who underwent immediate expander-based breast reconstructions using either AlloDerm (n = 25) or DermaMatrix (n = 25) dermal substitutes was performed. Primary endpoints were (1) incidence of seroma, (2) wound infection, (3) number of days requiring drains, (4) rate of tissue expansion, (5) final expanded volume, (6) final implant volume, and (7) neovascularization. Results: The mean follow-up was 6.7 months. During this time, no significant differences in the complication profile were found between the two groups. Both dermal substitutes were found to be well incorporated, with evidence of neovascularization, on histologic examination. Conclusions: This study demonstrated no significant differences in the rate of complications or material compliance. The total complication rate was 4 percent, with seroma and wound infection being the most common complications. The authors’ preliminary findings indicate no significant difference between implant/expander-based reconstructions using AlloDerm and those using DermaMatrix.

The pedicled descending branch muscle-sparing latissimus dorsi flap for breast reconstruction.

Background: The pedicled descending branch muscle-sparing latissimus dorsi flap with a transversely oriented skin paddle presents distinct advantages in breast reconstruction, including reduced donor-site morbidity and greater freedom of orientation of the skin paddle. This study reports the anatomical basis, surgical technique, complications, and aesthetic and functional outcomes following use of this flap for breast reconstruction. Methods: A retrospective study of 20 patients who underwent breast reconstruction with a pedicled muscle-sparing latissimus dorsi musculocutaneous flap was conducted. Indications for surgery included breast reconstruction following mastectomy, lumpectomy, and irradiation, and for correction of implant-related complications. Case-note review was performed, as was a functional evaluation consisting of a patient questionnaire, a Disabilities of the Arm, Shoulder, and Hand form, postoperative range-of-motion analysis, and instrumented strength testing comparing the operated and nonoperated sides. Aesthetic evaluation of the donor site was conducted by all patients. An anatomical study of 15 flaps harvested from fresh cadavers was performed to determine the location of the bifurcation of the thoracodorsal artery and the course of its descending branch. Results: Twenty-four descending branch muscle-sparing latissimus dorsi flaps were harvested. All donor sites were closed primarily, with skin paddle sizes ranging up to 25 × 12 cm. There was one case of minor flap tip necrosis and no instances of seroma. There was no statistically significant difference in strength or range of motion of the shoulder joint when comparing the operated to the nonoperated side. Two patients reported minor functional impact following surgery. Conclusions: The pedicled descending branch muscle-sparing latissimus dorsi flap with a transversely orientated skin paddle results in minimal functional deficit of the donor site, absence of seroma, large freedom of orientation of the skin paddle, low rate of flap complications, and a cosmetically acceptable scar.

Does hyperbaric oxygen therapy work in facilitating acute wound healing: A systematic review

Background: Adjunctive hyperbaric oxygen therapy is a safe and effective modality with which to increase tissue oxygenation and aid in healing of difficult wounds. The majority of the literature surrounding hyperbaric oxygen therapy supports its use in chronic wounds, but its use in acute wounds, flaps, and grafts is less well supported. Methods: The authors reviewed the Ovid, PubMed, and Cochrane Library databases, and selected studies, level III and above, using hyperbaric oxygen therapy in the treatment of complicated acute wounds, flaps, and grafts. Results: A total of eight studies were found to meet criteria for evaluation of adjunctive hyperbaric oxygen therapy in the treatment of complicated acute wounds, flaps, and grafts. Conclusions: When combined with standard wound management principles, hyperbaric oxygen therapy can augment healing in complicated acute wounds. However, it is not indicated in normal wound management. Further investigation is required before it can be recommended as a mainstay in adjuvant wound therapy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Use of the serratus anterior fascia flap for expander coverage in breast reconstruction.

BACKGROUND Postmastectomy partial submuscular tissue expander placement can prevent the upper pole fullness commonly seen with complete submuscular prosthesis placement. The resultant inferior and lateral margins require coverage to prevent prosthesis exposure. The fascial layer overlying the serratus anterior muscle can be used as an alternative to previously defined techniques to provide composite lateral coverage. This method offers adequate coverage, prevents expander lateralization, and minimizes use of allogenic material. This study reports the anatomy, surgical procedure, clinical outcomes, and aesthetics following use of the serratus anterior fascial flap for lateral expander coverage in postmastectomy expander-based breast reconstruction. METHODS Twenty-two patients (31 breasts) who underwent breast reconstruction with serratus fascia were included in a retrospective case-note analysis after approval by the institutional review board. Demographics, perioperative factors, postoperative complications, patient satisfaction, and aesthetics were recorded as relevant endpoints. Ten fresh cadaver hemichests were dissected, and the serratus fascia for each was measured for length and width. RESULTS At a mean follow-up of 197 days (range, 71 to 370 days), seroma occurred in two breasts, wound infection occurred in one breast, partial mastectomy skin flap necrosis occurred in four breasts, and minor wound dehiscence occurred in one breast. There were no incidences of capsular contracture or hematoma. Four patients (five breasts) reported very mild tightness or banding in the lateral chest wall. The mean length of cadaver serratus fascia was 164.3 mm and the mean width was 122.8 mm. CONCLUSION The serratus anterior fascia flap is a versatile and safe alternative for providing vascularized composite lateral prosthesis coverage in expander-based breast reconstruction.

Social Networks Uncovered: 10 Tips Every Plastic Surgeon Should Know

Understanding online social networks is of critical importance to the plastic surgeon. With knowledge, it becomes apparent that the numerous networks available are similar in their structure, usage, and function. The key is communication between Internet media such that one maximizes exposure to patients. This article focuses on 2 social networking platforms that we feel provide the most utility to plastic surgeons. Ten tips are provided for incorporation of Facebook and Twitter into your practice.

The pedicled subpectoral fascia flap for expander coverage in postmastectomy breast reconstruction: a novel technique.

BACKGROUND In expander-based breast reconstruction, providing adequate tissue coverage of the prosthesis is necessary to prevent complications. The authors have previously described the use of the serratus anterior fascia for this purpose-but when this fascia is unavailable or inadequate, the subpectoral fascia can be used. This study describes the anatomy of the subpectoral fascia, the surgical technique for harvesting it, and an algorithm for choosing between the serratus and subpectoral fascia flaps. Clinical and functional outcomes following use of the subpectoral fascia in expander-based breast reconstruction are reported. METHODS Thirteen patients (17 breasts) were included in the study. After approval by the institutional review board, retrospective case note analysis was performed for demographic and perioperative factors. Postoperative complications including capsular contracture, seroma, hematoma, wound dehiscence, and infection were recorded. Cadaver studies involving 10 hemichests were undertaken. The subpectoral fascia for each hemichest was dissected and measured for length and width. RESULTS At a mean follow-up of 589 days (range, 115 to 960 days), seroma occurred in one breast, wound infection occurred in one breast, and minor wound dehiscence occurred in one breast. There were no incidences of capsular contracture or hematoma. The mean +/- SD length of cadaver subpectoral fascia was 148 +/- 26.6 mm and the mean width was 83 +/- 32.1 mm. CONCLUSIONS The subpectoral fascia flap is a novel and safe option for providing vascularized lateral or inferior coverage of prosthesis in expander-based breast reconstruction. Its harvest and use are not associated with adverse clinical outcomes.

How Should Results of Nonsurgical Subcutaneous Fat Removal Be Assessed? Accuracy of B-Mode Ultrasound.

Background: Nonsurgical fat reduction has become extremely popular among patients; however, a reliable method of measuring its efficacy has not been established. Methods: Ultrasound measurement of human female abdominal subcutaneous fat thickness was carried out on five volunteers. Forty-seven measurements were performed using a GE Venue 40 diagnostic ultrasound device with a 12-MHz transducer. Transducer pressure measurements were recorded simultaneously according to the protocol described by Toomey et al.. Results: Reproducible measurements of abdomen subcutaneous fat could be consistently achieved with a margin of error (95 percent CI) of ±0.558 mm. Conclusions: Using a protocol with a transducer pressure less than 1 N (Toomey protocol) allows accurate and reliable measurement of subcutaneous fat. The authors further conclude that such a protocol is practically reproducible in the clinical setting and should be the standard for evaluating the results of nonsurgical fat removal, particularly in the abdomen. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Infection in face-lift surgery: an evidence-based approach to infection prevention.

Background: Complications in face-lift surgery are rare but can present a difficult experience for the patient and surgeon. It is the objective of this review to evaluate the clinical efficacy of routine perioperative safety measures in preventing surgical-site infection in face-lift surgery. Methods: A review of the literature was performed to assess the correlation of preoperative decolonization, prophylactic antibiotic use, perioperative hypothermia, body mass index, and smoking status with the incidence of surgical-site infection in cosmetic surgery, especially pertaining to face-lift surgery. Results: Studies supporting safe practice in cosmetic surgery and “clean” procedures are analyzed and discussed. Conclusion: This article provides the current evidence on perioperative safety measures and recommendations regarding the prevention of infection in cosmetic surgery, especially in face-lift surgery.

The Modern Male Rhytidectomy: Lessons Learned

Background: Cosmetic surgery among male patients has become increasingly popular. The face-lift technique is different in male patients, specifically regarding preservation of hair follicles, restoration of a youthful and well appearance, and reduction of the risk of hematoma. Methods: A retrospective review of a single surgeon’s past 20 years of consecutive male rhytidectomies revealed a cohort of 83 patients. A control group was created by random selection of 83 age-matched female rhytidectomy patients during the same period. Data were collected and analyzed critically for factors contributing to complications, including hematoma, seroma, skin sloughing, alopecia, infection, and nerve injury. The evolution in the senior author’s technique in male rhytidectomy is described. Results: Differences in facial analysis and rhytidectomy technique in male patients and female patients are highlighted. Five male patients (6.0 percent) and no female patients in the control group developed postoperative hematoma (p = 0.0587). No other complications occurred. Conclusion: Respecting the patterns of hair growth in incision design, avoiding damage to follicles during dissection, and exercising standard of care (especially avoidance of hypotensive anesthesia) in prevention of postoperative hematoma have delivered safe and consistently reproducible aesthetic outcomes and acceptable complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Importance of the Anterior Septal Angle in the Open Dorsal Approach to Rhinoplasty.

Functional and aesthetic manipulation of the nose relies on a detailed understanding of nasal anatomy and a meticulous dissection. Maneuvers are performed in four regions of the nose: nasal tip, dorsum, posterior septum, and caudal septum. Positioned at the cornerstone of these regions, the anterior septal angle acts as a point of reference, especially in secondary rhinoplasty. Identification of the anterior septal angle early in the nasal dissection aids in reliable exposure, either wide or limited, and facilitates desired maneuvers. In addition, alteration of the position of the anterior septal angle can affect nasal tip projection, especially in cases such as the tension tip deformity. The authors emphasize the importance of the anterior septal angle in their simplified methodology for the open dorsal approach in rhinoplasty.