Rodney J Rohrich

Clearing the Smoke: The Scientific Rationale for Tobacco Abstention with Plastic Surgery

The use of tobacco is a significant contributor to preventable morbidity and mortality in the United States. A significant proportion of cardiovascular diseases, various oral and pulmonary neoplasms, nonmalignant respiratory diseases, and peripheral vascular disorders can be attributed to the use of cigarettes. Surgical outcomes can also be adversely affected as a result of cigarette smoking with intraoperative and postoperative pulmonary, cardiovascular, and cerebrovascular complications as well as increased wound healing complications. These are found across the entire spectrum of surgical specialties. Tissue ischemia and wound-healing impairment secondary to the influence of tobacco is particularly problematic for the plastic surgeon, especially during elective facial aesthetic procedures, cosmetic and reconstructive breast operations, abdominoplasty, free-tissue transfer, and replantation procedures. By educating and providing guidelines to those patients who smoke and by refusing to operate on individuals who fail to abstain, tobacco-associated surgical morbidity in the plastic and reconstructive surgery patient can be eliminated.

The anatomy of suborbicularis fat: Implications for periorbital rejuvenation

Background: Periorbital rejuvenation has increasingly relied on augmentation with fillers. Numerous techniques have been described, including augmentation of the sub–orbicularis oculi fat. Cadaver studies initiated 2 years ago yielded presumptive evidence that sub–orbicularis oculi fat consists of two distinct regions. Knowledge of this anatomy is important for precision in facial rejuvenation. Methods: A pilot study was performed with radiopaque dye injection into the sub–orbicularis oculi fat and computed tomographic evaluation with three-dimensional reconstruction. Eight hemifacial fresh cadaver dissections were then performed with a modified dye injection technique to isolate regions of sub–orbicularis oculi fat and periorbital fat. The relationship of suborbicularis fat to deep cheek fat was observed. Results: This study confirms the presence of two distinct regions of sub–orbicularis oculi fat. A medial component extends along the orbital rim from the medial limbus to the lateral canthus. A lateral component extends from the lateral canthus to the temporal fat pad. The lateral component terminated superiorly at the lateral orbital thickening. Deep cheek fat abutted the medial sub–orbicularis oculi fat, thus creating a deep fat system in continuity across the face of the maxilla and along the orbital rim. Conclusions: This anatomy helps to define midface adipose tissue as a system of superficial and deep fat, of which medial and lateral sub–orbicularis oculi fat are a part. A working hypothesis of facial aging continues with the concept that loss and/or ptosis of deep fat compartments leads to changes in shape and contour. Folds, in contrast, occur at transition points between thick and thinner superficial fat compartments. These anatomical observations further the goal of site-specific augmentation and facial rejuvenation.

Inferior turbinate surgery: an adjunct to successful treatment of nasal obstruction in 408 patients.

Septal deviation is often associated with hypertrophy of the contralateral inferior turbinate. Failure to reduce the size of the turbinate at the time of septal reconstruction may result in persistent nasal obstruction. The authors present their experience with 408 patients who underwent one of four turbinate procedures over a 6-year period. Most patients underwent unilateral turbinate surgery, although bilateral procedures were undertaken in 7 percent of patients. A graduated surgical approach was taken that varied according to the amount of turbinate enlargement and the degree to which mucosa and bone were involved. Full-thickness excision of the anterior third to half of the inferior turbinate (turbinectomy) became a favored procedure. Relief of nasal obstruction was obtained in greater than 90 percent of patients. Healing was satisfactory regardless of the method, and complications, including hemorrhage and infection, were few. Long-term follow-up revealed no untoward sequelae, and no patient developed atrophic rhinitis. The authors conclude that turbinate surgery, particularly when unilateral, in the carefully selected patient with nasal obstruction is a useful adjunct to septal surgery.

The gluteus maximus musculocutaneous island flap; refinements in design and application

The gluteus maximus island musculocutaneous flap has been described using a variety of designs. We employ an island whose long axis is directed toward the pressure sore, minimizing tension in wound closure. Skin overlying the greater trochanter is avoided. Previously undermined skin can be included in the flap. Fifty patients with ischial or sacral pressure sores have been managed by this technique. Superficial dehiscence occurred in 13 percent of patients, and deep dehiscence occurred in 10 percent. The dehiscence closed spontaneously in all but one patient. Forty-nine of the 50 patients experienced complete wound healing at the pressure sore site. The patients have been observed for an average of 20 months (range 3 to 38 months), with one recurrent pressure sore seen at 28 months postoperatively. The gluteus maximus musculocutaneous island flap has proven to be both reliable in healing and durable over the observed interval.

Soft-tissue fillers in rhinoplasty.

Summary: Soft-tissue fillers have been applied throughout the face; however, the literature has largely ignored the injection of fillers into the nasal anatomy. This Special Topic article reviews proper filler choice and injection technique for the nose based on the senior author’s (R.J.R.) experience. Discussion includes indications for soft-tissue filler injection into the nose as well as specific technical pearls based on filler material, anatomic area, and potential complications. The application of soft-tissue fillers to rhinoplasty has certainly broadened the nasal surgeon’s armamentarium. While major structural changes of the nose are best accomplished through surgical alteration of the osseocartilaginous framework, soft-tissue fillers offer an excellent method to augment areas or refine irregularities. These often subtle alterations require precise preinjection nasal analysis.

Reduction mammoplasty with free-nipple transplantation: indications and technical refinements.

Multiple techniques for breast reduction have been proposed. For carefully selected women with macromastia, the technique of choice may be amputation mammoplasty with free nipple-areolar grafting. These select groups include the following: the poor-risk elderly, women with systemic disease that could affect the vascularity of the skin flaps or impair wound healing, women with previous operative procedures in the breast affecting skin flap or pedicle vascularity, and women with indications for removal of tissue in the region of the inferior pedicle. Our experience demonstrates that in these high-risk women, amputation mammoplasty with certain technical refinements provides an aesthetic safe result without significant perioperative surgical or medical complications. A clinical series is presented with an average follow-up of 2.75 years.

Reversal of skin aging with topical retinoids

Topical skin care and its place in plastic surgery today are often overlooked by clinicians formulating a plan for facial rejuvenation. Not only is it important to consider topical skin care as part of comprehensive care, but clinicians should also be educated with the data available in todays literature. This review aims to familiarize the reader with the biological processes of skin aging and evidence-based clinical outcomes afforded by various topical therapies. Furthermore, this review will focus on solar damage, the value of retinoids, and how they can be used in conjunction with forms of treatment such as chemical peel, dermabrasion, and lasers. Finally, guidelines will be provided to help the physician administer appropriate skin care based on the data presented.

The role of the plastic surgeon in disaster relief

Awareness of large-scale disasters among members of the medical community and the public at large has been heightened by recent events such as the 1995 Oklahoma City bombing incident, the 2001 World Trade Center attack, and the 2005 London Underground bombings. Experience with these events has highlighted the critical role of surgical specialists, including plastic surgeons. As part of their residency, plastic surgeons are trained in acute trauma management. In addition, they also are required to demonstrate expertise in the assessment and treatment of soft-tissue injuries, upper extremity trauma, facial fractures, and both operative and nonoperative burn management. Accordingly, the plastic surgeon is among the most qualified of physicians to provide specialized injury care, especially in the disaster medicine setting. In turn, training programs should include key elements of incident command and catastrophe relief.

Management of advanced foot deformities in dystrophic epidermolysis bullosa.

Treatment for the characteristic hand deformities of dystrophic epidermolysis bullosa has been well described in the literature. We present our first experience delineating the surgical treatment for advanced foot deformities in this disease. This case emphasizes the need for release of contractures, the use of split-thickness skin grafts, and the need for rigid fixation to maintain surgical correction until healing is complete.

Closed complex dorsal dislocation of the middle finger metacarpophalangeal joint: anatomic considerations and treatment.

A rare complex isolated metacarpophalangeal joint dislocation of the middle finger is described, and the pathology is reviewed. The dorsal longitudinal incision used in this case provided excellent exposure for the reduction and helped avoid injury to the digital nerves on the palmar side of the injury. Early mobilization with extension blocking is advocated to maximize joint range of motion postoperatively.