Russell S. Frautschi

Current Evidence for Clinical Efficacy of Platelet Rich Plasma in Aesthetic Surgery: A Systematic Review

Background Platelet rich plasma (PRP) has attracted attention in a number of surgical fields due to a wide variety of potential clinical benefits. Yet PRP has not gained wide popularity in aesthetic surgery as a result of uncertainty surrounding objective clinical evidence. Objectives We aim to describe the current applications, define preparation and activation, explore effectiveness, and propose a classification system to facilitate comparisons across studies. Methods A comprehensive review of the literature regarding the use of platelet rich plasma in aesthetic surgery was performed. Data gathered included: PRP application, study type, subject number, centrifugation, anticoagulation, activation, PRP composition, and outcomes. Results Thirty-eight reports were identified. Applications included injection into aging skin (29%), scalp alopecia (26%), lipofilling (21%), fractional laser (13%), and facial surgery (11%). The majority of studies (53%) were case series without controls. Leucocytes were sparsely defined (32%). The concentration of injected and/or baseline platelets was rarely clarified (18%). The mechanism of activation was described in 27 studies (71%), while anticoagulation was uncommonly elucidated (47%). While most studies (95%) claim effectiveness, objective measures were only utilized in 17 studies (47%). Conclusions Current studies produce context-dependent results with a lack of consistent reporting of PRP preparation, composition, and activation in aesthetic applications, making meaningful meta-analysis unrealistic. Thus the method of PRP preparation warrants increased attention. We recommend a set of descriptors, FIT PAAW (described below), to produce scientifically grounded conclusions, facilitating a clearer understanding of the situations in which PRP is effective. Level of Evidence 4

Pterygopalatine Fossa Anatomy for a Surgical Approach to Sphenopalatine Ganglion.

AbstractThe sphenopalatine ganglion is an extracranial neural structure within the pterygopalatine fossa. Modulation of this region via implantation of a neuromodulatory device presents a novel therapy for the treatment of facial and head pain. Yet sex, race, and genetic factors contribute to morphological variations between individuals. This study defines the standards and variations of the bony landmarks surrounding the pterygopalatine fossa. One hundred dry skulls were analyzed from the Hamann-Todd osteological collection. Ten anatomical dimensions were measured on each side of the face for each specimen (vidian foramen, zygomatic buttress, zygomatic maxillary suture, pyriform rim, infraorbital rim, pterygoid maxillary suture, greater palatine foramen, auditory canal, and pterygoid fossa). A statistical analysis was performed for both sides of the face based on sex and race. When stratified by sex, 7 of the 10 measurements revealed a statistically significant difference bilaterally. When stratified by race, 5 of the 10 measurements demonstrated a statistically significant difference bilaterally. Both male and African American skulls showed greater hemifacial values bilaterally when compared with their respective counterparts. The only statistically significant measurement on both the left and right sides of all skulls was the length from the vidian foramen to the infraorbital rim. Defining the anatomical mean distance between skull landmarks and highlighting differences between sex and race not only provides further insight into relative skull anatomy, but also sets the stage for device innovation.

Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients.

Background: Although the literature is replete with favorable facelift results, there are few validated facial rejuvenation outcome measures. Apparent age (AA), a visual estimate of age by objective observers, has been utilized in several studies; although attractive, AA lacks validation. Objective: The aim of this study is to examine the reliability of AA, highlighting the importance of the exclusive use of validated outcome measures in future studies. Methods: Ten blinded reviewers assessed pre‐ and postoperative photographs of 32 patients who underwent facelift. Each reviewer completed 3 surveys at 3‐month intervals composed of 40 randomly ordered photos; totaling 1200 photographs assigned an AA. The intra‐class correlation coefficient was classified as “excellent,” “good,” “fair,” or “poor.” The accuracy of assigned AA, agreement within 5 years, and reduction in AA were also evaluated. Results: The mean difference of preoperative true age from assigned AA was 2.74 ± 4.36 years. Forty‐three percent of raters were within 5‐years (±2.5) of the mean. Intra‐rater reliability preoperatively and postoperatively were 0.77 (95% CI, 0.82‐0.72) and 0.75 (95% CI, 0.79‐0.71), respectively. Inter‐rater reliability preoperatively was 0.98 (95% CI, 0.99‐0.96), while postoperatively was 0.95 (95% CI, 0.99‐0.95). Mean AA reduction was 5.23 ± 2.81, with an intra‐rater reliability 0.15 (95% CI, 0.03‐0.34) and inter‐rater reliability 0.65 (95% CI, 0.84‐0.38). Conclusion: Using current statistical measures and analysis, AA is an acceptable tool for pre‐ and postoperative facial evaluation when assessed by a group of 10 reviewers. Therefore, apparent age represents a reliable and valid objective observer assigned measure for evaluation of facelift outcomes.

Watershed Areas in Face Transplantation

BACKGROUND The maxillary artery has traditionally been considered the main blood supply of the facial skeleton. However, the deep and concealed location makes the harvest of facial allografts based on this artery challenging, giving preference to the facial artery. There is growing evidence that the junction between the hard and soft palate may represent a watershed area in facial artery-based allografts. The aim of this study was to review the occurrence of partial allograft necrosis and modify the available craniofacial techniques, allowing for a reliable harvest of maxillary artery-based facial allografts. METHODS PubMed/MEDLINE databases were searched for articles presenting allograft perfusion details and the occurrence of partial flap necrosis. Next, 25 fresh cadaver heads were used: eight allografts were harvested by means of a traditional Le Fort III approach, in six the maxillary artery was injected with latex, in three cadaver heads lead oxide gel was injected in the maxillary artery, and eight full facial allografts were harvested through a modified approach. RESULTS Seven patients developed palatal fistulas or palatal necrosis (41 percent) when allograft was perfused through the facial artery. The traditional Le Fort III approach demonstrated consistent injury to maxillary artery/branches. The modified approach allowed for preservation of the maxillary artery under direct vision. CONCLUSIONS Current facial transplantation outcomes indicate that facial artery-based allografts containing Le Fort III bony components can experience compromised palate perfusion. The described modified Le Fort III approach allowed safe dissection of the maxillary artery, preserving the arterial blood supply to the facial skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.Background: The maxillary artery has traditionally been considered the main blood supply of the facial skeleton. However, the deep and concealed location makes the harvest of facial allografts based on this artery challenging, giving preference to the facial artery. There is growing evidence that the junction between the hard and soft palate may represent a watershed area in facial artery–based allografts. The aim of this study was to review the occurrence of partial allograft necrosis and modify the available craniofacial techniques, allowing for a reliable harvest of maxillary artery–based facial allografts. Methods: PubMed/MEDLINE databases were searched for articles presenting allograft perfusion details and the occurrence of partial flap necrosis. Next, 25 fresh cadaver heads were used: eight allografts were harvested by means of a traditional Le Fort III approach, in six the maxillary artery was injected with latex, in three cadaver heads lead oxide gel was injected in the maxillary artery, and eight full facial allografts were harvested through a modified approach. Results: Seven patients developed palatal fistulas or palatal necrosis (41 percent) when allograft was perfused through the facial artery. The traditional Le Fort III approach demonstrated consistent injury to maxillary artery/branches. The modified approach allowed for preservation of the maxillary artery under direct vision. Conclusions: Current facial transplantation outcomes indicate that facial artery–based allografts containing Le Fort III bony components can experience compromised palate perfusion. The described modified Le Fort III approach allowed safe dissection of the maxillary artery, preserving the arterial blood supply to the facial skeleton. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The Cardioplastic Approach to the Treatment of Infected Aortic Grafts

Background Aortic graft infection (AGI) is a rare complication following reconstructive aortic surgery, yet it represents a significant source of morbidity and mortality. There is no consensus regarding the optimal surgical management, due in part to the small cohorts of patient reports. Pedicled muscle or omental flap coverage of AGI has been shown to improve outcomes, making them a valuable consideration in the treatment algorithm. Thus, we aim to compile and evaluate cases of autologous vascularized tissue (AVT) in the treatment of infected aortic grafts, summarizing location specific trends, treatments, and outcomes. Methods A comprehensive review of peer-reviewed literature regarding the management of AGI was performed. Data collected included patient characteristics, original procedure, pathogen, infection location, tissue utilized, technique of tissue isolation and delivery, staging, outcome, length of follow-up, and level of evidence. Results Ninety-four cases of AGI managed with AVT transfer were identified. Infection of ascending aorta grafts accounted for 59% of cases, followed by a combination of ascending aorta and aortic arch (21%), the descending thoracic aorta (18%), and the thoracoabdominal aorta (2%). The infected graft was preserved in 81% of cases, followed by debridement and AVT coverage. The omentum was the most commonly applied flap (69%) for all divisions of the aorta followed by the pectoralis major (19%), the rectus abdominis (5%), and latissimus dorsi (4%). Mortality was limited, and the Powered by Editorial Manager and ProduXion Manager from Aries Systems Corporation overall survival was 93% (7 deaths), with a mean follow-up of 33.5 months. Conclusions Autologous vascularized tissue coverage has proven to be a successful approach for treatment of infected aortic grafts. Although the incidence of AGI is rare, it represents an area of scarce evidence-based literature that warrants increased attention and surgical refinement. These results, which show a remarkably low infection-related mortality rate (3%), should encourage interdisciplinary collaboration with the plastic surgeon, cardiothoracic surgeon, and infectious disease specialists with the goal of improving outcomes in the treatment of infected aortic grafts.

A Subglandular Breast Cerebrospinal Fluid Pseudocyst Following Postsurgical Shunt Migration.

Summary: Cerebrospinal fluid (CSF) drainage catheters have been associated with numerous complications in various anatomic locations, because of migration, infection, and obstruction. However, breast-related CSF shunt complications tend to occur infrequently or have seldom been reported in the empirical literature. Therefore, a case is presented detailing a breast pseudocyst caused by migration and subsequent coiling of a ventriculoperitoneal shunt in the right breast pocket. To the best of the authors’ knowledge, this is the first case that has been reported in the peer-reviewed literature of a pseudocyst resulting from a CSF drainage catheter coiling around the breast implant post pancreaticoduodenectomy. Moreover, this case highlights the importance of cross-disciplinary procedural awareness, particularly in regards to breast, ventriculoperitoneal shunt, and pancreatic procedures.

Developing a protocol for normothermic ex-situ limb perfusion

Ischemia time represents a significant limitation for successful extremity transplantation because of the rapid deterioration of ischemic muscle. Normothermic ex‐situ preservation is an emergent method to prolong the organ viability following procurement, by replicating the physiologic conditions. The aim of this study was to develop an ex‐situ normothermic limb perfusion system to preserve the viability and function of porcine limbs for 12 hours following procurement.

Abstract: Reconstruction of Secondary Calvarial Defects with Ex-Situ Split Calvarial Bone Grafts

CONCLUSION: We could achieve complete bone healing and premorbid occlusion using microplates. The microplates are strong enough to keep comminuted mandibular fractures reduced. Their small size and malleability allow multiple fixation of comminuted bony segments in accurate-anatomical position, less periosteal stripping and self-occlusal adjustment. Therefore, microplate fixation may be one of good options for reconstruction of comminuted mandibular fractures.

Abstract: Ex Vivo Normothermic Limb Perfusion and Limb Specific Monitoring Evaluation of Perfusion Quality

PSTM Abstract Supplement practice and associated with angiogenesis and accelerated wound healing. This experimental model evaluated topical negative pressure as a mechanism for non-inva-sive preconditioning for perforator flap microvascularity and perfusion. MethodS: Two gluteal perforator flaps (matched control and intervention) were designed on sixteen 400g Sprague-Dawley male rats. NPWT was applied to the flap area directly continuously at-125mmHg for 7 days, after which the rats were divided into two principal groups. Group A (n=8) underwent 4D computed tomographic and angiography (CTA) with a body volume perfusion protocol after NPWT and euthanized. Group B (n=8), control and intervention flaps were raised, isolated on a single pedicle and laid back down and monitored for a further 7 days. Group B flaps were assessed using laser-assisted indocyanine fluorescence angiography before surgery, following flap harvest and at 7 days prior to euthanasia. Half of all rats in each group were analyzed with Micro-CT to assess the microvasculature. All paired specimens were assessed histologically with H&E and immunohistochem-istry (IHC). ReSultS: There was a 17% increase in CT tissue perfu-sion in skin treated with NPWT versus matched controls (P=0.001). LA-ICGFA demonstrated higher perfusion following NPWT treatment (P=0.006), however no significant difference immediate post flap harvest (P=0.19) but a difference was seen 7 days postoperatively (P=0.03). Micro-CT evaluation showed an increase in average vessel volume (%) from 0.005 in control to 0.009 in the NPWT flaps (P=0.04).H&E analysis showed significant difference in the epidermal thickness (P<0.001), but comparable dermal thickness (P=0.34).Quantitative analysis of CD31 IHC demonstrated a mean area fraction percentage of 4.30 and 2.68 in the NPWT and control flaps respectively (P=0.002).There was partial necrosis in the control (n=3) and NPWT flaps (N=1), however this was <5% in the NPWT flap. ConCluSion: We present novel multimodal approaches using static and dynamic imaging and histological assessment to provide a proof of concept on the use of NPWT for non-invasive conditioning of flaps. The study provides the basis for further investigation and clinical studies with potential for direct translation into clinical practice. Disclosure/Financial support: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. PuRPoSe: Ischemia time represents a significant limitation for successful extremity replantation and transplantation because of the rapid deterioration of ischemic muscle. Static cold storage (SCS) of the limb is the standard clinical practice. Normothermic ex vivo perfusion system has the potential to prolong viability …

Management of the Salivary Glands and Facial Nerve in Face Transplantation.

Background: Since the first face transplant in 2005, 35 cases have been performed worldwide with acceptable graft survival and satisfactory return of function and appearance. With increasing experience, it is emerging that the salivary glands can contribute to the challenges encountered in the perioperative period. Methods: A comprehensive review of the literature regarding management of the salivary glands and facial nerve in facial transplantation was performed. Data gathered included inclusion or exclusion of submandibular and parotid glands in the recipient and allograft, extent of mucosal inclusion in the allograft, salivary complications and treatment, level and method of facial nerve repair, and motor nerve outcomes. Results: Information on salivary gland management was available for 25 cases. Undesirable salivary events were documented in 12 cases (48 percent). The source of complications was the parotid in five cases (42 percent), a combination of the parotid and submandibular glands in three cases (25 percent), and minor salivary glands in four cases (33 percent). Postoperative botulinum toxin injections resolved salivary collections in four cases. Facial nerve continuity was restored at the level of the trunk/primary divisions (66 percent) or the terminal branches (34 percent), with inclusion of the whole parotid dictating a trunk repair and exclusion of the parotid dictating a terminal branch repair. Conclusions: The salivary glands warrant increased attention in surgical planning and postoperative care. Exclusion of the salivary glands from the facial allograft with repair of the terminal branches of the facial nerve appears to be preferable. Botulinum toxin should be considered for prophylaxis and treatment of salivary collections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.