Plastic Surgery International The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Evaluation of Complication Rates after Breast Surgery Using Acellular Dermal Matrix: Median Follow-Up of Three Years Mon, 12 Jun 2017 00:00:00 +0000 Introduction. Acellular dermal matrices (ADMs) are now commonly used for breast reconstruction surgery. There are various products available: ADMs derived from human (HADM), porcine (PADM), or bovine (BADM) sources. Detailed long-term follow-up studies are necessary to detect differences in complication rates between these products. Material and Methods. From 2010 to 2015, forty-one patients underwent 52 ADM-breast reconstructions in our clinic, including oncologic breast reconstructions and breast augmentation revisions (). 15x HADMs (Epiflex®/DIZG), 21x PADMs (Strattice®/LifeCell), and 16x BADMs (Tutomesh®/RTI Surgical) were implanted. Retrospective data collection with median follow-up of 36 months (range: 12–54 months) was performed. Results. Overall complication rate was 17% after ADM implantation (HADM: 7%; PADM: 14%; BADM: 31%). In a composite endpoint of complications and Red Breast Syndrome, a lower event probability was observed between BADMs, PADMs, and HADMs (44%, 19%, and 7%, resp.; for the trend). Furthermore, capsular contracture occurred in 6%, more frequently as compared to the current literature. Conclusions. When ADM-based reconstruction is indicated, the authors suggest primarily the use of HADMs and secondary the use of PADMs. It is shown that BADMs have the highest complication probability within our patient cohort; nevertheless, BADMs convey physical advantages in terms of flexibility and better aesthetic outcomes. The indication for the use of ADMs should be filled for each case individually. Felix J. Paprottka, Nicco Krezdorn, Heiko Sorg, Sören Könneker, Stiliano Bontikous, Ian Robertson, Christopher L. Schlett, Nils-Kristian Dohse, and Detlev Hebebrand Copyright © 2017 Felix J. Paprottka et al. All rights reserved. Plastic Surgery Inclusion in the Undergraduate Medical Curriculum: Perception, Challenges, and Career Choice—A Comparative Study Tue, 23 May 2017 00:00:00 +0000 Objective. The undergraduate medical curriculum has been overcrowded with core learning outcomes with no formal exposure to plastic surgery. The aim of this study was to compare medical students from two educational settings for the basic understanding, preferred learning method, and factors influencing a career choice in plastic surgery. Design and Setting. A prospective cohort study based on a web-based anonymous questionnaire sent to final year medical students at Birmingham University (United Kingdom), McGill University (Canada), and a control group (non-medical staff). The questions were about plastic surgery: (1) source of information and basic understanding; (2) undergraduate curriculum inclusion and preferred learning methods; (3) factors influencing a career choice. A similar questionnaire was sent to non-medical staff (control group). The data was analysed based on categorical outcomes (Chi-square χ2) and level of significance . Results. Questionnaire was analysed for 243 students (Birmingham, , 52%) (McGill , 54%). Birmingham students (14%) considered the word “plastic” synonymous with “cosmetic” more than McGill students (4%, ). Teaching was the main source of knowledge for McGill students (39%, ) while Birmingham students and control group chose the media (70%, ). McGill students (67%) more than Birmingham (49%, ) considered curriculum inclusion. The preferred learning method was lectures for McGill students (61%, ) but an optional module for Birmingham (61%). A similar proportion (18%) from both student groups considered a career in plastic surgery. Conclusions. Medical students recognised the need for plastic surgery inclusion in the undergraduate curriculum. There was a difference for plastic surgery source of information, operations, and preferred method of learning for students. The study highlighted the urgent need to reform plastic surgery undergraduate teaching in collaboration with national educational bodies worldwide. M. Farid, R. Vaughan, and S. Thomas Copyright © 2017 M. Farid et al. All rights reserved. The Efficiency of Sclerotherapy in the Treatment of Vascular Malformations: A Retrospective Study of 63 Patients Thu, 15 Dec 2016 14:23:43 +0000 Background and Aims. Vascular malformations are a vast group of congenital malformations that are present at birth. These malformations can cause pain, pressure, and cosmetic annoyance as well as downturn growth and development in a child in the case of high flow. Sclerotherapy has become an important tool in the treatment of vascular malformations. However, little is known about the success rate of sclerotherapy. Material and Methods. In this study, the efficiency of sclerotherapy in the treatment of vascular anomalies was investigated retrospectively in 63 patients treated in Turku University Hospital between 2003 and 2013. Results. Out of the 63 patients investigated, 83% (53) had venous malformations (VMs) and 9% (5) were defined as having arteriovenous malformations (AVMs). Patients with a VM were operated on, in 14% (8) out of all VM cases. Hence 86% (45) of patients with a VM received adequate help to their symptoms solely from sclerotherapy. The duration of treatment for the 14% of the VM patients that needed a surgical procedure was prolonged by 7–9 months, that is, by 41%. Conclusions. Sclerotherapy is an effective method in the treatment of VMs with a satisfactory clinical response in patients symptoms in 84% of cases. Esko Veräjänkorva, Riitta Rautio, Salvatore Giordano, Ilkka Koskivuo, and Otto Savolainen Copyright © 2016 Esko Veräjänkorva et al. All rights reserved. A Comparison of Barbed Sutures and Standard Sutures with regard to Wound Cosmesis in Panniculectomy and Reduction Mammoplasty Patients Tue, 29 Nov 2016 11:11:36 +0000 Cosmesis is a vital concern for patients undergoing plastic and reconstructive surgery. Many variations in wound closure are employed when attempting to minimize a surgical scar’s appearance. Barbed sutures are one potential method of achieving improved wound cosmesis and are more common in recent years. To determine if barbed sutures differ from nonbarbed in wound cosmesis, we conducted a single-blinded, randomized, controlled trial of 18 patients undergoing bilateral reduction mammoplasty or panniculectomy. Patients were their own controls, receiving barbed sutures on one side and standard sutures on the contralateral side. Surgical scars were evaluated postoperatively by patient preference self-assessment and an observer. Ten patients were evaluated at 3 months postoperatively, yielding a mean Stony Brook Scar Evaluation Scale (SBSES) rating of 4.4 for barbed suture and 3.5 for regular suture (). At 6 months, 8 patients performed self-assessment to determine their preference; 4 preferred the barbed sutures, 1 preferred the regular sutures, and 3 had no preference. Further research with larger sample sizes is needed to determine if barbed sutures convey any advantage over standard sutures in wound healing. However, our results suggest that barbed sutures are a reasonable alternative to standard sutures particularly with regard to wound cosmesis. Kristen Aliano, Michael Trostler, Indira Michelle Fromm, Alexander Dagum, Sami Khan, and Duc Bui Copyright © 2016 Kristen Aliano et al. All rights reserved. A Fast-Track Referral System for Skin Lesions Suspicious of Melanoma: Population-Based Cross-Sectional Study from a Plastic Surgery Center Wed, 20 Jul 2016 12:47:58 +0000 Introduction. To minimize delay between presentation, diagnosis, and treatment of cutaneous melanoma (CM), a national fast-track referral system (FTRS) was implemented in Denmark. The aim of this study was to analyze the referral patterns to our department of skin lesions suspicious of melanoma in the FTRS. Methods. Patients referred to the Department of Plastic Surgery and Breast Surgery in Zealand University Hospital were registered prospectively over a 1-year period in 2014. A cross-sectional study was performed analyzing referral patterns, including patient and tumor characteristics. Results. A total of 556 patients were registered as referred to the center in the FTRS for skin lesions suspicious of melanoma. Among these, a total of 312 patients (56.1%) were diagnosed with CM. Additionally, 41 (7.4%) of the referred patients were diagnosed with in situ melanoma. Conclusion. In total, 353 (63.5%) patients had a malignant or premalignant melanocytic skin lesion. When only considering patients who where referred without a biopsy, the diagnostic accuracy for GPs and dermatologists was 29% and 45%, respectively. We suggest that efforts of adequate training for the referring physicians in diagnosing melanocytic skin lesions will increase diagnostic accuracy, leading to larger capacity in secondary care for the required treatment of malignant skin lesions. Reem Dina Jarjis, Lone Bak Hansen, and Steen Henrik Matzen Copyright © 2016 Reem Dina Jarjis et al. All rights reserved. Bilateral Breast Reconstruction with Abdominal Free Flaps: A Single Centre, Single Surgeon Retrospective Review of 55 Consecutive Patients Mon, 18 Jul 2016 08:18:03 +0000 Breast reconstruction using free tissue transfer is an increasingly utilised oncoplastic procedure. The aim was to review all bilateral breast reconstructions using abdominal free flaps by a single surgeon over an 11-year period (2003–2014). A retrospective review was performed on all patients who underwent bilateral breast reconstruction using abdominal free flaps between 2003 and 2014 by the senior author (DAM). Data analysed included patient demographics, indication for reconstruction, surgical details, and complications. Fifty-five female patients (mean 48.6 years [ years]) had bilateral breast reconstruction. The majority (41, 74.5%) underwent immediate reconstruction and DIEP flaps were utilised on 41 (74.5%) occasions. Major surgical complications occurred in 6 (10.9%) patients, all of which were postoperative vascular compromise of the flap. Failure to salvage the reconstruction occurred on 3 (5.5%) occasions resulting in a total flap failure rate of 2.7%. Obesity (>30 kg/m2) and age > 60 years were shown to have a statistically increased risk of developing postoperative complications (). Our experience demonstrates that abdominal free flaps for bilateral breast reconstruction fares well, with a flap failure rate of 2.7%. Increased body mass index and patient age (>60 years) were associated with higher complication rates. Peter McAllister, Isabel Teo, Kuen Chin, Boikanyo Makubate, and David Alexander Munnoch Copyright © 2016 Peter McAllister et al. All rights reserved. Maximizing Outcomes While Minimizing Morbidity: An Illustrated Case Review of Elbow Soft Tissue Reconstruction Sun, 29 May 2016 07:08:36 +0000 Background. Injuries to the elbow have led to consequences varying from significant limitation in function to loss of the entire upper limb. Soft tissue reconstruction with durable and pliable coverage balanced with the ability to mobilize the joint early to optimize rehabilitation outcomes is paramount. Methods. Methods of flap reconstruction have evolved from local and pedicled flaps to perforator-based flaps and free tissue transfer. Here we performed a review of 20 patients who have undergone flap reconstruction of the elbow at our institution. Discussion. 20 consecutive patients were identified and included in this study. Flap types include local (), regional pedicled (), and free () flaps. The average size of defect was 138 cm2 (range 36–420 cm2). There were no flap failures in our series, and, at follow-up, the average range of movement of elbow flexion was 100°. Results. While the pedicled latissimus dorsi flap is the workhorse for elbow soft tissue coverage, advancements in microvascular knowledge and surgery have brought about great benefit, with the use of perforator flaps and free tissue transfer for wound coverage. Conclusion. We present here our case series on elbow reconstruction and an abbreviated algorithm on flap choice, highlighting our decision making process in the selection of safe flap choice for soft tissue elbow reconstruction. Adrian Ooi, Jonathan Ng, Christopher Chui, Terence Goh, and Bien Keem Tan Copyright © 2016 Adrian Ooi et al. All rights reserved. Defining the Best Nasal Tip Projection among Iranian Women Mon, 16 May 2016 09:34:41 +0000 Rhinoplasty is one of the most complicated aesthetic surgeries. One important factor in nasal profile analysis before surgery is the NTP (Nasal Tip Projection). There has been controversy over defining the best tip projection and due to cultural differences there is a need to find the best formulation for Iranian noses. We selected 50 randomized patients. Lateral nasal views were captured from all of the patients. In order to equalize the photos, all tip rotations changed first to 105. We selected four methods for measuring NTP (Goode, Crumley 1, Crumley 2, and Powell and Humphreys). Based on these methods NTP was shown in four pictures. A questionnaire was designed for rating the pictures. Questionnaires were filled in by 3 different groups: rhinoplasty surgeons, general people, and artists. A total of 73 questionnaires were filled in. The analysis and comparison were done. Crumley 2 is the best NTP measurement method from the surgeons’ and artists’ view. Goode is the method preferred by general people. Powell & Humphreys method seems to be the worst method from all 3 groups’ view. It seems that general people prefer smaller noses, because projection in Goode method is almost less than Crumley 2. Alireza Mohebbi, Hesam Jahandideh, Zhaleh Faham, and Morteza Jafari Copyright © 2016 Alireza Mohebbi et al. All rights reserved. Predictors of Nasal Obstruction: Quantification and Assessment Using Multiple Grading Scales Mon, 16 May 2016 09:34:10 +0000 Objective. To evaluate the association between nasal obstruction and (1) demographic factors, (2) medical history, (3) physical tests, and (4) nasal exam findings. Study Design. Case series. Methods. Chart review at a tertiary medical center. Results. Two hundred-forty consecutive patients ( years old, with a Nasal Obstruction Symptom Evaluation (NOSE) score of ) were included. Demographic factors and inferior turbinate sizes were not associated with NOSE score or Nasal Obstruction Visual Analog Scale (NO-VAS). A significant association was found between higher NOSE score on univariate analysis and positive history of nasal trauma (), allergic rhinitis (), use of nasal steroids (), higher grade of external nasal deformity (), higher internal nasal septal deviation grade (), and narrow internal nasal valve angle (). Multivariate analysis identified the following as independent predictors of high NOSE score: NO-VAS: ≥50 (Odds Ratio (OR) = 17.6 (95% CI 5.83–61.6), ), external nasal deformity: grades 2–4 (OR = 4.63 (95% CI 1.14–19.9), ), and allergic rhinitis: yes (OR = 5.5 (95% CI 1.77–18.7), ). Conclusion. Allergic rhinitis, NO-VAS score ≥ 50, and external nasal deformity (grades 2–4) were statistically significant independent predictors of high NOSE scores on multivariate analysis. Inferior turbinate size was not associated with NOSE scores or NO-VAS. Macario Camacho, Soroush Zaghi, Victor Certal, Jose Abdullatif, Rahul Modi, Shankar Sridhara, Anthony M. Tolisano, Edward T. Chang, Benjamin B. Cable, and Robson Capasso Copyright © 2016 Macario Camacho et al. All rights reserved. Growth Hormone-Releasing Peptide 6 Enhances the Healing Process and Improves the Esthetic Outcome of the Wounds Wed, 20 Apr 2016 11:18:32 +0000 In addition to its cytoprotective effects, growth hormone-releasing peptide 6 (GHRP-6) proved to reduce liver fibrotic induration. CD36 as one of the GHRP-6 receptors appears abundantly represented in cutaneous wounds granulation tissue. The healing response in a scenario of CD36 agonistic stimulation had not been previously investigated. Excisional full-thickness wounds (6 mmØ) were created in the dorsum of Wistar rats and topically treated twice a day for 5 days. The universal model of rabbit’s ears hypertrophic scars was implemented and the animals were treated daily for 30 days. Treatments for both species were based on a CMC jelly composition containing GHRP-6 400 μg/mL. Wounds response characterization included closure dynamic, RT-PCR transcriptional profile, histology, and histomorphometric procedures. The rats experiment indicated that GHRP-6 pharmacodynamics involves attenuation of immunoinflammatory mediators, their effector cells, and the reduction of the expression of fibrotic cytokines. Importantly, in the hypertrophic scars rabbit’s model, GHRP-6 intervention dramatically reduced the onset of exuberant scars by activating PPARγ and reducing the expression of fibrogenic cytokines. GHRP-6 showed no effect on the reversion of consolidated lesions. This evidence supports the notion that CD36 is an active and pharmacologically approachable receptor to attenuate wound inflammation and accelerate its closure so as to improve wound esthetic. Yssel Mendoza Marí, Maday Fernández Mayola, Ana Aguilera Barreto, Ariana García Ojalvo, Yilian Bermúdez Alvarez, Ana Janet Mir Benítez, and Jorge Berlanga Acosta Copyright © 2016 Yssel Mendoza Marí et al. All rights reserved. Does Acellular Dermal Matrix Thickness Affect Complication Rate in Tissue Expander Based Breast Reconstruction? Tue, 12 Apr 2016 11:42:01 +0000 Background. While the benefits of using acellular dermal matrices (ADMs) in breast reconstruction are well described, their use has been associated with additional complications. The purpose of this study was to determine if ADM thickness affects complications in breast reconstruction. Methods. A retrospective chart review was performed including all tissue expander based breast reconstructions with AlloDerm (LifeCell, Branchburg, NJ) over 4 years. We evaluated preoperative characteristics and assessed postoperative complications including seroma, hematoma, infection, skin necrosis, and need for reintervention. We reviewed ADM thickness and time to Jackson-Pratt (JP) drain removal. Results. Fifty-five patients underwent 77 ADM-associated tissue expander based breast reconstructions, with average age of 48.1 years and average BMI of 25.9. Average ADM thickness was 1.21 mm. We found higher complication rates in the thick ADM group. Significant associations were found between smokers and skin necrosis () and seroma and prolonged JP drainage (); radiated reconstructed breasts were more likely to suffer infections (), and elevated BMI is a significant predictor for increased infection rate (). Conclusion. We found a trend toward increased complication rates with thicker ADMs. In the future, larger prospective studies evaluating thickness may provide more information. Jessica F. Rose, Sarosh N. Zafar, and Warren A. Ellsworth IV Copyright © 2016 Jessica F. Rose et al. All rights reserved. Does the Use of Intraoperative Breast Sizers Increase Complication Rates in Primary Breast Augmentation? A Retrospective Analysis of 416 Consecutive Cases in a Single Institution Tue, 22 Mar 2016 08:51:35 +0000 Background. Is the use of intraoperative breast sizers beneficial for plastic surgeons or do they result in higher complication rates? Methods. This is a retrospective study of 416 consecutive cases of primary breast augmentation with silicone implants at the Plastic Surgery Service of Professor Ivo Pitanguy at the 38th Infirmary Santa Casa Misericórdia Hospital, Rio De Janeiro, from January 2011 to March 2014. 212 cases (51%) were carried out with use of intraoperative breast sizers with 204 cases (49%) without the use of implant sizers. This study compares the outcome of cases that employed the use of intraoperative implant sizers versus those that did not in terms of infection, hematoma/seroma formation, and capsular contracture. Results. Of 416 primary breast augmentation cases, there were 5 cases of infection (1.2%), 4 cases of seroma (1%), 3 cases of hematoma (0.7%), and 7 cases of capsular contracture (Baker’s Grade III/IV)(1.7%). Total complication rate limited to infection, seroma, hematoma, and capsular contracture was 1.15% (95% CI 0.96–1.93%). There was a significant difference in the scores for breast sizers (M = 4.3, SD = 1.4) and no breast sizers (M = 2.3, SD = 0.87) conditions, (8) = 2.79, . The use of implant sizers was correlated with a higher complication rate. Conclusion. Good results could be obtained without the use of breast sizers in primary breast augmentation with use of a biodimensional tissue based planning system while eliminating risks of infection and reducing intraoperative time. Notwithstanding, in a residency program breast sizers can be an excellent training tool to shorten the learning curve in the novice surgeon. Lee Seng Khoo, Henrique N. Radwanski, Vasco Senna-Fernandes, Nsingi Nsosolo Antônio, Leonardo Luiz Fernandes Fellet, and Ivo Pitanguy Copyright © 2016 Lee Seng Khoo et al. All rights reserved. Therapeutic Options of Chondrodermatitis Nodularis Helicis Wed, 27 Jan 2016 14:07:07 +0000 Chondrodermatitis Nodularis Helicis is a benign inflammatory process affecting the skin and cartilage of the ear. It typically presents as a painful nodule surrounded by an area of erythema and often prevents the patient from sleeping on the affected side. Many treatments have been described in the literature, but the condition is prone to recurrence. A literature search was performed in order to identify the best possible treatment. Fifty-eight articles were included, describing and investigating nonsurgical as well as surgical treatment modalities. Large prospective, controlled, and randomised long-term studies are lacking, but based on the available literature, we recommend starting with a conservative approach using decompression devices. Simple surgical procedures should only be used if conservative measures fail. Lea Juul Nielsen, Caroline Holkmann Olsen, and Jørgen Lock-Andersen Copyright © 2016 Lea Juul Nielsen et al. All rights reserved. The Role of Current Techniques and Concepts in Peripheral Nerve Repair Wed, 20 Jan 2016 11:32:08 +0000 Patients with peripheral nerve injuries, especially severe injury, often face poor nerve regeneration and incomplete functional recovery, even after surgical nerve repair. This review summarizes treatment options of peripheral nerve injuries with current techniques and concepts and reviews developments in research and clinical application of these therapies. K. S. Houschyar, A. Momeni, M. N. Pyles, J. Y. Cha, Z. N. Maan, D. Duscher, O. S. Jew, F. Siemers, and J. van Schoonhoven Copyright © 2016 K. S. Houschyar et al. All rights reserved. Nasal Septal Deviations: A Systematic Review of Classification Systems Mon, 11 Jan 2016 06:16:45 +0000 Objective. To systematically review the international literature for internal nasal septal deviation classification systems and summarize them for clinical and research purposes. Data Sources. Four databases (including PubMed/MEDLINE) were systematically searched through December 16, 2015. Methods. Systematic review, adhering to PRISMA. Results. After removal of duplicates, this study screened 952 articles for relevance. A final comprehensive review of 50 articles identified that 15 of these articles met the eligibility criteria. The classification systems defined in these articles included C-shaped, S-shaped, reverse C-shaped, and reverse S-shaped descriptions of the septal deviation in both the cephalocaudal and anteroposterior dimensions. Additional studies reported use of computed tomography and categorized deviation based on predefined locations. Three studies graded the severity of septal deviations based on the amount of deflection. The systems defined in the literature also included an evaluation of nasal septal spurs and perforations. Conclusion. This systematic review ascertained that the majority of the currently published classification systems for internal nasal septal deviations can be summarized by C-shaped or reverse C-shaped, as well as S-shaped or reverse S-shaped deviations in the anteroposterior and cephalocaudal dimensions. For imaging studies, predefined points have been defined along the septum. Common terminology can facilitate future research. Jeffrey Teixeira, Victor Certal, Edward T. Chang, and Macario Camacho Copyright © 2016 Jeffrey Teixeira et al. All rights reserved. Nose and Midface Augmentation by Rib Cartilage Grafts: Methods and Outcome in 32 Cases Thu, 10 Dec 2015 07:38:31 +0000 Recession of the midface is a relatively common condition that can have a negative impact on facial and nasal aesthetic appearance, and it poses a challenge to plastic surgeons. In cases with generalized maxillary retrusion and/or malocclusion, bone advancement surgery is required, but in localized cases, mostly seen in cleft lip patients, the quest is for an ideal material and a proper technique that would be used to augment the receding area. Throughout a period of seven years, thirty-two patients with nose and midface retrusion were managed by a construct of rib cartilage grafts designed to compensate the deficiency at the maxillary, piriform, and premaxillary areas. Results were satisfactory for most patients in terms of improved fullness of malar area, improved nasal tip projection and rotation, and improvement of upper lip. The presented technique of rib cartilage grafting is a safe and effective method for nose and midface augmentation. Adham Farouk and Saad Ibrahiem Copyright © 2015 Adham Farouk and Saad Ibrahiem. All rights reserved. Stem Cell-Based Therapeutics to Improve Wound Healing Sun, 15 Nov 2015 12:35:26 +0000 Issues surrounding wound healing have garnered deep scientific interest as well as booming financial markets invested in novel wound therapies. Much progress has been made in the field, but it is unsurprising to find that recent successes reveal new challenges to be addressed. With regard to wound healing, large tissue deficits, recalcitrant wounds, and pathological scar formation remain but a few of our most pressing challenges. Stem cell-based therapies have been heralded as a promising means by which to surpass current limitations in wound management. The wide differentiation potential of stem cells allows for the possibility of restoring lost or damaged tissue, while their ability to immunomodulate the wound bed from afar suggests that their clinical applications need not be restricted to direct tissue formation. The clinical utility of stem cells has been demonstrated across dozens of clinical trials in chronic wound therapy, but there is hope that other aspects of wound care will inherit similar benefit. Scientific inquiry into stem cell-based wound therapy abounds in research labs around the world. While their clinical applications remain in their infancy, the heavy investment in their potential makes it a worthwhile subject to review for plastic surgeons, in terms of both their current and future applications. Michael S. Hu, Tripp Leavitt, Samir Malhotra, Dominik Duscher, Michael S. Pollhammer, Graham G. Walmsley, Zeshaan N. Maan, Alexander T. M. Cheung, Manfred Schmidt, Georg M. Huemer, Michael T. Longaker, and H. Peter Lorenz Copyright © 2015 Michael S. Hu et al. All rights reserved. Use of Lateral Calcaneal Flap for Coverage of Hindfoot Defects: An Anatomical Appraisal Wed, 11 Nov 2015 13:08:47 +0000 Lateral calcaneal flap is an established surgical option for coverage of lateral calcaneum and posterior heel defects. Lateral calcaneal flap vascularization and innervations are based on lateral calcaneal artery neurovascular bundle, that is, lateral calcaneal artery, small saphenous vein, and sural nerve. Anatomical research has allowed exploration of its many advantages but can also lead to its various modifications, permitting a wide variety of clinical applications. In this paper the authors report an anatomical and clinical study on lateral calcaneal artery course and lateral calcaneal flap clinical applications. Anatomic part of our study focused on lateral calcaneal artery course and optimization of surgical technique for flap harvesting. Data were used for design of lateral calcaneal flap in 5 patients. Our results were satisfactory in terms of coverage adequacy, perioperative morbidity, and functional and aesthetical outcome. Panagiotis Zygouris, Adamantios Michalinos, Vassilis Protogerou, Evangelos Kotsiomitis, Antonios Mazarakis, Ioannis Dimovelis, and Theodore Troupis Copyright © 2015 Panagiotis Zygouris et al. All rights reserved. Mandibular Ramus Fracture: An Overview of Rare Anatomical Subsite Tue, 03 Nov 2015 14:32:04 +0000 Aim. The present study aims at exemplifying the incidence, and aetiology and analyses the outcomes of open reduction internal fixation (ORIF) over closed treatment of mandibular ramus fractures. Patients and Method. In the present retrospective analysis of mandibular fracture patients, variables analysed were age, sex, cause of injury, pretreatment occlusion, treatment given, period of maxillo-mandibular fixation (MMF), and posttreatment occlusion. Results. Out of 388 mandibular fractures treated, ramus fractures were 12 (3.09%). In the present study, predominant cause of mandibular ramus fracture was road traffic accident (RTA) n = 07 (58.33%) followed by fall n = 04 (33.33%) and assault n = 1 (8.33%). The average age was 35.9 years with a male predilection. Of these, 9 patients were treated with ORIF while remaining 3 with closed treatment. The average MMF after closed treatment was 21 days and 3 to 5 days after ORIF. There was improvement in occlusion in all 12 patients posttreatment with no major complication except for reduced mouth opening in cases treated with ORIF which recovered with physiotherapy and muscle relaxants. Conclusion. Mandibular ramus fractures accounted for 3.09% with RTA as a common aetiology. ORIF of ramus fractures facilitated adequate functional and anatomic reduction with early return of function. Anendd Jadhav, Bhushan Mundada, Rahul Deshmukh, Umesh Bhutekar, Atul Kala, Kapil Waghwani, and Apoorva Mishra Copyright © 2015 Anendd Jadhav et al. All rights reserved. Telemedicine and Plastic Surgery: A Pilot Study Mon, 02 Nov 2015 14:16:19 +0000 Background. Telemedicine can be defined as the use of electronic media for transmission of information and medical data from one site to another. The objective of this study is to demonstrate an experience of telemedicine in plastic surgery. Methods. 32 plastic surgeons received a link with password for real-time streaming of a surgery. At the end of the procedure, the surgeons attending the procedure by the Internet answered five questions. The results were analyzed with descriptive statistics. Results. 27 plastic surgeons attended the online procedure in real-time. 96.3% considered the access to the website as good or excellent and 3.7% considered it bad. 14.8% reported that the transmission was bad and 85.2% considered the quality of transmission as good or excellent. 96.3% classified the live broadcasting as a good or excellent learning experience and 3.7% considered it a bad experience. 92.6% reported feeling able to perform this surgery after watching the demo and 7.4% did not feel able. 100% of participants said they would like to participate in other surgical demonstrations over the Internet. Conclusion. We conclude that the use of telemedicine can provide more access to education and medical research, for plastic surgeons looking for medical education from distant regions. Denis Souto Valente, Luciano Silveira Eifler, Lauro Aita Carvalho, Gustavo Azambuja Pereira Filho, Vinicius Weissheimer Ribeiro, and Alexandre Vontobel Padoin Copyright © 2015 Denis Souto Valente et al. All rights reserved. Sociodemographic Predictors of Breast Reconstruction Procedure Choice: Analysis of the Mastectomy Reconstruction Outcomes Consortium Study Cohort Thu, 29 Oct 2015 12:24:45 +0000 Background. To promote patient-centered care, it is important to understand the impact of sociodemographic factors on procedure choice for women undergoing postmastectomy breast reconstruction. In this context, we analyzed the effects of these variables on the reconstructive method chosen. Methods. Women undergoing postmastectomy breast reconstruction were recruited for the prospective Mastectomy Reconstruction Outcomes Consortium Study. Procedure types were divided into tissue expander-implant/direct-to-implant and abdominally based flap reconstructions. Adjusted odds ratios were calculated from logistic regression. Results. The analysis included 2,203 women with current or previous breast cancer and 202 women undergoing prophylactic mastectomy. Compared with women <40 years old with current or previous breast cancer, those 40 to 59 were significantly more likely to undergo an abdominally based flap. Women working or attending school full-time were more likely to receive an autologous procedure than those working part-time or volunteering. Women undergoing prophylactic mastectomy who were ≥50 years were more likely to undergo an abdominal flap compared to those <40. Conclusions. Our results indicate that sociodemographic factors affect the reconstructive procedure received. As we move forward into a new era of patient-centered care, providing tailored treatment options to reconstruction patients will likely lead to higher satisfaction and better outcomes for those we serve. Tiffany N. S. Ballard, Yeonil Kim, Wess A. Cohen, Jennifer B. Hamill, Adeyiza O. Momoh, Andrea L. Pusic, H. Myra Kim, and Edwin G. Wilkins Copyright © 2015 Tiffany N. S. Ballard et al. All rights reserved. Nummular Eczema of Breast: A Potential Dermatologic Complication after Mastectomy and Subsequent Breast Reconstruction Mon, 24 Aug 2015 11:10:27 +0000 Purposes. The present paper reports clinical cases where nummular eczema developed during the course of breast reconstruction by means of implantation and evaluates the occurrence patterns and ratios of this complication. Methods. 1662 patients undergoing breast reconstruction were reviewed. Patients who developed nummular eczema during the treatment were selected, and a survey was conducted on these patients regarding three items: (1) the stage of the treatment at which nummular eczema developed; (2) time required for the lesion to heal; (3) location of the lesion on the reconstructed breast(s). Furthermore, histopathological examination was conducted to elucidate the etiology of the lesion. Results. 48 patients (2.89%) developed nummular eczema. The timing of onset varied among these patients, with lesions developing after the placement of tissue expanders for 22 patients (45.8%); after the tissue expanders were replaced with silicone implants for 12 patients (25%); and after nipple-areola complex reconstruction for 14 patients (29.2%). Nummular eczema developed both in periwound regions (20 cases: 41.7%) and in nonperiwound regions (32 cases: 66.7%). Histopathological examination showed epidermal acanthosis, psoriasiform patterns, and reduction of sebaceous glands. Conclusions. Surgeons should recognize that nummular eczema is a potential complication of breast reconstruction with tissue expanders and silicone implants. Yoshiko Iwahira, Tomohisa Nagasao, Yusuke Shimizu, Kumiko Kuwata, and Yoshio Tanaka Copyright © 2015 Yoshiko Iwahira et al. All rights reserved. Free Flaps in a Resource Constrained Environment: A Five-Year Experience—Outcomes and Lessons Learned Tue, 11 Aug 2015 13:43:07 +0000 Introduction. Free flap surgery is a routine procedure in many developed countries with good surgical outcomes. In many developing countries, however, these services are not available. In this paper, we audit free flaps done in a resource constrained hospital in Kenya. Objective. This is a five-year audit of free flaps done in a tertiary hospital in Kenya, between 2009 and 2014. Materials and Methods. This was a prospective study of patients operated on with free flaps between 2009 and 2014. Results. A total of one hundred and thirty-two free flaps in one hundred and twenty patients were performed during the five-year duration. The age range was eight to seventy-two years with a mean of 47.2. All the flaps were done under loupe magnification. The overall flap success rate was eighty-nine percent. Conclusion. Despite the many limitations, free flaps in our setup were successful in the majority of patients operated on. Flap salvage was noted to be low due to infrequent flap monitoring as well as unavailability of theatre space. One therefore has to be meticulous during surgery to reduce any possibilities of reexploration. Wanjala F. Nangole, Stanley Khainga, Joyce Aswani, Loise Kahoro, and Adelaine Vilembwa Copyright © 2015 Wanjala F. Nangole et al. All rights reserved. Analysis of Complications in Postbariatric Abdominoplasty: Our Experience Wed, 08 Jul 2015 09:13:31 +0000 Abdominoplasty is one of the most popular body-contouring procedures. It is associated with a significant number of complications: the most common ones are seroma, hematoma, infection, wound-healing problems, and skin flap necrosis. From January 2012 to December 2014, 25 patients (18 women and 7 men) (mean age: 51 years) underwent abdominoplastic surgery at the Plastic Surgery Section, Department of Surgical Sciences, University of Parma, Italy. All patients reported a weight loss between 15 kg and 47 kg. All of the of 25 patients were included in the study; minor and major complications were seen in 17 (68%) and 8 (32%) patients, respectively. The percentage of complications in our patients was as follows: 9 patients with seroma (36%); 4 patients with wound dehiscence with delayed wound healing (16%); 3 cases with hematoma (12%); 2 patients with postoperative bleeding (8%); 1 patient (4%) with an umbilical necrosis; 1 patient (4%) with a deep vein thrombosis; 3 patients with infected seroma (12%); and 2 patients with wound infection (8%). There were no cases of postoperative mortality. The aim of this study is to analyze our complications in postbariatric abdominoplasty. Michele Grieco, Eugenio Grignaffini, Francesco Simonacci, and Edoardo Raposio Copyright © 2015 Michele Grieco et al. All rights reserved. One-Stop Clinic Utilization in Plastic Surgery: Our Local Experience and the Results of a UK-Wide National Survey Sun, 05 Jul 2015 09:55:38 +0000 Introduction. “See and treat” one-stop clinics (OSCs) are an advocated NHS initiative to modernise care, reducing cancer treatment waiting times. Little studied in plastic surgery, the existing evidence suggests that though they improve care, they are rarely implemented. We present our experience setting up a plastic surgery OSC for minor skin surgery and survey their use across the UK. Methods. The OSC was evaluated by 18-week wait target compliance, measures of departmental capacity, and patient satisfaction. Data was obtained from 32 of the 47 UK plastic surgery departments to investigate the prevalence of OSCs for minor skin cancer surgery. Results. The OSC improved 18-week waiting times, from a noncompliant mean of 80% to a compliant 95% average. Department capacity increased 15%. 95% of patients were highly satisfied with and preferred the OSC to a conventional service. Only 25% of UK plastic surgery units run OSCs, offering varying reasons for not doing so, 42% having not considered their use. Conclusions. OSCs are underutilised within UK plastic surgery, where a significant proportion of units have not even considered their benefit. This is despite associated improvements in waiting times, department capacity, and levels of high patient satisfaction. We offer our considerations and local experience instituting an OSC service. Mark Gorman, James Coelho, Sameer Gujral, and Alastair McKay Copyright © 2015 Mark Gorman et al. All rights reserved. Free Flap Transfer to Preserve Main Arterial Flow in Early Reconstruction of Open Fracture in the Lower Extremity Thu, 12 Mar 2015 12:09:01 +0000 The selection of recipient vessels is crucial when reconstructing traumatized lower extremities using a free flap. When the dorsalis pedis artery and/or posterior tibial artery cannot be palpated, we utilize computed tomography angiography to verify the site of vascular injury prior to performing free flap transfer. For vascular anastomosis, we fundamentally perform end-to-side anastomosis or flow-through anastomosis to preserve the main arterial flow. In addition, in open fracture of the lower extremity, we utilize the anterolateral thigh flap for moderate soft tissue defects and the latissimus dorsi musculocutaneous flap for extensive soft tissue defects. The free flaps used in these two techniques are long and include a large-caliber pedicle, and reconstruction can be performed with either the anterior or posterior tibial artery. The preparation of recipient vessels is easier during the acute phase early after injury, when there is no influence of scarring. A free flap allows flow-through anastomosis and is thus optimal for open fracture of the lower extremity that requires simultaneous reconstruction of main vessel injury and soft tissue defect from the middle to distal thirds of the lower extremity. Mitsuru Nemoto, Shinsuke Ishikawa, Natsuko Kounoike, Takayuki Sugimoto, and Akira Takeda Copyright © 2015 Mitsuru Nemoto et al. All rights reserved. Clinical Features of Primary Vein Grafts in Free Tissue Transfers Thu, 12 Mar 2015 09:19:21 +0000 The outcomes of free tissue transfers combined with vein grafts have been inconsistent, and discussions continue regarding their appropriate use. Of the 142 free tissue transfers that we performed from January 2004 to December 2011, we retrospectively analyzed 15 consecutive patients who underwent free tissue transfers in combination with vein grafts. Etiologies included trauma (8 patients), infection (4), and tumor (3). Types of free tissue transfers were fibula (4), anterolateral thigh (3), groin (3), jejunum (3), latissimus dorsi (1), and dorsal pedis (1). Vein grafts were used for the artery (6), vein (2), or both (7). The donor veins were the saphenous vein (12) and the external jugular vein (3). The mean length of the grafted veins was 10.8 cm (range: 4–18 cm). Even though complications of congestion occurred in 2 patients, these flaps survived by reexploration. The flap success rate was 15 of 15 (100%) of vein grafted free flaps versus 124 of 127 (97.6%) of free flaps not requiring vein grafts. To improve the success rate of free tissue transfers combined with vein grafts, securing healthy recipient vessels, meticulous surgical handling, a reliable vascular anastomosis technique, and strict postoperative monitoring are crucial. Mitsuru Nemoto, Kenichi Kumazawa, Eiju Uchinuma, Natsuko Kounoike, and Akira Takeda Copyright © 2015 Mitsuru Nemoto et al. All rights reserved. The Versatility of Autologous Fat Transplantation in Correction of Facial Deformities: A Single-Center Experience Tue, 03 Mar 2015 06:34:08 +0000 Deformities in the craniofacial region are of great social and functional importance. Several surgical techniques have been used to treat such pathologies often with high morbidity and lacking the ability to address smaller contour defects. The minimally invasive technique of fat transplantation has evolved rapidly within the last few decades. The objective of this paper is to present the versatility and applicability of fat transplantation in a wide range of contour deformities in the craniofacial region. We share our experiences in treating 13 patients with autoimmune disorders, congenital malformations, and acquired defects. Future perspectives of fat transplantation in the field of craniofacial reconstruction are discussed. Niels Hammer-Hansen, Javed Akram, and Tine Engberg Damsgaard Copyright © 2015 Niels Hammer-Hansen et al. All rights reserved. Effects of Intense Pulsed Light on Tissue Vascularity and Wound Healing: A Study with Mouse Island Skin Flap Model Tue, 03 Feb 2015 08:49:22 +0000 Intense pulsed light (IPL) has been used extensively in aesthetic and cosmetic dermatology. To test whether IPL could change the tissue vascularity and improve wound healing, mice were separated into 4 groups. Mice in Group I were not treated with IPL, whereas, dorsal skins of mice in Groups II, III, and IV were treated with 35 J/cm2, 25 J/cm2, and 15 J/cm2 IPL, respectively. After 2 weeks, dorsal island skin flaps were raised, based on the left deep circumflex iliac vessels as pedicles; then, survival rate was assessed. Flaps in Group IV (treated with lowest dose of IPL) have a survival rate significantly higher than other groups. Counting blood vessels did not demonstrate any significant differences; however, vessel dilation was found in this group. The results show that IPL at the therapeutic doses which are usually applied to humans is harmful to mouse dorsal skin and did not enhance wound healing, whereas, IPL at much lower dose could improve wound healing. The possible mechanism is the dilation of tissue vasculature thanks to the electromagnetic character of IPL. Another mechanism could be the heat-shock protein production. Trinh Cao Minh, Do Xuan Hai, and Pham Thi Ngoc Copyright © 2015 Trinh Cao Minh et al. All rights reserved. Combined Liposuction and Excision of Lipomas: Long-Term Evaluation of a Large Sample of Patients Wed, 28 Jan 2015 11:58:06 +0000 Background. Lipomas are benign tumors of mature fat cells. They can be removed by liposuction, yet this technique is seldom employed because of concerns that removal may be incomplete and recurrence may be more frequent than after conventional excision. Objectives. We assessed the short- and long-term clinical outcomes and recurrence of combined liposuction and limited surgical excision of subcutaneous lipomas. Methods. From 2003 to 2012, 25 patients with 48 lipomas were treated with liposuction followed by direct excision through the same incision to remove residual lipomatous tissue. Initial postoperative follow-up ranged from 1 week to 3 months, and long-term outcomes, complications, and recurrence were surveyed 1 to 10 years postoperatively. Results. Lipomas on the head, neck, trunk, and extremities ranged from 1 to 15 cm in diameter. Early postoperative hematoma and seromas were managed by aspiration. Among 23 survey respondents (92%), patients were uniformly pleased with the cosmetic results; none reported recurrent lipoma. Conclusions. The combination of liposuction and excision is a safe alternative for lipoma removal; malignancy and recurrence are uncommon. Liposuction performed through a small incision provides satisfactory aesthetic results in most cases. Once reduced in size, residual lipomatous and capsular tissue can be removed without expanding the incision. These favorable outcomes support wider application of this technique in appropriate cases. Libby R. Copeland-Halperin, Vincenza Pimpinella, and Michelle Copeland Copyright © 2015 Libby R. Copeland-Halperin et al. All rights reserved.