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Abstract: PRS AAPS Poster Proofs 2016

Plastic and Reconstructive Surgery - Global Open: April 2016 - Volume 4 - Issue 4S - p 116–129
doi: 10.1097/GOX.0000000000000695
AAPS and PSRC 2016 Abstract Supplement

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A Prospective Study Using Validated Outcome Instruments for Platelet-Rich Plasma Therapy for Facial Rejuvenation

Sammy Sinno, MD, Grace Poudrier, BA, Jennifer Thompson, BS, Z-Hye Lee, MD, Michael V. Chiodo, MD, Alexes Hazen, MD

From the New York University, New York, N.Y.

PURPOSE: Platelet-rich plasma (PRP) therapy can be used for facial rejuvenation. To date, the efficacy and degree of patient satisfaction after PRP treatment has not been evaluated in a standardized fashion with validated patient outcome tools.

METHODS: Twenty-five patients were selected for PRP therapy for facial rejuvenation. All patients completed the following FACE-Q scales preprocedure: appearance appraisal, quality of life, adverse effect checklists for treatment, and process of care. PRP was prepared using a standardized protocol. At 6 weeks posttreatment, another FACE-Q was completed, and 2 blinded observers (1 plastic surgeon and 1 dermatologist) were asked to evaluate results, including completion of the Wrinkle Severity Rating Scale.

RESULTS: All of the patients in this study were female. Compared with preprocedure FACE-Q scores, patients had higher degrees of satisfaction with appearance appraisal, quality of life, and process of care postprocedure. There were no reported complications. An improvement in Wrinkle Severity Rating Scale was noted between pretreatment and posttreatment (P < 0.05).

CONCLUSIONS: This is the first study to use validated instruments to demonstrate the effectiveness of PRP therapy for facial rejuvenation.

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Determining the Safety and Efficacy of Platelet-Rich Plasma for Facial Rejuvenation: A Systematic Review

Sammy Sinno, MD, Karan Mehta, MD, Z-Hye Lee, MD, Pierre B. Saadeh, MD, Alexes Hazen, MD

From the New York University, New York, N.Y.

PURPOSE: Platelet-rich therapy (PRT) has been increasingly used for facial rejuvenation. The purpose of this systematic review is to provide practitioners with greater evidence for the utility and usage of platelet-based therapies.

METHODS: A MEDLINE search was performed for platelet-rich plasma (PRP) therapy, yielding 3046 studies. This search was then narrowed by including studies performed only for facial rejuvenation.

RESULTS: A total of 19 studies, 7 with PRT only and 12 with PRP and fat grafting, encompassing 518 patients were selected. For PRT only, the average age of patients was 48.72 years with a mean follow-up time of 3 months. Most often, 3 treatments consisting of 1.5 ml of PRP each were used. The lower eyelid, nasolabial folds, and crow’s feet were most commonly injected areas. Roughly 88.8% of patients reported subjective improvements in overall appearance with 70% and 91% specifying diminished wrinkles and greater skin tonicity, respectively. A total of 87.6% and 68.8% of physicians noticed improvement in patient wrinkles and tonicity, respectively. Skin pigmentation was enhanced in 66% of studies. Mild complications were rarely reported. For PRP with fat grafting, 1 treatment with a 1:2 ratio of PRP and autologous fat was most commonly used. The nasolabial folds and malar regions were most often injected. Patients reported 99% satisfaction with treatment, and the addition of PRP resulted in significantly greater preservation of fat graft (82.3% vs 31%).

CONCLUSIONS: Platelet-rich therapies represent a promising new minimally invasive tool in facial enhancement. Additional studies are needed to better analyze this technique.

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Cosmetic Surgery Practice at an Academic Institution: A Report of 4705 Cases with Trends and Comparisons with National Statistics

Michael G. Tecce, BS, Michael A. Lanni, BS, Chen Yan, MD, Ivona Percec, MD, PhD

From the University of Pennsylvania, Philadelphia, Pa.

PURPOSE: The majority of cosmetic plastic surgical procedures in the United States are conducted by private practitioners. The purpose of this study is to report the experience of an academic cosmetic surgical practice at the University of Pennsylvania compared with national records and determine its functionality within the surgical training framework.

METHODS: Records of all surgical and nonsurgical procedures performed by the senior author (IP) from 2010 to 2015 were reviewed. Unique procedures listed by CPT code were analyzed for trends and percent changes. Further analysis included classification of each surgical procedure by type and age for comparison with the 2014 ASAPS National Data Bank Statistics.

RESULTS: The largest cohort of patients by age group was 51 to 64 years in the academic setting as opposed to the 35 to 50 age group most likely to undergo cosmetic surgery nationwide. Neurotoxin and filler injections were overall the most prevalent procedure representing 24% to 29% of the practice. Of the ASAPS top 5 surgical procedures, abdominoplasty (33%) was most commonly performed by the senior author compared with the ASAPS statistics (15%). The most common procedure at the national level, liposuction (31%), comprised 21% of the academic cosmetic surgical practice.

CONCLUSIONS: A cosmetic surgical practice can be successfully developed at an academic institution despite national trends relegating cosmetic surgery to private practice models. Although the patient population and procedure demographics may differ from national statistics, it is critically important to retain cosmetic surgery within the academic setting for both academic practice diversity and comprehensive resident training.

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The Impact of 2 Operating Surgeons on Microsurgical Breast Reconstruction

Gretl C. Lam, BA,* Katie E. Weichman, MD,† Stelios C. Wilson, MD,* Jamie P. Levine, MD,* Robert J. Allen, MD,* Nolan S. Karp, MD,* Mihye Choi, MD,* Vishal D. Thanik, MD*

From the *New York University Langone Medical Center, New York, N.Y.; and †Montefiore Medical Center/Albert Einstein School of Medicine, Bronx, N.Y.

PURPOSE: The use of 2 operating surgeons has been employed in an effort to improve surgical efficiency and outcomes, but its impact is yet unknown. Here, we compare the outcomes of patients undergoing microsurgical breast reconstruction with 1 operating surgeon with those with 2 surgeons.

METHODS: A retrospective review identified all patients undergoing microsurgical breast reconstruction from July 2011 to January 2014 at a single academic institution. Patients were divided into 2 cohorts—those undergoing reconstruction with 1 surgeon and those undergoing reconstruction with 2 surgeons—for analysis of demographics, surgical characteristics, and outcomes.

RESULTS: A total of 157 patients underwent 248 breast reconstructions: 103 patients (170 flaps) had 2 surgeons and 54 patients (78 flaps) had 1 surgeon. Patients undergoing both bilateral and unilateral reconstructions with 2 surgeons had significantly decreased mean operating room times and lengths of stay compared with those with 1 surgeon. In addition, patients with 1 surgeon were more likely to have postoperative donor-site breakdown compared with those with 2 surgeons [6.4% (n = 4) vs 0.6% (n = 1), P = 0.01].

CONCLUSIONS: The collaborative approach of 2 operating surgeons has demonstrable effects on microsurgical breast reconstruction outcomes. The addition of a second surgeon significantly decreases operating room time and shortens hospital length of stay in both unilateral and bilateral reconstructions. It also significantly decreases donor-site wound healing complications.

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Comparison of Pain Experience after Tissue Expander Breast Reconstruction Using Either Liposomal Bupivacaine or Silastic Bupivacaine Pain Pump

Morgan Brgoch, MD, Jason Muelleck, BS, Sanjib Adhikary, MD, John Potochny, MD

From the Penn State Hershey Medical Center, Hershey, Pa.

PURPOSE: A reported national crisis of opioid overprescription and potential for abuse has prompted the need to identify effective nonopioid alternative analgesia after surgical procedures. Liposomal bupivacaine (Exparel) was recently introduced as an adjunct treatment modality for maintaining adequate postoperative analgesia. With its extended duration of action, proponents argue the potential for effective pain reduction while limiting the amount of opiates administered. In this study, we aim to determine the impact of Exparel versus a silastic bupivacaine pain pump (BPP) on postoperative outcomes in patients who underwent bilateral complete mastectomies with tissue expander breast reconstruction (TEBR).

METHODS: After institutional review board approval, we conducted a retrospective review of TEBRs performed at our tertiary care center between September 2012 and September 2015. In addition to patient demographics, data were collected on intraoperative fill volume, total opiate administration (intravenous morphine equivalent), subjective pain scores, potential surgical site infection, wound dehiscence, seroma, or hematoma. The data were evaluated using t test or chi-square analysis as appropriate.

RESULTS: Eighty-eight patients met the study inclusion/exclusion criteria; Exparel: n = 41 and BPP: n = 47. Patients receiving Exparel required significantly higher opiate administration than the BPP group (26.1 vs 18.6 mg; P = 0.006) to achieve adequate analgesia (24 hours postoperative). No significant differences were found with respect to intraoperative fill volume, patient pain scores, surgical site infection, wound dehiscence, seroma, or hematoma.

CONCLUSIONS: In comparison with BPP, patients who received Exparel required significantly higher opiate administration after bilateral mastectomies and TEBR. Subjective pain scores and rates of postoperative complications did not differ between study groups.

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A Validated Multiinstitutional Approach to Optimizing Outcomes of Reduction Mammoplasty: A Critical Analysis of 7068 Patients

Pablo A. Baltodano, MD,* M. Eliann Reinhardt, BM, BS,† Ashar Ata, PhD,* Wesley Wong, BS,* Malcolm Z. Roth, MD,* Ashit Patel, MBChB*

From the *Albany Medical Center, Albany, N.Y.; and †Johns Hopkins University, Baltimore, Md.

PURPOSE: The aim of this study is to develop a validated risk model to identify patients at high risk for postoperative surgical site morbidity (SSM) after reduction mammoplasty.

METHODS: Retrospective review was performed of all females undergoing reduction mammoplasties from the ACS-NSQIP2 2005 to 2012 data. SSM included surgical site infection and wound disruption events. Stepwise multivariable logistic regression was used to identify the risk factors associated with SSM. The model was validated using bootstrap replications (n = 100) and Hosmer-Lemeshow test. The model was converted into a clinical risk score predictive of SSM.

RESULTS: We identified 7068 reduction mammoplasties. Rate of 30-day SSM was 3.98%. Independent risk factors included resident participation [odds ratio (OR), 1.5; 95% confidence interval (CI), 1.1–2.0; P = 0.004], body mass index (for every 5 unit increase: OR, 1.3; 95% CI, 1.1–1.4; P < 0.001), smoking (OR, 1.6; 95% CI, 1.1–2.4; P = 0.014), steroid use (OR, 3.5; 95% CI, 1.4–8.4; P = 0.006), and operation in third quarter of the year (OR, 1.5; 95% CI, 1.1–1.9; P = 0.014). The factors were integrated into a clinical risk score ranging from 0 to 16. Predicted probability of SSM associated with each risk score was estimated. Predicted and observed risks of SSM were highly comparable.

CONCLUSIONS: We present the first validated risk stratification tool for predicting 30-day SSM after reduction mammoplasty using data available to the clinician.

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Nipple Resection and Reconstruction after Attempted Nipple-Sparing Mastectomy

Briar L. Dent, MD, Jerry Chao, MD, Daniel J. Eden, BS, Benjamin V. Stone, BA, Alexander Swistel, MD, Mia Talmor, MD

From the New York-Presbyterian Hospital/Weill Cornell, New York, N.Y.

PURPOSE: Occult nipple malignancy is detected in 0% to 58% of attempted nipple-sparing mastectomies (NSMs), prompting excision of the involved nipple. We report our experience with nipple resection after attempted NSM and our outcomes with subsequent nipple reconstruction.

METHODS: An institutional review board-approved retrospective review was performed of attempted NSM cases with immediate implant-based reconstruction from July 2006 to April 2015. Patients who underwent nipple excision were identified. Indications for excision, pathology reports, and reconstructive outcomes were reviewed.

RESULTS: Five hundred sixty-eight NSMs were performed in 330 patients. Thirty-four cases (6%) underwent nipple excision, 53% for positive frozen sections, 29% for positive permanent sections, 3% for clinical suspicion, and 15% either at patient request or for symmetry. All of the cases with positive frozen sections had disease on permanent section, and 56% had residual disease in the resection specimen. Of the cases with positive permanent sections, frozen sections were negative in 50%, suspicious or atypical in 30%, and not sent in 20% of cases. Thirty percent had residual disease in the resection specimen. Frozen section sensitivity was 64% (or 75% if suspicious and atypical findings are included). There were no false positive results on frozen section. Sixty-eight percent of cases have undergone nipple reconstruction by CV flap (57%), skate flap (39%), or nipple-sharing technique (4%). The aesthetic result after reconstruction was excellent in 83% of cases.

CONCLUSIONS: Our findings support the benefit of intraoperative subareolar frozen section for detection of occult disease. When nipple excision is required, patients can still achieve an excellent aesthetic result with nipple reconstruction.

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Quantitative 3D Geometry of the Aging Eyelids

Cristina A. Flores, BA, Helena O. Taylor, MD, PhD, Margaret E. Byrne, RN,* Jose A. Gonzalez, BS, Joseph L. Mundy, PhD†

From the *Warren Alpert Medical School, Brown University, Providence, R.I.; and †Vision Systems Inc, Providence, R.I.

PURPOSE: Although facial aging is a well-known phenomenon, it has not been quantitatively characterized. Current methods for measuring and assessing eyelids, which rely almost exclusively on 2D imaging, are limited. This study introduces a novel technique for capturing periorbital structures using 3D imaging and point cloud data collection. Analyses are performed to assess changes in normal eyelids with age.

METHODS: Under institutional review board approval, 46 white females were included and divided into 3 age groups: 20 to 39 years (n = 16), 40 to 59 years (n = 15), and 60+ years (n = 15). Patients were scanned with the Canfield 3D photogrammetry system, and data files were exported to the point cloud processing software CloudCompare. Superior creases and the following features were defined: the medial canthus, lateral canthus, inferior margin midpoint, superior margin midpoint, and superior crease midpoint. The manually selected points provided the basis for characterizing age effects through a fitted model and principal component analysis.

RESULTS: The visualized 3D models and principal component analysis performed across the age groups suggest the width and height of the palpebral fissure decreases, with the width decreasing more rapidly. The superior crease height diminishes with age, and the crease impinges on the superior margin. The depth of the lateral canthus relative to the medial canthus decreases with age.

CONCLUSIONS: This technique enables rigorous evaluation of the eyelid shape and how it may change over time. This series suggests age-induced changes to eyelid margin, crease, and lateral canthus positions, which have been noted anecdotally but poorly quantified until now.

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Immediate, Permanent Implant Versus Tissue Expander Reconstruction in Nipple-Sparing Mastectomy: Fewer Operative Procedures but Greater Complication Rates?

Jordan D. Frey, MD, Michael Alperovich, MD, Jamie P. Levine, MD, Mihye Choi, MD, Nolan S. Karp, MD

From the Hansjörg Wyss Department of Plastic Surgery, NYU Langone Medical Center, New York, N.Y.

PURPOSE: Optimal reconstruction techniques for nipple-sparing mastectomy (NSM) continue to be established; thus, we aim to compare outcomes with permanent implant and tissue expander (TE)-based reconstruction.

METHODS: All patients undergoing NSM were reviewed, and outcomes were compared between those who underwent permanent implant and TE-based reconstruction.

RESULTS: Of 842 NSMs, 160 and 447 underwent reconstruction with immediate, permanent implants and TEs, respectively. Age (P = 0.8988), mastectomy indication (P = 0.0991), and body mass index (P = 0.4313) were similar; however, permanent implant reconstruction patients were significantly less likely to be current or former smokers (P = 0.0176). They were more likely to have lateral inframammary fold and less likely to have lateral radial mastectomy incisions (P < 0.0001). Permanent implant size was significantly greater compared with initial TE fill volumes (P < 0.0001); permanent implant reconstruction patients had significantly more acellular dermal matrix coverage (P < 0.0001). Permanent implant reconstruction patients had significantly fewer operative reconstructive procedures (P < 0.0001) and shorter follow-up times (P < 0.0001). Permanent implant reconstruction patients had significantly more full-thickness (P = 0.0052) and partial-thickness (P = 0.0042) nipple–areola complex necrosis, explantation (P = 0.0052), and minor mastectomy flap necrosis (P < 0.0001). TE-based reconstruction patients had significantly more cellulitis requiring oral antibiotics (P = 0.0076). Other complications were similar.

CONCLUSIONS: Immediate, permanent implant-based reconstruction in NSM provides a breast with fewer operative procedures but greater rates of NAC necrosis, explantation, and mastectomy flap necrosis compared with TE-based reconstruction. This technique may still provide excellent results in appropriately selected patients.

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Lowering of the Mammary Fold Using Form-Stable Breast Implants: Lessons Learned from 185 MemoryShape Breast Implants

Aldo B. Guerra, Jr, MD,* William Gus Kortesis, MD†

From the *Guerra Plastic Surgery Center, Scottsdale, Ariz.; and †Hunstad/Kortesis Plastic Surgery Center and Medspa, Huntersville, N.C.

PURPOSE: MemoryShape breast implants offer plastic surgeons the opportunity to achieve good results with breast augmentation. However, these implants are associated with a steep learning curve. Inframammary fold lowering is the most challenging step with this operation. The focus of the study is on proper patient selection, preoperative planning, and execution of the procedure with an emphasis on fold lowering.

METHODS: The study was carried out by 2 experienced plastic surgeons. One hundred eighty-five patients underwent breast augmentation in a prospective study. A preoperative plan was established before surgery. When lowering of the fold was carried out, it was done using a standardized protocol.

RESULTS: The results demonstrate that 74.8% of patients required lowering of the fold. In a total of 25.2% of the patients, breast augmentation was done without any fold lowering. In patients requiring fold drop, the average distance was 1.13 cm. The median volume used in this study was 375 ml. The most common implant used were MM+ (43%) and MM (34%). The overall complication rate was 24.6%. There were no cases of rotation postoperatively.

CONCLUSIONS: Breast augmentation using MemoryShape breast implants is an excellent operation with a high satisfaction rate. This study offers a greater understanding of the relationship of the nipple-to-fold distance, implant shape and size selection, and mammary fold lowering. On the basis of these results, we believe that up to a quarter of the patient population can be appropriate candidates for MemoryShape breast implants without the need to lower the fold.

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Crowdsourcing as a Novel Method for the Evaluation of Postoperative Outcomes in Unilateral Cleft Lip Repair

Eugene Oh, MD, PhD,* Raymond Tse, MD†

From the *University of Washington, Seattle, Wash.; and †Seattle Children’s Hospital, Seattle, Wash.

PURPOSE: Lack of convenient and reliable methods to grade esthetic outcomes limits the ability to study results and optimize treatments. Crowdsourcing involves soliciting contributions from a large group to achieve a greater task. We hypothesized that crowdsourcing could be used to reliably grade esthetic outcomes after unilateral cleft lip repair.

METHODS: Fifty deidentified photographs of 8- to 10-year-old subjects were used (46 unilateral cleft lip repairs and 4 controls). Crowds performed pairwise comparisons of the sample set to produce a rank order for nasal appearance. N = 50 comparisons per image was used to generate ELO scores for ranking. Asher-McDade scores were obtained for each subject (n = 38). Two distinct surveys of each method were conducted. In addition, expert surgeons were asked to perform the same tasks on a smaller set.

RESULTS: Two thousand five hundred anonymous layperson comparisons were obtained within 2 to 4 hours for each round. Rank order was reproducible with a correlation coefficient of 0.892. Greater than 1900 Asher-McDade scores were generated within 2 hours and showed excellent interrun consistency (correlation coefficient = 0.988). Comparing ELO rank and Asher-McDade score showed strong correlation of −0.920. Furthermore, Crowdsourced data correlated well to expert assessments with correlation coefficients of 0.931 (ELO score) and 0.950 (Asher-McDade score). Expert analysis required months and ultimately was not fully completed.

CONCLUSIONS: Large numbers of layperson assessments generated aggregate rankings and ratings of esthetic outcomes that were highly reliable and correlated well to expert assessments. Despite smaller sample set, data collection took much longer for our expert cohort. Crowdsourcing is a convenient, rapid, and reliable means to assess postoperative outcomes.

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Anaplastic Large-Cell Lymphoma: Emerging Beliefs and Management Patterns among Board-Certified Plastic Surgeons

Kenneth L. Fan, MD,* Megan A. Rudolph, BA,† Troy Pittman, MD*

From the *MedStar Georgetown University Hospital, Wash.; and †George Washington University School of Medicine, Wash.

PURPOSE: Our study seeks to examine plastic surgeon practice patterns in relation to ALCL, given its increasing discourse in the literature.

METHODS: A 19-question survey was sent electronically to US surgeons and International Board-Certified Plastic Surgeons. Data were analyzed using chi-square test.

RESULTS: One thousand three hundred eighty-three surgeons (United States: 702 and International: 681) responded at a rate of 13.5%. Of the 62.1% of surgeons who aspirate late seroma fluid, 27.8% do not send for cytology. Only 36.6% physicians include ALCL risk in informed consent with 25.7% counseling on the topic. Physicians were twice as likely to consent with personal [P < 0.05; odds ratio (OR), 1.930] or colleague (P < 0.05; OR, 1.952) experience with ALCL. Plastic surgeons from Australia and United Kingdom (P < 0.05; OR, 1.916) are twice as likely to consent about ALCL compared with US counterparts. Physicians who aspirate and send for cytology were over twice as likely to include ALCL in consent (P < 0.05; OR, 2.628). Those using textured implants are more likely to counsel on ALCL risk (P < 0.05; OR, 1.318). Ten percent respondents had ALCL cases, equating to 193 cases.

CONCLUSIONS: Twenty-eight percent of surgeons are not sending fluid from a late seroma for cytology, deviating from Food and Drug Administration guidelines. Personal or colleague experience and use of textured implants make one twice as likely to include ALCL in the consent and preoperative consultation, respectively. Those who are more informed of diagnostic workup are more likely to consent their patients about ALCL. ALCL cases are likely being underreported.

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Posterior Vault Distraction and Osteogenesis: A Single Institution’s Experience

Jing Li, MD, Wen Xu, BS, Patrick Gerety, MD, Scott Bartlett, MD, Jesse Taylor, MD

From the Children’s Hospital of Philadelphia, Philadelphia, Pa.

PURPOSE: There is growing literature on the advantages of posterior cranial vault distraction (PVDO) in treating syndromic craniosynostosis. This study aims to describe our institution’s evolving use of PVDO.

METHODS: A prospective craniofacial database of patients was queried for cases involving PVDO from 2009 to 2015. An age of 5 years or older was used to distinguish older from younger subjects. Demographic, perioperative, and distraction data were collected. Older and younger groups were compared using a Wilcoxon rank-sum and Fisher’s exact tests.

RESULTS: Forty-two cases met inclusion criteria with 93.8% involving syndromics and 31% with previous craniofacial surgery. Average age was 3.1 years with a range of 0.3 to 14.1 years. Average duration of distraction was 25.5 days with 26.4 mm distracted. Complications occurred in 21.4%, whereas 19% required immediate postoperative blood transfusion. Resolution of symptoms was found in 95.2% in short-term follow-up. Reported cases were followed up by further craniofacial reconstruction in 52.3%. Statistically, the older group had less weight-based blood loss (P = 0.0007) and transfusion volumes (P = 0.0001), as well as shorter follow-up (P = 0.0288).

CONCLUSIONS: PVDO is a safe and efficacious method of cranial vault expansion in children with craniosynostosis, with similar perioperative outcomes in older and younger patients. Future work will focus on optimization of timing of surgery and the ways to decrease perioperative morbidity.

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A New Flap Design for Oncoplastic Breast Reconstruction: Perforator-Based Inferior Pole Island Flap

Mark G. Albert, MD, Eleanor R. Goldwasser, MD, Ashling O’Connor, MD, Robert M. Quinlan, MD, Mustafa Akyurek, MD, PhD

From the University of Massachusetts, Worcester, Mass.

PURPOSE: The use of breast conservation therapy for isolated tumors is increasing in popularity. The lower pole of the breast has been emphasized as a flap donor site. However, limited flap mobility may be a shortcoming particularly for upper pole defects. This study presents the perforator-based inferior pole island flap for reconstruction of lumpectomy defects.

METHODS: Sixteen cadaver breasts were infused with latex to evaluate internal mammary artery perforators and delineate vascular supply of the inferior pole of the breast. In 14 patients, upper pole defects were reconstructed with the medially based perforator flap of the lower pole.

RESULTS: Anatomic study revealed that the inferior pole island flap was consistently supplied by the lower IMA perforators at an average of 8.5 cm from the midline in the fourth interspace and 3cm from the midline in the fifth interspace. Clinical experience demonstrated uneventful flap survival in all the cases. One patient developed a postoperative hematoma, and 2 patients required mastectomy for positive margins.

CONCLUSIONS: This study introduces the perforator-based inferior pole island flap. It is a new design to utilize the lower pole of the breast, with reliable vascularity and unrestricted mobility, to reconstruct lumpectomy defects of the entire upper aspect of the breast. Furthermore, the use of a separate superomedial pedicle flap, along with the described lower pole flap, allows for a refined reconstruction of the breast.

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Phenotypic Norms for Unilateral Cleft Lip Preoperatively and Postoperatively: A Large-Scale, Multicultural Study of Facial Morphology and Severity

Caroline A. Yao, MD, MS,*† Jordan Swanson, MD,†‡ Thomas Imahiyerobo, MD,§ Allyn Auslander, MPH,*† Diego F. De Cardenas, DDS, PhD,¶ Melinda Costa, MD,† Jane C. Figueiredo, PhD,‖ Richard Vanderburg, RN, BSN,¶ William P. Magee III, MD, DDS*†

From the *Division of Plastic and Reconstructive Surgery, University of Southern California Keck School of Medicine, Los Angeles, Calif.; †Children’s Hospital Los Angeles, Los Angeles, Calif.; ‡Division of Plastic and Reconstructive Surgery, Children’s Hospital Los Angeles, Los Angeles, Calif.; §Division of Plastic and Reconstructive Surgery, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, N.Y.; ¶Operation Smile International, Virginia Beach, Va.; and ‖Institute of Global Health, Keck School of Medicine of the University of Southern California, Los Angeles, Calif.

PURPOSE: Unilateral cleft lip has a spectrum of disease, and qualitative assessments of the deformity are often utilized because of a lack of objective data. We define the norms and variability of unilateral cleft lip morphology and surgical results across multiple ethnicities.

METHODS: Anthropometric measurements and standardized photographs were prospectively collected in Morocco, Bolivia, Vietnam, and Madagascar during medical missions. Symmetry was analyzed using cleft side/noncleft side ratios of nostril width, philtral height, and horizontal vermillion length. Standardized cleft width was calculated by dividing the preoperative cleft width by commissure width. Two experienced cleft surgeons and 2 laypeople subjectively ranked photographs based on degree of deformity.

RESULTS: One hundred forty-nine patients were analyzed. Nasolabial symmetry significantly improved from preoperatively to postoperatively for all measurements [P < 0.001, mean (SD)]: columellar angle [65 (SD = 17) to 87 (SD = 8) degrees], nostril width ratio [1.7 (SD = 0.68) to 1.0 (SD = 0.22)], philtral height ratio [0.8 (SD = 0.14) to 1.0 (SD = 0.14)], and lip length ratio [0.9 (SD = 0.26) to 1.0 (SD = 0.11)]. Mean preoperative cleft width ratio was 0.4 (SD = 0.12). As preoperative ratios became more asymmetrical, postoperative results varied more widely. All measurements were normally distributed and did not differ between each country (P > 0.05). Surgeon and layperson rankings showed high interrater reliability [Cronbach α (preoperatively and postoperatively) = 0.97 and 0.87, respectively]. Preoperatively, multivariate regression showed that cleft width ratio, nostril width ratio, and philtral height ratio were predictive of rank (P < 0.01, P < 0.01, and P = 0.02). Postoperatively, multivariate regression showed that philtral height ratio was most predictive of rank (P < 0.001).

CONCLUSIONS: Unilateral cleft lip deformities have a similar morphology across multiple ethnicities. Postoperative philtral height symmetry best correlated with perceptions of postoperative deformity/outcome.

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Nasal Septal Anatomy in Skeletally Mature Patients with Cleft Lip/Palate

Christopher M. Runyan, MD, PhD, Jonathan P. Massie, BS, Marleigh J. Stern, BA, Michael Alperovich, MD, David A. Staffenberg, MD, Roberto L. Flores, MD

From the New York University, New York, N.Y.

PURPOSE: Septal deviation commonly occurs in patients with cleft lip and palate (CL/P); however, the contribution of the cartilaginous and bony septum to airway obstruction in skeletally mature patients is poorly understood.

METHODS: This study compares facial cone beam computed tomography scans of skeletally mature CL/P patients with that of age-matched controls. Septal deviation was measured in 3 coronal sections: the cartilaginous septum [anterior nasal spine (ANS)], bony septum (posterior nasal spine), and midpoint between the ANS and the posterior nasal spine (MID). Stenosis was defined as the smallest distance between nasal septum and lateral nasal wall. Perpendicular plate of the ethmoid and vomer displacement were measured as angles from vertical at the coronal slice of maximal septal deviation. Comparisons between groups were made using Student’s t test. Stepwise multivariable linear regression was used to compare septal deviation with stenosis. Statistical significance was held at P < 0.05.

RESULTS: Twenty-four CL/P patients and 16 age-matched controls were identified for the study. Septal deviation (a) and stenosis (b) were significantly increased at all 3 sections in CL/P patients compared with controls. The vomer, but not plate of the ethmoid, was significantly displaced from vertical (c). The severity of vomerine deviation (d) predicted the obstruction at the ANS.

CONCLUSIONS: Skeletally mature CL/P patients have significant septal deviation involving both cartilage and bone. Resection of the bony and cartilaginous septum should be considered at the time of definitive cleft rhinoplasty.

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Childbearing Experiences and Perceptions during Residency Training: A Comparative Study

Minh-Bao Mundschenk, MD, Susan E. Mackinnon, MD, Marissa M. Tenenbaum, MD

From the Washington University in St. Louis, St. Louis, Mo.

PURPOSE: Despite the increasing number of women entering medicine, most surgical residency programs are for predominantly men. Furthermore, female residents are increasingly becoming pregnant during residency. This study characterized the childbearing experience during residency at a single institution and compared the perceptions of childbearing between genders, medical subspecialties, and trainees over time.

METHODS: A 75-item survey was distributed to current resident physicians in the Departments of Surgery, Medicine, Anesthesia, Orthopedics, and Neurosurgery at Washington University in St. Louis, Mo. Responses were collected anonymously, analyzed, and compared with results obtained from female residents in 2008.

RESULTS: In 2015, 94 responses were collected. Among all female residents, 33.3% residents ranked their program higher because of the presence of residents who had been pregnant; similarly, 41.7% did so because of the presence of female faculty. A total of 45.2% of men and 65% of women perceived a negative stigma regarding pregnancy. Only 7.9% of women and 10% of men felt unfairly burdened by pregnant residents. Across medical specialties, most respondents felt that their faculty supported pregnancy during residency. Marital status and time considerations were the main factors in childbearing decisions for nonpregnant women; this was also true in 2008. Marital status was the main factor for women who became pregnant and men, whereas in 2008, age was the greatest factor for women who became pregnant.

CONCLUSIONS: Numerous factors affect childbearing decisions, and the importance of these factors has changed over time. Most trainees perceive a negative stigma concerning pregnancy despite reporting evenly distributed workload and faculty support.

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The Extended Pedicle Anterolateral Thigh Flap and Its Application in Scalp Reconstruction

Gregory A. Lamaris, MD, PhD, Rebecca Knackstedt, MD, PhD, Nasim Abedi, BSc, MD, Brian Gastman, MD

From the Cleveland Clinic Foundation, Cleveland, Ohio.

PURPOSE: Large soft-tissue defects of the scalp can present difficulties in reconstruction. The ideal flap for scalp reconstruction has yet to be described although the latissimus dorsi flap is frequently referred to as the first choice for reconstruction in this setting.

METHODS: After institutional review board approval, we reviewed our experience in scalp, maxillary, and base of skull microsurgical reconstruction in the past 4 years. Patient demographics, indication for reconstruction, flap choice, complications and long-term outcome were recorded.

RESULTS: A total of 24 patients underwent anterolateral thigh free flap reconstruction for maxillary and base of skull as well as scalp coverage. In the majority of cases, the indication for reconstruction was resection of a cutaneous malignancy. In most cases, the facial artery and vein were used for anastomosis, whereas the superficial temporal vessels were used only in 2 cases. None of the cases required the use of vein grafts to increase pedicle length. One of 24 flaps failed and required salvage reconstruction with a latissimus dorsi flap.

CONCLUSIONS: The anterolateral thigh flap can emerge as a viable alternative to the latissimus dorsi flap in scalp reconstruction, obviating the need for vein grafting even when the proximal neck vessels are used as the recipient targets. The anterolateral thigh flap can provide a durable skin island that can withstand adjuvant radiation and can simplify monitoring for tumor recurrences. This is the first study highlighting the ALT flap as a bone fide alternative to the LD in scalp reconstruction.

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Tissue Expansion for Single-Stage Ear Reconstruction Using Hyaluronic Acid Filler: A Novel Concept for Difficult Areas

Amir Inbal, MD,* Benjamin T. Lemelman, MD,* Eran Millet, MD,† Andrew Greensmith, MD†

From the *University of Chicago Section of Plastic and Reconstructive Surgery, Chicago, Ill.; and †Melbourne Institute of Plastic Surgery, Malvern, Australia.

PURPOSE: Auricular reconstruction is one of the most challenging procedures in plastic surgery. An adequate skin envelope is essential for cartilage framework coverage, yet few good options exist without additional surgery. We propose a novel method for minimally invasive tissue expansion using hyaluronic acid (HA) filler to allow for single-stage ear reconstruction.

METHODS: Macrolane is a large particle biphasic HA gel, composed of stabilized HA of nonanimal origin developed for volume restoration and soft-tissue contouring. Off-label expansion of the nonhair-bearing mastoid skin is performed in clinic weekly or every other week. Average expansion is 2 ml per session. Patients undergo assessments of skin color, thickness, pliability, capillary refill, tightness, and tenderness before, during, and after each session. Final expansion is performed 1 week before surgery. In addition, tissue from one patient’s expanded pocket was sent for histological analysis using hematoxylin and eosin stain.

RESULTS: Ten patients underwent single-stage auricular reconstruction with preoperative expansion. Mean total number of sessions was 9.70. Mean injected volume per session was 2.03 ml per patient, for an average total of 19.8 ml. No complications related to Macrolane occurred. One minor complication was seen 1 year postoperatively related to exposed wire. Hematoxylin and eosin stain revealed similar histology to that seen with traditional expanders.

CONCLUSIONS: This novel expansion technique using serial Macrolane injections allowed for optimized skin coverage of the costal cartilage framework in single-stage ear reconstruction. Future studies should explore tissue expansion of other difficult areas using this technique.

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In Vitro Characterization of Phenotype, Genotype, and Clonogenic Properties and Tolerogenic Potential of Human Hematopoietic Chimeric Cells: A Novel Strategy for Tolerance Induction in Transplantation

Ewa Bryndza Tfaily, PhD, Joanna Cwykiel, MSc, Maria Siemionow, MD, PhD, DSc

From the University of Illinois at Chicago, Chicago, Ill.

PURPOSE: Cellular therapies represent a new approach for tolerance induction that could reduce negative impact of life-long immunosuppression. The aim of this study was to create and characterize human hematopoietic chimeric cells (HHCCs) as novel tolerogenic approach for VCA transplantation.

METHODS: Twenty ex vivo fusions were performed to create HHCC. Briefly, CD34+ cells isolated from 2 unrelated bone marrow donors were stained separately by PKH26 and PKH67 and fused with polyethylene glycol. Double PKH26- and PKH67-stained cells were sorted out and subjected to further analysis. Flow cytometry (CD34, CD133, CD117, CD90, CD4, CD19, and CD14 markers; proliferation; and viability assays), confocal microscopy, PCR-rSSOP, STR, fluorescence in situ hybridization, CFU assays, and real-time polymerase chain reaction were used to characterize HHCC.

RESULTS: Flow cytometry and confocal microscopy analysis confirmed CD34+ cell fusion. PCR-rSSOP and STR results showed that HHCC share human leukocyte antigen and STR alleles specific for both fusion donors. After fusion, approximately 99% of HHCCs were viable with low level of apoptosis (2.7% and 1.2% of HHCC in early and late stages of apoptosis, respectively). HHCC increased 6-fold after 7-day culturing. HHCC expressed all assessed markers. The percentage of polyploid cells within HHCC was low (0.48%). HHCC differentiated into all classes of myeloid and erythroid progenitor cells. HHCCs have tolerogenic potential as they express protolerogenic T helper 2 cytokines.

CONCLUSIONS: We confirmed the feasibility of ex vivo HHCC creation. We characterized phenotype, genotype, and clonogenic properties and tolerogenic potential of HHCC. Application of HHCC as a supportive therapy represents a novel approach for tolerance induction in VCA transplantation.

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Risk Stratification of Incisional Hernia after Bariatric Surgery: Guiding Patient Selection for Prophylactic Mesh Augmentation Based on 2161 Operations

Marten N. Basta, MD,* Michael N. Mirzabeigi, MD,† Valeriy Shubinets, MD,† Jeffrey A. Drebin, MD, PhD,† Joseph M. Serletti, MD,† Stephen J. Kovach, MD,† John P. Fischer, MD, MPH†

From the *Brown University, Rhode Island Hospital, Providence, R.I.; and †University of Pennsylvania Health System, Philadelphia, Pa.

PURPOSE: Incisional hernia (IH) is a persisting cause of morbidity, diminished quality of life, and healthcare costs. Literature suggests that prophylactic mesh reduces IH risk in bariatric surgery, but predictive models are not available. This study aimed to identify factors associated with IH after bariatric surgery to develop a clinically actionable risk stratification tool to optimize outcomes and mitigate healthcare costs after bariatric surgery.

METHODS: Patients undergoing open or laparoscopic bariatric surgery from January 1, 2005 to January 6, 2013, at 1 institution were identified. Comorbidities and operative characteristics were assessed. The primary outcome was surgically treated IH after index procedures. Patients with previous hernia, <1 year follow-up, or body mass index < 40 kg/m2 were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance were conducted.

RESULTS: Two thousand one hundred sixty-one bariatric patients were included, and 2.4% developed a surgically treated IH (follow-up, 28.3 ± 25.4 months). Predictors for IH included open approach [hazard ratio (HR) = 10.3], malnutrition (HR = 3.10), previous abdominal surgery (HR = 2.89), and body mass index > 60 kg/m2 (HR = 2.60). Patients were stratified into low-, moderate-, and high-risk groups for IH. A total of 15.2% of high-risk patients developed IH versus 0.6% of low-risk patients (C-statistic = 0.85). IH and associated complications exceeded $3.5 million in costs.

CONCLUSIONS: Bariatric surgery conferred a 2.4% IH risk, which led to more readmissions, complications, and substantially greater healthcare resource utilization. This risk tool allows identification of candidates for prophylactic mesh augmentation to optimize outcomes and mitigate costs.

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One-Stage Functional Composite Reconstruction of Limb-Sparing Sarcoma Resections

John T. Stranix, MD,* Z-Hye Lee, MD,* Gretl Lam, BS,* Timothy Rapp, MD,† Pierre B. Saadeh, MD*

From the *Wyss Department of Plastic Surgery and †Department of Orthopedic Surgery, New York University Langone Medical Center, New York, N.Y.

PURPOSE: Innervated muscle transfer can improve functional outcomes after extensive limb-sparing sarcoma resections. We report our experience using composite anterolateral thigh (ALT) flaps with plicated iliotibial band (ITB) for static stability and motorized vastus lateralis (VL) for functional reconstruction of large oncologic extremity defects.

METHODS: Retrospective chart review identified 4 patients who underwent limb-sparing sarcoma resection with immediate functional reconstruction. Patient demographics, treatment, and outcomes were examined.

RESULTS: Follow-up ranged from 14 to 36 months, and all patients demonstrated VL motor innervation by 6 months. At 12 months, motor strength ranged from 2 to 4/5, active range of motion was 25% to 92% of normal, and MSTS scores were between 21 and 26/30.

CONCLUSIONS: The composite ALT/VL flap demonstrated a number of advantages for functional reconstruction of limb-sparing sarcoma resections: (1) Generous soft tissue for coverage, long pedicle length, and large caliber vessels. (2) VL meets the functional requirements for ambulation. (3) ITB allows for in-line ligament/tendon reconstruction. (4) ITB provides static musculoskeletal stabilization. (5) Minimal donor-site morbidity and avoids sacrificing trunk muscles important in patient transfer. (6) Does not require intraoperative repositioning for flap harvest allowing a 2-team approach that minimizes operative time. Limb-sparing techniques for upper and lower extremity sarcomas continue to evolve. Our experience has validated the ALT/ITB/VL free flap as an excellent option for 1-stage functional reconstruction of large limb defects.

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Disarticulation and Total Thigh Flap as a 1-Stage Procedure for the Treatment of Complex End-Stage Pressure Ulcers in Spinal Cord Injury Patients: A 20-Year Retrospective Review

Lilian C. Azih, MD, Lori Aliksanian, MD, Salah Rubayi, MD

From the Division of Plastic and Reconstructive Surgery, Rancho Los Amigos National Rehabilitation Center, Downey, Calif.

PURPOSE: Extensive recurrent stage IV end-stage pressure ulcers present a unique reconstructive challenge to the plastic surgeon in spinal cord injury (SCI) patients. For the extreme complex end-stage cases when all other flap options have been exhausted, a hip disarticulation with total thigh flap may be the only reconstructive option.

METHODS: We conducted a retrospective review over 20 years on 35 patients with SCI with chronic recurrent end-stage stage IV pressure ulcers between 1991 and 2014. All patients underwent excision of the primary pressure ulcer with immediate total thigh flap reconstruction.

RESULTS: Thirty-five patients underwent hip disarticulation with immediate total thigh flap for recurrent chronic trochanteric, sacral, perineal, ischial, and pelvic stage IV pressure ulcers. Sixteen patients developed intraoperative and postoperative complications, which included intraoperative blood loss and superficial flap dehiscence. Fourteen of the patients with superficial flap dehiscence were salvaged with local wound care alone with 2 patients needing revision for surgical correction.

CONCLUSIONS: Total thigh flap is a lifesaving procedure in the SCI patient with multiple recurrent ulcers involving the perineum and pelvis. With limited reserve of muscle and skin in the lower extremity and pelvis, total thigh flap is a viable option to create soft tissue padding over the bony structures left in the pelvis in the SCI patient with proper patient selection and preoperative urinary and bowel diversion. Our study demonstrates that total thigh flap in SCI patients with complex end-stage perinoeopelvic ulcers heal well and resume wheelchair sitting with overall improved quality of life.

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Dental Arch Relationships after BMP-2 Versus Non-BMP-2 Alveolar Cleft Repairs

Jeremy A. Goss, BA,* Lawrence A. Rudolf, BS, BA,* Richard O’Brien, DDS,† Margie S. Hunter, BS,* Eric S. Armbrecht, PhD,‡ Ross E. Long, Jr., DMD, MS, PhD,§ Alexander Y. Lin, MD*

From the *Saint Louis University School of Medicine, St. Louis, Mo.; †Center for Advanced Dental Education - Saint Louis University, St. Louis, Mo.; ‡Saint Louis University Center for Outcomes Research, St. Louis, Mo.; and §Lancaster Cleft Palate Clinic, Lancaster, Pa.

PURPOSE: A former surgeon at our institution frequently used bone morphogenetic protein-2 (BMP-2) instead of autograft for alveolar bone reconstruction. Goslon Yardstick scores (GS) and maxillary intermolar distances (IMDs) were used to compare dental arch relationships between patients who underwent BMP-2 [BMP-yes (BY)] versus non-BMP-2 alveolar bone reconstruction [BMP-no (BN)].

METHODS: Four raters evaluated all preorthodontic treatment dental casts available using the GS and IMDs from the mesial buccal cusps of the maxillary first molars. Data were averaged and analyzed by BMP-2 exposure history, age at alveolar surgery, and time between cast and surgery. A general linear model was used for analysis.

RESULTS: Primary dentition (0–6 years) number of patients: BY, 36; BN, 8. Age alveolar surgery: BY, 2.0; BN, 3.4; P = 0.164. GS: BY, 3.12; BN, 3.60; P = 0.291. IMD: BY, 41.84; BN, 43.92; P = 0.303. Mixed dentition (6–13 years) number of patients: BY, 6; BN, 10. Age alveolar surgery: BY, 8.5; BN, 10.0; P = 0.042. GS: BY, 4.48; BN, 3.21; P = 0.061. IMD: BY, 43.75; BN, 41.68; P = 0.536. When combined, total number: BY, 42; BN, 18. Age alveolar surgery: BY, 2.9; BN, 7.1; P < 0.001. Follow-up time (date cast − date alveolar surgery): BY, 6.3; BN, 2.9; P = 0.001. GS: BY, 3.32; BN, 3.38; P = 0.850. IMD: BY, 42.11; BN, 42.67; P = 0.695. Analysis of covariance controlling for follow-up time showed adjusted means GS: BY, 3.35; BN, 3.30; P = 0.896. IMD: BY, 41.63; BN, 43.80; P = 0.184.

CONCLUSIONS: In patients for whom BMP-2 was used for alveolar cleft repairs, postoperative dental arch relationships do not appear to be significantly different from non-BMP-2 alveolar surgeries as evidenced by averaged GS and maxillary IMDs.

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Midcarpal and STT Arthritis in Patients with CMC Arthritis

Evan B. Katzel, MD, Dierde Bielicka, MD, John Fowler, MD, Glenn A. Buterbaugh, MD, Joseph E. Imbriglia, MD

From the University of Pittsburgh Medical Center, Pittsburgh, Pa.

PURPOSE: A segment of the population undergoing carpometacarpal (CMC) arthroplasty will continue to have pain after surgery. The authors hypothesize that unrecognized midcarpal (capitolunate) arthritis may contribute to persistent pain after CMC arthroplasty. The prevalence of midcarpal arthritis in patients with basal joint arthritis is unknown. The purpose of this study is to establish the radiographic prevalence of midcarpal arthritis in patients with CMC arthritis and/or scaphotrapezotrapezoid (STT) arthritis.

METHODS: Patients with CMC arthritis were identified from a billing search using International Classification of Diseases 9 code 716.94. Hand radiographs were graded using the Eaton classification and Sodha classification for CMC arthritis. STT arthritis and midcarpal arthritis were graded using the Sodha classification for arthritis as follows: grade 1: no or nearly no arthrosis, grade 2: definite arthrosis but not severe, and grade 3: severe arthrosis.

RESULTS: Eight hundred ninety-six AP x-rays were reviewed. At the CMC joint, the average Eaton score was 3.14 ± 0.03 (mean ± SEM), and the average Sodha score was 2.51 ± 0.02. The prevalence of STT arthritis was 64%, and the mean Sodha score at the STT joint was 1.90 ± 0.03. The prevalence of midcarpal arthritis was 24%, and the mean Sodha score at the midcarpal joint was 1.30 ± 0.02.

CONCLUSIONS: The prevalence of midcarpal arthritis in patients with CMC arthritis is 24%. The presence of 2 locations of arthritis may explain persistent hand and wrist pain in this population despite CMC arthroplasty. Clinically, these data will allow hand surgeons to better educate patients with CMC and midcarpal arthritis regarding the possibility of incomplete pain relief following CMC arthroplasty.

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Optimizing Patient Outcomes: A Multidisciplinary Evidence-Based Approach to Abdominal Wall Reconstruction

Ronald E. Hoxworth, MD, Ronnie A. Pezeshk, MD, Benson J. Pulikkottil, MD, Nathaniel E. Schaffer, PhD, Steven Mapula, MD, Heather D. Conover, RN, Robert V. Rege, MD, Jeffrey M. Kenkel, MD

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Tex.

PURPOSE: Complex abdominal wall reconstruction in the modern age of the affordable care act presents a formidable challenge to the surgeon. The future of medicine will necessitate a multidisciplinary approach to justify the treatment of many complex medical issues including abdominal wall reconstruction. In this article, we outline our approach to complex abdominal wall reconstruction and demonstrate improved outcomes when utilizing a multidisciplinary approach.

METHODS: A retrospective analysis was carried out on patients who presented for open abdominal hernia repair performed by a single surgeon. Two groups of patients were compared: 1 arm consisted of 100 randomly selected patients who underwent an “optimized” treatment program, which is described in the Discussion section, and the other arm consisted of 100 randomly selected “nonoptimized” patients who underwent hernia repair before the implementation of the structured multidisciplinary program.

RESULTS: The number of patients suffering a recurrent hernia was significantly reduced among optimized patients with the recurrence rate falling from 28% to 12% with optimization (P < 0.01).

CONCLUSIONS: A multidisciplinary team of specialists employing an evidence-based plan of care can identify risk factors, create standardized protocols, and optimize patient outcomes. Standardized care increases efficiency, patient safety, and resource utilization, and the Abdominal Wall Reconstruction Program described provides objective data in support of this evidence-based approach to healthcare.

© 2016 American Society of Plastic Surgeons