Showing papers in "Plastic and Reconstructive Surgery in 2011"
TL;DR: The origin of levels of evidence, their relevance to the EBM movement and the implications for the field of plastic surgery as well as the everyday practice of plastic Surgery are focused on.
Abstract: As the name suggests, evidence-based medicine (EBM), is about finding evidence and using that evidence to make clinical decisions. A cornerstone of EBM is the hierarchical system of classifying evidence. This hierarchy is known as the levels of evidence. Physicians are encouraged to find the highest level of evidence to answer clinical questions. Several papers published in Plastic Surgery journals concerning EBM topics have touched on this subject. 1–6 Specifically, previous papers have discussed the lack of higher level evidence in PRS and need to improve the evidence published in the journal. Before that can be accomplished, it is important to understand the history behind the levels and how they should be interpreted. This paper will focus on the origin of levels of evidence, their relevance to the EBM movement and the implications for the field of plastic surgery as well as the everyday practice of plastic surgery.
1,326 citations
TL;DR: Clinical and mechanistic data support use of hyperbaric oxygen for a variety of disorders, but further work is needed to clarify clinical utility for some disorders and to hone patient selection criteria to improve cost efficacy.
Abstract: Background
This paper outlines therapeutic mechanisms of hyperbaric oxygen therapy (HBO2) and reviews data on its efficacy for clinical problems seen by plastic and reconstructive surgeons.
419 citations
TL;DR: Characteristic indocyanine green lymphography patterns are consistent and correlate with clinical severity, and supported the generation of a novel anatomical lymphedema severity staging system, the dermal backflow staging system.
Abstract: Background:Indocyanine green lymphography has been a highly useful modality in the clinical examination and surgical management of patients with lymphedema. No formal classification system of indocyanine green imaging findings according to the severity of lymphedema exists, however. The purpose of t
335 citations
TL;DR: The low incidence of capsular contracture supports the growing body of evidence that human acellular dermal matrix–assisted direct-to-implant breast reconstruction following mastectomy is safe and reliable, with a low overall long-term complication rate.
Abstract: Background:The advent of skin- and nipple-sparing mastectomy in conjunction with the use of human acellular dermal matrix to provide lower pole coverage has made direct-to-implant immediate breast reconstruction following mastectomy feasible. The purpose of this study was to evaluate long-term compl
314 citations
TL;DR: Immediate single-stage implant reconstruction using acellular dermal matrix offers a cost-effective reconstruction with a low complication rate and may be the procedure of choice in select patients.
Abstract: Background:Immediate single-stage direct-to-implant breast reconstruction with acellular dermal matrix optimizes aesthetics by preserving the mastectomy skin envelope. The authors report trends, early complications, and costs.Methods:A retrospective review of three surgeons' experience was performed
285 citations
TL;DR: Optizing the inframammary fold with acellular dermal matrix creates a superior aesthetic result and is associated with less capsular contracture and mechanical shift and improvement in the infamammary Fold appearance, without increasing postoperative complications.
Abstract: Background:Acellular dermal matrix is frequently used in implant-based breast reconstruction to cover the inferior aspect of the breast pocket. Its performance profile remains equivocal. The authors studied whether adding it in implant-based immediate breast reconstruction improved outcomes when com
284 citations
TL;DR: The arm dermal backflow stage, based on indocyanine green lymphographic findings, is a simple severity staging system that demonstrates a significant correlation with clinical stage.
Abstract: Background:Management of arm lymphedema following breast cancer treatment is challenging, and emphasis should be put on early diagnosis and prevention of secondary lymphedema. Indocyanine green lymphography is becoming a method of choice for evaluation of lymphedema.Methods:Twenty patients with seco
271 citations
TL;DR: The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients, indicating that the leg dermal backflow stage allows early diagnosis of secondaryLower Extremity lyMPhedema even in a subclinical stage.
Abstract: BACKGROUND Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy. METHODS Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage. RESULTS Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n=19) and limbs without them (n=9): age, 51.4±15.3 years versus 34.8±12.7 years (p=0.007); body weight, 75.1±7.9 kg versus 50.1±5.3 kg (p=0.012); body mass index, 23.1±4.2 versus 19.7±1.8 (p=0.005); leg dermal backflow stage of asymptomatic limb, 1.2±0.4 versus 0.0±0.0 (p<0.001); and leg dermal backflow stage of symptomatic limb, 3.5±0.6 versus 2.8±0.8 (p=0.033). CONCLUSIONS The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, V.
245 citations
TL;DR: Lipofilling after breast cancer treatment leads to a low complication rate and does not affect radiologic follow- up after breast-conserving surgery, and a prospective clinical registry including high-volume multicenter data with a long follow-up is warranted to demonstrate the oncologic safety.
Abstract: Background:Lipofilling is now performed to improve the breast contour, after both breast-conserving surgery and breast reconstruction. However, injection of fat into a previous tumor site may create a new environment for cancer and adjacent cells. There is also no international agreement regarding l
232 citations
TL;DR: The use of acellular dermal matrix in two-stage expander/implant reconstruction offers a safety profile similar to that of standard submuscular techniques, and offers the advantage of a more rapid reconstruction with less need for manipulation of the prosthetic through filling.
Abstract: Background:The use of acellular dermal matrix to assist in two-stage expander/implant breast reconstruction has increased over recent years. However, there are questions regarding the potential for increased morbidity when using these techniques relative to standard submuscular coverage techniques.
228 citations
TL;DR: It is demonstrated that radiotherapy during tissue expansion may compromise the outcome of implant-based breast reconstruction in patients with locally advanced breast cancer.
Abstract: Background:The therapeutic role of postmastectomy radiation therapy has been demonstrated both in locally advanced breast cancer and in other high-risk conditions. Implant-based breast reconstruction for irradiated patients can generate higher complication rates. In this study, the authors observed
TL;DR: The common perception that distal replantation is associated with little functional gain is not based on scientific evidence, and this systematic review showed a high success rate and good functional outcomes following distal digital replantations.
Abstract: The replantation of a single digit amputated proximal to the insertion of the flexor digitorum superficialis (FDS) is contra-indicated in adults because this replanted digit usually leads to a stiff proximal interphalangeal joint (PIPJ) that interferes with overall hand function.1–4 Replantation of distal amputations is analogous to the commonly performed distal interphalangeal joint (DIPJ) fusion that still maintains PIPJ motion. However, distal replantation is not commonly performed because it is a technically challenging operation and the loss of function due to a missing fingertip is perceived to be negligible. Despite over 40 years of effort in refining digital replantation surgery, a rigorous evaluation of the outcomes has not been performed. A randomized controlled trial is not possible because it would be unethical and unfeasible to randomize patients to replantation, revision amputation, or some form of reconstruction. A systematic review is the only possible research method to use best available evidence from the literature to determine the outcomes of digital replantation.
The specific aim of this study is to apply strict inclusion criteria to select publications with sufficient details in the data presentation in order to provide comparable data to assess outcomes of distal finger replantation. We hypothesize that replantation of distal digital amputations will have good outcomes.
TL;DR: The January 1, 2011, issue of Plastic and Reconstructive Surgery chronicled the official inauguration of a specialty-wide evidencebased medicine initiative for plastic surgery, and the Journal inaugurates the listing of the level of evidence on all articles amenable tolevel of evidence grading.
Abstract: The January 1, 2011, issue of Plastic and Reconstructive Surgery chronicled the official inauguration of a specialty-wide evidencebased medicine initiative for plastic surgery.1 A multispecialty group of journal editors and plastic surgery and related specialty society leaders along with evidence-based medicine experts met in Colorado Springs in August of 2010 to discuss how they could integrate evidence-based medicine into the basic daily fabric of plastic surgery. One of the key action points from that meeting was to have the scientific journals of the sponsoring societies begin to indicate the level of evidence grade for their articles. Beginning with this issue of Plastic and Reconstructive Surgery, the Journal inaugurates the listing of the level of evidence on all articles amenable to level of evidence grading. Listing of the level of evidence clinical question and level of evidence grade is a relatively straightforward yet highly visible way of promoting and advancing evidence-based medicine. Plastic and Reconstructive Surgery will do this in two ways. First, at the end of the article abstract, we will indicate the level of evidence question addressed by the article (diagnostic, therapeutic, or risk) and the level of evidence of evidence presented in the article (I through V) (Tables 1 through 3).2 Second, immediately to the left of the clinical question and level of evidence, we will place a visual icon of the level of evidence pyramid (Figs. 1 and 2), a symbol that also indicates the clinical question and level of evidence. Although in tandem they are somewhat redundant, together the two elements provide quickly assimilated visual cues as to the overall strength of the data presented in the article.
TL;DR: Patient selection for prosthesis reconstruction involving acellular dermal matrix should be judicious, especially among smokers and patients with elevated body mass index, one should be careful about putting in too high of an initial volume.
Abstract: Background:Acellular dermal matrix has become a common adjunct in prosthesis-based breast reconstruction. The authors' aim was to determine whether acellular dermal matrix use in immediate prosthesis-based breast reconstruction is associated with higher rate of complications.Methods:Over a 5½-year p
TL;DR: This virtual surgical planning technique combined with stereolithographic model–guided osteotomy is the mainstay of the authors' approach to fibular osteotomy when dealing with patients requiring mandibular reconstruction and may be particularly useful if free fibular mandibULAR reconstruction is performed less frequently.
Abstract: Summary:Fibular osteotomy remains a challenging aspect of mandibular microsurgical reconstruction, dependent largely on surgeon experience, intraoperative judgment, and technical speed. Virtual surgical planning and stereolithographic modeling is a relatively new technique that can allow for reducti
TL;DR: The consensus on the definition and classification of propeller flaps reached by the authors that gathered at the First Tokyo Meeting on Perforator and Propeller Flaps in June of 2009 are reported.
Abstract: Background:Over the past few years, the use of propeller flaps, which base their blood supply on subcutaneous tissue or isolated perforators, has become increasingly popular. Because no consensus has yet been reached on terminology and nomenclature of the propeller flap, different and confusing uses
TL;DR: The traditional reconstructive ladder has withstood the test of time, serving as a thought paradigm to guide surgeons in choosing their method of wound closure for an assortment of defects.
Abstract: The traditional reconstructive ladder has withstood the test of time, serving as a thought paradigm to guide surgeons in choosing their method of wound closure for an assortment of defects. Advances in anatomical understanding and technological innovations have improved our ability to achieve definitive closure in a wide variety of patients. In this article, the older construct is updated to reflect the use of negative-pressure wound therapy and dermal matrices. Perforator flap concepts are also discussed in terms of their inclusion as a rung on the ladder.
TL;DR: The review of complications and revisions showed that the silicone gel implants were far better than saline implants and highly cohesive Microcell textured CMH and CML implants had by far the best capsular contracture profile.
Abstract: Background:The problem of double capsules and late seromas is a relatively new phenomenon in breast augmentation surgery.Methods:The author's experience with double capsules in 14 patients is outlined. The author reviewed all primary bilateral breast augmentations and primary bilateral mastopexy-aug
TL;DR: The results suggest that the skeletal morphology of the face changes with age, and this change in skeletal morphology may contribute to the appearance of the aging face.
Abstract: Background:Facial aging is a dynamic process involving the aging of soft-tissue and bony structures. In this study, the authors demonstrate how the facial skeleton changes with age in both male and female subjects and what impact these structural changes may have on overall facial aesthetics.Methods
TL;DR: A retrospective study evaluated all nipple-sparing mastectomies performed at a single institution for therapeutic or prophylactically indications between 1989 and 2010 and concluded that Nipple-Sparing mastectomy can be safe in properly selected patients.
Abstract: Background Nipple-sparing mastectomy remains controversial and its adoption has been slow because of oncologic and surgical concerns Methods A retrospective study evaluated all nipple-sparing mastectomies performed at a single institution for therapeutic or prophylactic indications for which records were available Results Between 1989 and 2010, 162 nipple-sparing mastectomies were performed in 101 women Forty-nine (30 percent) were performed for therapeutic purposes on 48 patients A subareolar biopsy specimen was taken in 39 of 49 breasts (80 percent); four (10 percent) revealed ductal carcinoma in situ, and the nipple or nipple-areola complex was later removed Four of 49 breasts (8 percent) in the therapeutic group had ischemic complications involving the nipple-areola complex, one of which (2 percent) was excised With a mean follow-up of 2 years 6 months (range, 5 months to 9 years 5 months), no patients developed cancer in the nipple-areola complex The remaining 113 mastectomies (70 percent) were performed prophylactically on 80 patients The subareolar tissue was biopsied in 80 breasts (71 percent) One biopsy revealed lobular carcinoma in situ; none had ductal carcinoma in situ or invasive cancer Two nipple-areola complexes (18 percent) were ischemic and excised With a mean follow-up of 3 years 7 months (range, 5 months to 20 years 6 months), no patients developed new primary cancers in the nipple-areola complex Conclusions Nipple-sparing mastectomy can be safe in properly selected patients A subareolar biopsy can effectively identify nipple-areola complexes that may harbor cancerous cells Ischemic complications resulting in nipple loss can be minimized, and long-term follow-up suggests that this technique deserves further investigation in properly selected patients Clinical question/level of evidence Therapeutic, IV
TL;DR: The data provided by Saint-Cyr et al. and Rozen et al., coupled with the authors' own original work on the vascular territories of the body and their subsequent studies, reinforce the angiosome concept and provide the basis for the design of safe flaps for patient benefit.
Abstract: Background Island "perforator flaps" have become state of the art for free-skin flap transfer. Recent articles by Saint-Cyr et al. and Rozen et al. have focused on the anatomical and the clinical territories of individual cutaneous perforating arteries in flap planning, and it is timely to compare this work with our angiosome concept. Methods The angiosome concept, published in 1987, was reviewed and correlated with key experimental and clinical work by the authors, published subsequently at different times in different journals. In addition, new data are introduced to define these anatomical and clinical territories of the cutaneous perforators and to aid in the planning of safe skin flaps for local and free-flap transfer. Results The anatomical territory of a cutaneous perforator was defined in the pig, dog, guinea pig, and rabbit by a line drawn through its perimeter of anastomotic vessels that link it with adjacent perforators in all directions. The safe clinical territory of that perforator, seen not only in the same range of animals but also in the human using either the Doppler probe or computed tomography angiography to locate the vessels, was found reliably to extend to include the anatomical territory of the next adjacent cutaneous perforator, situated radially in any direction. Conclusion The data provided by Saint-Cyr et al. and Rozen et al., coupled with the authors' own original work on the vascular territories of the body and their subsequent studies, reinforce the angiosome concept and provide the basis for the design of safe flaps for patient benefit.
TL;DR: There is strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminate or reduce the frequency, duration, and intensity of migraine headache in a lasting manner.
Abstract: Background: This study was designed to assess the long-term efficacy of surgical deactivation of migraine headache trigger sites. Methods: One hundred twenty-five volunteers were randomly assigned to the treatment (n 100) or control group (n 25) after examination by the team neurologist to ensure a diagnosis of migraine headache. Patients were asked to complete the Medical Outcomes Study 36-Item Short Form Health Survey, Migraine-Specific Quality of Life, and Migraine Disability Assessment questionnaires before treatment and at 12- and 60-month postoperative follow-up. The treatment group received botulinum toxin to confirm the trigger sites; controls received saline injections. Treated patients underwent surgical deactivation of trigger site(s). Results were analyzed at 1 year (previously published) and 5 years postoperatively (the subject of this report). Results: Eighty-nine of 100 patients in the treatment group underwent surgery, and 79 were followed for 5 years. Ten patients underwent deactivation of additional (different) trigger sites during the follow-up period and were not included in the data analysis. The final outcome with or without inclusion of these 10 patients was not statistically different. Sixty-one (88 percent) of 69 patientshaveexperiencedapositiveresponsetothesurgeryafter5years.Twenty (29 percent) reported complete elimination of migraine headache, 41 (59 percent) noticed a significant decrease, and eight (12 percent) experienced no significant change. When compared with the baseline values, all measured variables at 60 months improved significantly (p 0.0001). Conclusion: Based on the 5-year follow-up data, there is strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminateorreducethefrequency,duration,andintensityofmigraineheadache in a lasting manner. (Plast. Reconstr. Surg. 127: 603, 2011.)
TL;DR: In high-risk plastic surgery patients, postoperative enoxaparin prophylaxis is protective against 60-day venous thromboembolism when controlling for baseline risk and length of stay.
Abstract: Background:Venous thromboembolism is a major patient safety issue. The Plastic Surgery Foundation–sponsored Venous Thromboembolism Prevention Study examined whether postoperative enoxaparin prevents symptomatic venous thromboembolism in adult plastic surgery patients.Methods:In 2009, four sites unif
TL;DR: Hemangioma continues to be commonly misused to describe any type of vascular anomaly, and terminological imprecision is prevalent among both medical and surgical fields.
Abstract: Background: A binary classification of vascular anomalies was approved 14 years ago by the International Society for the Study of Vascular Anomalies. The purpose of this study was to determine whether the International Society for the Study of Vascular Anomalies system is being used to categorize anomalies, and whether incorrect nomenclature affects patient care.
Methods: The PubMed database was searched for English language publications with the term "hemangioma" in the title/abstract during 2009. Outcome variables were (1) whether accepted nomenclature was used to describe the vascular anomaly and (2) whether or not patients received incorrect treatment. Predictive variables for terminological accuracy were patient age, location of the anomaly, and the primary author's medical specialty.
Results: "Hemangioma" was used incorrectly in 71.3 percent (228 of 320) of publications. Patients whose lesions were mislabeled were more likely to receive improper treatment (20.6 percent) compared with subjects whose lesions were designated using International Society for the Study of Vascular Anomalies terminology (0.0 percent) (p = 0.001). The patients were younger in articles that properly identified hemangioma (4.1 months) compared with articles that used hemangioma to describe another anomaly (36.1 years) (p < 0.0001). Publications focused on integument/soft-tissue lesions were more accurate (57.4 percent) than those in other anatomical areas (86.3 percent) (p < 0.0001). The erroneous use of hemangioma was independent of the authors' discipline: pediatrics (60.0 percent), internal medicine (61.4 percent), surgery (68.9 percent), and obstetrics/gynecology (70.0 percent) (p = 0.68).
Conclusions: Hemangioma continues to be commonly misused to describe any type of vascular anomaly, and terminological imprecision is prevalent among both medical and surgical fields. Inaccurate designation of the vascular anomaly is associated with an increased risk of erroneous management.
TL;DR: Osteomyelitis is best managed by a multidisciplinary team and requires accurate diagnosis and optimization of host defenses, appropriate anti-infective therapy, and often bone débridement and reconstructive surgery.
Abstract: Background:Osteomyelitis is an inflammatory disorder of bone caused by infection leading to necrosis and destruction. It can affect all ages and involve any bone. Osteomyelitis may become chronic and cause persistent morbidity. Despite new imaging techniques, diagnosis can be difficult and often del
TL;DR: The diagnosis and management of secondary velopharyngeal insufficiency are discussed and the features of the cleft lip nasal deformities and reliable surgical techniques for unilateral clefts lip repair, bilateral cleft Lip repair, and radical intravelar veloplasty are demonstrated.
Abstract: This article provides an introduction to the anatomical and clinical features of the primary deformities associated with unilateral cleft lip-cleft palate, bilateral cleft lip-cleft palate, and cleft palate. The diagnosis and management of secondary velopharyngeal insufficiency are discussed. The accompanying videos demonstrate the features of the cleft lip nasal deformities and reliable surgical techniques for unilateral cleft lip repair, bilateral cleft lip repair, and radical intravelar veloplasty.
TL;DR: In this article, the authors present a standard for technique or data regarding long-term volume maintenance with fat grafting of the breasts, but there remain unanswered questions regarding long term volume maintenance.
Abstract: Background:Despite the increased popularity of fat grafting of the breasts, there remain unanswered questions. There is currently no standard for technique or data regarding long-term volume maintenance with this procedure. Because of the sensitive nature of breast tissue, there is a need for radiog
TL;DR: Epidermal invasion of the hemangioma is of predictive value for residual lesions and may add to a more detailed prediction of outcome and may help to decide which patient should be treated or not.
Abstract: Background: Hemangiomas of infancy can give rise to alarm because of their rapid growth and occasional dramatic appearance. The objective of this study was to investigate the growth pattern of hemangiomas and risk factors for residual lesions. Methods: A follow-up study was performed of patients with hemangiomas that were clinically monitored between 1985 and 2000 and who did not receive any treatment. The data were retrieved from medical files. Patients (parents) were asked to complete a questionnaire and invited to our outpatient clinic where the questionnaire was discussed and physical examination was performed. The growth phases of the hemangioma were documented, the timeline of these phases was constructed, and an assessment was made of the residual lesion if present. Results: In 97 patients, 137 hemangiomas were evaluated. A precursor lesion was present in 48 percent of children. Maximum size was reached in 8 months. Involution started at a median age of 2 years and was completed at a median age of 4 years. Residual lesions were present in 69 percent of cases. Superficial nodular hemangiomas showed significantly more residual lesions (74 percent) than the deep hemangiomas (25 percent) (p <0.001; odds ratio, 8.4; 95 percent confidence interval, 2.4 to 29.1). Untreated infection, ulceration, or bleeding produced a scar in 97 percent of the cases. Conclusions: Epidermal invasion of the hemangioma is of predictive value for residual lesions. There is no correlation between the growth pattern of a hemangioma and the risk for a residual lesion. This may add to a more detailed prediction of outcome and may help to decide which patient should be treated or not. (Plast. Reconstr. Surg. 127: 1643, 2011.)
TL;DR: This article summarizes the various approaches to breast reconstruction and offers a balanced view of the risks and benefits of each, all of which in the end offer the opportunity for excellent and predictable results with a high degree of patient satisfaction.
Abstract: Learning objectives After reading this article, the participant should be able to: 1. Describe the mental, emotional, and physical benefits of reconstruction in breast cancer patients. 2. Compare the most common techniques of reconstruction in patients and detail benefits and risks associated with each. 3. Outline different methods of reconstruction and identify the method considered best for the patient based on timing of the procedures, body type, adjuvant therapies, and other coexisting conditions. 4. Distinguish between some of the different flaps that can be considered for autologous reconstruction. Summary Breast cancer is unfortunately a common disease affecting millions of women, often at a relatively young age. Reconstruction following mastectomy offers women an opportunity to mollify some of the emotional and aesthetic effects of this devastating disease. Although varying techniques of alloplastic and autologous techniques are available, all strive to achieve the same goal: the satisfactory reformation of a breast mound that appears as natural as possible without clothing and at the very least is normal in appearance under clothing. This article summarizes the various approaches to breast reconstruction and offers a balanced view of the risks and benefits of each, all of which in the end offer the opportunity for excellent and predictable results with a high degree of patient satisfaction.
TL;DR: An overview of patient-reported outcome measures can be found in this paper, where the authors aim to provide plastic surgeons with the necessary critical appraisal skills to interpret and apply evidence from patientreported outcomes research in their own clinical practice.
Abstract: Understanding patients' perceptions of surgical results and their impacts on quality of life is of primary importance in plastic surgery, as procedures are largely performed to improve either appearance or function. Patient-reported outcome measures are questionnaires specifically designed to quantify aspects of health-related quality of life from the patient's perspective. This article presents an overview of patient-reported outcome measures. It also aims to provide plastic surgeons with the necessary critical appraisal skills to interpret and apply evidence from patient-reported outcomes research in their own clinical practice.