Society Will Select Your Health Care Options on a Feeling Thermometer

Fundamental Principles of Conducting a Surgery Economic Analysis Study.

Kotsis SV, Chung KC: Plast Reconstr Surg 2010; 125 (February): 727-735

The government uses $50,000 per quality-adjusted life-year as the limit for adopting health care interventions.

Background: In 1993, the U.S. Public Health Service developed guidelines to improve the quality of economic analysis studies of health care. Agencies use such studies as the basis for decision-making on health care options. As the government controls more of health care finances, it also increasingly controls the options available. Objective: Surgeons need to understand economic analysis and its benefits and perils. Design/Methods: This paper is an overview of existing principles of economic analysis as used by the U.S. government. This reviewer's prcis offers basic familiarity. The paper is adequately referenced for additional reading. Important concepts are utilities, quality adjusted life-years (QALYs), and outcomes. The underpinnings of these studies are "utilities." Utilities are the preferences for a particular health state. They are assigned a numerical value, usually by selecting from a visual scale or "feeling thermometer." Alternatively, utilities may be defined by answers to standard gamble or time trade-off questions. Government policy provides that these preferences come from society and not from the patients involved or from health care professionals. Results: Judgments regarding health care are made by persons who are not directly affected by those decisions or knowledgeable about the subject. The product of the numerical value (the utility) and the number of years of life yields the QALY for that result. The QALYs of individual results are multiplied by the probability of each and summed to give the overall outcome. Conclusions: The authors suggest that, of the 4 types of economic study commonly used, the cost-utility type of analysis is the most helpful because it can compare treatments with different outcomes. The fundamental arithmetic, therefore, relates the sum of costs associated with the treatment to the community's preference for a particular state of health (its utility). Reviewer's Comments: Economic analyses of this type are already the basis for the rationing of health care in the United States. The authors observe that current U.S. policy has $50,000 per QALY as the limit for funding. Unfortunately, numerous studies have shown that the public's ability to make such health state assessments is hampered by disinterest, ignorance of the details of disease and treatment, and underestimation of the quality of life when the lives of others are at stake. As we move toward a more socialistic model, studies of this type will be the instruments cited to justify the restriction of options for patients and physicians. Our society polls citizens who are neither interested in nor knowledgeable about health states to determine their preferences on a feeling thermometer and offers those as the basis of what is described as a quantitative and scientific approach to the analysis of health care options. (Reviewer-Norman V. Godfrey, MD).
2010, Oakstone Medical Publishing
Keywords: Outcome Measures, Surgery Economic Analysis Print Tag: Refer to original journal article

Acellular Human Dermis -- the Good and the Bad

Acellular Human Dermis Implantation in 153 Immediate Two-Stage Tissue Expander Breast Reconstructions: Determining the Incidence and Significant Predictors of Complications.
Antony AK, McCarthy CM, et al: Plast Reconstr Surg 2010; 125 (June): 1606-1614

Acellular human dermis may have some advantages in tissue expander breast reconstruction, but there is also an increased rate of complications.

Background: 2-stage tissue expander-implant reconstruction of breasts with acellular human dermis is becoming more and more common, but little is known about the incidence of complications associated with the use of this material. Objective: To study the incidence of complications and significant predictors of complications associated with use of acellular human dermis in tissue expander breast reconstruction. Design: Retrospective review. Methods: All patients from 2004 to 2008 who underwent 2-stage immediate tissue expander reconstruction with acellular human dermis were studied. A 4 x 16 cm sheet of Alloderm was used with drains in the mastectomy space. Complications were evaluated, and a comparison of complication rates using non-acellular human dermis techniques was performed. Results: 153 expanders with acellular human dermis were placed in 96 women; 92.8% of the expanders were successfully exchanged for an implant. Eleven expanders were removed because of infection, exposure, or patient preference. There was a 7.2% rate of seromas, and 9 of 11 cases underwent aspiration. By multivariate analysis, age, body mass index, and axillary dissection were independent risk factors for complications. Percent volume expansion, nipple-sparing mastectomy, and adjuvant therapy were not predictive of complications. Compared with cohorts of patients who had expander reconstruction without acellular human dermis, the group with acellular human dermis had a higher incidence of overall complications, especially for seroma and reconstructive failure. Infection was the most common reason for reconstructive failure in these cases (3.3%). Conclusions: Acellular human dermis can be useful in immediate tissue expander reconstruction but can also be associated with an increased risk of complications, especially seroma and reconstructive failure. Reviewer's Comments: Although some studies have looked at complications related to acellular human dermis use, this study is the largest to date and looks at one particular operation and technique rather than combining a heterogeneic group of operations. This study is, therefore, the most compelling to date showing that the use of acellular human dermis can be associated with a higher risk of complications. It is particularly useful in identifying independent predictors of complications such as age, body mass index, and axillary dissection. Acellular human dermis has potential benefits in higher initial expander volumes, appearance of the lower pole, and reduction of muscle dissection. This paper helps surgeons select appropriate patients and potentially avoid selecting high-risk patients for acellular human dermis use. (Reviewer-Christine H. Rohde, MD).
2010, Oakstone Medical Publishing
Keywords: Acellular Human Dermis, Tissue Expander, Breast Reconstruction, Acellular Dermal Matrix Print Tag: Refer to original journal article

How Satisfied Are Women With Breast Reconstruction After Mastectomy?

Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, and Implant Techniques.
Yueh JH, Slavin SA, et al: Plast Reconstr Surg 2010; 125 (June): 1585-1595

Among women undergoing breast reconstruction, patient satisfaction rates are highest with abdominalbased autogenous tissue techniques.

Background: With the advent of the deep inferior epigastric perforator (DIEP) flap and advances in other breast reconstruction techniques, women often have a difficult time choosing among breast reconstruction techniques. Therefore, patient satisfaction studies that evaluate different reconstruction techniques can provide valuable information for women with breast cancer who will be undergoing a mastectomy. Objective: To compare patient satisfaction in women who have undergone reconstruction with tissue expanders/implants, latissimus flaps, pedicled transverse rectus abdominis muscle (TRAM) flaps, and DIEP flaps. Factors influencing satisfaction were also analyzed. Design: This study was based on a questionnaire and a retrospective chart review. Participants: All patients examined in this study underwent breast reconstruction at the Beth Israel Deaconess Medical Center in Boston between January 1, 1999, and January 1, 2007. Methods: Questionnaires were sent to 583 women who underwent implant-based reconstructions or reconstructions with latissimus flaps with or without implants, pedicled TRAMs, or DIEP flaps. Questions assessed general and aesthetic satisfaction rates, as well as patient involvement in decision making. Nonresponders received a second questionnaire and were then contacted by phone if they still did not respond. Results: 439 of the 583 women responded (75.3%). Autologous reconstruction techniques had significantly higher general and aesthetic satisfaction rates than implant-based reconstructions. Among autologous tissue techniques, latissimus flaps had lower general and aesthetic satisfaction rates than abdominal-based flaps. TRAM patients had the highest level of aesthetic satisfaction (77%), while DIEP patients had the highest level of general satisfaction (80%); however, when the 2 groups were compared against each other, these satisfaction differences were not statistically significant. Conclusions: Autogenous, abdominal-based reconstructions had the highest satisfaction rates among the 4 groups studied. However, after logistic regression analysis, there were no statistically significant differences in patient satisfaction between TRAM and DIEP flaps. Reviewer's Comments: This is a very useful study that provides helpful information to many women undergoing breast reconstruction. Furthermore, the results should also prove useful to young plastic surgeons who learn all of these techniques but who do not have the long-term follow-up that is often needed to best counsel patients. As a surgeon who does a high volume of breast reconstruction, the results seem consistent with what I have witnessed; that is, while many implant reconstruction patients are very happy, there seems to also be a higher percentage of these patients who are less satisfied over time than patients who have had reconstruction with autogenous tissues. Furthermore, this study helps to confirm that pedicled TRAM patients can achieve patient satisfaction that is just as good as that of patients who undergo the more complex DIEP procedure. (Reviewer-Jeffrey A. Ascherman, MD).
2010, Oakstone Medical Publishing
Keywords: Breast Reconstruction, Patient Satisfaction, Breast Implants, Latissimus Flaps, TRAM Flaps, DIEP Flaps Print Tag: Refer to original journal article

Implantable Dopplers Do Not Increase Salvage Rates

Introduction of the Implantable Doppler System Did Not Lead to an Increased Salvage Rate of Compromised Flaps: A Multivariate Analysis.
Smit JM, Werker PMN, et al: Plast Reconstr Surg 2010; 125 (June): 1710-1717

The use of implantable Dopplers for free flap monitoring does not increase flap salvage rates.

Background: The implantable Doppler system (Cook-Swartz) enables the direct monitoring of free flap vessels by placing a Doppler probe continuously on a free flap vessel. It can be used in conjunction with other monitoring methods or alone in a completely buried flap. Objective: To determine whether use of the implantable Doppler improves the salvage rate of flap revisions. Design: Retrospective case-control study. Methods: Over a 3-year period, all free flap cases monitored with an implantable Doppler system that needed revision were studied. The cuff was placed around the venous pedicle. These patients were compared with another group of patients over an equal time span monitored by conventional methods. Only revision cases in which vascular compromise was found (true positives) were included. False positives were excluded from the analysis of revision outcome. Results: 327 flaps were monitored during the study period, and 35 required revision. The control group had 303 flaps, with 40 that needed revision. For the patients monitored with an implantable Doppler, 69% of the revisions were successful. For the conventional monitoring group, 60% of the flaps were salvaged. Univariate and multivariate analysis showed no statistical difference between these 2 success rates. Revisions of breast reconstructions were more likely to be successful than reconstructions performed for other defects. Conclusions: The use of an implantable Doppler system did not significantly increase the salvage rate of revised free flaps. However, it has benefits such as ease of use and interpretation. Reviewer's Comments: Implantable Dopplers are another means to monitor blood flow in free flaps. These systems make monitoring by medical staff and nursing easier since less clinical judgment is involved and the patient does not need to be touched or awoken at night. The systems can also provide continuous information about the blood flow through the flap. They are especially useful for buried flaps when there are no other means of monitoring the flap. However, this study shows that these devices do not necessarily improve outcomes for patients since they do not increase the success rate of revisions over conventional monitoring methods. There can also be a high false-positive rate since the probes can be easily dislodged, leading to unnecessary surgical explorations. The authors of this paper continue to use implantable Dopplers because of their ease of use. The revision success rate is not the only measure of the utility of a monitoring device. Generally, I tend to avoid the use of implantable Dopplers except when other conventional methods cannot be used because of the false-positive readings. However, the Cook Doppler is invaluable in cases in which there is no other way to monitor a free flap. (Reviewer-Christine H. Rohde, MD).
2010, Oakstone Medical Publishing
Keywords: Flap Monitoring, Free Flaps, Doppler System Print Tag: Refer to original journal article

Fat Grafts to Irradiated Orbits Work Well

Reconstruction of the Irradiated Orbit With Autogenous Fat Grafting for Improved Ocular Implant.
Kim SS, Kawamoto HK, et al: Plast Reconstr Surgery 2010; 126 (July): 213-220

Autologous fat grafting may improve aesthetics and the fit of ocular implants in irradiated orbits.

Background: Patients with tumors of the orbit requiring enucleation and irradiation often have insufficient soft tissue to support an ocular prosthesis. Objective: The authors present a series of 6 such patients in whom Coleman fat grafting was used to reconstruct orbital soft tissue. Design: Retrospective review. Participants/Methods: 6 patients underwent serial autologous fat grafting after orbital irradiation and enucleation for primary orbital tumors. The amount of fat transferred was measured, as was the fat retention (assessed using surface area analysis and 3-dimensional photography). Outcomes were measured by physicians and patients on a 0- to 4-point scale. In addition, fat retention in these patients was compared to that of nonirradiated patients who had malar fat injections for cosmetic purposes. Results: 6 patients had a mean of 3 fat injections of a mean of 24 cc each. Four of 6 patients were successfully fitted with orbital prostheses. Physician and patient outcomes were rated as 3.1 and 3.3, respectively. Fat retention between nonirradiated and irradiated patients was initially 81% versus 78%, but the difference became more significant at long-term follow-up, at 72% versus 38%. Conclusions: Autologous fat grafting may improve the aesthetics and fit of ocular implants in irradiated, enucleated orbits. Reviewer's Comments: This article presents a successful series of Coleman fat grafting used to augment soft-tissue loss in irradiated, enucleated orbits. Four of 6 patients were successfully fit for ocular prostheses after serial autologous fat grafting, representing a significant aesthetic and functional improvement. However, despite the authors' optimistic results, long-term outcomes were significantly less promising than short-term ones, with fat retention of only 38% in irradiated orbits at a late time point. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Autologous Fat Grafting, Ocular Implants, Orbit, Radiation, Irradiated Orbit Print Tag: Refer to original journal article

Homograft Rib Melts AwayJust a Matter of Time

Irradiated Homologous Rib Grafts in Nasal Reconstruction.
Menger DJ, Trenit GJN: Arch Facial Plast Surg 2010; 12 (March/April): 114-118

Do not use a homograft rib for structural support; it will lose all its strength with time.

Background: Many nasal surgeons, particularly otolaryngologists, have a preference for irradiated homograft rib over autograft. This paper is a study of the performance of such grafts. Objective: To assess the long-term resorption and complication rates for irradiated homologous rib grafts in rhinoplasty with reference to various nasal recipient sites. Design/ Participants: The paper reports a retrospective study of 66 patients who received a total of 177 nasal grafts crafted from irradiated homologous rib cartilage. An effort was made to determine the degree of resorption as it affected structural support and volume and to correlate the results with the site of graft placement. Methods: Volume absorption was evaluated by comparing postoperative photographs 3 months after surgery to late-result photographs. Structural integrity was assessed by manual palpation. The authors categorized 0% to 25% volume loss as no resorption, 25% to 50% volume loss as moderate, and >50% loss as complete. Results: The quality of the data in this study is poor; 27% of patients were unavailable for postoperative evaluation, begging the question, Were those the worst results? Some grafts were wrapped in Surgicel; others were not. The evaluation was retrospective and was largely based on photographic review. Six of 66 patients (9%) had complications; 68% of grafts had 0% to 25% resorption, and 31% of grafts had 25% to 50% resorption. In addition, as the follow-up term increased from 2 to 4 years to 6 to 8 years, the rates of absorption increased consistently. Resorptions were characterized by a loss of structural support effect more than by a loss of visible volume. Grafts in the nasal tip in the form of shields did particularly poorly. Conclusions: Surprisingly, the authors concluded that these rates of resorption and complications supported the continued use of such homograft cartilage. This conclusion was made while the authors opined that, with time, all the grafts would lose their structural integrity but might retain their volume. Reviewer's Comments: This fascination with homograft cartilage is prevalent but somewhat curious. This study, as have others before it, demonstrated significant resorption rates with a homograft rib used in the nose, and those rates appear to increase (and likely will increase more into the future) with greater time from surgery. Because rhinoplasty patients are typically a younger population, the importance of a lasting result cannot be overemphasized. These data demonstrated that a homograft rib does not offer that prospect. This paper is an attempt to use retrospective data that show poor results as vindication of a flawed technique. I believe this paper is important but draws a conclusion opposite from that drawn by the authors: these data show poor results and substantiate the thought that a homograft rib is a poor reconstructive material for nasal patients. (Reviewer-Norman V. Godfrey, MD).
2010, Oakstone Medical Publishing
Keywords: Rhinoplasty, Cartilage Graft, Homograft Cartilage Print Tag: Refer to original journal article

Perforator Flaps Work as Well as Free Flaps for Some Lower Extremity Wounds
Lower Limb Reconstruction Using the Islanded Posterior Tibial Artery Perforator Flap.
Schaverien MV, Hamilton SA, et al: Plast Reconstr Surg 2010; 125 (June): 1735-1743

Wounds of the lower third of the lower extremity may be successfully reconstructed using a propellerdesign flap based on perforators from the posterior tibial artery.

Background: Reconstruction of the lower third of the leg can be difficult due to lack of local tissue options and morbidity associated with free flaps. The authors of this paper describe their experience using an islanded propeller-design flap based on perforators from the posterior tibial (PT) artery. Objective: To describe the surgical technique utilized for this flap and to examine complication rates and outcomes. Design: Retrospective review. Methods: 106 flaps were performed in 100 patients over a 10-year period by multiple surgeons. The PT perforators are marked on the skin using Doppler ultrasound preoperatively. The flap is designed according to the defect, and an anterior incision is made to identify the perforators. If the perforator is of sufficient caliber, both incisions are completed; all other perforators are clamped, as is the base of the flap. If the flap appears viable, it is islanded, rotated up to 180, and inset. The donor site is skin grafted. Characteristics of patient demographics and wound types as well as complications and outcomes were analyzed. Results: 72% of defects were at the lower third of the leg, and 10% were at the ankle, heel, or foot; 88% were associated with fractures. Sixty-one percent of flaps were performed within 72 hours. All but 3 perforators were located between 6 and 12 cm from the tip of the medial malleolus, and the median angle of rotation was 160. The mean time to union was 5.9 months. Five percent of the patients developed osteomyelitis, and there was an 8.5% complete and 12% partial failure rate. Cigarette smoking was associated with partial flap loss, and diabetes mellitus and peripheral vascular disease were associated with complete loss. Conclusions: The islanded propeller-design PT artery perforator flap is a viable option for reconstruction of the distal third of the leg, with complication rates similar to those reported in the literature for free flaps. Reviewer's Comments: Very good description of a technique to add to the reconstructive surgeons armamentarium. The rates of flap loss for this series are comparable to those described in the literature for free flaps without the morbidity of extra anesthesia time. This case series is the experience of only one institution, and these numbers may not be the same in a different patient population; however, this study provides good evidence that the operation is safe to try and has good outcomes. The description of the surgical technique is clear with good illustrations, and there are a number of helpful references to other papers looking at outcomes of other flaps in the region for comparison. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Lower Extremity Reconstruction, Rotational Flaps, Local Flaps, Trauma Print Tag: Refer to original journal article

Radiesse vs Cosmoplast for Treating Nasoloabial Folds

Calcium Hydroxylapatite (Radiesse) for Treatment of Nasolabial Folds: Long-Term Safety and Efficacy Results.
Bass LS, Smith S, et al: Aesthetic Surg J 2010; 30 (March): 235-238

Radiesse is a safe, effective, and long-lasting filler for treatment of the nasolabial fold.

Background: Wrinkle fillers are exploding in popularity. More than 1.5 million people were treated with fillers last year. The most common fillers are hyaluronic acid based. Growing in popularity is Radiesse, made of calcium hydroxylapatite microspheres suspended in an aqueous gel carrier. Objective: To compare the efficacy and longevity of Radiesse with Cosmoplast collagen. Design: Nonrandomized comparison study using each patient as his or her own control. Participants/Methods: 117 patients with at least moderately deep wrinkles randomly received Radiesse on 1 nasolabial fold and Cosmoplast on the other side. A maximum of 2 additional injections were performed as needed on one or both sides between weeks 2 and 4. Patients were seen at 1, 3, 6, and 12 months. Ninetynine patients continued the long-term study and were evaluated at 18, 24, and 30 months. The nasolabial folds were rated with the Lemperle Rating Scale and the global aesthetic improvement scale. Results: The Lemperle ratings showed improvement in nasolabial folds at 6 months in the Radiesse side but not on the collagen side. Nearly 95% of the Radiesse sides were rated as improved at 6 months versus only 3% of the collagen sides. In the long term, 40% of patients still rated the Radiesse-treated side as improved at 30 months. Conclusions: This study supported the use of Radiesse as a long-term filler of nasolabial folds. The 30-month mark for improvement in 40% of patients provides Radiesse with the best long-term data of the nonpermanent fillers. No long-term safety issues were raised during the study. Reviewer's Comments: This study provides hard data for clinical plastic surgeons who use wrinkle fillers. Radiesse is a long-lasting deep filler. Now we have data that provide some hard science to the "experience" of practitioners. Radiesse lasts >2 years in a large proportion of patients. One drawback of Radiesse is that it cannot be used superficially for fine wrinkles. Clinically, it has a tendency to create nodules when placed superficially or in the lips. It is commonly used for the nasolabial folds, the marionette lines, cheek depressions, and the depression medial to the jowls. This positions Radiesse along with hyaluronic acid fillers for superficial wrinkles. More controversial is the use of the permanent fillers such as silicone and Artefill. (Reviewer-Arthur W. Perry, MD).
2010, Oakstone Medical Publishing
Keywords: Wrinkle Fillers, Radiesse, Calcium Hydroxylapatite Print Tag: Refer to original journal article

Understand Patients Motivations for Cosmetic Surgery

Psychosocial Characteristics of Young Norwegian Women Interested in Liposuction, Breast Augmentation, Rhinoplasty, and Abdominoplasty: A Population-Based Study.
Javo IM, Srlie T: Plast Reconstr Surg 2010; 125 (May): 1536-1543

The nose is the feature most commonly the focus of body dysmorphic disorder.

Background: This article is the second that analyzes the psychosocial characteristics of Norwegian women with reference to aesthetic surgery. The previous article analyzed subjects' attitude toward cosmetic surgery in general, while this paper focuses on those traits that motivate patients toward specific procedures (ie, liposuction, breast augmentation, rhinoplasty, and abdominoplasty). Objective: To define psychosocial traits typical to the cosmetic surgery patient population. Design/ Participants: Data were extracted from answers to a questionnaire distributed to Norwegian women 18 to 35 years of age. Subjects were asked about their interest in specific cosmetic procedures. In addition, they were given questions to define their psychosocial functioning. Methods: A total of 3292 questionnaires were delivered to subjects; 1862 subjects (56%) of the questionnaires were returned. Questions assessed many psychosocial characteristics, including previous cosmetic surgery, body dysmorphic disorder, personality inventory, interpersonal security, self-esteem, body image, sexual satisfaction, eating disorders, emotional distress, quality of social relationships, teasing history, social acceptance, and physical exercise. Results: Interest in cosmetic surgery varied with the procedures. In regard to the 4 specific procedures, 25% of subjects were interested in liposuction, 15% in breast augmentation, 7% in rhinoplasty, and 5.6% in abdominoplasty. Only 4% of the subjects had previously undergone cosmetic surgery. Low appearance evaluation, referral for cosmetic surgery, an acquaintance with someone who had undergone cosmetic surgery, and a low educational level were significant predictors of interest in all procedures. Body dysmorphic syndrome was the strongest predictor of interest in rhinoplasty. A history of childbearing was the strongest predictor of interest in abdominoplasty, whereas a history of teasing was a predictor of interest in all procedures except abdominoplasty. Conclusions: The authors concluded that it was possible to identify psychosocial characteristics that correlated with interest in different types of cosmetic procedures. They suggest that additional study may refine our understanding of patients' personalities and motivation and assist us in providing better advice and treatment. Reviewer's Comments: This paper is interesting, yet falls short of expectations. Understanding our patients' orientation and motivation toward surgery would be extremely helpful, and its prospect is very appealing. Unfortunately, the huge complexity of the interactions and the limitations of the available methods to characterize these multiple variables leave studies like this far short of detailed and specific answers. Nonetheless, the findings that were offered resonated with this reviewer's clinical experience as valid and useful. The authors themselves point out that there remain questions of the applicability of findings from a small cohort of northern Norwegian women to other populations. Nonetheless, this reviewer feels that, as surgeons attempting to best counsel our patients toward good decisions regarding surgery, we need to consider characteristics far beyond just their anatomic particulars. (Reviewer-Norman V. Godfrey, MD).
2010, Oakstone Medical Publishing
Keywords: Cosmetic Surgery, Personality Evaluation, Body Dysmorphic Disorder Print Tag: Refer to original journal article

Excise Dermatofibromas for Cosmetic Reasons, Not for Risk of Progression

Benign and Premalignant Skin Lesions.
Lee EH, Nehal KS, Disa JJ: Plast Reconstr Surg 2010; 125 (May): 188e-198e

The ABCDE acronym (asymmetric, border irregular, color variegated, diameter >6 mm, and evolving changes) helps identify disturbing melanocytic lesions.

Background: Plastic surgeons are frequently consulted for diagnostic and therapeutic decisions regarding skin lesions. Objective: To provide a concise, up-to-date review of the common benign and premalignant skin lesions. Design: Review article. Results/Conclusions: Actinic keratosis is an ultraviolet-induced epidermal lesion. While the future of any specific lesion is uncertain, approximately 10% of actinic keratoses will evolve into squamous cell carcinomas. Treatment is indicated because of this malignant potential. Options include cryotherapy, topical 5-fluorouracil (5-FU), photodynamic therapy, and ablative laser. Properly applied, all are effective but offer different practical advantages. Dermatofibroma is a benign fibrohistiocytic dermal tumor. Firm and typically identifiable by the pinch test that causes dimpling of the overlying skin, dermatofibromas sometimes regress. Unless the diagnosis is uncertain or appearance is unacceptable, treatment is not required. When indicated, cryotherapy or excision may be effective. Dysplastic nevi are markers for melanoma and possibly precursors. The ABCDE acronym (asymmetric, border irregular, color variegated, diameter >6 mm, and evolving changes) is helpful to determine clinical indication for excision. Preferred treatment is excision with a 2-mm margin. Halo nevus is a melanocytic nevus with an annulus of depigmentation, possibly representing cell-mediated immune destruction of the nevus. Excision with a 2-mm margin is probably the best treatment for disturbing morphology or change in appearance. Keratoacanthoma is a rapidly growing epidermal neoplasm with a crater-like appearance. Some resolve spontaneously. Due to rapid progression and uncertainty of diagnosis (possibly squamous cell carcinoma), surgical excision, Mohs micrographic excision, radiotherapy, or intralesional 5-FU is used. Nevus sebaceous is a congenital hamartoma of sebaceous glands. A few will develop into malignancies. Routine excision has been the historical standard, but some clinicians now monitor the lesions for change. Pilar cysts are benign and frequently excised for cosmesis. Pilar cystic tumors are more aggressive and merit excision with a margin. A malignant histology requires a more aggressive approach. Seborrheic keratoses are benign epidermal lesions of variably dark color and a verrucous, waxy, "stuck-on" appearance. Treatment options include curettage, cryotherapy, and shave. Spitz nevi are dome-like deeply pigmented (blue-black) dermal lesions. Malignant potential varies, and evolving lesions or lesions with atypical histology merit wide excision and consideration of sentinel node biopsy to assess malignant potential. Syringomas are benign, yellow, papular lesions typically occurring on the lower eyelids of women. Histology shows ducts with eccrine differentiation. Where indicated, treatment options include electrodessication, peels, and laser ablation. Reviewer's Comments: Familiarity with the numerous common lesions and their appropriate management is fundamental to virtually every general plastic surgeon's practice. This paper is a worthwhile review. (ReviewerNorman V. Godfrey, MD).
2010, Oakstone Medical Publishing
Keywords: Skin Lesions, Premalignant Lesions, Nevi, Keratosis Print Tag: Refer to original journal article

Do Guidelines Improve Tx Outcome for Carpal Tunnel?

Indications for Performing Carpal Tunnel Surgery: Clinical Quality Measures.
Maggard MA, Harness NG, et al: Plast Reconstr Surg 2010; 126 (July): 169-179

Recommendations for median nerve surgery can be standardized based on severity of symptoms, results of electrodiagnostic testing, and response to nonsurgical treatments.

Background: Hand surgeons vary widely in their indications and recommendations for carpal tunnel surgery. Objective: To assess criteria that are used to recommend surgery linking outcomes to the methodologies used facilitated by the experience of panelists identified as having expertise in this area. Design: Outcomes review article. Methods: Multiple mild, moderate, and severe clinical scenarios of median nerve compression neuropathy were presented to a multidisciplinary team of surgeons. This group rated the indications for surgery as necessary or unnecessary. Results were analyzed using a modified Delphi panel consisting of experts in plastic hand surgery, orthopedic hand surgery, general orthopedics, occupational medicine, neurology, physical medicine and rehabilitation family medicine, and physical therapy. Results: For mild or moderate symptoms with low clinical probability, the lack of an attempt at nonoperative treatment, and no confirmatory electromyographic (EMG) testing, surgery was deemed inappropriate. For patients with severe symptoms, surgery was deemed necessary with confirmatory EMG testing or when prior nonoperative treatment was unsuccessful. Conclusions: Standardized measures for surgery can prevent underuse and overuse of procedures. Reviewer's Comments: While carpal tunnel surgery is widely performed, the decision to perform the procedure is often made based on clinical judgment as opposed to standardized indications. For most mild cases, an attempt at nonoperative treatment with splinting or steroid injection can be both diagnostic and therapeutic. An important point made in this paper is that in cases of severe carpal tunnel symptoms, the decision to perform surgery should be relatively straight-forward. Not every patient needs an EMG. Standardization of patient care for such a common surgical problem may help avoid unnecessary diagnostic tests and may help stratify patients to surgical treatment before their conditions worsen to the point where the procedure would no longer be of as much benefit. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Carpal Tunnel Syndrome, Surgery Print Tag: Refer to original journal article

Normal Breast Characteristics Further Described

The Three Breast Dimensions: Analysis and Effecting Change.
Hall-Findlay EJ: Plast Reconstr Surg 2010; 125 (June): 1632-1642

Breast shape and distribution varies based on the footprint of the breast.

Background: Better results in breast surgery of all types can be achieved by communicating what particular aspects of the breast can be altered by the planned surgery. Objective: To provide descriptions of breast measurements and anatomy that will help surgeons achieve better outcomes and offer their patients enhanced descriptions of what can be achieved with surgery. Design: Review article. The first 2 dimensions of the breast represent its footprint on the chest wall, while the third and final dimension represents the shape of the breast projection. Methods: The author describes her analytic technique of assessing the breasts and their functional anatomical characteristics. The characteristics and variability of the breast footprint are described and recommendations are made for effecting change. In this description, the upper and lateral breast borders are shown to offer good mobility, whereas the medial and inferior borders do not. The breast adherence zones are fixed to the skin, not the chest wall. Results: Measurements were made before and after various breast surgeries to determine the efficacy of planned changes for the patients in the various breast dimensions. The nipple position drops an average of 2 cm relative to the suprasternal notch in breast augmentations and augmentations combined with mastopexy. This distance stays stable for breast reduction and mastopexy alone. Conclusions: With appropriate planning, measuring, and evaluation of a patient's breast in the various dimensions, the plastic surgeon can effectuate change and manage expectations in the breast surgery patient. Reviewer's Comments: This paper is an excellent review of a complex issue. The author makes an exceptionally important point about the difference between high- and low-breasted patients and the relevance of acknowledging this in preoperative planning. Also discussed is the fact that the breast itself is not fixed to the chest wall, but to the skin itself. Therefore, resuspension to the chest wall is not anatomic and often does not endure. Many other salient points are made, demonstrating once again Dr Hall-Findlay's exceptional understanding of breast dynamics and geometry. This paper is a wonderful tool for achieving better perspective of cosmetic breast anatomy. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Planning Breast Surgery, Breast Dimensions Print Tag: Refer to original journal article

Novel Approach to Capsular Contracture Reduction Is Described

Surface Modification of Silicone Breast Implants by Binding the Antifibrotic Drug Halofuginone Reduces Capsular Fibrosis.
Zeplin PH, Larena-Avellaneda A, Schmidt K: Plast Reconstr Surg 2010; 126 (July): 266-274

Surface modification of silicone implants with fibrotic disorder inhibitors may lead to decreased capsular contraction rates after implant placement.

Background: Capsular contracture is a common postoperative complication in the placement of silicone breast implants. Transforming growth factor-beta (TGF-) has been implicated as a key mediator in this fibrotic process. Objective: To compare rates of capsular contracture formation when the surface of a miniaturized textured silicone implant is either coated or not with an antifibrotic substance in a rat model. Design: Prospective nonrandomized animal study. /Methods: Halofuginone is a TGF- inhibitor. This study examines capsule formation in response to silicone implants placed submuscularly with the implant surface either untreated or coated with halofuginone. A total of 28 rats were studied, 14 in the control and 14 in the experimental group. Results: Rats whose implants were treated with halofuginone exhibited a significant decrease in CD68+ histiocytes, TGF-, fibroblasts, collagen type I and type III, and capsular thickening when studied at 3 months after implant placement. Conclusions: Implants treated with halofuginone may provoke a significant decrease in capsular formation. Reviewer's Comments: The results of this study are promising. There are several concerns with drawing premature conclusions. For one, this study was conducted in rats, and therefore may or may not translate to a human model. Secondly, while the implants were coated with the substance (therefore avoiding a systemic response), studies of systemic anti-inflammatory use in humans have demonstrated the dangers of this suppression despite its success with capsule formation. Anything on the implant will likely be absorbed to some degree. Finally, while it is clear that the formation of a thick capsule around an implant is due to fibrosis and is therefore likely limited by antifibrotics, this information does little to elucidate the basis of the capsule formation itself. Maybe the antifibrotic substance helps, but why is the capsule forming in the first place? Is this treatment merely a band-aid to an unsolved problem? And if so, then what prevents the capsule from forming later on after the fibrinolytic therapy is discontinued? To this end, it would have been interesting to preserve some implants for a few months after cessation of halofuginone therapy to see if the lack of capsule formation had a lasting effect or if it was merely staved off. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Breast Implants, Capsular Contracture, TGF- Antagonists Print Tag: Refer to original journal article

Meta-Analysis Supports Single Monocortical Miniplates for Mandibular Angle Fx

Internal Fixation of Mandibular Angle Fractures: A Meta-Analysis.
Regev E, Shiff JS, et al: Plast Reconstr Surg 2010; 125 (June): 1753-1760

This meta-analysis found lower rates of infection, nonunion, reoperation, and malocclusion with the use of noncompression, monocortical, and single-plate fixation for mandibular angle fractures.

Background: The Arbeitsgemeinschaft fr Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) philosophy of open reduction and internal fixation (ORIF) holds that total rigidity and compression is necessary for fracture healing, whereas more recent work first reported by Michelet and Champy states that primary bone healing and absolute immobilization are not necessary. Multiple studies comparing these methods have been done but using multiple definitions and technical variations. Objective: To perform a meta-analysis of the literature comparing complication rates for different fixation methods. Design: Literature search and meta-analysis. Methods: The authors searched PubMed, EMBASE, and Cochrane for articles using the phrases "mandible angle" and "jaw angle" with "miniplate," "monocortical," "bicortical," "rigid fixation," "osteosynthesis," and "Champy." The meta-analysis compared 4 variables: compression/noncompression plates; monocortical/bicortical screws; number of plates; and location of plates. The outcomes measured were infection, reoperation, hardware removal, nonunion, and malunion. Results: 24 articles were located that met the criteria. For the first variable, compression versus noncompression, the compression group had higher rates of infection (20.7% vs 8.2%), reoperation (26.9% vs 15.1%), hardware removal (27% vs 14.4%), and malunion (14.1% vs 2.8) but no difference in rates of nonunion (3.1% vs 2.6%). For the monocortical/bicortical variable, the bicortical group had higher rates of infection (18.6% vs 7.8%), but no significant difference in other variables. With regard to the number of plates, infection, reoperation, and hardware removal rates were higher when 2 plates were used. For the fourth variable, location of plates, higher rates of infection, reoperation, and hardware removal were seen with the use of both superior and inferior plates than for single plate. The lowest complication rates where associated with plates placed on the superior border. Conclusions: The authors found lower complication rates with the use of noncompression, monocortical, and single-plate fixation, supporting the trend toward 1 monocortical miniplate placed on the superior border using a transoral approach. Reviewer's Comments: This is a very thorough review of the literature; however, it is restricted to English literature only, which may limit the results. The authors also acknowledge that inconsistent terminology throughout the literature was also a challenge. However, the results of the studies they did compare were consistent showing lower complications with noncompression, monocortical, and single-plate fixation. This is likely due to the minimal invasiveness of these approaches and increased vascularity of the tissue with less necrosis of the bone. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Mandible Fractures, Rigid Fixation, Facial Trauma Print Tag: Refer to original journal article

Does Fibrin Glue Plus Quilting Sutures Reduce Drainage?

The Combination of Fibrin Glue and Quilting Reduces Drainage in the Extended Latissimus Dorsi Flap Donor Site.
Ali SN, Gill P, et al: Plast Reconstr Surg 2010; 125 (June): 1615-1619

The presence of drains themselves can stimulate increased fluid collection after flap dissection.

Background: Quilting sutures have been shown to reduce the incidence of donor-site seromas. Fibrin glue has also been used to decrease the need for drain placement at surgical sites. Objective: This paper represents a prospective comparison between drainage quantities from extended latissimus dorsi donor sites closed with quilting sutures and those closed with quilting sutures and fibrin glue. Design: Nonrandomized prospective study. Participants/Methods: 11 consecutive patients underwent extended latissimus dorsi donor site closure with fibrin glue and quilting sutures, while a control group of 24 consecutive patients underwent donor site closure with quilting sutures alone. Results: The average drainage in the treatment group was significantly reduced from 170 cc to 13 cc in the immediate postoperative period (from 645 cc to 330 cc total) and the drain stay was reduced from 5 days to 4 days. Conclusions: Fibrin glue used in conjunction with quilting sutures reduces drainage from the latissimus dorsi donor site. This combination of techniques leads to shorter drain stays and may obviate the need for drain placement. Reviewer's Comments: There are several problems with this study. For one, the sample size is extremely small. Second, the authors state that there is a significant decrease in drainage in the "immediate postoperative period," which they define as the time between drain placement and the patient getting off the operating room table. This is not a reasonable comparison. If the purpose of the study is to claim that drains are not needed, then this claim can only be made on the basis of total output over the course of the drain stay or daily outputs in terms of what would exceed absorbable quantities. The total output for the treatment group averaged 330 cc over 4 days, which still vastly exceeds what the body can resorb; therefore, drains are still needed for these patients. If one accounts for 200 cc of this difference in the first few hours, then the overall difference becomes small, and the effect is not significant. Finally, one must consider that while in the U.K. they do keep patients as inpatient until drains are removed, this is not the norm. In the United States, most patients are sent home with drains; therefore, shorter drain stays do not impact hospital stays. Furthermore, the difference between 4 and 5 days is not tremendous. The difference between 4 and 14 days is, so without the quilting sutures most patients end up with 14-day drain stays. Therefore, the quilting appears to be the effective component of this treatment. Ultimately, keeping a drain in 1 more day is far less troublesome to the surgeon and to the patient than managing a seroma. The decreased drainage reported is not significant enough to suggest not placing drains in these patients. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Reducing Drainage, Seroma, Quilting Sutures, Fibrin Glue Print Tag: Refer to original journal article

The World Is Getting Flat for Plastic Surgeons, Too

Transatlantic Innovations: A Novel Approach to International Ideas and Technology.
Evans GRD, Blondeel P, et al: Plast Reconstr Surgery 2010; 126 (July): 316-336

Plastic surgeons worldwide agree that stem cell research will yield discoveries that will have an important impact on the future of the specialty.

Background: Transatlantic Innovations was the title of an international meeting in April of 2009 to help define the international attitudes of plastic surgeon specialists toward plastic surgery. Objectives: To compare and contrast current ideas and trends among practicing plastic surgeons. Design: Review article. Methods: 3 international groups were established: the United States, the European Union, and the "Rest of the World." The meeting focused on 10 topics ranging from surgical technologies to branding, and it concluded with a consensus statement. Results: The interactive response system in use at the meeting allowed for real-time audience response, idea sharing, and discussion regarding preliminary answers. Conclusions: While there were differences in opinion in the 3 groups, plastic surgeons on both sides of the Atlantic had more in common than not. Reviewer's Comments: This article highlights a very important reality for plastic surgery today: it is, like many businesses in the 21st century, becoming an international community. Many patients today travel for their surgeons, be it within the Unites States or abroad. Differences in policy, legislation, and technology strongly influence patient and surgeon attitudes. This article clearly illustrates the main differences between the 3 groups, which are listed next. (1) The United States is more focused on branding and marketing, and plastic surgeons in this country are far more susceptible to litigious patients. (2) The Unites States and Europe consider new technology integral to their future success, whereas the Rest of the World focuses more on patient satisfaction. (3) The United States is more likely to use injectable fillers instead of fat grafting than are the other 2 groups. On the whole, however, all plastic surgeons were concerned with the media image of plastic surgery and with the risks of a tourist marketplace driven by price. In this international marketplace, it is of paramount importance to know and understand the international community of plastic surgery, to be aware of trends and technologies, and to share information. It is also necessary to recognize that the plastic surgery patient exists on both sides of the ocean, and today's plastic surgeon does as well. Creating a more global perspective is a priceless vehicle for establishing the face of plastic surgery, furthering the field, and weeding out each community's roadblocks (such as litigation) in an effort to improve each one's social climate. (Reviewer-Robert T. Grant, MD).
2010, Oakstone Medical Publishing
Keywords: Plastic Surgery, International Ideas, Technology Print Tag: Refer to original journal article