A Retrospective Review of Aesthetic Malpractice Cases Settled Nationally in Court 2000-2004

Presenter:	Amardip Bhuller, MD, FRCSi
Co-Authors:	Wong Moon, MD, James Zins, MD, Warren Hammert, MD, DDS
Affiliation:	Cleveland Clinic Foundation, Cleveland, OH

Hypothesis: Cosmetic surgery lawsuits in the United States which proceeded to trial were reviewed to document the incidence and investigate any common denominators in the cause of action.

Methods: A team of lawyers performed a search of legal data bases between 2000-2004 and used ASAPS data to calculate incidence of malpractice.

Results: 40 breast augmentations, 36 liposuctions, 14 breast reductions, 9 facelifts and 8 rhinoplasties were identified. Breast augmentation had the highest incidence of litigation (1/38,913), followed by breast reduction (1/51,844), facelifts (1/69,670), liposuction (1/99,886) and rhinoplasty (1/101,099). Liposuction cases resulted in a mean award of $4,402,453 with the main reasons being lack of informed consent and uneven contours. Breast augmentation was $255,761 due to scarring, and lack of informed consent. Rhinoplasty was $305,000 due to lack of informed consent, difficulty breathing. Breast reduction was $302,483 due to scarring and lack of informed consent. For facelifts this was $400,077 due to lack of informed consent or scarring.

Discussion: The most common aesthetic procedure going to trial is breast augmentation, which also has the greatest incidence of litigation. Lack of informed consent remains the most common reason for a lawsuit occurring in spite of documentation with a signed consent form.

Presenter:	David A. Bray, MD
Co-Authors:	John Nguyen, MD, Benjamin E. Cohen, MD, Donald R. Collins, Jr, MD
Affiliation:	The Methodist Hospital of Houston, Houston, TX

Background: This investigation was designed to evaluate the efficacy of a local anesthetic pain infusion pump in management of postoperative pain in abdominoplasty patients. Methods: A retrospective study of 38 abdominoplasty patients with local anesthetic pain pumps and 35 abdominoplasty patients without pain pumps was performed. All patients were admitted postoperatively and started on a narcotic patient-controlled analgesia (PCA). Postoperative PCA narcotic use and pain scores were recorded every two hours by the nursing staff. For the first twenty-four hours of postoperative hospital stay, pain medication, pain scores, and anti-emetic use were determined from the patients' charts. Hospital stay was also reviewed. Results: In the pain pump group, there was a small but not statistically significant reduction in pain medication use (2.65 versus 3.04 pain units) (p=0.34). Interestingly, pain scores were higher in the pain pump group but not significantly (2.73 versus 2.31) (p=0.17). There was no statistically significant difference in the use of anti-emetics (0.8 versus 0.6) (p=0.60). Hospital length of stay averaged 2.2 in the pain pump group and 2.5 in the group without pain pumps (p=0.09). Conclusion: The postoperative use of pain pumps in abdominoplasty patients did not significantly improve pain management.

Experimental & Clinical Experience with Diced Cartilage Grafts in Nasofacial Reconstruction

Presenter:	Kevin A. Brenner, MD
Affiliation:	University of California, Irvine, Orange, CA

Purpose: Viability and feasibility of Surgicel-wrapped diced cartilage grafts (DCS) versus fascia-wrapped grafts (DCF) remains debated. Clinical failures and histological findings in human DCS prompted animal investigation to compare behaviors of unwrapped diced cartilage (DC) with DCS and DCF.

Methods: Human cartilage was diced and implanted in athymic rats as DC, DCS or DCF. At eight weeks the specimens were processed, stained, and evaluated for viability and architecture.

Clinical Application: DCF grafts were utilized to reconstruct failed DCS grafts (radix, dorsum, parapyriform, malar, etc.)in nasofacial reconstruction patients. Biopsy specimens obtained from clinical grafts during revision operations were analyzed.

Results: Experimental arm: DCS had the lowest viability and staining while DCF had the highest, with H & E, Trichrome, Safranin-O, and Von Giesson stains. Absolute numbers of nucleated and basophilic lacunae were significantly higher for DCF grafts. Clinical histology validated these findings.

Conclusions: Surgicel incites, while fascia minimizes,inflammatory response and cartilage absorption in diced cartilage grafts. This experimental study demonstrates that deep temporal fascia is the preferred envelope to facilitate graft containment and maintain chondrocyte viability. Laboratory findings are consistent with clinical use of DCF grafts. Long term permanence with DCF grafts proves encouraging with results at two years.

Abdominal Lipectomy and Simultaneous Reconstruction of Abdominal Wall Defects After Bariatric Surgery

Presenter:	Bryan K. Criswell, MD
Co-Author:	Mimis N. Cohen, MD
Affiliation:	University of Illinois at Chicago, Chicago, IL

Purpose: Ten to 20% of patients undergoing open gastric bypass surgery will develop incisional hernias and other abdominal wall defects. Plastic surgeons are often called to care for these patients. We evaluate the outcomes of abdominal lipectomy and simultaneous reconstruction of abdominal wall defects resulting from major abdominal surgery.

Methods: 327 patients were treated from 1991 to 2004. 229 presented with primary ventral hernias, 86 with recurrent hernias, and 12 with port site hernias. Components separation was used in 55.9% of the incisional hernias. 11.1% were closed directly and 33% required a bioprosthetic material. A Fleur-de-Lis lipectomy was used in the majority of cases.

Results: Follow-up ranged from 1 to 8 years. 7.3% developed seromas and 0.65% developed hematomas. Minor wound problems occurred in 16.1% and were treated conservatively. Major infection and dehiscence requiring surgical intervention occurred in 8.2%. Only 5.8% of our patients developed recurrent hernias.

Conclusions: Abdominal lipectomy can be combined with abdominal wall reconstruction without a significantly higher risk of complications. Procedures are individualized and based on the reconstructive requirements. Postoperative complications should be managed aggressively with early debridement and closure, while staged reconstruction can be considered when early definitive closure is not feasible or desirable.

Intense Pulsed Light Tattoo Removal in Conjunction with Imiquimod (Aldara®): a Double-Blind, Randomized Controlled Study

Presenter:	Dean DeRoberts, MD
Co-Author:	Joseph A. Molnar, MD, PhD, FACS
Affiliation:	Wake Forest University Baptist Medical Center, Winston-Salem, NC

Purpose: The most widely used methods of tattoo removal are lasers and Intense Pulsed Light (IPL). These modalities require multiple treatment sessions with varying degrees of success. Imiquimod (Aldara®, 3M) is a new immune response modifier medication that increases phagocytosis. We hypothesize that the combination of IPL and imiquimod would result in more efficient removal of tattoos. Methodology: An IRB approved study was performed using 24 patients separated into two groups. Both groups had their tattoos treated with the Vasculight IPL (Lumenis®). Immediately post-treatment either medication or vehicle control was applied and then reapplied each night for four weeks. This cycle was repeated a second time after three months. The clearance was judged by five plastic surgeons in a blinded fashion. Results: 23 of 24 patients completed the study. 8 of 11 imiquimod patients had complete or excellent clearance of their tattoo, while only 4 of 12 control patients obtained similar clearance. All patients in the control group had moderate to severe pigmentary and scarring changes to obtain clearance, while only 1 imiquimod patient had moderate hypopigmentation. Conclusion: Combined use of imiquimod with IPL increases the clearance of tattoos and reduces the side effects of scarring and pigmentary changes.

The Anatomic Relationship Between the Inframammary Fold and Pectoralis Major Origin

Breast reconstruction and cosmetic augmentation rely on the anatomy of the inframammary fold and pectoralis major origin. There is continued debate as to whether the pectoralis origin should be released in augmentation procedures. No study to date has determined the anatomic relationship between these two intimate locations. The anatomy of the fold has been previously defined histologically. The anatomy of the pectoralis origin has also been identified. The relationship between these two anatomic landmarks which are routinely dissected during aesthetic breast surgery remains undefined. In order to identify the specific relationship, four female and four male cadavers were dissected. Methylene blue was injected perpendicular to the superficial skin fold in order to stain its location along the rib cage. The dissection was then performed along the breast meridian. In all cases, the skin fold was located either one rib or one intercostal space below the pectoralis origin. This data indicates that the pectoralis origin at the breast meridian needs to be released in augmentation in order for implants to fill the breast envelope down to the inframammary fold, thus avoiding excessive upper pole fullness. Living subjects undergoing breast procedures such as mastectomy and augmentation are currently being studied.

Presenter:	Lisa Jewell, MD
Co-Author:	Reza Nabavian, MD
Affiliation:	University of Southern California, Los Angeles, CA

INTRODUCTION Recent graduates of plastic surgery training programs seem to have abandoned the traditional model of mixed reconstructive and cosmetic practices in favor of seeking only cosmetic patients. In this article we describe the demographics, referral sources, and payment methods of the first 100 surgical patients from a new, private, single surgeon, cosmetic practice in a major metropolitan city. METHODS The first 100 patients operated on in this setting were included in this study. Date of surgery, patient age, gender, type of surgery, type of payment, and source of referral were studied. RESULTS Fifty-two reconstructive and 48 cosmetic cases were performed. The most common payment types were insurance (42%), cash (33%), and credit card (20%). The most common referral source was the ER (36%) followed by patients (23%), physicians (23%), and friends (14%). One hundred percent of ER referrals were reconstructive and 100% of patient referrals were cosmetic. Eighty-six percent of friend referrals and 39% of physician referrals were cosmetic. DISCUSSION Although this surgeon had set out to establish a purely cosmetic practice, in reality, his practice followed a more traditional model. In fact, it appears that the volume of reconstructive cases positively contributed to the success of the practice.

Breast Reduction Scars: Does Population Demographics and Pre-operative Education Affect Scar Expectations and Patient Satisfaction?

Presenter:	Andrew Jimerson, II, MD
Co-Authors:	Andrea Holinga, Robert Ruberg, MD
Affiliation:	Ohio State University, Hillard, OH

Background: Scar dissatisfaction is high in reduction mammaplasty. The purpose of this study is to determine patient satisfaction in relation to population demographics and pre-operative education.

Methods: A retrospective chart review of 138 patients who underwent the inverted-T inferior-pedicle breast reduction between 2000 an 2004 at Ohio State University was done. Patients completed questionnaires on demographic variables and pre-operative patient education methods. They also ranked thier scar satisfaction relative to scar expectations. The results were analyzed by chi-square and logistic regression analysis.

Results: No statistical significance was found between satisfaction groups regarding age, BMI, tissue removed, race, complexion or post-operative complications. However, marital status, reasons for surgery and pre-operative patient education were all found to be statistically significant with regard to scar satisfaction post-operatively.

Conclusions: The majority of patients were satisfied with their scars and would undergo reduction mammaplasty again. Divorced patients were more likely to be dissatisfied with scar outcomes compared to married patients. Patients undergoing reductions for symptomatic reasons were more dissatisfied with their scar outcomes compared to those undergoing surgery for both cosmetic and symptomatic reasons. Lastly, patients shown both photos and drawings were less likely to be dissatisfied with scars compared to patients shown neither.

Presenter:	Kenneth K. Kim, MD
Co-Authors:	E. Bradley Strong, MD, Linping Zhao, Peter Belafsky MD, Pravin K. Patel, MD
Affiliation:	Northwestern University, Chicago, IL

Purpose: The K-wire technique for fixation of rib cartilage grafts to the maxilla is a powerful tool in rhinoplasty. However, the technique is challenging because of poor maxillary visualization through the open rhinoplasty approach. This study evaluates the efficacy of a surgical navigation to guide K-wire placement.

Methods/Materials: K-Wires were placed into the maxillas of twelve fresh cadaver heads by a surgical resident. Six control specimens had K-wires placed without navigation. Six treatment specimens had K-wires placed with the look-ahead navigation, in which a navigation was attached to the K-wire gun. All maxillas were then sectioned to determine K-wires' final location.

Results: 80% of the K-wires were successfully placed in the treatment group, while only 50% of the K-wires were successfully placed in the control group. The average K-wire deviation in the axial plane was less for the treatment group (0.2 ± 0.4 mm) than for the control group (1.8 ±1.5 mm) (p<0.05). The average depth of penetration for the treatment group was 7.6 ± 1.9 mm, while for the control group, it was 11.7± 6.1 mm (p>0.05).

Conclusion: When surgical navigation is used in K-wired cartilage strut graft placement to maxilla, it can improve the accuracy of K-wire placement.

Presenter:	Shashidhar Kusuma, MD
Co-Authors:	James Zins, Frank Papay
Affiliation:	Cleveland Clinic Foundation, Cleveland, OH

Patients who seek rhinoplasty may present with inferior turbinate hypertrophy. Recently, endoscopic resection of the inferior turbinate submucosa and stroma with a microdebrider, has proven to be an excellent alternative to the traditional techniques to reduce the size of the inferior turbinate. This technique has been shown to preserve the inferior turbinate mucosa while reducing the anatomic obstruction caused by the inferior turbinate. We have used this technique to address inferior turbinate hypertrophy at our institution since January of 2005. We present our initial experience with this novel technique at our institution.

We identified 6 patients who underwent the procedure since January of 2005. There were 4 males and 2 females. The average age of the patients was 36. The mean follow up was 5 months. There were no peri-operative complications. All patients have symptomatic improvement in their airway. Intranasal examination revealed patent airways with well healed inferior turbinate mucosa.

Conclusion: Endoscopic inferior turbinoplasty is an excellent technique to address inferior turbinate hypertrophy. With experience, this technique can be done expeditiously with minimal complications. This technique can reduce some of the complications associated with the traditional methods to reduce the inferior turbinate.

Presenter:	Thuy Le, MD
Co-Author:	George W. Commons, MD, FACS
Affiliation:	Stanford University, Stanford, CA

With our continued experience in liposuction procedures and the progressive technological developments, we felt a review of our recent large volume liposuction cases was warranted.

A retrospective chart review was performed on 138 consecutive patients who underwent liposuction procedures of at least 5000 cc total fat aspirated per procedure. Data collection included patient demographics, total aspirate volumes, fluid input and output.

Candidates were between 19-65 years old and were within fifty pounds of their ideal body weight. Total fat aspirated ranged from 5-14 liters. Eight patients underwent two-stage procedures with over five liters total fat removed at each procedure. The majority of complications were minor postoperative seromas, occurring in 5% of cases. Other minor complications such as hypertrophic scarring, neuropraxia, and skin necrosis resolved uneventfully.

The review of our large volume liposuction cases over the past five years has reinforced our belief that this remains a safe and viable option for body contouring. We now incorporate ultrasonic lipolysis routinely in our practice and for extremely large volume cases, we have moved from a single stage large volume procedure to a multistage effort. These changes have proven to be extremely useful and effective in maintaining quality outcomes with minimal complications.

Presenter:	Samuel Lin, MD
Co-Authors:	Neel Patel, MD, Neil A. Fine, MD
Affiliation:	Northwestern University Medical School, Chicago, IL

Over the last several years, medical imaging techniques have continually improved. However, measuring aesthetic outcome using conventional photography has its inherent limitations; visualizing an area such as the face, which has 3 dimensions, using plain photography, which has 2 dimensions, may be inaccurate in determining the change from preoperative to postoperative images. At our institution, we have begun using a 3-D imaging device to visualize facial aesthetic patients preoperatively and during their postoperative course.

In consecutive patients undergoing Contour thread placement for facial rejuvenation, we prospectively imaged these patients both preoperatively and postoperatively at separate timepoints. From these 3-dimensional images we were able to find movement vectors in all 3 axes for changes in soft tissue. Analyzed images revealed midface soft tissue elevation and improved nasolabial contour over a period of months postoperatively. Average improvement in nasolabial furrowing was 2.3 mm in these patients, and images showed stability of the improvement of the nasolabial area over time.

In conclusion, we have found that 3-dimensional imaging techniques may be an important development in the accuracy of medical imaging, both in the aesthetic and reconstructive patient. The use of 3-dimensional imaging may be applicable to numerous clinical settings.

Presenter:	David W. Mathes, MD
Co-Authors:	Jeffrey M. Kenkel, MD, Rod J. Rohrich, MD
Affiliation:	University of Texas, Southwestern, Dallas, TX

Introduction: Aesthetic surgery of the medial thigh continues to be a challenging area for surgical rejuvenation. This paper outlines the importance of preoperative assessment and classification and includes new modifications for the massive weight loss patient. Methods: All medial thigh lifts performed from 1999 to 2004 were identified. The type of medial thighplasty was based on the degree of skin laxity and lipodystrophy. Each patient was assigned to one of five separate categories of medial thigh deformity and were evaluated for the outcome of the medial thigh lift and for complications. In addition our recent modifications in techniques were reviewed. Results: 29 patients underwent a primary medial thigh lift. (12 of were massive weight loss patients). 4 patients presented with minor wound dehiscences (17%), 3 with prolonged postoperative edema (12.5 %), and 1 patient with scar widening (4%). Finally, 2 patients in this group underwent a subsequent secondary medial thigh lift (8%). Conclusion: The medial thigh lift is a powerful technique. However,in order to maximize the opportunities for success one must identify to type of medial thigh problem and tailor the operation according to the type of thigh encountered.

Peri-Operative Blood Pressure Fluctuations and Hematoma Following Reduction Mammaplasty

Presenter:	W. Thomas McClellan, MD
Co-Author:	Jeffrey Weinzweig, MD, FACS
Affiliation:	Lahey Clinic Foundation, Burlington, MA

Hematoma following reduction mammaplasty can be a serious complication. Intra-operative hypotension and post-operative hypertension may promote in hematoma development.

We reviewed patients who underwent reduction mammaplasty from 2001 to 2004. A hematoma was defined as a collection that required operative exploration. A non-hematoma cohort of 20 was randomly selected for statistical comparison. The operation was divided into three equal phases and mean blood pressure (BP) for each period recorded. The phases were defined as shaping, hemostasis, and closure. Perioperative and demographic data were collected.

538 wise pattern inferior pedicle reductions and 8 hematomas (1.5%) were identified. Mean age was 41 years and mean BMI was 30. Mean operative time 2 hours. Average resection was 788 grams(R) and 771 grams(L). Analysis demonstrated BP during hemostasis phase was significantly lower in the hematoma group. (p<0.004) Post-operative BP was significantly higher in the hematoma group. (p<0.007) The mean swing of systolic BP from the hemostatic phase to post-op was significantly larger in the hematoma group. (p<0.001)

Hypotension during the hemostasis, post-operative hypertension, and large BP fluctuations were all significant in our series. Normotensive hemostasis and tight post-operative BP management may decrease the development of hematoma following reduction mammaplasty

Single Stage Sub-muscular Breast Augmentation and Mastopexy in the Massive Weight Loss Patient

Presenter:	Sarah E. McMillan, MD
Co-Author:	Bivik Shah, MD
Affiliation:	Ohio State University, Columbus, OH

Background: Single stage breast augmentation and mastopexy has been fraught with complications. The difficulty of combining gland augmentation and skin reduction raises concerns for nipple-areolar necrosis and implant malposition. The surgeon must often convince the patient that two operations are better than one. Massive weight loss patients may have severe breast deformities that are often dealt with in staged operations; however, we present a single stage operation as a viable alternative.

Objective: To review the surgeon's technique, results and complications in massive weight loss patients undergoing single stage breast augmentation and mastopexy.

Methods: Forty-six patients, the majority of whom had Grade III ptosis, underwent single stage augmentation and mastopexy over a period of three years. Sub-muscular augmentation was performed first, followed by Wise pattern mastopexy. Forty-one patients underwent additional concurrent body contouring procedures.

Results: No patient suffered total nipple-areolar loss, however one patient (2%) had partial loss of one areola. Four patients (9%) required return to the operating room for reasons such as implant deflation (1 patient), implant infection (1 patient), and implant malposition (2 patients).

Conclusion: Single stage sub-muscular breast augmentation and mastopexy may be performed with an acceptable complication rate in the massive weight loss patient.

An in Vitro Comparison of Concentrated Bacitracin Foam for Bacterial Control in the Breast Implant Pocket

Presenter:	Adam Newman, MD
Co-Author:	Victor Manuel Perez, MD
Affiliation:	Kansas University, Kansas C ity, KS

Breast implant pocket irrigation has been suggested to control the bacteria that can lead to subclinical infections and capsular contractures. The purpose of this study is to compare other commonly used irrigation protocols in vitro against a proven bacterial control method of Betadine with Cefazolin and Gentamycin. Bacitracin foamed into 10ml saline; diluted Bacitracin solution; Betadine with Cefazolin and Gentamycin; and saline alone were compared for in vitro efficacy against the common implant pathogens: S. epidermidis, S. aureus, E. coli, and Pseudomonas. Efficacy was determined by irrigating the colonized agar plates. Saline alone and dilute Bacitracin did not provide adequate bacterial control. Bacitracin foam was equally effective as the proven method. However, Bacitracin foam placed after saline irrigation remains in the implant pocket and provides longer antibacterial control, has the benefits of decreased detrimental effect on wound healing and less harmful effect on the implant as compared to Betadine, and remains a simpler cheaper method for bacterial control as opposed to other antimicrobial mixtures.

Primary Breast Lymphoma in a Patient with Silicone Breast Implants: a Case Report and Review of the Literature

Presenter:	Michael K. Newman, MD
Co-Authors:	Abdalla Z. Bandak, MD, Neil J. Zemmel, MD
Affiliation:	Virginia Commonwealth University Medical Center, Richmond, VA

Primary breast lymphoma is a rare disease. We report a patient who developed anaplastic large cell lymphoma in her breast adjacent to a silicone breast implant 14 years after elective breast augmentation. The patient initially presented with a periprosthetic fluid collection and metastatic work up revealed no other focus of disease. She was treated with systemic chemotherapy and then developed a recurrent periprosthetic fluid collection 4 months later prompting breast implant removal and capsulectomy. Pathology revealed recurrent lymphoma and additional chemotherapy was initiated. Review of the literature revealed 5 cases of primary breast lymphoma associated with a breast implant. All 5 patients had anaplastic large cell lymphoma, the same histological subtype as our patient. Including this case, patients presented with either a mass or a periprosthetic fluid collection an average of 8 years after either silicone gel filled or saline filled breast implant placement. Review of 6 total patients with breast implants and anaplastic large cell lymphoma suggests the possibility of an association, however, no conclusions relating silicone implants to lymphoma can be made. Clinicians should include malignancy in the differential diagnosis of periprosthetic fluid collections and periprosthetic masses.

Vertically-rotated reverse sliding osteotomy: a new technique for reduction genioplasty

Presenter:	Thornwell H. Parker, III, MD
Co-Authors:	Dan A. Hatef, MD, P. Craig Hobar, MD
Affiliation:	UT Southwestern, Irving, TX

INTRODUCTION: Along with the nose, the chin is arguably the most important aesthetic feature of a face in profile. Patients with extreme protrusion of the chin may seek treatment for this rare condition, but as of yet there is no consensus as to what the optimal surgical management is. We describe our experience with a new adjunct to the traditional reverse sliding genioplasty. METHODS/MATERIALS: In the previous four patients with this problem, a reverse sliding genioplasty was performed, with rotation of the osteotomy segment in a posteroinferior direction in the vertical plane. RESULTS/CONCLUSIONS: Historically, protrusion of the chin has been a difficult aesthetic problem to treat. Burring and cutting of the protruding chin was done in the past, with disastrous soft tissue consequences resulting in witches chin deformity. Reverse sliding genioplasty has provided an improvement, but it results in slack in the genioglossus, geniohyoid, and mylohyoid muscles. We have described a modification to the reverse sliding genioplasty in which the osteotomy segment is rotated to give more vertical dimension to the chin, and to maintain the normal tension of the soft tissue. We believe this gives superior results to previously described techniques.

A New Approach To Correction Of Truncal Redundancy Following Massive Weight Loss, The Lateral Thoracoabdominoplasty (L-TAP)

Presenter:	Shahrad R. Rahban, MD
Co-Author:	John Gross, MD
Affiliation:	University of Southern California, Los Angeles, CA

The purpose of this paper is to describe a new approach of correcting two difficult problems seen following massive weight loss. The first problem is the residual transverse abdominal laxity that is not addressed by either abdominoplasties or circumferential lipectomies and the second is the lateral decent of the breast mound and IMF, which is not well addressed by traditional mastopexies.

We present a case report of a procedure that we believe corrects both of these anatomical changes simultaneously. We have named it the Lateral ThoracoAbdominoplasty, L-TAP. This procedure is intended for patients who have undergone minimally invasive bariatric surgery or lost weight by diet and exercise and thus lack an existing midline incision. We advocate resecting the redundant tissue from the lateral aspect of the trunk, instead of the traditional approach, which utilizes a midline abdominal incision. The anterior abdomen is left unblemished and the scars are concealed along the mid-axillary line from axilla to iliac crest.

Our patient is extremely satisfied and has had no complications at greater than one year follow up.

The L-TAP utilizes a concealed mid-axillary approach to effectively correct the vertical abdominal laxity and lateral breast decent seen after massive weight loss.

Presenter:	Sean Simon, MD
Co-Authors:	Nirmal Nathan, BS, Seth Thaller, MD, DMD
Affiliation:	University of Miami, Coral Gables, FL

The purpose of this study was determine whether or not performing abdominoplasty in conjunction with additional procedures would result in an increased complication rate. A total of 102 patients that underwent body contouring procedures, either alone or combined with additional surgery, between March 2003 and March 2005 were included. A retrospective study design was utilized with Internal Review Board approval. All operative and postoperative notes and tests were reviewed for complications. The combined surgeries included breast reduction, mastopexy, hysterectomy, colostomy revisions, and hernia repairs among others. Complication rates were also correlated with BMI. Twenty seven patients underwent abdominoplasty alone and 47 in the abdominplasty combined group. The complication rates of 18.5% vs. 17% respectively were analyzed with a t-test (p = .44). Complication rates for all patients were further stratified in relation to BMI. There was a direct correlation between increasing BMI and increasing complication rate. Comparison of BMI < 25 (normal) with BMI > 30 (obese) revealed complication rates of 9% vs. 36% respectively (p < .02). Obesity is an significant predictor of postoperative complications. Combining abdominoplasty with additional surgical procedures does not lead to increased complication rates and is safe with carefully selected patients and appropriate DVT prophylaxis.

Horizontal or Vertical? An Evaluation of Patient Preferences for Reduction Mammaplasty Scars

Presenter:	Amy McLean Sprole, MD
Co-Authors:	Ife Adepoju, BA, Jeff Ascherman, MD, Lloyd Gayle, MD, Robert Grant, MD, Mia Talmor, MD
Affiliation:	New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY

Purpose: Limited incision techniques of reduction mammaplasty have experienced increased popularity in recent years. In this study, we evaluated patient preferences for breast reduction scar location.

Methods: All patients in our practice who had undergone bilateral Wise-pattern reduction mammaplasty between July 1999 and June 2004 were included. Responses were generated from anonymous questionnaires.

Results: Of the 57 survey respondents, 49 were highly satisfied with their breast reduction surgery. However, 37 respondents indicated dissatisfaction with their surgical scars (p=0.02). Thirty-one patients were bothered by one particular component of the scar. Of these patients, 20 indicated that the horizontal component was most bothersome (p<0.001). Patients were then asked which part of the scar they would erase, if they could do so. Of the 46 respondents, 23 patients indicated that they would erase the vertical component (p=0.02).

Conclusion: This study underscores the importance of promoting operations that minimize breast reduction scars. One can deduce from the patient opinions expressed in this study that short-scar breast reduction optionsboth pure vertical and pure horizontal techniques--would be welcomed. The choice of technique must be tailored to a particular patient, so as to minimize the overall scar burden, while maximizing symptom relief and aesthetic outcome.

Presenter:	Adam Bryce Weinfeld, MD
Co-Authors:	Edward Lee, BS, Chandrasekhar Bob Basu, MD, Eser Yuksel, MD
Affiliation:	Baylor College of Medicine, Houston, TX

Purpose: To date no published system exists to categorize variations in labial attractiveness. I present a classification of female lips.

Methods: Photographs of 102 female faces (ethnically varied, 14-78 years old) were evaluated. A three-tiered classification system with add-on modifiers was devised.

Results: Female lips were categorized as Type I, II, or III based on geometric characteristics and tissue present. Type I lips are plump in the vermillion region, have a concave profile, and have sufficient vermillion show. Type II lips are atrophic/hypoplastic, especially in the vermillion and adjacent regions. They have a planar or convex profile and have insufficient vermillion show. Type III lips have a negative vector (columella-labial junction further anterior than upper vermillion border) and have insufficient vermillion show. Modifiers include R (rhytids) L (long upper lip) and D (discordant, upper lip significantly more atrophic/hypoplastic than lower lip). The sample population demonstrated the following classification distributions: I=13.6%, II=72.8%, and III=13.6%. With the use of the modifiers, the representation was: I=10.2%, I-L=3.4%, II=16.9%, II-R=15.2%, II-L=6.8%, II-D=5.1%, II-RL=28.8%, III=10.2%, III-L=1.7%, and III-RL=1.7%.

Conclusion: A systematic classification system of the female lips facilitates scholarly discourse regarding labial aesthetics and the planning of procedures to enhance lip appearance.

Presenter:	Sameer A. Patel, MD
Co-Authors:	Berish Strauch, MD, Christine Rhode, MD, Mick Patel, MD
Affiliation:	Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY

Body contouring procedures after massive weight loss are becoming more and more common in this era of widespread obesity and increasing rates of gastric bypass procedures. Although the recent literature has presented numerous discussions about the treatment of redundant abdominal tissue, little has been published about breast contouring in these patients. Following weight loss surgery, women lose volume and projection of the breasts. Additionally, the lateral breast fold sags and becomes a significant fold frequently extending almost to the midline of the back as the upper back fold. The authors discuss an algorithm for improving the appearance of the breast in postbariatric surgery patients, based on the use of a superolateral parenchymal pedicle (SLPP) and utilizing a modified wise pattern or a vertical pattern with or without prosthetic augmentation to correct specific anatomic abnormalities. The concept of autologous augmentation is utilized to correct specific deformities.

Empiric Antibiotic Therapy for Marine Organism Associated Injuries: A Four Season Study

Presenter:	Joseph Christopher Berardi, MD
Affiliation:	University of Texas Medical Branch, Galveston, TX

In an effort to further advance patient care and guide treatment planning with salt water associated injuries, studies have been conducted of marine organisms and environmental hazards, which are a source of many marine associated injuries. Oysters, barnacles, stone and concrete structures are a frequently the source of wounds treated in the UTMB Emergency Department.

Samples were collected during four seasons. Specimens included oyster, barnacle, surface swabs and water. These were cultured for identification of microbes and antimicrobial sensitivity.

Four bodies of water surrounding Galveston Island were chosen. These areas were chosen due to the presence of rock or concrete formations and high volumes of outdoor enthusiasts. Specimens were collected during low tide and low seas conditions.

Interpretation of the data concluded that dual antibiotic coverage with tetracyclines and quinolones would be necessary to address Vibrio species and multiple resistant fecal coliforms species. Vibrio species were isolated during two seasons, in which the water temperature was 80.9 degrees (F) and 79.8degrees on average.

Previous recommendation for salt water wound contamination call for single antibiotic therapy. Recent cultures of Galveston waters showed multi-resistant organisms in addition to Vibrio species. Therefore, dual antibiotic coverage is recommended.

Microdeformational Wound Therapy: Effects on Angiogenesis and Matrix Metalloproteinases in Chronic Wounds of Debilitated Patients

Presenter:	Arin K. Greene, MD, MMSc
Co-Authors:	Mark Puder, MD, PhD, Roopali Roy, PhD, Danielle Arsenault, BS, Stephanie Kwei, MD, Marsha A. Moses, PhD, Dennis P. Orgill, MD, PhD
Affiliation:	Harvard University, Wellesley, MA

Purpose: We previously have shown that the vacuum assisted closure (VAC) device causes microdeformations of the wound surface in contact with the foam. Because angiogenesis and matrix metalloproteinase (MMP) activity are altered in chronic wounds, we hypothesized that VAC-induced microdeformations stimulate capillary formation and affect MMP activity. Methods: A VAC device was used to deliver microdeformational wound therapy (MDWT) to the chronic wounds of three debilitated patients. Debrided tissue was obtained from wound areas with and without foam contact. Microvessel density and MMP activity were determined by immunohistochemistry and zymography, respectively. Results: Microvessel density of MDWT treated wounds was 4.5% (+/- 0.8) compared to areas not covered by foam [1.6% (+/- 0.1)] (P= 0.05) during the first week of treatment and 2.7% (+/- 0.3) compared to non-treated tissue [1.3% (+/- 0.1)] (P=0.03) during the second treatment week. Wounds subjected to MDWT had greater microvessel density compared to the same wound prior to treatment [1.5% (+/- 0.3)] (P=0.02). MMP-9/NGAL, MMP-9, latent MMP-2 and active MMP-2 were reduced by 15%-76% in MDWT treated wounds. Conclusions: MDWT increases angiogenesis while decreasing MMP activity in chronic wounds. Providing a favorable environment for endothelial proliferation may be one mechanism by which MDWT accelerates wound healing.

The Terminal Anatomy and Intramuscular Innervation of the Upper Branches of The Facial Nerve

Presenter:	Jeffrey D. Hoefflin, MD
Co-Authors:	William W. Shaw, MD, Robert T. Grant, MD
Affiliation:	The New York-Presbyterian Hospital, New York, NY

Purpose: Although previous guidelines have established the anatomic landmarks for avoiding facial nerve injury during aesthetic and reconstructive procedures, reports of injuries persist. Facial nerve paralysis can be a potentially devastating complication.

The purpose of our study was to identify the terminal anatomy and intramuscular innervation of the upper branches of the facial nerve.

Methods: Fifteen anatomic dissections were performed on nine formalin-fixed cadaver heads. Magnifying loupes(4X) and a surgical microscope(100X) were used in tracing the facial nerve from the sylomastoid foramen through to it's terminal innervation into the frontalis, orbicularis oculi, and zygomaticus muscles. Tissue sectioning permitted identification of neuromuscular junctions.

Results: The frontalis muscle is innervated by 1-3 (average 1.7) terminal temporal branches. A dual innervation was witnessed in 46.7% of our dissections. Intramuscular innervation occured 27-55 mm from a medial-lateral canthal baseline. Axial, plexiform, and combination of branching patterns were identified. Neuromuscular junctions (80%) were located along the inferolateral portion of the muscle.

Conclusion: With an increasing number of deeper dissections and brow lifts performed for facial rejuvenation, precise anatomic knowledge of the terminal anatomy of the facial nerve is mandatory. Our dissections detail the specific branching patterns and plane of travel for avoiding nerve injury.

The Effect of Seprafilm Envelopes on Peri-Prosthetic Capsule Formation in the Rat Radiated Implant Model

Presenter:	Ewa Komorowska-Timek, MD
Co-Authors:	Kerby C. Oberg, MD, PhD, Tomasz A. Timek, MD, Daila S. Gridley, PhD, Duncan Miles, MD
Affiliation:	Loma Linda University, Loma Linda, CA

Purpose: Peri-prosthetic capsular fibrosis particularly in an irradiated breast is a vexing phenomenon in reconstructive breast surgery. Seprafilm has been used to reduce adhesion formation in radiated fields, however, its role as a peri-prosthetic barrier has not been investigated. Methods: Seventy 5ml saline implants were placed in 35 Spraque-Dawley rats. Prior to implantation, the right prosthesis was wrapped in a sheet of Seprafilm (Seprafilm subgroup) while the left implant served as paired control (Bare subgroup). Seventeen animals underwent radiation treatment with 21.5 Gy delivered tangentially to bilateral implants 2 days after the procedure (Radiation group) while the remaining rats formed the Non-radiation group. Animals from both groups were sacrificed at 3 (Non-radiation n=8, Radiation n=9) and 12 weeks (Non-radiation n=10, Radiation n=8). Peri-prosthetic capsules were harvested and submitted for tensiometry and histological measurement of total capsular thickness.

Results: See table below. Total capsular thickness did not differ between the groups.

Conclusions: The tensile strength of peri-prosthetic capsules increased overtime irrespective of radiation. At twelve weeks, Seprafilm reduced the tensile strength of a radiated peri-prosthetic capsules without affecting capsular thickness. Reduction in tensile strength may be a reflection of diminished collagen deposition which in turn could attenuate post-radiation capsular contracture.

Presenter:	Andrew Lofman, MD
Co-Authors:	Ian T. Jackson, MD, Gustavo Bello-Rojas, MD, Frances Williams, Hanadi Bu’Ali, Ahmad W Ahad
Affiliation:	Providence Hospital, Southfield, MI

Cells obtained from bone marrow or embryonic donors are the most frequent source of pluripotential cells for tissue engineering and cell-based therapy. Chondrocytes obtained from preadipocyte differentiation can be used to create cartilage, that can be used for reconstruction of deformities and defects in the absence of native cartilage. Predipocytes were extracted from the stromal fraction of the fat obtained form the groin fat pad of Zucker rats, and incubated in preadipocyte medium (PAM) that supported cell growth but not cell differentiation. Beta-galactaside assay confirmed the retention of preadipocyte morphology. At 85% confluency, the pre-adipocytes were induced to differentiation. Red oil histological and Alcian Blue staining was performed. Once Chondrocyte differentiation had been confirmed, the chondrocytes were placed in two different scaffolding materials (Chitosan and Surgisis). The scaffolds were placed in subcutaneous pockets on the dorsum of the rat, harvested in 8 weeks and studied hisotlogically using alcian blue and H & E staining. The scaffolds with the chondrocytes were studied after harvesting and revealed the presence of chondrocytes embedded in a glycosaminoglycan matrix that were suggestive of cartilage formation. Pre-adipocytes obtained from fat undergo invitro differentiation to chondrocytes when exposed to specific factors known to induce these differentiation pathways.

The Functional and Histologic Effects of Preconditioning with a Nitric Oxide Donor in a Rat Muscle Flap Model

Presenter:	John A. LoGiudice, MD
Affiliation:	Medical College of Wisconsin, Milwaukee, WI

It has been shown that vasoactive mediators such as nitric oxide are involved in the period of I/R and are likely initiators of a cascade of events that ultimately lead to late phase I/R injury protection. Twenty-seven Sprague-Dawley rats were used in 3 arms of the study involving isolation of the neurovascular pedicle and induction of ischemia in the extensor digitorum longus muscle. Experimental animals systemically received a nitric oxide donor, spermine-NONOate, 1 hour prior to a 6 hour flap ischemia period involving the extensor digitorum longus (EDL) muscle. Twenty-one days after the ischemic insult, the EDL muscle was analyzed by tetanic force testing, followed by histology. Ischemia/reperfusion-only animals (I/R) and control animals underwent identical analysis. Data demonstrate functional benefits in tetanic force testing in animals treated with spermine-NONOate 30 minutes before muscle flap ischemia compared to animals undergoing ischemia/reperfusion only (p<0.0001). Histology reveals attenuation in the stigmata of organ and cellular ischemic injury in the spermine-NONOate group compared to the I/R group. In conclusion, spermine NONOate prior to 6 hours of ischemia with reperfusion in a rat muscle flap model confers physiologic and histologic advantages 21 days after injury.

Presenter:	Pramit Malhotra, MD
Affiliation:	University of Wis. Hospital & Clinics, Madison, WI

Purpose: A universal goal of surgical education is to train confident surgeons. Current ACGME operative logs simply emphasize the number of procedures done. This study aims to collect data on residents self perception of adequate training.

Methods: A survey was distributed to 200 residents at a regional and national plastic surgical meeting. Eighty-two surveys were returned with fifty-two meeting criteria of final year of training or completion in the last year. Statistical analysis was performed using frequency of response and percentage response data.

Results: The response rate was 41% with 26 % meeting inclusion criteria. In answer to rate your current level of comfort with performing the following procedure, the following responses were obtained:

Breast Reduction 94%, 0% Blepharoplasty 60%, 8% Rhytidectomy 44%, 17% Rhinoplasty 31%, 23% Eyelid ptosis repair 25%, 52%

The three areas of weakness in which residents would like more training in were: Rhinoplasty 58% Rhytidectomy 38% Eyelid ptosis repair 38%

Conclusion: We present a novel tool to evaluate resident training as well conclude inadequate training in rhinoplasty, ptosis surgery, and rhytidectomy.

Back to the Basics: The Incorporation of Full Thickness Skin Grafts at the Cellular Level

Presenter:	John C. Oeltjen, MD, PhD
Affiliation:	Baylor College of Medicine, Houston, TX

Although commonly used as a therapeutic modality, skin graft physiology remains poorly understood. Using recent advances in murine models, the present study was undertaken to investigate the survival of the vasculature donor cells and in-growth of vasculature recipient cells within full thickness skin grafts. Full thickness skin grafts were exchanged between immunohistocompatible C57BL6 control mice and transgenic enhanced green fluorescent protein (eGFP) expressing C57BL6 mice. These grafts were then harvested with underlying tissue over a series of time points from 3 days to 2 months. Using fluorescent labeling of endothelial cells, the survival of both donor and recipient endothelial cells were analyzed. Full thickness skin grafts exchanged between the two mice survived for up to two months. The vasculature demonstrates fluorescent staining indicating both donor and recipient origin. Vasculature of recipient origin presents later in time during the graft incorporation. Using advances in transgenic mice, we have developed a potentially powerful model system for studying donor and recipient physiology of grafting. The use of this model has demonstrated at the cellular level that revascularization of full thickness skin grafts is dependent both upon the reanastomosis of preexisting vessels, inosculation, and the in-growth of new vessels.

Overview of Spring Mediated Cranial Reconstruction for the Treatment of Craniosynostosis

Presenter:	Claire Sanger, DO
Co-Authors:	Lisa David, MD, Steven Glazier, MD, Louis Argenta, MD
Affiliation:	Wake Forest University, Winston-Salem, NC

Purpose: Craniofacial surgery has come full circle from the total cranial vault remodeling (CVR) to less invasive surgical interventions including distraction osteogenesis. Method: This is a two part IRB approved prospective study. The basic science portion consisted of the animal trial with New Zealand Rabbits to confirm the safety and efficacy of the springs. The clinical part consisted of 36 children with scaphocephaly confirmed clinically and radiographically. All study patients were treated with a 1 cm strip craniectomy and placement of 2 internal cranial springs at a mean age of 4 months and mean duration of 4 months. Results: All patients enrolled in the clinical study successful underwent placement and removal of the cranial springs with no major morbidity or mortality. Patients at the time of this report had a mean follow up of 30 months. Normalization of the cephalic index and three dimension computerized scanning confirmed the efficacy of this treatment modality. Conclusions: The use of internal cranial springs in conjunction with sagittal strip craniectomy has been shown to be both safe and effective for the treatment of Scaphocephaly. The clinical study is underway to incorporate the absorbable foot plates to hold the springs in place and facilitate removal.

What Is Plastic And Reconstructive Surgery? A Survey Of Residents, Medical And Nursing Students And Lay Persons In The Age of Reality TV

Presenter:	Michelle Spring, MD
Co-Author:	Karol A. Gutowski, MD
Affiliation:	University of Wis. Hospital & Clinics, Madison, WI

Purpose: Patients are commonly confused about whom to turn to in a competitive market of physicians offering cosmetic surgery. In light of the recent explosion in television shows depicting plastic surgery, it is not clear what impact this has on the public. Methods: In order to determine the effects of this media coverage, we designed an internet-based survey of University of Wisconsin residents, medical and nursing students, as well as the lay public consisting of undergraduate and graduate students. 2675 participants responded to questions about their television viewing habits and opinions of plastic surgery. 75% of the respondents were female, and 95% were under 35 years of age. Results: A majority of respondents believe that media coverage of plastic surgery has not helped explain the risks and benefits of plastic surgery, and reality TV shows have decreased respect for plastic surgery. The most commonly viewed reality show for each group was Extreme Makeover. Twice as many respondents would be less likely (compared to more likely) to go to a plastic surgeon based on what they have learned from these television shows. When asked to describe plastic surgeons, the most common adjectives reported were words such as money-hungry, greedy and superficial.

Presenter:	Craig Birgfeld, MD
Co-Authors:	Patricia Glick, DMD, Davinder Singh, MD, Don LaRossa, MD, Scott Bartlett, MD
Affiliation:	Philadelphia, PA

BACKGROUND: The Ectrodactyly-Ectodermal Dysplasia-Clefting (EEC) Syndrome involves abnormalities of the hands and feet, skin and teeth, and clefts of the lip and palate. Patients have abnormalities of facial features, namely clefts of the lip and palate and abnormal dentition, which affect the growth of their midface region. The purpose was to describe characteristics of mid-face growth in patients with EEC. METHODS: A retrospective chart review was conducted for patients seen at CHOP between the years of 1987 and 2004. Surgeon's assessment and cephalometric measurement was analyzed. Comparison was made to Bolton standards for normal facial growth to determine deficiency. RESULTS: All 8 patients displayed mid-face disproportion. Five of the 8 were found to have some degree of mid-face retrusion. The upper anterior facial height was found to be deficient for 50% of the patients. Six patients had deficient lower facial height and 4 patients had deficient total face height. Two have undergone mid-face distraction osteogenesis. CONCLUSIONS: Our study identified a subset of patients within the cleft clinic who carry the diagnosis of EEC syndrome. They tend to have poor dentition which, coupled with clefts of the lip and palate, inhibits normal mid-face growth and may require surgical correction.

Presenter:	Mark F. Blake, MD
Co-Authors:	Gustavo Bello-Rojas, MD, Ian T. Jackson, MD, John Spolyar, D.D.S, Barbara Beal, B.S., R.N., CPSN, Yeon-Jeen Change, MD
Affiliation:	Providence Hospital, southfield, MI

OBJECTIVE: Since 1991, a new method of repair of the complete bilateral cleft lip and palate has been performed. SUBJECTS AND METHODS: Nineteen patients were available for long term follow-up. The procedure is three stage after initial orthodontic management using the Latham appliance to align the premaxilla. At three months - bilateral closure from the buccal sulcus to the end of the primary palate with upturned flaps and bilateral buccal mucosal flaps. Six months - closure of lip with muscle reconstruction, closure of palate with muscle reconstruction of soft palate and nasal layer lengthening with a buccal myomucosal flap. Third stage, if necessary - lengthening of columella as indicated using central lip advancement flap. The follow-up concentrated on growth patterns and on nasal development. RESULTS: There was minimal growth retardation on follow-up. Lip development was more harmonious. Secondary procedures were few apart from columellar lengthening when necessary. CONCLUSION: This makes for easy closure of the most difficult area, since this was done when exposure is maximal. The lip and palate closure is lengthy but not difficult since segment alignment is satisfactory and there is minimal tension on the repair.

Presenter:	Casey N. Isom, MD
Co-Authors:	Richard Hopper, MD, Joseph S. Gruss, MD, Richard Ellenbogen, MD, Shahram Salemy, MD
Affiliation:	Harborview Medical Center, Seattle, WA

PURPOSE: Craniosynostosis (CS) is typically treated by cranial vault expansion (CVE) before one year of age. Some cases are diagnosed late, or present with non-specific symptoms of increased intracranial pressure (ICP). The purpose of this study is to review the symptoms, clinical findings, and outcomes of patients undergoing late CVE. METHODS: Retrospective chart review of 18 patients >2 years of age undergoing CVE. The 9 males and 9 females ranged from 25 months to 13 years (mean=6.8 yrs). Follow-up was 1 month to 6 years (mean=2.1 yrs). RESULTS: Thirteen patients had associated symptoms of increased ICP including headaches (HA's), nausea and vomiting (N/V), vision changes and photophobia. HA's were most common (9 patients), followed by vision changes (7 patients), N/V (5 patients), and photophobia (1 patient). Four patients with HA's and N/V had normal pre-operative CT scans. All patients with HA's, N/V, and photophobia had resolution of symptoms post-operatively. CONCLUSION: The diagnosis of increased ICP is difficult in the absence of papilledema or CT findings. Three patients had normal CT scans and only symptoms indicating increased ICP. Symptoms of increased ICP are improved with late CVE and are useful in determining who would benefit from an operation.

Presenter:	William R. Rhodes, MD
Co-Author:	James A. Lehman, MD
Affiliation:	Summa Health System, Akron, OH

This study reviews the experience with excision of nevus sebaceous by a single plastic surgery group from 1999-2005. This superficial skin lesion is present at birth and typically presents as a well-circumscribed irregularly raised yellowish plaque. An analysis of the reviewed charts revealed 95 nevus sebaceous lesions in 92 patients. Variables measured included the patient's sex, age, location of lesion, type of excision performed, any complications or recurrences, and the type of anesthetic used. Results showed that of the 92 patients, 57% were male and 43% were female. Ages ranged from six months to 70 years. Seventy-six percent of the lesions were located on the scalp or forehead. Alopecia was the major issue for the scalp lesions. There were five complications, with two requiring additional surgery. There were no recurrences. Sizes ranged from .1 - 6.5 cm. Eighty-five of the lesions required simple excision and ten required more complex excisions, including the use of one tissue expander. Fifty-four percent of these procedures were performed using general anesthetic. One basal cell carcinoma was found within one of the lesions. In conclusion, our findings in 92 patients were consistent with the most recent studies.

Presenter:	Rachel A. Ruotolo, MD
Co-Authors:	C. Francisco Espinel, MD, Cynthia B. Solot, MA, CCC, Donna M. McDonald-McGinn, MS, Elaine H. Zackai, MD, Richard E. Kirschner, MD
Affiliation:	University of Pennsylvania, Philadelphia, PA

PURPOSE: To determine whether preoperative velar motion in 22q11.2 Deletion Syndrome determines speech outcome after VPI surgery.

METHODS: A retrospective review was conducted of 25 patients with 22q11.2 Deletion Syndrome and VPI. Velopharyngeal gap size and motion were examined preoperatively by nasendoscopy or videofluoroscopy. Gap size was designated as small/moderate (0-50% of resting VP area) or large (51-100%). Velar motion was defined as poor/fair (Group A) when motion contributed <50% to VP closure or good/excellent (Group B) when motion contributed to >50%.

RESULTS: Nineteen (76%) and seven (24%) patients were treated with a PPF and a sphincter pharyngoplasty, respectively. Velar motion was rated as poor/fair in 6 (24%) patients (Group A) and good/excellent in 19 (76%) patients (Group B). Large gaps were noted in 67% and 26% of patients in Group A and Group B, respectively.

Although the mean preoperative nasality score was higher in Group A than in Group B (3.6 vs. 2.5), this difference did not reach statistical significance. Postoperatively, the mean nasality score was .63 in Group A and .75 in Group B (p=NS).

CONCLUSIONS: Most 22q11.2 Deletion patients demonstrate good/excellent velar motion. Acceptable resonance may be achieved regardless of velar motion by individualizing surgical management.

Presenter:	John M. Thomassen, MD
Co-Authors:	Elan Reisin, MD, Mark Venturi, MD, Michael J. Boyajian, MD
Affiliation:	Georgetown University, Bethesda, MD

Cleft palate fistula occurrence after primary palatoplasty has been reported to range from 0-63%, the most recent reports have quoted rates of 11 to 25%. The cause of these fistulas have been attributed to many factors, including the extent of clefting, the type of repair, the timing of repair, and operator experience. This report describes the postoperative cleft palate fistula incidence in a cohort of patients operated on using the Veau-Wardhill-Kilner method by a single operator at our institution. A retrospective review of charts for complete and incomplete non-syndromic cleft palate patients who underwent the Veau-Wardhill-Kilner method of repair by our senior author was completed. All patients with a cleft lip component were treated with a Millard rotation advancement at 3 months of age. Veau-Wardill-Kilner technique with muscle pushback was used to repair the cleft palate between 9-12 months of age. A total of 290 patients met the inclusion criteria for this study, and were treated by the senior author between 1984 and 2001. The incidence of cleft palate fistula in this series was 3.9%. This low rate of fistula is attributed to technical aspects of the cleft palate repair detailed in the study.

Presenter:	Anthony A. Admire, MD
Affiliation:	Saint Louis University, St Louis, MO

Treating chronic open wounds is a fundamental part of plastic surgery. An ever increasing list of commercially available wound healing agents can easily confuse the health care provider as to which ones are literature proven to be efficacious.

A complete review of the literature was undertaken using common internet search sites Google and Medline. In addition, an investigation of a local hospital wound center was employed to find the most commonly stocked and used wound healing agents. The common wound healing agents were divided into the following categories: enzymatic debriders, occlusives, bioengineered substitutes and growth factors.

Our results demonstrated not all of the common wound healing agents listed in this report are literature proven to be efficacious. None of the studies were double-blinded and randomized. However, the literature does indicate enzymatic debriders, occlusives, and some biosynthetics are efficacious. Limited evidence-based data is available for the newer bioengineered skin substitutes and growth factors.

To our knowledge, this is the only literature review examining the efficacy of common wound healing agents to date. It is our hope that this report will guide the plastic surgeon and any general health care provider in choosing the appropriate therapy for a given chronic open wound.

VAC Dressing Change Pain Assessment Using Topical Lidocaine vs. Placebo: A Double Blind, Prospective, Randomized Sudy

Presenter:	Jayant Agarwal, MD
Co-Authors:	Mieczyslawa Franczyk, PT, PhD, Robert Lohman, MD, Lawrence J. Gottlieb, MD, Mieczyslawa Franczyk, PT, PhD
Affiliation:	University of Chicago, Chicago, IL

Background: VAC dressing changes are frequently painful. We hypothesized that using topical lidocaine would decrease the pain during VAC dressing changes. Methods: A double blind, randomized, prospective study was performed on patients (N=65) undergoing VAC dressing changes at a single institution between 12/03 and 6/05. Patients were randomized to receive either 0.2% lidocaine or 0.9% saline administered through the VAC suction tubing into the foam dressing 30 minutes prior to each dressing change. All patients received morphine sulfate ad lib. Pain scores were assessed according to the 0-10 numeric pain distress scale method. Results: Patients receiving lidocaine experienced less pain than did control patients during and immediately after the first dressing change (p<.05). However, opioid use in the first half hour after the dressing change was greater in this group. Other measures of pain and anxiety, namely blood pressure and heart rate were similar in both groups. Conclusions: During the initial VAC dressing change, 0.2% lidocaine administered via the suction tubing led to a reduction in pain experienced by patients in our study. The impact of the lidocaine may be short lived as patients in this group requested more opiates in the period after the dressing change.

Is Withholding Warfarin Necessary In Minor Burn and Wound Surgery of the Extremity?

Presenter:	Saied Asfa, MD
Co-Authors:	Louis H. Riina, MD, Roger L. Simpson, MD, FACS
Affiliation:	Nassau University Medical Center, East Meadow, NY

Introduction: Plastic surgeons commonly encounter patients who are anticoagulated for various conditions. Many of these patients also suffer from burn injuries or chronic lower extremity wounds that require autografting. The standard of perioperative care for anticoagulated patients involves discontinuation of warfarin 4-5 days before surgery, and resumption of warfarin postoperatively +/- low molecular weight heparin. This transition may increase risk of perioperative thrombotic complications and cost. Methods: A retrospective study of 15 patients (8 females / 7 males) who underwent autografting of extremity burns (<2% TBSA) or chronic wounds (<1% TBSA) while remaining on warfarin (INR 2-3) was performed. All burns/wounds were tangentially excised under tourniquet control. Hemostasis was obtained utilizing electrocautery, thrombin spray and pressure dressings. Grafts were affixed with fibrin sealant, and donor skin was harvested from the ipsilateral thigh. Results: There were no peri/post-operative bleeding complications. No graft loss was noted. Conclusion: Based on this limited number of patients, it may be safe to continue warfarin therapy in patients requiring autografting for minor burn and chronic wounds of the extremities. Further study is required to demonstrate the safety of this approach statistically.

Comparison of Acticoat ^TM, Allevyn^TM, and Xeroform^TM as a Donor Site Dressing in a Rodent Model

Presenter:	Marc Bisseck, MD
Co-Authors:	Puya Davoodi, MD, John H. Robinson, MD
Affiliation:	Med. University of South Carolina, Charleston, SC

Re-epithelialization of split-thickness skin graft donor sites continues to pose a challenge to plastic surgeons. Rakel et al. in an extensive donor site dressing review concluded that moist healing environment provided optimal healing times. The purpose of this study is to compare re-epithelialization rates of Acticoat^TM and Allevyn^TM to a known standard Xeroform^TM. In a population of rats, three split-thickness skin grafts were taken from the back of each male rat (n=17). The three wounds were covered with Acticoat^TM, Allevyn^TM, and Xeroform^TM on each rat. On post-operative days three and six the Acticoat^TM and Allevyn^TM dressings were removed, new dressing placed, and digital photographs of the wounds taken. The photographs were shown to three experienced plastic surgeons, and the degree of wound healing was evaluated for each rat at each donor site. Epithelialization was the measured end-point. The Xeroform^TM dressed wounds epithelialized more rapidly. Cost comparisons were also included in this study.

Penile Replantation - The Use of Medicinal Leech Therapy to Alleviate Corporal Hematoma

Presenter:	Stephanie A. Caterson, MD
Co-Authors:	Adam J. Vernadakis, MD, James Orman, MD, Jeffrey Weinzweig, MD
Affiliation:	Lahey Clinic, Burlington, MA

Self-emasculation, often the result of acute psychosis, has been reported in the literature. Technically, replantation of the amputated penis is challenging but feasible. The goals of replantation are to achieve a viable and sensate penis with both urinary and erectile function. We report a case of self-inflicted penile amputation that used microsurgical techniques in combination with medicinal leech therapy for a successful penile replant.

Because corporal vessels cannot be surgically anastomosed, they are prone to develop hematomas. Postoperative corporal hematoma can result in venous congestion, flap failure, or compartment syndrome. We used leeches in the immediate postoperative period to treat an evolving corporal hematoma.

The evolving corporal hematoma resolved and penile flap edema was controlled, resulting in a successful penile replantation. One complication occurred secondary to positioning, resulting in localized hemorrhage and a suture line dehiscence. The penis remained viable and the patient was electively taken back to the operating room for debridement and local skin flap coverage to protect the microsurgical anastomoses.

Replantation is a realistic option after self-emasculation. Preemptive leeching minimizes corporal hematoma following penile microsurgical replantation. Postoperatively, cautious patient positioning is essential.

Current Practices in the Application of Negative Pressure Therapy: a Review of 309 Consecutive Cases

Presenter:	Robert C. Dinsmore, MD
Co-Authors:	Edmond F. Ritter, Jack C. Yu
Affiliation:	Medical College of Georgia, Evans, GA

PURPOSE: This study reviewed all cases of Negative Pressure Therapy (NPT) at our institution during the previous year. We report on current patterns of usage, successful techniques for application, problems encountered and techniques for addressing them.

METHODS: Retrospective review of all cases of NPT during the preceding year was conducted. The indications, treatment course and outcome were determined for each case. Also reviewed were techniques of application, timing of dressing changes, methods for pain modulation, concurrent infusion of topical antibiotics and cost considerations.

RESULTS: 309 consecutive cases in which NPT was used were identified. Non-plastic surgery services used NPT for wound closure essentially 100% of the time. Plastic surgery NPT use was evenly divided between wound closure, temporizing measures prior to surgical closure, and as a dressing following wound coverage with skin graft or other dermal template.

CONCLUSIONS: The efficacy of NPT for chronic wound closure has lead to its increasing use in other areas, a pattern which will likely continue. NPT application can be problematic in areas of complex curves, such as the perineum, axilla and neck. Patient pain during dressing changes can also limit use. Techniques for overcoming these difficulties are a useful addition to any surgeon's armamentarium.

Contracted small finger following burns: Is it Wartenberg's sign of ulnar nerve lesion?

Presenter:	Venkata Erella, MD
Co-Authors:	Jeffrey Demercurio, MD, Chenicheri Balakrishnan, MD
Affiliation:	Wayne State University, Clinton Township, MI

Despite continued emphasis of splinting, early excision and grafting, burn scar contractures occur following burns of the upper extremity. Post burn claw deformity is hyperextension of the metacarpophalangeal joint and flexion of the proximal interphalangeal joint. Frequently, there is ulnar deviation of the small finger. This study looks at the contracted small finger following burns.

Six patients over 2 years, treated for upper extremity flame burns, developed contracture of the small finger with ulnar deviation. All patients underwent early excision and skin grafting. Most had circumferential burns involving the wrist or forearm and underwent decompression of the carpal tunnel with escharotomy.

Clinical findings included hyperextension of the metacarpophalangeal joint, flexion of the interphalangeal joints and ulnar deviation of the small finger and decreased two-point discrimination. Electromyography and nerve conduction showed peripheral neuropathy with slow spike potential of the hypothenar muscles with reinnervation of the muscle. Since median nerve decompression along with excision of the burns was carried out, no slowing of conduction was noted across the carpal tunnel in these patients.

Results showed that compression neuropathy of the ulnar nerve occurred within the forearm or Guyon's canal during the acute burn injury leading to the Wartenberg's sign following treatment.

Anatomical Restoration of the Rectus Abdominus Muscle with Mesh and Panniculectomy (A-RAMP) for Repair of Giant Ventral Hernias

Presenter:	Vikisha T. Fripp, MD
Affiliation:	New York Presbyterian Hospital-Weill Cornell University, New York, NY

This procedure is designed to avoid the compications associated with hernia repair, restore the function of the abdominal wall and improve the overall appearance of the abdominal wall.

The primary advantage of this procedure is the return of the Rectus abdominus muscle to its anatomic origin without incising the lateral musculature. Our repair is performed in two different planes with mesh to prevent both fistula and extrusion, and also to strengthen the repair. A panniculectomy is added to reduced the problems of redundant skin and adipose tissue and provide contour to the abdomen.

A restrospective review of all patients undergoing large ventral hernia repair between June 2002-June 2005 was conducted. Patient's charts were reviewed for Reason for surgery, complications from prior operations, Hernia size, Body Mass Index (BMI), Type of surgery, Type of mesh used, Complications, Patient satisfaction, Patient elaboration and Comments.

We have had no recurrences, improved functional status of the patients and complete patient satisfaction with the final appearance of the abdominal wall. We believe this method to be effective in reestablishing the natural anatomic unit of the abdominal wall musculature thereby restoring normal function.

Treatment of an Infected Thoracic Aortic Graft Infection with a "Wrap Around" Rectus Muscle Flap (Hot Dog Flap)

Presenter:	Stephen Gauthier, MD
Co-Authors:	Eric Wilson, MD, A. Jackson Crumbley, MD, John H. Robinson, MD, Richard M. Kline, MD
Affiliation:	Med. University of South Carolina, Charleston, SC

Purpose: Report the treatment of a descending thoracic aortic graft infection with a pedicle rectus muscle wrap around (hot dog flap).

Materials/Methods: A thirty-five year old hypertensive male developed a thoracic aortic aneurysm associated with a type B dissection of the descending aorta. The patient underwent a dacron tube graft repair from the left subclavian artery to the level of the diaphragm. Post-operatively he developed an acute graft infection complicated by necrotizing fasciitis and sepsis. Aggressive wound debridement over twenty-three days resulted in exposure of the aortic graft. Definitive management utilized a rectus abdominis flap based on the superior epigastric artery. The rectus muscle was wrapped around the exposed thoracic graft. Patient follow-up included clinical exams and serial cat-scans for five years without evidence of graft deterioration or chronic infection.

Conclusions: Infections of thoracic aortic grafts constitute a life-threatening complication and their management remains a challenge. Traditional measures involved excision and replacement with extra-anatomic bypass through unaffected tissue. Recent literature has documented alternatives to graft excision including soft tissue coverage with muscle flaps; however, to date salvage of an infected descending thoracic aortic graft with a rectus muscle pedicle has not been reported.

Use of Integra Dermal Regeneration Template for Large Defects of the Sole of the Foot

Presenter:	Roshini Gopinathan, MD
Affiliation:	University Hospital, University of Medicine and Dentistry of New Jersey, Newark, Newark, NJ

Summary: Purpose: Soft tissue defects of the sole of the foot can be challenging to reconstruct because of limited availability of local flaps. Skin grafts over weight bearing areas tend to be unstable and frequently require free tissue transfer. We used Integra to reconstruct two large defects on the sole of the foot. Methods and materials: Integra artificial skin (Integra Life Sciences Corp, Plainboro, NJ) is a dermal template consisting of bovine collagen, chondroitin-6-sulfate, and a silastic membrane. In the past few years it has achieved widespread use in the treatment of burns, both acute, and in delayed reconstruction. We used Integra in two patients with large defects on the sole of the foot. The first patient was an elderly male who had radical resection of an extensive melanoma. The second patient had resection of recurrent fibromatosis of the sole of the foot. Results and Conclusions: The wounds healed well and both patients were able to achieve full weight bearing ambulation, and no recurrence of disease. Integra can be used for reconstruction of defects in the sole of the foot with good functional outcomes.

Presenter:	Lynne Hackert, MD
Co-Authors:	John A. Lorant, MD, Garry S. Brody, MD, Msc, Susan Kay, MD
Affiliation:	University of Southern California, Glendale, CA

Purpose: Resurfacing glabrous skin of the pediatric patient presents a challenge due to its unique properties. An ideal donor site for palmar or plantar defects is the skin of the plantar arch.

Methods and Materials: Seven pediatric patients with palmar or plantar burn contracture or congenital syndactyly defects at Shriners Hospital for Children in Los Angeles were resurfaced with split thickness skin grafts harvested from the plantar arch.

Summary of Results: Graft take was successful with acceptable donor site healing in all patients. Because both palmar and plantar skin are glabrous the aesthetic result was a better match in color and texture than nonglabrous donor skin. Plantar wounds healed well and patients were immediately ambulatory. Follow-up ranged from 3 to 22 months.

Conclusions: Plantar arch skin grafts are ideal for resurfacing palmar and plantar defects because glabrous skin qualities are maintained and the donor site morbidity is minimal.

Presenter:	Jeffrey Hammoudeh, MD
Co-Authors:	Sean Simon, MD, Chris Lowe, Nirmal Nathan, Milton B. Armstrong, MD
Affiliation:	University of Miami/JMH, Miami, FL

Background: Necrotizing fasciitis is a soft tissue infection in which necrosis of the fascia and subcutaneous tissue occurs. Necrotizing fasciitis presents with disproportionate pain, localized erythema, and skin discoloration with vesicle formation. As the disease dissects along fascial planes, an area of deep necrosis develops along with eventual signs of systemic toxicity and sepsis. Management of necrotizing fasciitis consists of resuscitation and stabilization of the patient, aggressive surgical debridement of all nonviable tissue, and the administration of broad spectrum antibiotics. Local flap coverage or microvascular free tissue transfer are the preferred techniques in the surgical reconstructive ladder.

Methods: We present a case of severe necrotizing fasciitis in an insulin dependent diabetic who refused free autologus tissue transfer as an adjunct to his debridment. The artificial dermal substitute, Integra® has emerged as an adjunct to split thickness grafts or tissue transfer. We report on an alternative surgical reconstruction consisting of aggressive debridement and Integra®/STSG placement in the reconstruction of a complex leg wound in which there was a large area of exposed bone without periosteum.

Results: In our case, the use of Integra® prevented the amputation of the affected leg.

The Joint Flap for Nasal Tip and Alar Reconstruction -- A new solution for an old problem

Presenter:	Glenn Herrmann, MD
Co-Author:	Ramasamy Kalimuthu, MD
Affiliation:	University of Illinois @ Chicago, Chicago, IL

A cosmetically-acceptable reconstruction of the nose after tissue loss can be challenging. Drawbacks to previous reconstructive flap designs include flattening of the nasolabial fold, loss of definition of the alar groove and an inherent requirement for staged operations. The use of rotation and advancement flaps for resurfacing small surgical defects of the nasal tip and ala deserves reappraisal. The rich arborizing blood supply of the face allows for the design of flaps based both on dermal/subdermal plexuses as well as on musculocutaneous perforators.

Our proposed design combines Banner and nasolabial flaps. The first action is a 90-degree rotation of a donor flap to fill a defect, followed by a V-Y advancement of a second juxtaposed flap to fill the resultant defect of the first rotation flap.

There was no flap loss. 3/40 patients experienced a minor wound infection. 5/40 flaps required subsequent procedures to improve appearance.

A single surgeon's experience is presented including 40 patients treated between 2000 and 2005. All have nasal defects (average 1.2cm) after excision of carcinomas. This flap combination serves to resurface defects on the nasal tip/ala without flattening the nasolabial fold or erasing the alar groove. The design is simple and results are consistently superior.

Presenter:	John M. Houle, MD
Affiliation:	Southern Illinois University, Springfield, IL

Reconstruction can be challenging in patients with minimal normal tissue who require free tissue transfer. Pre-fabrication of flaps has expanded the options available for reconstruction but still requires healthy, normal donor tissue and a vascular carrier.

We report on a 36 year old male patient who suffered 80% total body surface area full thickness burns and anoxic brain injury. He subsequently developed joint contractures including one of the left elbow resulting in a chronic wound. We planned to release the contracture and cover the wound with an anterolateral thigh free flap; the thigh skin had been used as a skin graft donor site previously. Intraoperatively the venous drainage of the flap was compromised so the flap was left in place, observed on the floor and the contracture left intact.

The flap subsequently failed and was debrided. The pedicle and its venae comitante dissected back to it's origin along with a cuff of muscle distally. The flap donor site and vascular pedicle was covered with Integra and allowed to heal. After this neovascularization took place the Integra was skin grafted and then successfully transferred to the antecubital fossa. This is the first known free transfer of a tissue engineered, pre-fabricated flap.

Presenter:	Dimitri Koumanis, MD
Affiliation:	Nassau University Medical Center, East Meadow, NY

Abdominoplasty surgery is commonly performed as an outpatient procedure. A common sequalae is seroma fluid accumulation beneath the abdomoinal wall flap. Drain therapy has long been used to remove lymphatic fluid and allow the anterior fasciocutaneous flap to seal quickly. Authors have proposed however, that drains may actually produce additional reactive fluid and prolong initial healing time. Fibrin sealants have been used for several years in cardiac, vascular and intraabdominal surgery to seal anastomoses and minimize diffuse generalized surgical bed bleeding . We used fibrin sealants applied immediately prior to abdominoplasty flap closure in sixty (60) consecutive patients. A compartive and statistical evaluation of an aerosol sealant (Tisseel: Baxter) and a topical viscous sealant were (Orthovita) was compared against 60 controls. Factors analyzed included (1) Jackson Pratt output; (2) time to drain removal; (3) fap integrity; (4) complications. Our results indicated a (1) reduction in seroma formation (2) decreased drain output with a statistical P value (p<0.05). There was no difference in aerosol versus topical applications. Drains were removed an average of 2 days earlier than controls. We recommend fibrin sealant therapy as an adjunct in abdominoplasty and discuss future studies and applications in plastic surgery.

Factors Contributing to the Success of Reverse Flow Fasciocutaneous Flaps in Lower Extremity Trauma

Presenter:	Shankar Lakshman, MD
Co-Author:	Edward A. Luce, MD
Affiliation:	University of Tennessee, Memphis, TN

This study is a retrospective review of all reverse flow fasciocutaneous flaps for reconstruction of lower extremity trauma performed at a single institution between 1990 and 2005. Various parameters of the injury, type of reconstruction, and outcomes were evaluated. Approximately one hundred patients underwent lower extremity reconstruction with reverse flow fasciocutaneous flaps including the sural flap and other flaps based on perforators from the peroneal and posterior tibial arteries. The data base included extremity injury severity score, bone/soft tissue defect, procedure(s), use of prior delay, time to wound closure and bony union, and finally, ambulatory outcomes. Prior delay is a crucial factor in success in the application of reverse flow fasciocutaneous flaps in lower extremity trauma. Reverse flow flaps should be the primary option for closure of lower extremity complex wounds.

Presenter:	Joshua A. Lemmon, MD
Co-Author:	Jeffrey E. Janis, MD
Affiliation:	University of Texas -- Southwestern, Dallas, TX

Background: Hemicorporectomy is a radical surgical procedure that is rarely performed. The procedure requires urinary and fecal diversion, disarticulation of the lumbar spine, and resection of the bony pelvis, the pelvic organs, and both lower extremities. In patients with locally advanced pelvic malignancies and intractable pressure wounds with underlying pelvic osteomyelitis, hemicorporectomy may be offered as a last resort.

Methods: The authors present a retrospective study of a single institution's 21-year experience with this technique. Eleven translumbar amputations were performed. Available clinical data were analyzed, including indications, perioperative complications and follow-up results. A literature review is presented and important perioperative and postoperative considerations are discussed.

Results: Of the 11 patients reviewed, there were no perioperative mortalities. The majority of the defects were not closed primarily; instead, total and subtotal thigh flaps were used for the reconstruction in most cases. Wound complications, pulmonary complications, and small bowel obstruction were the most frequent perioperative morbidities.

Conclusions: Hemicorporectomy is a viable option for management of locally advanced pelvic malignancies or intractable pressure wounds. A multi-disciplinary approach must be employed to limit mortality and morbidity. Good long term results can be obtained with proper patient selection, a well-designed operative plan, and attentive postoperative management.

Presenter:	Michael W. Nagy, MD
Co-Author:	John B. McCraw
Affiliation:	University of Mississippi Medical Center, Jackson, MS

PURPOSE: Ultrasound technology and liposuction have not been routinely applied to reduction mammaplasty. The use of third generation ultrasound technology(TGU) and liposuction as an addition to excisional surgery were evaluated. METHODS:TGU was evaluated in 113 consecutive patients undergoing reduction mammaplasty over a one year period. All procedures were performed by the same attending plastic surgeon and plastic surgery resident. Two patient groups were identified: 1) TGU application and excision; and 2) TGU application, aspiration and excision. The parameters recorded were: 1) operative time, 2) TGU time, 3) aspiration time/volume, 4) excision time/volume, and 5) complications. Patient follow up included evaluation on post operative day 3, 1 week, 2 weeks, 1 month, 3 months, and 6 months postoperatively. RESULTS: Operative time was reduced using TGU and aspiration. Excision and shaping were easier after TGU. The volume and quality of aspiration were enhanced by TGU. Time spent cauterizing and blood loss were reduced. The axillary roll was able to be aggressively treated. There were no complications directly related to TGU. CONCULSIONS: No increased rate of complications compared to those reported in traditional reduction mammaplasty procedures. TGU is a safe and useful adjunct for breast shaping procedures.

Risk Factors For Complications In Tissue Expansion: The UT Southwestern Experience

Presenter:	Sacha Obaid, MD
Co-Authors:	Rod J. Rohrich, MD, James F. Thornton, MD
Affiliation:	University of Texas Southwestern, Dallas, TX

The purpose of this work was to perform a review of the risk factors associated with poor outcomes in tissue expansion. We have reviewed the current literature and published risk factors for poor outcomes in tissue expansion. We have also reviewed the UT Southwestern Department of Plastic Surgery's tissue expansion experience and determined which of these factors has lead to significantly poorer outcomes in our experience.

We performed a retrospective chart review of all cases of tissue expansion in the Department of Plastic Surgery at UTSW from July 2001 to January 2005. Data on age, indication, location, port type, incision, drain use and complications were recorded.

We found 28 major complications and 21 minor complications in 134 cases. We found that younger patients, patients who have had three or more previous rounds of tissue expansion, and those in whom an intralesional incision were used all had statistically significant higher complication rates (p<0.05). The use of drains, external ports, location of expander placement, and indication for expansion did not affect the complication rate.

Patient age, choice of incision, and limiting the number of rounds of tissue expansion are critical for successful outcomes in tissue expansion.

Presenter:	Gregory C. Park, MD
Co-Author:	W. Bradford Rockwell, MD
Affiliation:	University Utah Medical Center, Salt Lake City, UT

Injured, avascular skull is treated differently than other avascular bone. Bone is left in place to maintain protection of the brain. Vascularized tissue coverage often results in skull revascularization. If the skull is not revascularized, the fate of overlying flaps is in doubt.

Two patients sustained high-voltage injuries. Injuries to the head created full-thickness scalp loss with charring of the outer skull cortex, but the skull maintained its structural integrity. Free latissimus transfers were used for wound coverage.

Months following free muscle transfer, small skin openings developed along the flap margins in both patients. CT and tagged WBC scans revealed resorption and chronic osteomyelitis of the underlying skull. Avascularized skull was removed and the defects were repaired with methyl methacrylate.

Accurate assessment of the degree of bone damage from electrical injury is challenging. Therefore, predicting the fate of injured bone is difficult. These cases support coverage of injured skull with a vascularized free flap without removal of bone. If bone trauma results in chronic infection and resorption, then resection and reconstruction of involved skull is necessary. These cases illustrate that no serious complications to underlying brain or overlying free flap are likely to occur.

Long term Experience Treating Complicated Abdominal Hernias with the Component Separation Technique

Presenter:	Nikesh K. Patel, MD
Co-Authors:	Adrian Przybyla, MD, Michael VanVliet, Joshua King, MD
Affiliation:	Albany Medical College, Albany, NY

Since its original description by Ramirez et al., several reports have reviewed long term results and complications of component separation of abdominal parts through multi surgeon based large series of patients. This study analyzed long term results and complications in one of the largest series for this procedure. We retrospectively reviewed charts for 55 patients who underwent component separation for large, complex, or recurrent ventral hernias over a 7 year period. Data analysis identified 26 females and 29 males with an average age of 52 years, BMI of 34kg/m2, and 1.6 previous attempts for repair. The average follow up was 337 days. A total of 10 (19.2%) patients experienced skin necrosis, skin dehiscence, or minor skin infections. One patient (2%) experienced a hematoma, while 8 (15.4%) developed seromas. Recurrence was identified in 8 (15.4%) with other major complications occurring in 3 (5.7%) patients. This study provides one of the largest series of patients undergoing component separation and demonstrates long term results for the treatment of complex or recurrent abdominal hernias. These results are consistent with previous reports and reaffirm the benefits of this the technique over other methods.

Presenter:	Yale Popowich, MD
Co-Authors:	Daniel A. Ladizinsky, MD, Vigen B. Darian, MD
Affiliation:	Oregon Health & Sciences University, Portland, OR

Implant infection can be a devastating setback to the patient and physician, often setting reconstruction back six months. We demonstrate a system that salvages a failing implant via a suction irrigation system, thus offering little interruption to the reconstructive schedule.

Patients were chosen on the degree of infection. When cellulitis did not resolve with antibiotics, a capsulotomy was performed to gain implant access. Cultures were obtained. The pocket was lavaged with Bacitracin-infused normal saline. Two drains were placed, superiorly and inferiorly within the pocket, and the wound closed in layers. Continuous infusion of Bacitracin (50,000 u/L normal saline) was continued for 48 hours through the inferior drain with the superior drain placed to wall suction. Warning labels were placed to prevent accidental infusions. Patients were discharged on appropriate antibiotics with both drains to bulb suction.

Six patients with submuscular implants were treated over five years. Of these, one failed treatment and required implant removal. Of the remaining, two required subsequent implant removal, one for size reasons, the other for a painful capsule.

With proper patient selection, infected implants can be salvaged with this minimally invasive approach, saving the patient both valuable time and emotional expense.

Presenter:	Elan Reisin, MD
Co-Authors:	Scott L. Spear, MD, Pranay M. Parikh, MD, Nathan Menon, MD
Affiliation:	Georgetown University, Washington, DC

Prosthetic reconstruction remains the most common technique for breast reconstruction after mastectomy. Subpectoral device placement has been criticized for inadequate control of the lower pole. One innovation has been the insertion of Alloderm along the inferior border of the pectoralis major muscle. This provides a secure attachment of that muscle inferolaterally without the need for total sub-muscular pocket dissection. The Alloderm graft creates a secure pocket, defines the inframammary fold, and provides an additional layer of coverage for the device. After completion of expansion, expanders were exchanged to permanent implants. The final reconstructive result was assessed by patients and surgeons using a standardized instrument. We assessed time to complete reconstruction, complication rates, patient satisfaction, and cosmetic outcome. 58 breasts in 43 women were reconstructed with tissue expanders and Alloderm. 41 breasts in 30 women completed exchange to implants. Mean time to complete reconstruction was 199 days. Complications after expander and Alloderm placement included mastectomy flap necrosis(5.2%), cellulitis(5.2%), seroma(3.4%), and explantation(1.7%). There were no complications after exchange to implants. Alloderm appears to be a useful adjunct in immediate prosthetic breast reconstruction. Use of Alloderm has a low complication rate, helps create an aesthetically pleasing breast, and affords an expeditious reconstruction.

The Infected Breast Prosthesis after Mastectomy Reconstruction: Successful salvage of nine implants in eight consecutive patients

Presenter:	Matthew Schulman, MD
Affiliation:	The Mount Sinai Medial Center, New York, NY

Background: The most conservative approach to the patient with an infected breast prosthesis after mastectomy reconstruction remains removal of the implant. However, removal makes subsequent reinsertion more difficult, with less predictable results. Timely surgical intervention directed towards salvage of an infected implant can not only be successful, but may minimize subsequent infection-induced capsular contracture.

Methods: We present nine consecutive cases of infected breast implants in eight patients who underwent mastectomy for malignancy with immediate expander/implant reconstruction. 6 patients had localized infections unresponsive to oral antibiotics, and 2 initially presented with systemic infection. All were given intravenous antibiotics followed by drainage of fluid, debridement of the infected pocket, device exchange, and post-operative antibiotics.

Results: All nine implants currently remain without infection and without severe capsular contractures. Mean time to follow-up is 14.6 months (range, 10 to 25 months)

Conclusion: In infected breast implants after reconstruction, timely operative intervention can salvage the previously unsalvageable implant; additionally, the salvaged implant tends to be free from severe capsular contractures often seen after infections. Surgical salvage of an infected breast implant after mastectomy is a treatment option that should be considered in recalcitrant infection.

Presenter:	Naveen C. Setty, MD
Co-Author:	Jon Limpert, MD
Affiliation:	St. Louis University, St. Louis, MO

Diverse techniques have been described for the repair of abdominal hernias with varying rates of success and complications. Recent literature has discussed the use of biomaterials such as acellular dermal allograft with low complication rates. This study evaluates the use of acellular bovine pericardium to repair incisional and recurrent abdominal hernias. Patients with incisional or recurrent abdominal hernias were treated between April and October 2005. Surgical techniques used included placing the allograft as an inlay or as an overlay in conjunction with a components separation. The technique used was determined preoperatively based on clinical exam and size of the anticipated defect. All data were reviewed retrospectively. Ten patients were treated. There were 6 females and 4 males and mean age was 40 years (range: 22-80). Three patients had ongoing infection at the time of hernia repair. Mean follow-up is 4 months (range 2-7). There has been one recurrence and one loss of allograft. Cost analysis showed a significant savings versus other allografts described in the literature. Acellular bovine pericardium can be a cost-efficient option in the repair of abdominal hernias with a lower complication rate than prosthetic mesh.

Presenter:	Julie Vasile, MD
Co-Authors:	Roger Simpson, MD, Faith Katzman, BS, MA, Geoffrey Pillersdorf, BS
Affiliation:	Nassau University Medical Center, Great Neck, NY

Question: The lower lip has a multitude of expressions and dysfunctions in facial paralysis. Can a treatment be standardized?

Method: 20 patients with unilateral complete (14) or partial (6) facial paralysis were reviewed preoperatively and postoperatively with attention to the lower lip. Patterns of form and function were classified according to etiology. Each patient was assessed for altered appearance, oral competency, and related speech abnormalities.

Result: Patients with complete unilateral paralysis undergoing reanimation showed improvement in appearance and speech. Oral competence was affected by the degree of correction of the commissure, as well as atrophy of the orbicularis muscle. Secondary procedures on the lower lip were performed in 12 of 14 patients with complete paralysis and 2 of 6 with partial isolated paralysis.

Discussion: The variable presentation of the lower lip in paralysis is responsible for the variety of symptoms noted. Reanimation procedures may deform the lower lip while improving commissural excursion. An algorithm will identify lower lip deformities in paralysis and review treatment focusing on fullness, dynamic tension, and speech control.

Conclusion: Lower lip paralysis shows variable preoperative and postoperative form and function. Based on etiology and degree of atrophy, an appropriate restoration of the lip can be designed.

Evaluating Complications in Breast Reconstruction Following Prophylactic Mastectomy

Presenter:	Mark L. Venturi, MD
Co-Authors:	Karl A. Schwarz, MD, Scott L. Spear, MD
Affiliation:	Georgetown University Medical Center, Washington, DC

Purpose: Prophylactic mastectomy is emerging as an effective risk reducing treatment option for women at high risk for breast cancer. The purpose of this study was to evaluate the complication rate associated with breast reconstruction following prophylactic mastectomy. Methods and Materials: The authors conducted a retrospective review of the senior author's experience with breast reconstruction following prophylactic mastectomy at Georgetown University Medical Center from January 2001 to January 2006. All complications during the course of reconstruction were included. A complication was defined as an intervention (surgical procedure or intravenous antibiotics) performed for: capsular contracture; implant rupture; extrusion; hematoma; infection; seroma; necrosis of the nipple, areola, or flap; tissue expander malfunction; and wound dehiscence. Results: The authors identified 76 patients who underwent 96 breast reconstructions following prophylactic mastectomies. During the follow-up period (mean, 31 mo; range 2 to 69 mo) complications were identified in 9 (12 percent) of the 76 patients and involved 2 (2.1 percent) of the 96 breasts reconstructed. The rate of complication was significantly lower (P<0.001) in the tissue expander/implant reconstruction group versus the flap with/without implant group. Conclusions: Breast reconstruction following prophylactic mastectomy appears to have a lower complication rate than typically encountered after oncologic mastectomy reconstruction.

Presenter:	W. Jason Martin, MD
Affiliation:	Rush University Medical Center, Chicago, IL

Historically, the ilium has been the preferred harvest site for cancellous bone grafts. This procedure, however, has well documented morbidity, including lateral femoral cutaneous nerve injury with potential for painful neuroma, significant post-operative pain, unsightly scar formation and iliac crest contour deformities. To avoid these complications, we propose an alternative harvest site for cancellous bone, the pubic tubercle and the superior ramus of the pubis. Utilizing the experience from fresh cadaver dissections, the procedure includes a 3cm transverse midline incision superior to the pubic tubercle, minimal soft tissue dissection to the tubercle, a pubic cortical window and procurement of the desired volume of cancellous bone. This procedure has now been successfully completed on 12 alveolar cleft patients. Post-operative clinical evaluations revealed no wound complications and minimal pain. An adequate volume of cancellous bone was easily obtained and the scar is hidden in the hair bearing area of the pubis. This technique is safe, simple and avoids the morbidity associated with iliac grafts.

Asymptomatic Carotid Artery Pseudoaneurysm Associated with Blunt Facial Trauma: a case report

Presenter:	Christopher Tiner, DDS, MD
Co-Authors:	Edward A. Luce MD, Robert D. Wallace MD, Roberto D. Lachica MD
Affiliation:	University of Tennessee, Memphis, TN

Abstract: Blunt carotid artery injury (BCI) is a rare injury and occurs in approximately 0.05% of all blunt trauma admissions. BCI comprises 3-10% of all carotid artery injuries (penetrating and non- penetrating), usually secondary to direct neck injury. BCI in association with facial fractures is a rare presentation (less than 1%) with implications regarding the treatment of facial fractures. Most BCI present with associated neurologic signs and symptoms in multisystem trauma patients. Asymptomatic carotid pseudoaneurysm with associated facial fractures is an even rarer subgroup of BCI. The following is a case report of an asymptomatic carotid artery pseudoaneurysm associated with severe facial fractures in a 23year old male motor vehicle accident victim.

Facial Cutaneous Anthrax: Prompt Recognition IS Pertinent With The Emerging Threat Of Bioterrorism

Accurate diagnosis of cutaneous anthrax, appropriate management and prompt disease surveillance depends on clinicians been familiar with the characteristic appearance of typical skin lesions. This has become more imperative with the emerging threat of bioterrorism worldwide. Plastic surgeons may well be initially consulted if a patient develops a cutaneous anthrax lesion in a non-endemic country.

Anthrax is primarily a zoonotic disease (e.g. cattle, goats and sheep). However cutaneous anthrax is seen in patients who are exposed to contaminated meat or animal products in endemic countries such as Haiti. If affected patients receive prompt antibiotic therapy, their mortality rate is significantly reduced (25% to <1%). Inhalational and gastrointestinal anthrax resulting from respiratory exposure or ingestion of anthrax spores respectively are less common (10% of naturally-acquired anthrax) and have a worse prognosis even with appropriate therapy.

We studied the epidemiology of naturally acquired anthrax in the Artibonite valley in Haiti, where anthrax is endemic in order to identify the risk factors and mode of patient exposure. The natural history of facial cutaneous anthrax lesions was elucidate from observing the clinical course of patients presenting to Hospital Albert Schweitzer which serves the entire region.

Is Hard Tissue Replacement-Patient Matched Implants (HTR-PMI) For Cranial Reconstruction As Safe As Previously Reported?

Presenter:	Michael Zarrabi, MD
Co-Authors:	Naiem Nassiri, BS, Shelley Winn, PhD, Amanda Severson, BS, Reid V. Mueller, MD
Affiliation:	Oregon Health & Science University, Portland, OR

Purpose: Low complication rates (010%) have previously been reported in craniofacial HTR-PMI reconstructions. We performed a retrospective study comparing our experience with that described in the literature.

Materials and Methods: 21 patients (10 males, 11 females) undergoing HTR-PMI reconstruction by seven surgeons over 3 years were reviewed. Complications were defined as implant exposure and/or infection. We evaluated implant location, preexisting bone infections and whether a history of diabetes or smoking was a risk factor for complication. Differences among outcome measures were evaluated using Fisher's exact test with significance established at p<0.05.

Results: Mean age was 43.8 years and the mean time of follow up was 8.3 months. Complication rate was 5/21 (23.8%), including 1 implant exposure, 1 soft tissue infection, and 3 implant infections. A statistically higher rate of infection was observed when compared to historical pooled data (p=0.0406). There was no correlation between implant location or preexisting bone infections and complication rates. Diabetes and smoking were not risk factors associated with complications.

Conclusion: Treating cranial bone defects with hard tissue replacement-patient matched implants (HTR-PMI) may be associated with a higher rate of complications than previously described.

Pediatric Carpal Tunnel Syndrome – A 30-Year Analysis and Treatment Algorithm

Presenter:	Umar Choudry, MD
Co-Author:	Steven L. Moran, M.D.
Affiliation:	Mayo Clinic, Rochester, MN

Background: Carpal Tunnel Syndrome (CTS) in the pediatric population is uncommon. The etiology and presentation is different from adults. There is debate in the literature about the treatment of CTS in children. Methods: We performed a retrospective review on all children (up to age 16 years) presenting with CTS from 1974 to 2005. Patient demographics, etiology, presenting signs and symptoms, treatment therapy, and long-term outcome were analyzed. Results: Thirty-two patients were diagnosed with CTS, either on history or nerve conduction tests (NCT) and electromyography (EMG). There were 21 females (66%) and 11 males (34%), with a mean age of 14 years (Range: 5 16 years). Twenty patients (63%) complained of bilateral symptoms. Overuse syndrome was the major cause of CTS (n=14, 44%). The signs and symptoms varied according to the etiology of the CTS. The success of the treatment modalities depended on the etiology of the CTS, with conservative therapy successful for overuse syndrome and surgery more successful in treating CTS secondary to genetic disorders and post-traumatic CTS. A treatment algorithm is presented. Conclusion: Overuse syndrome is becoming the leading cause of pediatric CTS. The presenting signs and symptoms as well as treatment modalities vary depending on etiology.

Presenter:	Jeffrey Friedrich, MD
Co-Author:	Nicholas B. Vedder, MD
Affiliation:	University of Washington, Seattle, WA

Purpose: The radial forearm flap has been an important tool in upper extremity reconstruction. The donor site, however, can be a source of morbidity. One method of possible morbidity reduction is a fascia-only flap, leaving donor site skin intact, and applying a skin graft on the flap itself. We report our experience with the radial forearm fascia flap compared with a similar group of fasciocutaneous flaps.

Methods: A review of patients who underwent upper extremity reconstruction with a radial forearm flap was conducted. Records were analyzed for type of reconstruction (fascia, fasciocutaneous), reconstruction complications, and donor site complications.

Results: Thirteen patients underwent radial forearm flap upper extremity reconstruction. Seven were fascia-only, six fasciocutaneous. In the fascia-only group, there were no donor site complications, however, there were 2 partial skin graft losses on the flap, and 3 partial flap necroses, all of which healed spontaneously. In the fasciocutaneous group, there were 2 episodes of graft loss on the donor site, and no flap losses.

Conclusions: While upper extremity reconstruction with a radial forearm fascia flap has potential for donor improvement and improved contour of the flap compared with fasciocutaneous reconstructions, the flap itself can be more tenuous in fascia-only reconstructions.

Increased prevalence of community-acquired MRSA in hand infections at an urban medical center

Presenter:	Ravi Kiran, MD
Co-Authors:	Beth McCampbell, MD, Adam Angeles, Richard Montilla, Carlos Medina, Avir Mitra, John Gaughn, Julia Spears, Amit Mitra
Affiliation:	Temple University Hospital, Philadelphia, PA

Introduction: The purpose of this paper is to report the increased incidence of CA-MRSA in hand infections at an urban medical center. Materials and methods: We performed a retrospective review of all patients with hand infections over a 21month period. Demographic data was collected along with risk factors for nosocomial MRSA. Based on chart review, cases determined to be nosocomial were separated from CA-MRSA cases. The study period was divided into three 7-month periods to evaluate the incidence of CA-MRSA. Results: A total of 343 hand infections were treated. 89 patients with culture positive MRSA were identified. 14 patients were determined to be hospital-acquired MRSA patients based on chart review. The remaining 75 patients were determined as CA-MRSA patients. The incidence of MRSA were significantly different during the 3 time periods . During the last 7-month period, a significant increase in CA-MRSA in hand infections was identified. Conclusions: We have found a significant increase in CA-MRSA in hand infections at our center over the last 7 months. We feel this trend may be occurring throughout the US, specifically at urban centers.

Use of absorbable plates and Vitoss (beta-tricalcium phosphate (ß-TCP) for bony reconstruction in phalangeal fracture: a case report

Presenter:	Beth McCampbell, MD
Co-Authors:	Ravi Kiran, MD, Paty Chavez, John Roussalis, Rhoda Powell, Julia Spears, Amit Mitra, MD, FRCS, FACS
Affiliation:	Temple University, Philadelphia, PA

Introduction: Bony deficits can be treated with approximation, grafting, and distraction osteogenesis. We have used Vitoss to fill in small bony deficits successfully. Due to its consistency, we have not used it in larger areas due to loss of shape. We present a patient with significant phalangeal bone loss in which Vitoss was used for bone replacement using an absorbable plate as scaffolding. Case: 52 y.o. male presented to the ER after injuring his index finger on a meat slicer. In the OR he had a bony defect of 2 x 3 cm on the mid-radial aspect of his index finger middle phalanx. The ulnar neurovascular bundle was intact. The wound was debrided and external fixation was performed. He was returned to the OR and the bony deficit was filled with Vitoss and an absorbable plate to create a scaffolding for the Vitoss. A groin flap was performed. Nine months post-operatively after flap separation, debulking and ex-fix removal the fracture is healed. Conclusion: Vitoss is useful in the treatment of fractures where bony tissue is lost. In areas where there's a large deficit, absorbable plates can create a mold for shaping and maintenance of the vitoss in the appropriate configuration.

Malignant Peripheral Nerve Sheath Tumor Masquerading as a Ganglion Cyst in the Hypothenar Eminence

Presenter:	Michael K. Obeng, MD
Affiliation:	The University Of Texas Medical Branch, Galveston, TX

Introduction: Malignant Peripheral Nerve Sheath Tumors (MPNSTs) account for 10% of all soft tissue sarcomas. More commonly associated with major nerve trunks such as the sciatic and sacral nerves, they are very rare in the upper extremity. When they are present, they usually involve the brachial plexus trunk. We hereby report a case of MPNST that presented as a ganglion cyst in the wrist. Case: A 43-year-old right hand dominant craftswoman presented with a one-year history of a slowly enlarging 1.5 X 2 cm mass located on the right hypothenar eminence. Surgical excision and pathologic evaluation revealed the tumor to be an MPNST. Over 48 months later, she is symptom-free, with no palpable mass or evidence of metastasis. Conclusion: This case represents a sporadic presentation of MPNST and the first of its kind in the hand, no reported cases are found in the literature. The hand surgeon should be aware that MPNST can present in the hand and awareness and familiarity with this rare entity will lead to more confidence in managing these tumors.

Presenter:	Satish Ponnuru, MD
Affiliation:	University of Kansas, Kansas City, KS

Purpose: To present a rare case of scaphoid fracture with ejection of the proximal scaphoid fracture to the volar forearm. Methods: A review of the current literature shows only one similar case reported in 1994. This case's findings correlate with the one previously reported where a high energy hyperextension injury led to a perilunate dislocation and displacement of the proximal fragment of the scaphoid 2 inches into the volar forearm. Conclusions: Scaphoid fractures with displacement of the proximal segment beyond the volar wrist crease with associated perilunate dislocation is a complex injury treated by distal row carpectomy in these two cases

Carpometacarpal Arthroplasty Utilizing Interosseous Permanent Suture Fixation of the Abductor Pollicis Longus

Presenter:	Allen Rodgers, MD
Co-Author:	John Dietrich, MD
Affiliation:	summa health system/NEOUCOM, Stow, OH

To evaluate a modified technique in carpometacarpal arthroplasty utilizing interosseous permanent suture fixation of the abductor pollicis longus muscle as an interposition arthroplasty.

A retrospective chart review yielded 35 procedures performed on 33 patients from 2000 to 2003. All patients returned for routine follow-up visits which averaged 11.05 months and included physical examination, radiographs, and subjective questioning regarding function, pain, and satisfaction with the procedure. The physical examination consisted of scar quality, range of motion, and grip/pinch strength determination.

Scar quality was excellent in 33/35 patients or 94.3% on follow-up with all patients developing satisfactory scars. Opposition was assessed in all patients and was good in 100% (opposition to the base of the 4th proximal phalynx), and excellent (opposition to base of 5th proximal phalynx) in 91.4%. Key pinch ranged from 4.3 to 5.1 kg and mean grip strength from 18 to 28 kg. Radiographically, 100% of patients maintained a satisfactory scaphometacarpal interval even under loaded pinch. Subjectively, satisfactory pain relief was reported in 33/35 patients or 94.3%.

Carpometacarpal arthroplasty utilizing interosseous permanent suture fixation of the abductor pollicis longus has shown good results in this follow-up interval.

Advances in the diagnosis of extensor tendon injuries and postoperative therapy

Presenter:	Prashant Soni, MD
Co-Author:	W. Bradford Rockwell
Affiliation:	University Utah Medical Center, Salt Lake City, UT

Purpose: To describe how improvements in radiographic imaging can be applied to earlier detection and differentiation of extensor tendon injuries and to define the best postoperative therapy for patients on an individualized basis.

Results: Cadaveric dissection and intraoperative confirmation have found sonography to be more accurate than physical exam and MRI in the detection of extensor tendon injuries.

Early motion postoperative protocols are superior to traditional static splinting based on grip strength, T.A.M. classification and ratio of excellent/fair results utilizing the Dargan scale. Early passive tendon motion, utilizing the dynamic outrigger splint and early active motion have shown equivalent results. Passive tendon mobilization by a therapist plus dynamic therapy shows the best return to function in certain digits and zones of injury.

Conclusion: High-resolution sonograms today allow earlier initiation of therapy in hard to diagnose cases. Identification of the variables that influence the effectiveness of either postoperative motion based protocols is essential in choosing the best form of therapy.

Friday, March 24, 2006

Presenter:	George Broughton, MD, PhD
Co-Authors:	Edward M. Reece, MD, Kimihiro Nojima, MD, Spencer A. Brown, PhD
Affiliation:	UT Southwestern Medical Center, Dallas, TX

Purpose. Perforator flaps are a popular tool for plastic surgeons because of decreased donor site morbidity. New surgical techniques and innovations are being developed to further exploit this flap. The purpose of this study is to map out skin perforators on the pig that can be used by researchers and clinicians as a reliable, predictable model.

Methods and Materials. Three female Yorkshire pigs (30kg) had Doppler examinations for perforator arteries. When a perforator was located, the site was marked. After the animals were euthanized, the skin was dissected along the subdermal plane identifying all perforator vessels found. The subdermal location of these perforators was then transposed to the skin and marked. The perforating arteries were mapped out in distance and direction using the tip of the scapula, anterior iliac spine, and greater trochanter as anatomical landmarks.

Results. Perforators identified using a Doppler were 1-2mm in diameter. The figure below shows the relative position of identified perforators (black dot) for a pig with a 100cm snout to anus length.

Conclusion. The pig has several constant arterial perforators that can be easily and then exactly located with a Doppler making the pig a suitable animal for perforator research.

Delayed Free Flap Coverage Of Severe Lower Extremity Fractures Does Not Increase Flap Related Complications And Non-union

Presenter:	David S. Chang, MD
Co-Authors:	Amarjit Dosanjh, MD, David M. Young, MD, Scott L. Hansen, MD
Affiliation:	UCSF, San Francisco, CA

Objectives: Delayed coverage (>7 days from injury) of severe lower extremity fractures historically resulted in high complication rates. We studied whether delaying soft tissue coverage > 7 days resulted in greater flap related complications (flap loss and infections) and non-union.

Methods: We reviewed 30 consecutive free flaps for lower extremity open fractures. Group 1 had soft tissue coverage within 7 days of injury (n=13). Group 2 had coverage > 7 days after injury (n=17). We studied the number of debridements prior to coverage, time to coverage, flap related complications, and non-union.

Results: Group 1 had coverage 5 days earlier than Group 2 (median 6 d vs. 11 d). Group 1 underwent 50% fewer debridements than Group 2 (2 vs. 4, p< 0.05). There was no difference in flap related complications. Group 1 had one flap loss and no infections. Group 2 had two flap losses and one infection. There was no difference in rates of non-union between Groups 1 and 2 (31% vs. 6 %)

Conclusions: Delayed free flap coverage of severe lower extremity fractures was not associated with higher complication rates. Furthermore, our results suggest that a more debridements and delayed coverage results in higher rates of bone healing.

Presenter:	Jonathan Cheng, MD
Co-Authors:	Michael Agresti, Ji-Geng Yan, Hani S. Matloub
Affiliation:	Medical College of Wisconsin, Milwaukee, WI

Introduction: Schwann cells establish a molecular milieu permissive toward regeneration of axons. Existing culture techniques require clinically unacceptable mitogenic factors or in vivo predegeneration, and also fail in the culture of Lewis rat Schwann cells. Lewis rats are especially favorable for the study of nerve reconstruction.

Methods: Adult Lewis rat sciatic nerve explants were placed in DMEM+10% FBS to undergo in vitro degeneration. Explants were then dissociated with collagenase and dispase. These microexplants were plated with BS media and a variable FBS regimen. Group 1 1wk degeneration, BS+10%FBS x4d then BS+2.5%FBS. Group 2 1wk degeneration, BS+2.5%FBS. Group 3 4wk degeneration, BS+10%FBS x4d then BS+2.5%FBS. Group 4 4wk degeneration, BS+2.5%FBS. At near-confluence, cells were subcultured in BS+2.5%FBS. Evaluation was by hemocytometry and immunocytochemistry.

Results: Groups 1 and 2 yielded >2x107 Schwann cells/g nerve, while Groups 3 and 4 yielded >5x107 cells/g nerve, with >85% purity. Yields were obtained by 8 and 12 weeks after initial harvest.

Conclusions: A technique for the successful culture of adult Lewis rat Schwann cells is described. Following a period of in vitro explant degeneration, the use of BS media with reduced levels of fetal bovine serum allows the differential expansion of Schwann cells over fibroblasts.

Near-Circumferential Musculocutaneous/Perforator Thigh Flap on a Single Arterial Pedicle: A Novel Option for Large Soft-Tissue Defects

Presenter:	Al Cohn, MD
Co-Authors:	Liza C. Wu, MD, Robert F. Lohman, MD, Lawrence J. Gottlieb, MD
Affiliation:	University of Chicago Hospitals, Chicago, IL

Background: When post-op radiation therapy is planned, closure of large wounds with reliable vascularized cutaneous flaps is preferable to soft tissue flaps covered by STSG. In combining the vascular territories of the medial and lateral descending branches of the Lateral Femoral Circumflex artery we describe a novel flap that serves to provide quality cutaneous coverage for large soft tissue defects on a single arterial pedicle. Methods: A 45 x 30 cm near circumferential perforator thigh flap was successfully transferred to a large shoulder defect with a single arterial (LFC) anastomosis and two venous (LFC and Saphenous) anastomoses. The entire flap was perfused by perforators of the medial and lateral branches of the LFC system, as well as muscular perforators arising via the incorporated rectus femoris muscle. Results: There were no flap related complications, nor were there donor site complications during the patient's post-op recovery. Conclusions: This near circumferential perforator thigh flap provides an additional option to reconstruct truly giant defects with a relatively thin skin flap, in lieu of combination flaps or soft tissue flaps covered by skin grafts. Morbidity is minimized by using donor tissues from a single location that, when harvested, result in a negligible functional impairment.

The Fate Of Lower Extremities With Failed Free Flaps: A Single Institution's Experience

Presenter:	Alfred Thomas Culliford, MD
Co-Authors:	Alan Blank, BA, Jason A. Spector, MD, Nolan S. Karp, MD, Jamie P. Levine, MD
Affiliation:	New York University, New York, NY

Purpose: Lower extremity reconstruction using microvascular techniques is often the only option for limb salvage. This study retrospectively analyzed patients treated at a single institution who underwent lower limb salvage with microsurgical techniques. Of particular interest are the outcome data for patients who had initial free flap failure.

Methods: Records from a prospective database were reviewed from 1980 through 2004. All patients with free flaps to the lower extremity were identified.

Results: Five hundred eighty eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83 percent) had a failure rate of 9%. The failure rate for trauma patients decreased from 11 percent (1980-1992) to 3.7 percent (1993-2004). Of patients who had a failed free flap, 18 percent went on to limb amputation; the remainder were salvaged with secondary free flaps, local flaps, or skin grafting.

Conclusion: This single institutional experience spanning 25 years represents the longest continual series of lower extremity free flaps. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary approach.

Presenter:	Wellington Davis, MD
Co-Authors:	Cindy Wu, Brandon Sorensen, David Sieber, Melissa Hulvat, Darl Vandevender
Affiliation:	Loyola University, Forset Park, IL

Differentiate outcomes between split and full thickness grafts in radial forearm donor sites.

A retrospective review of 55 patients with radial forearm reconstructions was performed. Split and full thickness grafts were used for donor site closure. The outcomes of each graft type were compared.

Outcomes measured: graft loss, tendon exposure, healing time at graft donor site, healing time at graft recipient site, need for additional procedures, number of post op dressings.

Covariables: Age, Gender, Diabetes, Past smoking history, PVD/CAD, Current smoking.

All outcome data was statistically compared using the T-test, Chi-square testing and Fisher's Exact test. Regression analysis was also performed. Significance was taken at p-value <0.05. Results

No statistical significance in any parameter except history of smoking which negatively affected donor site healing. Number of wound dressings approached statistical significance, by percentages tendon exposure and recipient site healing appear to be significant but were not, full>split.

Full thickness skin grafting does not increase the morbidity of radial forearm donor sites. There was no clinically significant difference between split and full thickness grafts. There may be a slight delay in wound healing and increase in wound care but this was not proven statistically.

Irradiated Autologous Tissue Breast Reconstruction Patients—Evaluation of Outcomes

Presenter:	Ida Fox, MD
Co-Authors:	Stephen Vega, Corinne Erickson, Alexander Au, Hulin Wu, Joseph M. Serletti, MD
Affiliation:	University of Rochester, Rochester, NY

Introduction: Timing of autologous tissue breast reconstruction in patients who require radiation therapy is controversial. Some advocate postponing reconstruction until a final decision regarding radiation treatment is made. The purpose of this study is to assess outcomes in patients who underwent autologous tissue breast reconstruction and subsequent irradiation.

Methods: Consecutive patients who underwent autologous tissue breast reconstruction prior to radiation treatment were identified. Patient self-assessment of aesthetic and psychological outcomes was obtained by a two-part questionnaire. Independent evaluation of aesthetic outcomes by physical exam was obtained. The data was collected and compared using Kendall's tau correlation analysis.

Results: Twenty-seven patients met the inclusion criteria and of these 14 participated in the study. Patients were generally satisfied with their aesthetic outcome and physical exam assessment by two uninvolved physicians mirrored the patients' self-perception. However, patients did not derive significant psychological benefits despite superior aesthetic outcomes.

Conclusion: Radiation therapy after autologous breast reconstruction does not adversely affect aesthetic outcomes as measured by patient self-assessment or a physician's physical exam. Psychological measures of satisfaction in post-mastectomy reconstruction are more nuanced and don't necessarily correlate with purely aesthetic measures.

Single-Stage Immediate Breast Reconstruction with the DIEP flap and Total Skin- Sparing Mastectomy: Approaching the Ideal?

Presenter:	Jonathan L. Le, MD
Co-Authors:	Amarjit Dosanjh, MD, Gabe Kind, MD, Robert Foster, MD, Scott L. Hansen, MD
Affiliation:	UCSF, San Francisco, CA

Purpose: Removal of the nipple-areolar complex (NAC) during mastectomy is the current standard of care. There is a recent trend towards nipple/areola skin preservation in selected patients. We evaluated the efficacy of total skin-sparing mastectomy (TSSM) and immediate reconstruction.

Methods: 39 patients underwent 59 TSSM at UCSF from January 2002 to January 2005. MRI excluded patients with disease within 2 cm of the nipple, involving skin or large central tumors. Intra-operative frozen sections were performed to confirm that the NAC was tumor-free.

Results: A variety of techniques, including implants (n=27), tissue expanders (n=7), pedicled TRAM flaps (n=14), latissimus dorsi flaps (n=1), DIEP flaps (n=9) and SIEA flaps (n=1) were used. 71% had superficial epidermolysis post-operatively which resolved within 3 weeks, yielding excellent long-term cosmetic results. Two patients experienced bilateral nipple skin loss. Two specimens were found to have DCIS, and these were subsequently removed.

Conclusions: Preservation of the entire skin envelope allows for a true single-stage reconstruction. Because of the significant rate of partial necrosis with this technique, implant reconstruction should be performed cautiously and autogenous tissue should be considered. Additionally, muscle-sparing flaps such as the DIEP or SIEA provide superior aesthetic results, with limited morbidity and shorter recovery times.

A Survey of Anticoagulation Protocols Following Lower Extremity Free Tissue Transfer

Presenter:	Elie Levine, MD
Co-Authors:	George D. Xipoleas, BA, Lester Silver, MD, MS, R. Michael Koch, MD, Peter J. Taub, MD
Affiliation:	Mount Sinai School of Medicine, new york, NY

Purpose: Reconstruction of the lower extremity using free tissue transfer is performed throughout the country by numerous surgical teams. However, no established protocol exists for perioperative anticoagulation. This study analyzed trends in current anticoagulation protocols regarding lower extremity free flap reconstruction.

Methods: A survey of perioperative anticoagulation protocols for lower extremity free flap reconstruction was designed and distributed via email to members of the American Society of Plastic Surgeons (ASPS).

Results: Of the 3,310 ASPS members contacted via email, 305 (9%) responded that they performed lower extremity free tissue reconstruction and responded to the questionnaire pertaining to perioperative anticoagulation in lower extremity free tissue transfer.

10.2% used preoperative anticoagulation, 62.2% intraoperative anticoagulation, and 67.3% used postoperative anticoagulation. Preoperatively and postoperatively the anticoagulation of choice was aspirin with aspirin accounting for 60% of preoperative anticoagulation and 67.7% of postoperative anticoagulation. Intraoperatively, the anticoagulation of choice was heparin, accounting for 63.1%.

Conclusion: While no set anticoagulation regimen has been established, there are trends that can be seen regarding the pharmacotherapy that surgeons prefer to use at various intervals in the perioperative period. These trends may in turn be used as a guideline to anticoagulative therapy in lower extremity free tissue reconstruction.

Cadaver Dissections of a New Arm Flap: the Anterior Lateral Arm Perforator Flap

Presenter:	Wong Moon, MD
Co-Authors:	Amardip Bhuller, MD, Risal Djohan, MD, Warren Hammert, Earl Browne, James Zins
Affiliation:	Cleveland Clinic Foundation, Cleveland, OH

We have identified a new perforator flap located on the anterior lateral arm. Purpose: To define the anatomy of this anterior lateral arm perforator flap Method: Twelve fresh cadaver arms were dissected using 2.5x magnification loopes. The following measurements were taken of this flap: pedicle length, vessel number, vessel diameters, and flap thickness. A methylene blue injection study was used to determine the size of this pedicle flap Results: On all dissections, the pedicle originated directly from the proximal brachial artery and vein. All the pedicles had 1 artery and 2 veins. Twenty-two percent of the pedicles were intramuscularly located in the brachialis muscle. The mean pedicle length, arterial diameter, and venous diameter were 8cm, 1.5mm, and 2mm, respectively. The mean flap thickness was 1.6cm. The flap measured 10cm x 15cm. The flap was harvested within 1 hr. The donor was easily closed when < 1/3 of the arm circumference was harvested for the flap. Without tension on its pedicle, the flap rotated to reach the shoulder, axilla, and lateral breast. Conclusion: We have identified the anatomy of a new anterior lateral arm perforator flap. This flap can be potentially used as a pedicled and free flap.

Optimal Timing of Microsurgical Reconstruction in Severe Lower Extremity Trauma Revisited: Outcomes Do Not Correlate with Early Flap Coverage

Traumatic lower extremity reconstruction defined by Godina (1986) recommends free flap coverage within 72 hours of injury. Complications in the delayed period (> 72 hrs) were 17.5% (infection) and 12% (flap loss). We hypothesized that definitive debridement, optimal dressing care, meticulous planning, and anastamoses outside the zone of injury would permit delayed reconstruction. Retrospective review of 14 Gustillo grade IIIb, lower extremity reconstructions was undertaken for: mechanism and concomitant injuries; number of pre-flap operations; VAC dressing; timing from injury to flap to discharge; length of hospitalization; transfer or primary admission; pre-operative vascular studies; minor and major complications; and follow up. 71% had significant associated injuries. Average time to flap was 22 days. 85% of patients utilized VAC dressing after debridement. All patients underwent extremity CT angiogram prior to free flap. Three minor (21%) and one major (7%) complication occured. Minor complications were small areas of skin graft loss and a donor site hematoma. The major complication, a late osteomyelitis (9 months), resolved. No free flaps failed. Average follow up was 28 weeks.Our data indicate reconstruction of Gustillo grade IIIb lower extremity injuries can be safely and reliably performed after 72 hours without an increase in flap loss or complications.

Presenter:	Eric H. Williams, MD
Co-Authors:	Laurence Z. Rosenberg, MD, Jorge I. de la Torre, MD, Jobe R. Fix, MD
Affiliation:	University of Alabama Birmingham, Birmingham, AL

Purpose: To evaluate the feasibility and outcome of immediate nipple reconstruction on a free TRAM flap

Materials and Methods: A retrospective review of patients having free TRAM flap breast reconstruction identified ten patients that underwent simultaneous nipple reconstruction. Comparison was made to fifteen patients with delayed nipple reconstruction. Multiple variables including age, BMI, co-morbidities, procedures required, complications, and length of reconstruction were compared. A multi-observer, multi-characteristic comparison of cosmetic outcome was conducted based on standardized photographs.

Results: Patients undergoing immediate nipple reconstruction had a significantly lower BMI (23.8 kg/M2 vs. 28 kg/M2, p = 0.02). They also required fewer procedures to get to the point of areolar tattooing (1.4 operations vs. 2.2 operations, p=0.001), and to complete the entire reconstruction (2.5 operations vs. 3.7 operations, p = 0.008).

Comparison of standardized postoperative photographs revealed no statistical difference in aesthetic outcome of the breast mound or nipple-areola complex between immediate and delayed nipple reconstruction.

Conclusion and Summary: Immediate nipple reconstruction on a free TRAM flap breast reconstruction using a fish tail flap is reliable. In a subset of thinner patients, it provides a symmetrical and aesthetically pleasing breast mound and nipple-areola complex reconstruction in fewer procedures.

Presenter:	Pankaj Tiwari, MD
Affiliation:	Baylor College of Medicine, Houston, TX

Purpose: To evaluate coagulability in patients who have undergone microvascular breast reconstruction.

Materials and Methods: Data from twenty patients comprise this study. Coagulability was determined using prothrombin time (PT), partial thromboplastin time (PTT) and thromboelastography (TEG). Levels were drawn pre-operatively, immediately post-operatively (POD#0), POD#1 and POD#2. Patients who had undergone reconstruction without vascular complication were eligible. T-test was used for statistical comparison (p<0.05).

Results: PT evaluation demonstrated a significant prolongation when POD#0 (15.2±0.79), POD#1 (15.8±1.14) and POD#2 (15.2±0.84) were compared pre-operatively (13.7±0.53). PTT was prolonged when the results from POD#2 (34.5±6.4) were compared to pre-operative (29.2±3.86) and POD#0 (30.2±5.5). Evaluation of fibrin kinetics pre-operatively versus POD#0 demonstrated an increased time to specific clot strength (TEG K-time, 1.49±0.4 versus 1.91±0.7) and a slower build-up and cross-linking of fibrin (TEG alpha, 69.2±4.0 versus 65.1±7.7). Platelet surface activation (TEG MA) decreased on POD#0 (58.1±6.0) and POD#1 (57.1±6.5) when compared pre-operatively (63.0±6.0). Platelet activation increased by POD#2 (61.6±3.9) when compared to POD#0 (58.1±6.0) and POD#1 (57.1±6.5).

Conclusion: Coagulation measures by POD#1 demonstrated decreased coagulability with prolonged PT, decreased fibrin kinetics and decreased platelet activation. By POD#2 PT/PTT remained prolonged; however, platelet activation increased. By POD#2 platelet contribution to clot strength predominates over enzymatic pathways.

Saturday, March 25, 2006

Panel/Interactive Discussion - Pearls to Success; The First Two Years - What Mistakes to Avoid, Q&A: Neal Reisman, MD, JD, Steve Davison, MD, XXX, MD

Interactive Forum - The Reality of Avoiding Lawsuits: Neal Reisman, MD, JD and Gerald Kaplan, MD, JD

Legal Interactions - How to Live With Lawyers - The Deposition: Neal Reisman, MD, JD and Gerald Kaplan, MD, JD

Presenter:	Neil Gottlieb, MD
Affiliation:	Duke University, Durham, NC

Presenter:	Ian Wilson, MD
Affiliation:	Medical College of Georgia, Augusta, GA

Presenter:	John Nigriny, MD
Affiliation:	Stanford University, Palo Alto, CA

Thursday, March 23, 2006

Friday, March 24, 2006

Saturday, March 25, 2006