New Composite Material

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

Yesterday, I came across this press release from John Hopkins regarding a new composite material which may someday be used to restore damaged soft tissue.  (photo credit)

The liquid material is a composite of biological and synthetic molecules which is injected under the skin.  Transdermal light is then used to "set" the material into a more solid structure.

The results of the early experiments in rats and humans has been reported in the July 27 issue of Science Translational Medicine (full reference below).

It is hoped that the new liquid material is a biosynthetic soft tissue replacement composed of poly(ethylene glycol) (PEG) and hyaluronic acid (HA).

From the press release

"Implanted biological materials can mimic the texture of soft tissue, but are usually broken down by the body too fast, while synthetic materials tend to be more permanent but can be rejected by the immune system and typically don't meld well with surrounding natural tissue," says Jennifer Elisseeff, Ph.D., Jules Stein Professor of Ophthalmology and director of the Translational Tissue Engineering Center at the Johns Hopkins University School of Medicine. "Our composite material has the best of both worlds, with the biological component enhancing compatibility with the body and the synthetic component contributing to durability."

The researchers created their composite material from hyaluronic acid (HA), a natural component in skin of young people that confers elasticity, and polyethylene glycol (PEG), a synthetic molecule used successfully as surgical glue in operations and known not to cause severe immune reactions. The PEG can be "cross-linked"—or made to form sturdy chemical bonds between many individual molecules—using energy from light, which traps the HA molecules with it. Such cross-linking makes the implant hold its shape and not ooze away from the injection site, Elisseeff says.

To develop the best PEG-HA composite with the highest long-term stability, the researchers injected different concentrations of PEG and HA under the skin and into the back muscle of rats, shone a green LED light on them to "gel" the material, and used magnetic resonance imaging (MRI) to monitor the persistence of the implant over time. The implants were examined at 47 and 110 days with MRIs and removed. Direct measurements and MRIs of the implants showed that the ones created from HA and the highest tested concentration of PEG with HA stayed put and were the same size over time compared to injections of only HA, which shrank over time.

The researchers evaluated the safety and persistence of the PEG-HA implants with a 12-week experiment in three volunteers already undergoing abdominoplasty, or "tummy tucks." Technicians injected about five drops of PEG-HA or HA alone under the belly skin. None of the participants experienced hospitalization, disability or death directly related to the implant, which was about 8 mm long—or about as wide as a pinky fingernail. However, the participants said they sensed heat and pain during the gel setting process. Twelve-weeks after implantation, MRI revealed no loss of implant size in patients. Removal of the implants and inspection of the surrounding tissue revealed mild to moderate inflammation due to the presence of certain types of white blood cells. The researchers said the same inflammatory response was seen in rats, although the types of white blood cells responding to implant differed between the rodents and humans, a difference the researchers attribute to the back muscles— the target tissue in the rats—being different than human belly fat.

It will be interesting to watch how this develops.




REFERENCE
New Composite Material May Restore Damaged Soft Tissue; John Hopkins Medicine, August 1, 2011

Photoactivated Composite Biomaterial for Soft Tissue Restoration in Rodents and in Humans; Hillel AT, Unterman S, Nahas Z, Reid B, Coburn JM,  Axelman J, Chae JJ, Guo Q, Trow R, Thomas A, Hou Z, Lichtsteiner S, Sutton D, Matheson C, Walker P, David N, Mori S, Taube JM, and Elisseeff JH; Sci Transl Med 27 July 2011: Vol. 3, Issue 93, p. 93ra67; DOI: 10.1126/scitranslmed.3002331

2-Stage Ear Reconstruction – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

There is a nice article on a 2-stage ear reconstruction for microtia (full reference below) in the current issue (May/June 2011) of the Archives of Facial Plastic  Surgery journal.

I am in awe of the surgeons who can carve the 3-dimensional cartilage framework fabricated in the first stage.  This is not something I mastered but continue to read to learn (while referring this patients to others).

In the article, Yanyong Zhao, MD  and colleagues describe the 2-stage procedure they used to reconstruct the ears of 68 patients (ages ranged from 5 to 17 years).  The surgeries were done  between January 1, 2006, to December 31, 2008. Forty-eight patients were boys, and 20 were girls. Unilateral microtia was present in 66 patients and bilateral microtia was present in 2 patients.

The authors clearly describe the procedure and have added nice photos such as this one to make it even more clear (photo credit).

The first stage involves elevating the skin flap and retroauricular fascial flap in the mastoid area, then the cartilage framework is wrapped by the fascial flap from behind and covered by the skin flap from front.

In the second stage the crus, the tragus, and the conchal cavity are reconstructed. So almost all of the fine structures of ear are reconstructed.

Here is one of the photos which shows their results (photo credit)

The article is worth reading, especially for students and residents.  Even experienced surgeons may find it useful.

REFERENCE

Original Article A 2-Stage Ear Reconstruction for Microtia; Haiyue Jiang, Bo Pan, Yanyong Zhao, Lin Lin, Lei Liu, Hongxing Zhuang; Arch Facial Plast Surg. 2011;13(3):162-166; doi:10.1001/archfacial.2011.30

Rare Facial Replantation Performed at UAMS

UAMS mails out a publication called UAMS Consult a few times each year. I found a pdf file of their March 2007 issue online (no longer active, 2013) but couldn’t find the current one with this case report. So I’m taking the liberty (they may ask me to take it down) to publish it here.

The 20-year-old patient presented to the UAMS Emergency Department via ambulance from Malvern, about 50 miles away. The patient’s nose, upper lip and most of his right cheek were amputated by the edge of a hollow metal pole that came through the patient’s windshield during the single-vehicle rollover accident. He also had multiple facial fractures with extensive damage to the palate and teeth.

At the accident site, the property owner directed emergency responders to the severed portion of the patient’s face some distance from the vehicle. The avulsed tissue was properly stored and brought to the ED along with the patient.

Only One Choice

Mauricio Moreno, MD, director of the UAMS Head and Neck Cancer Division and a fellowship-trained microvacsular surgeon, saw the patient in the ED and determined that the only choice was to attempt one of the largest known composite facial replantation surgeries in medical literature.

The ischemia time was critical to the outcome since most successful replantations of facial tissues are performed in less than 8 hours. Due to inclement weather, an effort to fly the patient to UAMS had been aborted, and nearly six hours had passed when the patient was taken to surgery.

Without a successful replantation, the patient’s prognosis was poor for both function and appearance. No amount of plastic and reconstructive surgery would provide a cosmetically satisfactory result, and the patient’s ability to eat, drink, or speak would be severely affected.

Prior to surgery, Moreno consulted with UAMS’ Marcus Moody, MD, a facial plastic and reconstructive surgery specialist, who agreed that the facial bone fractures could be repaired at a later date.

The Challenge

Success depended on reintroducing blood supply via a microvascular anastomosis of the facial artery to the angular artery and microvascular anastomosis of the retromandibular vein to the facial vein. Given the nature of the injury, the vessels were severely damaged at the point where they were transected. In order to overcome this problem the vessels were dissected from the transection site until they appeared less damaged, and the anastomosis was made at that point. This was one of the most technically challenging aspects of the case. Very short vessels forced the release of some tissues in the face and neck in order to achieve a tension-free anastomosis.

Moreno worked as quickly as possible, completing the replantation in about two hours, maintaining the total ischemia time just under eight hours.

Six days after surgery, while the patient remained sedated in the ICU, the retromandibular vein thrombosed and the patient was taken back into surgery to repair the clotted vessel. Two days later the same vessel thrombosed again requiring a third – and final – microsurgical procedure.

The episodes of thrombosis likely were related to the vessel trauma that resulted from the accident.

Leeches Help

Because the tissue was unable to accommodate the increased blood flow, medical leeches were flown to UAMS and applied to the replanted tissue for 72 hours. The leeches corrected the venous insufficiency, which can have the same deleterious effect as when replanted tissue gets too little blood supply.

The replantation was a success. It appears to be the largest composite nasal replantation in the medical literature of about 15 cases described worldwide.

Ninety percent of the tissue survived; only a small portion of the patient’s nose and right cheek did not survive, but that tissue can be replaced.

The patient lost vision in his right eye, and the right side of his face is paralyzed as a result of the trauma. Multiple procedures will be needed to repair the numerous facial fractures, restore facial symmetry and achieve the best possible cosmetic and functional outcome.

………..

Kudos to UAMS.

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Kim, Emergiblog, is the host for this week’s Angry Birds issue of Grand Rounds! You can read this week’s edition here (photo credit).

Welcome to the Angry Birds edition of that weekly compendium of medical blogosphere goodness, Grand Rounds! I’ve chosen my addiction du jour, Angry Birds, as the theme for my 7th turn as host.

For those who are not familiar, Angry Birds is a game in which Green Pigs steal Bird eggs, causing the Birds to become angry, start screeching and begin catapulting themselves from sling shots in an attempt to destroy the Pigs, who house themselves in various structures and giggle at the Birds.

Got it?
Okay then! Let’s get started!  ………..

……………………………

Last Tuesday @EvidenceMatters alerted me via twitter to a panel discussion regarding Vitamin D “Vigorous panel talk: Boosting Vit D - Not enough or too much? Liveblog: http://bit.ly/gL9JuX Video: http://bit.ly”

The webcast of the panel discussion can be viewed here.

The consensus report:  Dietary Reference Intakes for Calcium and Vitamin D

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I caught part of this great  @radiorounds episode (#509) this past Sunday afternoon.  The episode kicked off “Donate Life” month and  focused on the topics of organ donation and the organ shortage crisis.  It aired live on April 3 and will be available on April 5 on their iTunes page!   

The featured guests included:

• Dr. William K. Rundell, Director of Transplant Surgery at Miami Valley Hospital in Dayton, Ohio and Clinical Professor of Surgery at the Wright State Univ. Boonshoft School of Medicine

• Dr. John Donnelly, Asst. Professor of Family Medicine at the Wright State Univ. Boonshoft School of Medicine… and a pancreas transplant recipient

• Dr. Alex Tabarrok, Professor of Economics at George Mason University and co-author of the economics blog Marginal Revolution

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Victoria (@vpmedical), Beyond the Bedside, wrote her own post in response to mine:    Hand Transplant vs. Prosthesis

…. As a life care planning expert in amputation injury and limb loss, I find hand transplantation somewhat disturbing.  I can appreciate the technology and biological advances that have allowed transplantation to occur. …….

One need only to review the case of Mr. Jeff Kepner, a bilateral hand transplant patient, to understand the concerns of such a procedure.  One year after his transplant he still regretted his life changing decision. In his words……….

Be sure to read the comment from Wolf on my post.  It is very insightful.

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Engadget had an article by Christopher Trout yesterday:  Bionic eye closer to human trials with invention of implantable microchip

We've had our eye -- so to speak -- on Bionic Vision Australia (BVA) for sometime, and with the invention of a new implantable microchip it's coming ever closer to getting the bionic eye working on real-deal humans. The tiny chip measures five square millimeters and packs 98 electrodes that stimulate retinal cells to restore vision. ……...

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A lovely essay on the origin of how human hair wigs are sourced, created and distributed by Julia Sherman:  She Goes Covered

Following the global hair trade, from the braid-laden Peruvian highlands to the sheitel machers of Borough Park.

I.     In the fall of 2009, Helene Rosen, her husband, Yoni, and eight of their eleven children moved from Baltimore to Cusco, Peru, to harvest human hair.1 Helene is a forty-four-year-old Orthodox Jew and self-proclaimed “master sheitel designer” who began making wigs fifteen years ago, for ten dollars an hour; her custom hairpieces now sell for up to two thousand. “You can bring me any wig,” she said this past winter, sitting at the table in her spare dining room in Cusco, “and I can tell you how old it is, how much it has been worn, and if it has ever been repaired. I can tell you everything about it.”   ……….

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Arkansas Literary Festival begins this Thursday (April 7-13).  One of the authors this year is the son of a long time friend (from college days, a fellow physics grad who now works for Lockheed Martin in laser research). 

Benjamin Hale is a graduate of the Iowa Writers Workshop, where he received a Provost's Fellowship to complete his novel, which went on to win a Michener-Copernicus Award. He has been a night shift baker, security guard, trompe l'oeil painter, pizza deliverer, cartoonist, illustrator, and technical writer. He grew up in Colorado and now lives in New York. The Evolution of Bruno Littlemore is his first novel.

To visit Benjamin Hale's website, click here

Decision-Making in Severe Lower Leg Trauma

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

About the time I was reading the journal article on decision-making process for patients with severe lower leg trauma (full reference below), @sospokesaroj shared news article via twitter:  Nine-year-old loses leg while saving little sister’s life.

Another news article on the accident notes

Surgeons worked on Anaiah from 1 p.m. to midnight on Friday, Davis says, to try and save a shattered left leg.

On Saturday the leg was amputated. The brute force of the accident also broke Anaiah’s right leg, fractured her neck, damaged her spleen and destroyed one kidney.

Which brings me back to the journal article which is a qualitative analysis of patient preferences for amputation or reconstruction. Twenty patients with type IIIB or IIIC open tibial fractures participated in the study. These patients had undergone either amputation (4 primary, 5 secondary) or reconstruction (14) between 1997 and 2007. There were 15 men and 5 women, mean age was 47 (23 – 68) years.  Semi-structured interviews were conducted and qualitative outcomes were assessed.

It must be noted that current research has shown minimal difference in functional outcomes between patients who have below-knee amputation and those who have lower limb reconstruction following a severe open tibial fracture.

The interviews highlighted several issues involved with medical decision-making. Participants described not having a role in deciding which medical treatment to choose.

“I didn’t decide! Hospital decided for me…They all made the decision; I didn’t make no decision on nothin’.  I didn’t even see it.  All I know is that [my wife] told me that when she came to the hospital they told her that they had to take it off.”  --- Male, 67, primary amputation, 12 year post-injury

“I was conscious until I got here [to the hospital], but when I got here… from that time I was in a morphine daze for several days.  And most of those decisions were being made by my wife.”  --- Male, 53, primary amputation, 8 years post-injury

“I’m lucky my brother was here for 3 months, I mean he was here like the day after it happened… Because I wasn’t terribly coherent, I mean, it’s not that I wasn’t conscious, I was on a lotta drugs.  I had my own little morphine clicker.”  --- Female, 56, reconstruction, 8 years post-injury

As you can see from the interview snippets included (and there are others in the article), family and spouses played a greater role than the patient in decision making, often because of patients being medicated when needing to make a treatment choice.

The article notes both amputation and reconstruction patients described being satisfied with the outcomes of their surgical treatments, but also expressed second thoughts about their treatment choices.

“I have to say I am happy with the results of the surgery, who my surgeon was.  However, the problems …. Mine are not what everybody gets.  Some people never have bone spurs, some people never have neuromas.  But I do.  And why people that have trauma injuries suffer more than pain, I don’t know.  Why do we get a bursa?  It’s just there.  It’s painful.  There’s nothing they can do about it.”  --- Female, 62, primary amputation, 9 years post-injury

“I was kinda angry about it, you know, like why did they have to take my right [latissimus dorsi] one? ‘cause I’m right handed.  Like, why couldn’t they take my left?  I was really mad about it.”  -- Male, 36, reconstruction, 12 years post-injury

“No, as of today, sitting here I wouldn’t have changed my decision [to do the reconstruction], but we did second guess it, several times, as we went through the multiple surgeries and everything else that came as a result of that.”  --- Male, 41, reconstruction, 10 years post-injury

 
REFERENCES

A Qualitative Analysis of the Decision-Making Process for Patients with Severe Lower Leg Trauma; Aravind, Maya; Shauver, Melissa J.; Chung, Kevin C.; Plastic & Reconstr Surgery Vol 126(6):2019-2029, December 2010; doi: 10.1097/PRS.0b013e3181f4449e

Rebuilding the Face Injured by War

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Monday I happened to catch the NPR segment by Terry Gildea:  Rebuilding The Faces Of War 

And now, a story about the effects of war and violence in a different part of the world and how specialists are learning from it. The wars in Iraq and Afghanistan have created a need for innovative treatments for severe battle wounds. Service members often suffer injuries that disfigure and even eliminate parts of their face. At a Defense Department clinic in Texas, surgeons are restoring missing facial features and in a way they're restoring the identities of the wounded.

Texas Public Radio's Terry Gildea takes us to the clinic at Lackland Air Force Base in San Antonio. …

He's now working with doctors at the Maxillofacial Prosthetic Clinic at Wilford Hall Medical Center. Today his anaplastologist, Nancy Hanson, is fitting him with a new set of ears. …………..

……

The story notes that the Department of Defense has two such clinics.  It mentions  Lackland Air Force Base in San Antonio, TX but didn’t specify the other.  It took some “googling” but I finally found an article that mentioned the other one:

The maxillofacial prosthetics program is only one of two such programs in the Defense Department, said Col. (Dr.) Alan Sutton, the program’s director. The other program is at the National Naval Medical Center in Bethesda, Md., he said.

While looking for the second clinic, I found this 2008 article on Air Force Senior Airman Justin Jones who at the time was a maxillofacial prosthetic technician with 59th Dental Squadron here.  His job was to help service members who have suffered disfiguring facial injuries.  [Face of Defense: Airman Helps Injured Warriors 'Face' World]

and this article from August 3, 2010:  Air Force dental team helps patients ‘face’ the world, also featuring the MacKown Dental Clinic, which explains the process:

………Often most important to the patient is the restoration of function – speech, chewing and swallowing — in cases where injury or cancer to the mouth or jaws has occurred.

The team’s first step frequently starts in the stereolithography lab, located at MacKown Dental Clinic, which is one of only two located in the DoD.

Stereolithography is a rapid prototyping method, which allows the fabrication of anatomically accurate, three-dimensional epoxy and acrylic resin models from various types of medical data. There are myriads of data formats that can be assimilated, some of which include those from computed tomography, magnetic resonance imaging, and optical scanners.

“I can take a CT scan of a burn patient’s head and create an exact replica so our anaplastologist can build replacement ears and noses that will fit perfectly,” said Mr. Dave Carballerya, stereolithography lab supervisor. “This technology is also used to incorporate dental and craniofacial implants to enhance the doctors’ diagnosis and treatment planning.”

The team’s anaplastologist then works to create facial prosthetics for the patient.

Anaplastology is the art and science of restoring a malformed or absent part of the human body through artificial means. Again, Lackland is unique in that MacKown Dental Clinic employs the only certified clinical anaplastologist in the DoD, Ms. Nancy Hansen.

“Our patients are going through the traumatic experience of missing anatomical features,” said Ms. Hansen. “We get to see them blossom because they are given hope.”

Ms. Hansen begins by making an impression of the area of the missing anatomy. Prosthetic noses, ears, jaws, even eyes can be made with silicone or hard resin. Many steps are taken to give the prosthesis a realistic look.   …………

Are Patients Making Good Decisions About Breast Reconstruction?

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

An outcomes article in the January 2011 issue of the Journal of Plastic and Reconstructive Surgery asks the question:  Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy?

The objective of the study was to “measure women's knowledge about reconstruction and to evaluate the degree to which treatments reflected patients' goals and preferences.”

Their conclusion (bold emphasis is mine):

Women treated with mastectomy in this study were not well-informed about breast reconstruction. Treatments were associated with patients' goals and concerns, however, and patients were highly involved in their decisions. Knowledge deficits suggest that breast cancer patients would benefit from interventions to support their decision making.

Granted the study was small, but it left me wondering if we the medical community fails to educate these women.  

The study involved a cross-sectional survey of early-stage breast cancer survivors from four university medical centers.  The survey included measures of knowledge about specific reconstruction facts, personal goals and concerns, and involvement in decision making.   Only 84 patients participated (59% response rate).

Participants answered only 37.9% of knowledge questions correctly.

 

Here are the general information questions asked in the survey with the correct answers: 

1.  In general, which women are more satisfied with their breast
reconstruction --those who have reconstruction at the time of the mastectomy or who have delayed reconstruction?

They are both equally satisfied (only 33.3% of the women surveyed knew this)

2.  After which type of breast reconstruction are women more satisfied with the look and feel of the reconstructed breast—implants or flaps?

Flaps (only 15% knew this)

3.  Mark whether or not it is true for breast reconstruction with an implant -- uses fat and tissue from other parts of the body to make a breast.

Answer is false. (only 13.1% knew)

4.  Mark whether or not it is true for breast reconstruction with a flap -- usually requires more than one surgery.

Answer is true. (only 28.6% knew)

5.  Which breast reconstruction surgery is easier on the body, that is, heals faster? 

Implants are easier (only 57.1% knew this)

6.  Of every 100 women who have breast reconstruction, about how many will have a major complication, such as needing hospitalization or an unplanned procedure, within 2 years?

The answer is 25–50.  (only 3.6% knew the correct answer)

7.  How does breast reconstruction affect future screening for breast cancer?  

It has little or no effect on finding cancer  (only 35.7% knew this)

 

 

Which is right for you depends on many things. 

Are you a candidate for flap surgery and if so which is best for you – TRAM, Latissimus Dorsi, etc. 

What kind of recovery time are you willing to put up with?  Recovery from flap surgery is longer than for implant surgery

Does the thought of having a foreign body (implant) in your body bother you?  If so, then put up with the longer flap recovery time and forgo the implants.

Ask to talk with other patients who have been through the surgery, preferably with your surgeon.  They can tell you better than we can about recovery (ie the little things that can make life miserable or better).

 

 

REFERENCES

1.  Are Patients Making High-Quality Decisions about Breast Reconstruction after Mastectomy? [Outcomes Article]; Lee, Clara N.; Belkora, Jeff; Chang, Yuchiao; Moy, Beverly; Partridge, Ann; Sepucha, Karen; Plastic & Reconstructive Surgery. 127(1):18-26, January 2011.doi: 10.1097/PRS.0b013e3181f958de

2.  Determinants of Patient Satisfaction in Postmastectomy Breast Reconstruction; Alderman, Amy K.; Wilkins, Edwin G.; Lowery, Julie C.; Kim, Myra; Davis, Jennifer A.; Plastic & Reconstructive Surgery. 106(4):769-776, September 2000.

3.  Sacramento Area Breast Cancer Epidemiology Study: Use of Postmastectomy Breast Reconstruction along the Rural-to-Urban Continuum; Tseng, Warren H.; Stevenson, Thomas R.; Canter, Robert J.; Chen, Steven L.; Khatri, Vijay P.; Bold, Richard J.; Martinez, Steve R.; Plastic & Reconstructive Surgery. 126(6):1815-1824, December 2010.; doi: 10.1097/PRS.0b013e3181f444bc

4.  Patient Satisfaction in Postmastectomy Breast Reconstruction: A Comparative Evaluation of DIEP, TRAM, Latissimus Flap, and Implant Techniques; Yueh, Janet H.; Slavin, Sumner A.; Adesiyun, Tolulope; Nyame, Theodore T.; Gautam, Shiva; Morris, Donald J.; Tobias, Adam M.; Lee, Bernard T.; Plastic & Reconstructive Surgery. 125(6):1585-1595, June 2010.; doi: 10.1097/PRS.0b013e3181cb6351

Closure of Facial Mohs’ Defects

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.I

t is very likely there will never be a complete consensus on the best or correct way to close defects left by Mohs’ surgical excision of skin cancers on the face. 

Which is best?  Direct linear closure.  Local flap. Skin graft.

In my opinion, it comes down to multiple factors but perhaps the most important are:   Where on the face is the defect?  How lax is the surrounding skin? 

The authors of the recent Plastic & Reconstructive Surgery Journal article on the topic (full reference below) write in their introduction in favor of direct closure (the first step in the reconstructive ladder):

This first step on the reconstructive ladder is often overlooked in favor of more intricate local flap options. If performed properly, direct linear closure results in superior aesthetic results that are more predictable and involve less tissue dissection than local flap options. 

The article is a retrospective review of 1354 reconstructions performed post-Mohs’ facial defects by the senior author (JFT)between 2001 and 2008.  

Forehead (96/125 closed directly in this study) –-their maximum size for direct closure was 3.6 cm.  A nice tip from JFT to determine orientation of the final closure:

The senior author's (J.F.T.) preferred technique for forehead repairs is to place a single silk stitch in both directions, tailor-tack the wound closed, and orient the resultant closure based on which direction yields the least tension, with dog-ear excision following the closure. Dog-ears are meticulously excised on the forehead.

Nose (46/707 closured directly in this study) –- maximum defect size 1.2 cm on nasal dorsum, < 1 cm on tip.

The indications for direct linear closure on the nose are more limited than other anatomical areas on the face because of the relative paucity of skin laxity and the risk of alar distortion.

Lip (37/138 closed directly in this study) – maximum defect 3 cm.

Numerous textbooks have described linear closure of the lip as the preferred technique for defects of 25 percent of the upper lip and up to 30 percent of the lower lip. Our experience has shown that superior aesthetic results can be achieved with defects approaching 40 percent on the upper lip and exceeding 50 percent on the lower lip. This is particularly true in the elderly patient.

Cheek (117/186 closed directly in this study) – maximum defect 4 cm. 

The cheek, particularly in the elderly population, is an ideal area for direct linear closure of very large lateral defects. …..

The inherent laxity in the aging cheek and the ability to generously undermine this well-perfused region contribute to this result.

Chin (4/6 closed directly in this study) – maximum defect 2.2 cm.

Care must be taken with direct closure on the chin, as there is little skin laxity. Direct closure must be avoided in a horizontal plane, to prevent the inadvertent development of extrinsic lip ectropion.

Related posts:
Bilobed Flap for Repair of Nose (March 26, 2008)
Skin Grafting in Lower Third Nasal Reconstruction (April 1, 2010)
Reconstruction of the Lip -- Part I (January 29, 2008)


REFERENCE

The Rationale for Direct Linear Closure of Facial Mohs' Defects; Soliman, Sameer; Hatef, Daniel A.; Hollier, Larry H. Jr.; Thornton, James F.; Plastic & Reconstructive Surgery. 127(1):142-149, January 2011; doi: 10.1097/PRS.0b013e3181f95978

Hemifacial Microsomia

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

Every holiday season brings us news of thefts.   Sometimes followed up by good people stepping forward to restore or replace the item(s) stolen.  This year is no different.

Mid-November someone stole $8,000 from  a fundraiser held to raise money for a a New York City firefighter son.  Aidan Sullivan,  9 years old, was  born with hemifacial microsomia.  In Aidan’s case, this birth defect has left  one side of his face underdeveloped, deformed his jaw and skull and left him without a right ear.  (photo credit)

The Vincent Crotty Memorial Foundation  is replacing the money that was stolen.  The money is needed to offset the portion insurance doesn’t cover (deductible, family percentage, etc) which is estimated to be in the $10,000 to $15,000 range.  Aiden’s surgery is scheduled for this spring at NYU's Langone Medical Center in Manhattan.

Best wishes to you Aiden.

….

What is hemifacial microsomia? 

It is a developmental birth defect involving the first two branchial arches resulting in incomplete development of the ear, nose, soft palate, lip and mandible.  The syndrome varies in severity, but always includes the mal-development of the ear and the mandible. This is the second most common facial birth defect after clefts.

Hemifacial microsomia is also known as first and second branchial arch syndrome, craniofacial microsomia, oral-mandibular-auricular syndrome, otocraniocephalic syndrome, auriculobranchiogenic dysplasia, necrotic facial dysplasia, intrauterine facial necrosis, otomandibular dystosis, hemignathia and microtia syndrome, and unilateral facial agenesis.

Hemifacial microsomia syndrome is made up of a constellation of congenitally malformed facial structures which arise from the first and second branchial arches, the intervening first pharyngeal pouch and first branchial cleft.

Hemifacial microsomia is reported to occur in approximately 1 per 25-45,000 births.  Most cases are sporadic, but there are rare familial cases that exhibit autosomal dominant inheritance.

Hemifacial microsomia syndrome is most often not completely expressed.  If it were, the child would exhibit the following:

• Unilateral or bilateral underdevelopment of the external ear, middle ear, mandible, zygoma, maxilla, temporal bone, facial muscles, muscles of mastication, palatal muscles, tongue, and parotid gland.
• Macrostomia 
• First branchial cleft sinus

The goals of surgery will depend on the child’s problems, but in general aim to improve facial symmetry and restore normal occlusion and TMJ joint function.

Common surgeries include:

• lowering the upper jaw to match the opposite side and lengthening the lower jaw. Sometimes a bone graft is used to lengthen the jaw and sometimes a distraction device is used.
• Ear reconstruction at about 5-6 years of age, involves 3 to 4 surgeries.
• Occasionally, it may be necessary to add bone to build up the cheekbone.
• Some children benefit from the addition of soft tissues to further balance the face.

Related posts
Microtia (September 14, 2007)
Constricted Ear Deformity (September 15, 2007)


REFERENCES

Craniofacial, Distraction Osteogenesis; eMedicine article, June 30, 2009; Pravin K Patel, MD, Marco F Ellis, MD, and Linping Zhao, PhD, MSE

The National Craniofacial Association

The First and Second Branchial Arch Syndrome; Plastic & Reconstructive Surgery: November 1965 - Volume 36 - Issue 5 - ppg 485-508

Syndromes of the First and Second Pharyngeal Arches: A Review; Am J Med Genet Part A 149A:1853–1859, 2009; Passos-Bueno MR, Ornelas CC, Fanganiello RD.

Fiorina’s Infection Highlights Reconstruction Complications

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

The news report of California Republican U.S. Senate Candidate Carly Fiorina’s recent hospitalization due to an infection related to her breast reconstruction is an opportunity to talk about the risks of complication associated with breast reconstruction surgery.

Fiorina was diagnosed with breast cancer diagnosis in February 2009.  She was treated with chemotherapy, radiation and a double mastectomy.  I found several articles that note she had her reconstructive surgery at Stanford University Medical Center, the San Jose (Calif.) in July 2010, but none mention the reconstruction technique used.

My guess would be implant based reconstruction considering how quickly she returned to campaigning.  Recovery time for a TRAM flap (free or pedicle) or any other flap based reconstruction would have been much longer.

The chemotherapy and radiation put her at increased risk of surgical complications.  It’s all a balancing act.  Weighing the need/desire for reconstruction against the risks.  Treatment of the breast cancer is always the first priority.

As noted by in the eMedicine article (1st reference below)

The occurrence of complications using expander-implants can exceed 40% in published studies. However, despite a significant rate, the complications themselves are usually minor and do not prevent completion of a satisfactory reconstruction. In experienced hands, good to excellent aesthetic outcomes can be obtained in more than 80% of patients.

The 40% includes every little complication that can occur:  capsular contracture, infection, wound healing issues, seroma/hematoma, assymetry, poor implant position, etc.

Breaking it down better is the table found from the Mentor Large Simple Trial data that lists the complications that occur within 3 years.

Additional Operation (Reoperation)	40%
Loss of Nipple Sensation	35%
Capsular Contracture III/IV or grade unknown	30%
Asymmetry	28%
Implant Removal	27%
Wrinkling	20%
Breast Pain	17%
Infection	9%
Leakage/Deflation	9%
Irritation/Inflammation	8%
Delayed Wound Healing	6%
Seroma	6%
Scarring	5%
Extrusion	2%
Necrosis	2%
Hematoma	1%
Position Change	1%

What these numbers don’t do is individualize the risk.  You can’t tell from these numbers who had only radiation, who had only chemotherapy, who had both, which ones smoked, who had diabetes, etc.  All of these things increase the risk to the individual.

Related Post:

Infected or Exposed Breast Prosthesis (Sept 1, 2010)

Patient Satisfaction Following Breast Reconstruction Using Implants (June 7, 2010)

REFERENCES

Breast Reconstruction, Expander-Implant; eMedicine article, October 2009; Jorge I de la Torre, MD, FACS, Luis O Vasconez, MD, FACS

Breast Reconstruction Overview; eMedicineHealth

About Breast Reconstruction; Cancer Help UK

Tuberous Breasts

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

The latest edition of the Aesthetic Surgery Journal (Sept/Oct 2010) has a really nice article (first reference below) on this tuberous breasts. One of the best things about the article is the great photos, both of the deformity (includes this one to the right) and the corrective procedure.

Another nice thing the article has is the review of the breast’s embryology which is critical to understanding the formation of the deformity (bold emphasis is mine).

The breast originates from the mammary ridge, which develops in utero from the ectoderm during the fifth week. Shortly after its formation (in the seventh to eighth weeks), most parts of this ridge disappear, except for a small portion in the thoracic region, which persists and penetrates the underlying mesenchyme around 10 to 14 weeks. Further differentiation and development of the breast occurs during the intrauterine life and is completed by the time of birth, after which essentially no further development occurs until puberty.

During puberty, the mammary tissue beneath the areola grows with enlargement of the areola, until the age of 15 to 16, when the breast assumes its familiar shape. As a result of the ectodermal origin of the breast and its invagination into the underlying mesenchyme, the breast tissue is contained within a fascial envelope, the superficial fascia. This superficial fascia is continuous with the superficial abdominal fascia of Camper and consists of two layers: the superficial layer (which is the outer layer covering the breast parenchyma) and the deep layer (which forms the posterior boundary of the breast parenchyma and lies on the deep fascia of the pectoralis major and serratus anterior muscles). The deep layer of the superficial fascia is penetrated by fibrous attachments (suspensory ligaments of Cooper), joining the two layers of the superficial fascia and extending to the dermis of the overlying skin and the deep pectoral fascia. Of note is that the superficial layer of this fascia is absent in the area underneath the areola, as can easily be demonstrated by the invagination of the mammary bud in the mesenchyme.

Clinical experience has shown us and other authors that in cases of tuberous breasts, there is a constricting fibrous ring at the level of the periphery of the nipple-areolar complex that inhibits the normal development of the breast. This constricting ring of fibrous tissue is denser at the lower part of the breast and does not allow the developing breast parenchyma to expand during puberty. Histology confirmed the existence of such dense fibrous tissue in the area of this “constricting ring.” Specimens from two of our patients have been examined, and they showed large concentrations of collagen and elastic fibers, arranged longitudinally. We believe this ring represents a thickening of the superficial fascia, as described earlier. Perhaps the two layers of this fascia join at a higher level than usual, or the suspensory ligaments are thicker and more dense.

Tuberous breast deformity is a rare condition that becomes apparent during teenage years as the breast develop. As noted in the embryology description, the deformity is due to a constricting fibrous ring which does not allow the breast to form in a normal shape.

The deformity which was first described in 1976 by Rees and Aston, can be either unilaterally or bilaterally. When bilateral, the deformity may be vary in degree. It has many other names: tubular breasts, Snoopy breasts, herniated areolar complex, domed nipple, nipple breast, constricted breast, lower pole hypoplasia, and narrow-based breast.

A common classification of tuberous breast deformity is the one proposed by Grolleau et al (photo credit):

• Type I: deficiency of the lower medial quadrant. (A)
• Type II: deficiency of both lower quadrants. (B)
• Type III: deficiency of all four quadrants. (C,D)

The only way to correct this deformity is surgery. Even if no implant is needed or desired, the nipple/areolar complex benefits from a periareolar donut-type skin excision, reducing the areola to the desired size, usually 4 to 4.5 cm in diameter.

I agree with the authors that the constricting fibrous ring needs to be divided so the breast parenchyma can assume a more natural shape. When an implant is used, the subglandular or duel-plane position is preferred.

I would encourage reading the full article for more tips.

REFERENCES

Aesthetic Reconstruction of the Tuberous Breast Deformity: A 10-Year Experience; Mandrekas AD, Zambacos GJ; Aesthetic Surgery Journal September/October 2010 30: 680-692, doi:10.1177/1090820X10383397

The tuberous breast; Rees TD, Aston SJ; Clinics of Plastic Surgery 1976;3:339-347.

Breast Base Anomalies: Treatment Strategy for Tuberous Breasts, Minor Deformities, and Asymmetry; Grolleau, Jean-Louis; Lanfrey, Etienne; Lavigne, Bruno; Chavoin, Jean-Pierre; Costagliola, Michel; Plastic & Reconstructive Surgery. 104(7):2040-2048, December 1999.

Aesthetic Reconstruction of the Tuberous Breast Deformity; Mandrekas, Apostolos D.; Zambacos, George J.; Anastasopoulos, Anastasios; Hapsas, Dimitrios; Lambrinaki, Nektaria; Ioannidou-Mouzaka, Lydia; Plastic & Reconstructive Surgery. 112(4):1099-1108, September 15, 2003.

Facial Prosthetics Restores Face

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

This is an amazing story of restoring a face using surgery and prosthetics. I learned of it through the AMA News article by Carolyne Krupa: Medical team gives Oregon woman a new face.

A surgeon and two maxillofacial experts in prosthetics help a 27-year-old mother, disfigured by a shotgun blast, appear more normal to her young son.

Krupa tells the story and then links to this one:
REBUILDING CHRISSY STELTZ'S FACE: A Special Report by The Oregonian – chronicles the story from the beginning with a list of articles written through the years and a nice timeline slideshow which includes this one.

Other recent news stories regarding facial prosthetics
Military's Facial Prosthetic Program Transforms Injured Troops
Miracle Army Lab Gives Soldiers Their Faces Back
If you are interested in learning how to make such prosthetics, check out these sources
The Facial Prosthetics Training Program (John Hopkins)
International Anaplastology Association
University of Illinois Biomedical Visualization

Reprise – Scalp Avulsion Injuries

This one I wrote in response to the horrific injury a young girl suffered in a Ferris wheel accident.  It was posted originally August 8, 2007.

Updated 3/2017 -- photos and all links removed as many no longer active. and it was easier than checking each one.

Recently a post by Scalpel about a successful scalp replantation, after a 11 year old girl somehow gets her hair caught in a ferris wheel. Pictures of the case (and photo credit) can be seen here (not for the faint-of-heart). So I thought I'd share more about this injury.

 

The nature and mechanism of scalping injury have been reported by Koss et al. They emphasized "that it requires an oblique force to produce scalping, thus giving rise to the theory that the scalp tears at either of the bony ridges. The actual extent depends on the site, amount of hair caught, and the direction of the force." This was reemphasized by Bhattacharya et al. In all these descriptions, the extent of avulsion was from the supraorbital ridge to the nuchal line posteriorly. A case of avulsion of the face in continuity with the scalp reported by Dr. Abraham Thomas (1998) broke this pattern and showed that the actual extent depended on the speed and force of injury from the mechanical device and also the attitude and protective movements of the patient (successfully replanted--face and scalp). It was 1976 when the first successful replantation of a totally avulsed scalp was reported by Miller & others with return of normal hair growth and frontalis muscle funtion.

Scalp Anatomy:
The layers of the scalp are easily remembered by the mnemonic SCALP:
S (skin) is the thickest in the body, measuring between 3-8 mm.

C (subcutaneous tissue)- The vessels, lymphatics, and nerves course through the subcutaneous layer just superficial to the galea.

A (aponeurotic layer) --The galeal aponeurosis, the strength layer of the scalp, is contiguous with the paired frontalis muscles anteriorly, the paired occipitalis muscles posteriorly, and the temporoparietal fascia laterally.

L (loose areolar tissue) is also known as the subgaleal fascia, the innominate fascia, and the subaponeurotic plane. The loose areolar tissue of this plane allow for scalp mobility. Scalp avulsions routinely occur through this layer, leaviing pericranium intact.

P (pericranium) is tightly adherent to the skull and should be left intact in scalp reconstruction to allow for "back-grafting" of the donor site or for a means of alternative recontruction in the event of a failed local tissue transfer.

The scalp is supplied by arterial branches and vena comitantes of the internal and external carotid systems into four distinct vascular territories. Extensive collateralization (connections between the four territories) of these vascular territories allows total scalp replantation based on a single vascular anastomosis. The scalp is innervated by branches of the three divisions of the trigeminal nerve, cervical spinal nerves, and branches from the cervical plexus.

Replantation is the treatment of choice in scalping injuries and should always be considered, even in case of a badly damaged scalp. Specific procedures regarding pre-, intra- and postoperative care are crucial to success in replantation. These include: haemodynamic stabilization of the patient without causing damage to possible donor vessels; cooling, cleaning and further proper care of the avulsed specimen; use of antibiotics and haemodilution to optimize the intra- and post-operative situation.

When replantation is not possible then as in the past the goals are to obtain calvarial (bone) coverage to prevent calvarial desiccation, sequestration, and sepsis. However, today, the reconstructive surgeon should also strive for a cosmetically appealing result in addition to merely achieving coverage. The best replacement for scalp tissue is scalp tissue. There is no other donor site in the body that will approximate the same hair-bearing qualities of scalp tissue.

A wide variety of techniques has been used to close scalp defects. They include:

• Primary Closure--For small defects this is often the best option. Defects less than 3 cm in diameter can be closed primarily, but this varies depending on location. If primary closure is selected, any defect in the galea should be closed first with buried resorbable sutures, and skin edges should be reapproximated using suture or staples.
• Skin Grafting and Tissue Expansion--Placing split-thickness skin grafts can provide a quick and effective means of defect closure. Skin grafts require an adequately vascularized wound bed and are not successful if applied directly to exposed bone. Intact pericranium is typically sufficient to support a skin graft. Tissue expansion usually provides ample tissue with preservation of scalp sensation, color, thickness, and hair; however, it ultimately requires a minimum of 2 operative procedures. Patients should understand beforehand that this requires a commitment of at least 1-2 months
• Local Flaps--Local flaps are the workhorses of small to midsized scalp reconstructions. These flaps consist of skin, subcutaneous tissue, and galea, although occasionally small superficial defects may be adequately reconstructed using a flap elevated in the subcutaneous plane. Any local flap is best raised over named arterial systems. Raising a large flap and then covering the donor site with a skin graft is probably safest. One should avoid suture lines in areas where prosthetic material might be exposed.
• Free-tissue transfers--Before the advent of free-tissue transfers, closure of scalp defects covering more than 15-20% of the scalp was essentially impossible with a single procedure. Free flaps provide for single-procedure closure of large defects or complicated wounds involving scalp and bone. They can also provide improved wound healing in the setting of radiation or infection. However, they are time-consuming and expensive, and they all involve at least some donor site morbidity. Therefore, they should be reserved for appropriate situations when local flaps, skin grafting, or healing by secondary intent is not an option.
• Vacuum assisted Closure Device (VAC)--A vacuum assisted closure device has been used for large defects over the dura to promote the growth of granulation tissue. This tissue is then covered with a skin graft. The device works by applying uniform subatmospheric pressure to the wound, allowing it to develop a better blood supply, decreased bacterial counts, and robust granulation tissue.

REFERENCES:

Reconstruction of Acquired Scalp Defects: An Algorithmic Approach; Plastic & Reconstr Surg, Vol 116(4):54e-72e, September 15, 2005. Leedy, Jason E. M.D.; Janis, Jeffrey E. M.D.; Rohrich, Rod J. M.D.

Psychological Sequelae of Failed Scalp Replantation; Plastic & Reconstr Surg.; Vol 113(6):1573-1579, May 2004. Mowlavi, Arian M.D.; Bass, Michael J. B.S.; Khurshid, Khurshid A. M.D.; Milner, Stephen M.D.; Zook, Elvin G. M.D.

Total Face and Scalp Replantation [Case Report]; Plastic and Reconstructive Surgery, Vol 102 (6) November 1998, pp 2085-2087; Thomas, Abraham M.S., M.A.M.S., M.Ch., F.A.I.S., F.I.C.S.; Obed, Vijay M.S., M.Ch.; Murarka, Anil M.S., M.Ch.; Malhotra, Gopal M.S., M.Ch.

Scalping Injury; Plast. Reconstr. Surg., Vol 55: 439, 1975; Koss, N, Robson, M, and Krizek, TJ

Successful Replantation of an Avulsed scalp by Microvascular Anastomoses; Plast. Reconstr. Surg. Vol 58: 133, 1976.; Miller, G D H, Anstee, E J, and Snell, J A

Can Anyone Help?

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I continue to occasionally get comments on my facial/orbital fracture series (2008).  These days they are mostly from patients who are looking for advise.  The most recent one is from tyler has the post "Nasoethmoid Orbital Fractures"

With his permission (via email), I am posting it here and asking for help.

Hi I just came across this and I’m wondering if there’s anyone out there that can give me advice.  I suffered an orbital fracture 3 years ago resulting in double vision.  I had surgery once and it didn’t work. I still live with double vision and I’m thousands in debt.  If there’s anyone out there that could give me advice it would be greatly appreciated (charity programs, grants, anything).  My email is juoncl@gmail.com

The only suggestions I had were possibly state programs (ie Medicaid, etc), but these would be income dependent and maybe the Lion’s Club.   Though I didn’t ask and he didn’t say, I’m assuming he has no insurance because reconstructive surgery for “double vision” is something insurance would cover.

If you have any suggestions for him, please, either email him directly or leave a comment here or both.  I would love to know of any resources available.

Scalp Reconstruction – an Article Review

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

The March issue of Plastic Surgery Practice has a very nice article on scalp reconstruction (full reference below). The short article is an overview of HRS (hair restoration surgery) options for massive hair loss resulting from illness or injury.

The degree of deformity generally determines the treatment choice. Advancements in HRS in the past 2 decades are significant in yielding natural and almost undetectable results. Using a combination of HRS and cosmetic and reconstructive techniques, most deformities can be treated effectively.

There are many HRS techniques available, including follicular unit transplantation (FUT), follicular unit extraction (FUE), scalp reduction, scalp flaps, and tissue expansion.

The article gives some nice tips for use of tissue expanders:

• Planning is critical. Patient/family counseling regarding temporary deformity is crucial.
• It is best to overestimate the needed expansion and choose the largest commercially available expander that fits the patient’s anatomy.
• The vertical dimension is the most important factor providing the greatest gain in flap expansion. When the distance over the expanded tissue minus the base width of the expander is equal to 120% of the defect width, the expansion is complete.
• Overexpansion even by a modest amount will increase patient safety by providing excess tissue to cover the defect, allowing closure with minimal or no tension.
• If the entire defect cannot be removed and the residual defect is significant, leave the expander in place for a second expansion.

The article also mentions Operation Restore , a charity program which matches prospective hair loss patients with volunteer ISHRS physicians to obtain hair restoration services to help restore the physical and emotional wellness of the individual. The foundation will provide financial, travel, lodging, and medical assistance to eligible patients. The ISHRS Pro Bono Program was also featured in Association Forum Magazine.

Other posts you may find interesting:
Scalp Avulsion Injuries
Eyebrow Reconstruction
Hair Transplantation

REFERENCE

Scalp Reconstruction: An Aesthetic Challenge; Plastic Surgery Practice, March 2010, pp 14-18; E. Antonio Mangubat, MD

Reconstruction of Acquired Scalp Defects: An Algorithmic Approach; Plastic & Reconstr Surg, Vol 116(4):54e-72e, September 15, 2005. Leedy, Jason E. M.D.; Janis, Jeffrey E. M.D.; Rohrich, Rod J. M.D.

Skin Grafting in Lower Third Nasal Reconstruction

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Skin grafts for the lower third nasal defects should not be overlooked as an option.  The article listed below  (first one)reminds us that  skin grafts can give a better cosmetic results than a local flap in certain situations.  

The lower third of the nose is defined by its margins, which include the alar rims inferiorly, the nasolabial grooves laterally, and the alar groove, which forms the junction with the upper two-thirds of the nose.

Classically, the lower third of the nose is composed of six subunits: bilateral ala and soft triangles, the central tip, and columella. (photo credit)

The skin in this area is thick, richly populated with sebaceous glands, often stiff and difficult to rotate and form into local flaps.

Criteria given for selecting lower third nasal defects that can be acceptably treated with full-thickness grafts

include defect location; size smaller than 1 cm; and a partial-thickness defect with underlying dermis, subcutaneous tissue, or perichondrium.

Rather than increasing the small defect to a larger defect (whole subunit size), the authors achieved acceptable cosmetic results using full-thickness skin grafts to reconstruct lower third defects smaller than 1 cm in diameter.

Any defects larger than 1 cm were reconstructed more successfully with entire subunit reconstructions using more standard reconstruction techniques (local or adjacent flap techniques).  Defects that involve cartilage or deeper are by definition complex nasal defects that will require onlay cartilage grafting for satisfactory reconstruction.  These are not appropriate for skin grafting.

Donor site selection is important to try to match “like with like.”   Best choices include:

The senior author prefers preauricular and more preferably forehead skin for lower third nasal reconstruction. Forehead sites offer thicker skin, with a relatively sebaceous, oily texture, and they suffer the same degree of daily sun exposure and actinic damage as the lower third of the nose.

Other donor sites available to the reconstructive surgeon include the nasolabial fold, postauricular skin, and supraclavicular skin.

Poor donor site choices:

Postauricular donor sites suffer very little (if any) daily sun exposure and have much thinner skin than the nasal lobule. Therefore, they are prone to pigmentation changes and do not provide a good contour match for reconstructing the lower third of the nose.

Likewise, the skin of the supraclavicular region contains very few sebaceous elements and is often hyperpigmented before harvest.

 

Any distortion of the alar rim or obliteration of the nasolabial groove is exceedingly noticeable and difficult if not impossible to correct secondarily so care must be taken regardless of technique used in these area.

REFERENCE

Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?; Plast Reconstr Surg. 124(3):826-835, September 2009; McCluskey, Paul D.; Constantine, Fadi C.; Thornton, James F.

Nasal Reconstruction, Principles and Techniques: Multimedia; eMedicine article, August 28, 2008; Joseph Fata, MD

Nasal Reconstruction-Beyond Aesthetic Subunits: A 15-Year Review of 1334 Cases;  Plast Reconstr Surg. 2004;114:1405-1416; discussion 1417-1419; Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK.

Chinese Boy with 31 Fingers and Toes

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Daily Mail ran a story recently on a Chinese boy, 6, who was born with 31 fingers and toes (15 fingers and 16 toes).  The story reporting on the child having surgery to correct the congenital anomaly.  (photo credit)

Polydactyly is a condition in which a person has more than five fingers per hand or five toes per foot.  Rarely is it more than one or two extra.  Polydactyly  occurs in approximately 1 out of every 1,000 births. Usually, only one hand is affected.

In the hand, the extra digit(s) may be located on the thumb side  (radial), the small finger side (ulnar), or in the middle (central). 

In the black population an extra finger on the little finger side (ulnar polydactyly) is most common. The most common congenital hand difference in the Asian population is an extra thumb (radial polydactyly).

Central polydactyly is inherited as an autosomal dominant condition with variable expression, meaning that it may be more or less severe from one generation to the next.

This young Chinese boy’s extra fingers were located centrally and the skin fused together (syndactyly).  This is much more rare than either radial or ulnar polydactyly.  (photos credit)

Symmastia After Augmentation Mammoplasty

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Symmastia (also known as synmastia) is a condition that occurs when breast implants sit too close to the middle of the patient’s chest.  Extreme cases can even lead to the “uniboob” look. Fortunately, it is a rare complication of augmentation mammoplasty surgery. 

Developmental symmastia can occur without prior surgery in patients who have breast hypertrophy and an aberrant soft-tissue connection across the midline.

Dr Spear (4th reference article below) noted (bold highlight is mine):

Based on our experience with postaugmentation synmastia, a number of facts have emerged. All of the implants were subpectoral. The majority of these women had undergone more than one operation. Many of them had undergone successive operations to enlarge the size of their implants and breasts. Many of them had large implants, arbitrarily defined by us as greater than 400 cc or with a diameter of 14 cm or more. Several of the patients had associated chest wall skeletal deformities, and some had undergone simultaneous mastopexy at the time of their breast enlargement.

Prevention of symmastia is much better than having to try to fix it.   Care must be taken in dissection of the pocket, especially medially.  It is preferable to use implants that “fit the body.”  By this I mean, implants should not be wider than the available hemithorax of the individual patient.  Try to get the patient to use a smaller implant or perhaps a high profile with a smaller base width.  Avoid excessive detachment of the pectoralis muscle’s medial sternal attachments. 

Correction of symmastia requires restoration of the presternal subcutaneous integrity and medial closure of the pocket.   Techniques to achieve this include capsulorrhaphy, capsular flaps, AlloDerm or other materials, adjustable implants, explantation with delayed reimplantation, and change to a subglandular pocket.  All have drawbacks in terms of reliability, technical difficulty, and convenience.

 

REFERENCES

1.  Symmastia: The Problem of Medial Confluence of the Breasts;  Plast & Reconstr Surg 73(2):261-266, February 1984; Spence, Robert J.; Feldman, Joel J.; Ryan, James J.

2.  Surgical Reconstruction of Iatrogenic Symmastia; Plas & Recontr Surg 121(3):143e-144e, March 2008; Foustanos, Andreas; Zavrides, Harris

3.   The "Neosubpectoral" Pocket for the Correction of Symmastia; Plast & Reconstr Surg 124(3):695-703, September 2009; Spear, Scott L.; Dayan, Joseph H.; Bogue, David; Clemens, Mark W.; Newman, Michael; Teitelbaum, Steven; Maxwell, G Patrick

4.   Synmastia after Breast Augmentation; Plas & Reconstr Surg 118(7S):168S-171S, December 2006; Spear, Scott L.; Bogue, David P.; Thomassen, John M.

5.   Correcting Symmastia; Steven Teitelbaum, MD, FACS Website (nice photos)

6.   Correction of Symmastia After Augmentation; Thomas M. DeWire, Sr., MD, FACS Website  (nice photos)
7.   YouTube Video of Symmastia Repair
8.    My Breast Augmentation & Chin Revision (YouTube Video)

Neoumbilicoplasty

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

The umbilicus is perhaps the only scar that all of us want.  The umbilicus forms after birth as a result of the placental cord being transected as the infant is “detached” from his/her mother.  As the stump of the cord necroses, the scab falls away as the base heals leaving a scar:  the umbilicus.

The umbilicus has been described as a depressed scar surrounded by a natural skin fold that measures 1.5 to 2 cm in diameter and lies anatomically within the midline at the level of superior iliac crest.

Neoumbilicoplasty in simple terms is the creation or reconstruction of a new umbilicus to replace the missing or deformed umbilicus. 

Craig et al. reported on the ideal female umbilicus, but it should always be remembered  “the ideal umbilicus should be regarded as one that is satisfying to the patient.” 

The most aesthetically pleasing umbilicus is small in size, T or vertical in shape, and possesses a superior hood or shelf.

Those characteristics found to be unappealing include a large overall umbilical size, a horizontal or distorted shape, and the presence of umbilical protrusion.

In reconstructing the umbilicus, plastic surgeons should strive to attain these attractive characteristics and incorporate a modest size, with a superior shelf or hood and a T or vertical shape.

Reconstruction of a new umbilicus is indicated in congenital conditions associated with umbilical agenesis, loss of umbilicus due to omphalocele or gastroschisis repair, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump, and in surgical procedures for wide ventral herniorrhaphy.

In my humble opinion, the site of the new umbilicus should correspond to where “nature” would have placed it.  If there is any of the old umbilicus present, this can be used as an indication of where the new umbilicus should be placed.  If not, then  Dr. Susam Park, et al has this suggestion:

Based on our study, it is usually 3 cm above the level of the anterior superior iliac spine in a baby and 6 cm above in an adult, although differences in height and weight may affect these measurements.

Or as  Dr. Suhas Abhyankar, et al put it:

1. The distance between the xyph0sternum and umbilicus-distance between the umbilicus and the pubic symphysis ratio is approximately 1.6:1.

2. Also, the distance between the umbilicus and the anterior superior iliac spine-distance between the right and left anterior superior iliac spines ratio is 0.6:1.  This implies that when each of the anterior superior iliac spines is taken as a center, and arcs are drawn with a radius 0.6 times that of the inter-anterior superior iliac spine distance, the point of intersection of these arcs is the location of the umbilicus, taking into consideration the above ratio (1.6:1).

Surgery varies depending on whether a completely new umbilicus is being created or simply an “outie” being turned into an “innie” or maintaining the umbilicus with other surgery (ie abdominoplasty).

 
  
REFERENCES
*****After noticing the first referenced article below on MDLinx, I did a search of articles in the Journal of Plastic and Reconstructive Surgery first using “neoumbilicoplasty” and then “umbilical reconstruction.”  The second gave me a great list of articles (only a few listed below).

Neoumbilicoplasty is a Useful Adjuvant Procedure in Abdominoplasty; Can J Plast Surg 2009; 17 (4): e20-e23; AA Al-shahan

In Search of the Ideal Female Umbilicus; Plast Reconstr Surg 105: 389, 2000; Craig, S. B., Faller, M. S., and Puckett, C. L.

New Technique for Scarless Umbilical Reinsertion in Abdominoplasty Procedures; Plast Reconstr Surg 102(5):1720-1723, 1998; Schoeller, Thomas M.D.; Wechselberger, Gottfried M.D.; Otto, Angela M.D.; Rainer, Christian M.D.; Schwabegger, Anton M.D.; Lille, Sean M.D.; Ninkovic, Milomir M.D.

A Simplified Technique for Umbilical Reconstruction; Plast Reconstr Surg 114(2):619-621, 2004; Korachi, Ali; Oudit, Deemesh; Ellabban, Mohammed

Umbilical Reconstruction after Repair of Omphalocele and Gastroschisis; Plast Reconstr Surg  104(1):204-207, 1999; Park, Susam; Hata, Yuiro; Ito, Osamu; Tokioka, Kazuyuki; Kagawa, Koji

Simplified Technique for Creating a Youthful Umbilicus in Abdominoplasty; Plast Reconstr Surg 109: 2136, 2002; Lee, M. J., and Mustoe, T. A.

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Clinical and Radiographic Poland Syndrome Classification: A Proposal – an Article Review

The authors of the recent Aesthetic Surgery Journal article (full reference below) have proposed a new classification of Poland Syndrome based on both clinical and radiographic presentation (CRPS). Using their CRPS classification, they present an algorithm for planning surgical treatment.

The article begins with a review of Poland Syndrome:

Classically, it consists of a combination of unilateral aplasia of the sternocostal portion of the pectoralis major muscle (PMM) and hypoplasia of the ipsilateral hand, with syndactyly and synbrachydactyly.

The reported incidence of Poland Syndrome (PS) is one in 30,000 live births. Male-to-female ratio is 3:1. The right side is affected twice as often as the left.

The etiology of PS is still unknown, but recently a vascular hypothesis suggests hypoplasia of the ipsilateral subclavian artery.

Using data obtained from 28 female patients, they classify PS patients as follows:

First Degree (Mild): The diagnosis of first-degree PS would be made in a patient with mammary asymmetry caused by hypomastia or amastia and areolar asymmetry, with or without a partial absence of the pectoralis major muscle (PMM). No other musculoskeletal alterations are observed; other congenital alterations may or may not be present.

Second Degree (Severe): Hypomastia or amastia, areolar asymmetry, total absence of the PMM, and alterations of the ipsilateral muscle group and/or bones of the chest results in a diagnosis of second-degree PS; ipsilateral superior limb alteration and other congenital alterations may or may not be present.

Third Degree (Very Severe): Third-degree PS would be diagnoses in patients with amastia; areolar asymmetry; major ipsilateral musculoskeletal chest alterations, such as total absence of the PMM, the pectoralis minor muscle, and /or the serratus anterior muscle; possible lung herniation; widened opening of the mediastinum; and ipsilateral superior limb alteration. Other congenital alterations may or may not be present.

Suggested surgical approach for each degree of presentation:

First Degree (mild) – Breast implantation or customized breast implantation and contralateral mammary reduction or augmentation when needed (symmetrization procedure).

Second Degree (severe) – Tissue expander placement when needed; regional local flap surgery; breast implantation or customized breast implantation; symmetrization procedure.

Third Degree (very severe) – Tissue expander placement; latissimus dorsi flap or other flap surgery, such as a free flap or transverse rectus abdominis myocutaneous (TRAM) flap; breast implantation or customized breast implantation as needed; other surgeries such as the Ravitch procedure and a contralateral symmetrization procedure.

REFERENCE

Clinical and Radiographic Poland Syndrome Classification: A Proposal; Aesthetic Surgery Journal, Volume 29, Issue 6, Pages 494-504 (November 2009); Ricardo Cavalcanti Ribeiro, Renato Saltz, M. Gabriela Moreira Mangles, Hilton Koch (subscription required)