Category: National Laser Institute

A Technique for the Prevention of Recurrent Eyebrow Ptosis After Brow Lift Surgery

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imageBackground
Preventing the recurrence of eyebrow ptosis after brow lift surgery is challenging. We developed a novel technique to maintain elevation of the eyebrow after brow lift surgery.
Methods
A consecutive sample of patients who underwent brow lift surgery between June 2014 and June 2016 was divided into 2 groups. Group A underwent resection of excess skin during brow lift surgery; group B underwent the new eyebrow lift technique, which involved resecting skin and the lateral part of the orbital orbicularis oculi muscle, elevating the lower margin of the orbital orbicularis oculi muscle, and suturing it to the orbital periosteum. Eyebrow height and patient satisfaction were measured preoperatively and after surgery.
Results
This study included 273 patients. Mean follow-up time was 24.8 months (range, 6–52 months). Brow height was similar in groups A and B immediately postoperatively (group A: 28.37 ± 3.02 mm vs group B: 29.21 ± 2.97 mm) and at 6 months after operation (group A: 26.65 ± 2.53 mm vs group B: 27.45 ± 2.77 mm). At 12 months (group A: 22.73 ± 2.31 mm vs group B: 25.61 ± 2.62 mm) and 24 months (group A: 20.76 ± 2.22 mm vs group B: 24.74 ± 3.10 mm) after operation, the amount of brow elevation was significantly greater in group B. Two patients in group B experienced supraorbital neuralgia after surgery, which resolved by the 6-month follow-up. At 12 and 24 months after operation, patients in group B were significantly more satisfied with their surgery than patients in group A.
Conclusion
Our novel technique is simple and effective for preventing recurrent eyebrow ptosis after brow lift surgery.

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Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band–Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique

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imageBackground
Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion.
Methods
Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications.
Results
Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5–32 cm) and 5.2 cm (range, 1–12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting.
Conclusions
The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

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The Gracilis Free Flap Is a Viable Option for Large Extremity Wounds

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Skin Care news and information found at www.SpaTreatmentTraining.com brought to you by National Laser Institute. Are you interested in a career that can train you to be a Med Spa technician? Want to become a certified Laser Hair Removal Specialist, Laser Tattoo Removal Specialist, Botox Injections or many more exciting Medical Spa courses? Enroll in the National Laser Institute and find yourself on the fast track to success.

imageBackground
Traditionally, the gracilis free flap is used for coverage of small- to medium-sized wounds (100 cm2).
Methods
We retrospectively reviewed records of 34 patients who underwent extremity soft-tissue reconstruction using gracilis free flaps for wounds larger than 100 cm2 from 1998 to 2016. The primary outcome was overall flap success rate. Secondary outcomes were rates of major and minor complications. Mean defect size was 145 cm2 (range, 104–240 cm2). Seven flaps covered defects greater than 175 cm2. Indications were tumor extirpation (n = 18) and traumatic/posttraumatic wounds (n = 16). The most common time period for flap coverage was immediately (3 days or less) after the defect was created (n = 14). Most flaps were solely muscle (n = 28) and were used for lower extremity or foot coverage (n = 29).
Results
The overall success rate was 94%. Major and minor complications occurred in 5 and 13 cases, respectively. The most common major complication was unplanned reoperation (n = 5), and the most common minor complications were partial skin graft loss (n = 3), partial flap necrosis (n = 3), and planned recipient-site reoperation (n = 5).
Conclusions
Reconstruction of large extremity wounds using the gracilis free flap showed a 94% success rate with few major complications.

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Outcome of the Modified Meek Technique in the Management of Major Pediatric Burns

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imageIntroduction
The modified Meek micrografting technique has been used in the treatment of severely burned patients and a number of articles have examined the use of the modified Meek technique in adults and in mixed-age groups. However, there is a paucity of research pertaining to the outcome in the pediatric age group. The aim of this study is to present our favorable outcome in pediatric major burns using the modified Meek technique.
Methods
A retrospective review of burn cases in Hospital Universiti Sains Malaysia from 2010 to 2015 was conducted. Cases of major burns among pediatric patients grafted using the Meek technique were examined.
Results
Twelve patients were grafted using the Meek technique. Ten (91.7%) patients were male, whereas 2 (8.3%) were female. The average age of patients was 6 years (range, 2–11 years). The average total body surface area was 35.4% (range, 15%–75%). Most burn mechanisms were due to flame injury (66.7%) as compared with scalds injury (16.7%) and chemical injury (16.7%). There was no mortality. All patients were completely grafted with a good donor site scar. The average graft take rate was 82.3%, although 8 cases had positive tissue cultures from the Meek-grafted areas. The average follow-up duration was 3.6 years (range, 1.1–6.7 years). Only 1 case developed contracture over minor joint.
Conclusions
The Meek technique is useful when there is a paucity of donor site in the pediatric group. The graft take is good, contracture formation is low, and this technique is cost-effective.

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Salvage of Threatened Cardiovascular Implantable Electronic Devices: Case Series and Review of Literature

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Skin Care news and information found at www.SpaTreatmentTraining.com brought to you by National Laser Institute. Are you interested in a career that can train you to be a Med Spa technician? Want to become a certified Laser Hair Removal Specialist, Laser Tattoo Removal Specialist, Botox Injections or many more exciting Medical Spa courses? Enroll in the National Laser Institute and find yourself on the fast track to success.

imageBackground
The treatment of infected or exposed cardiac pacing and defibrillator devices is controversial. The conservative and widely accepted management calls for removal of the device and leads with immediate or delayed replacement of new components in a new site. Lead extraction carries a 2% major complication risk. In this article, we describe our experience with device salvage techniques and review the current literature.
Methods
This is a retrospective case series of consecutive patients with infected, exposed, or at-risk implanted cardiac devices that were treated with aggressive surgical debridement, local pocket irrigation, and revision. A comprehensive review of the literature regarding device infection management was performed.
Results
Ten patients with threatened devices were identified. Surgical revision with the aim to salvage the device was successful in 8 (80%) of 10 cases. Seventeen retrospective publications were reviewed. All indicate success with attempted salvage surgery, but heterogeneity of data limits formal meta-analysis and prevents management recommendations.
Conclusions
Cardiac pacing and defibrillator devices with low-grade infection or threatened exposure may be salvaged without explantation. Despite the lack of clear management guidelines or data, plastic surgeons may be asked to assist in the management of threatened cardiac devices. Further prospective trials are required to evaluate the safety, efficacy, and cost-effectiveness of attempted implant salvage.

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The Tuck-in Mastopexy

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Skin Care news and information found at www.SpaTreatmentTraining.com brought to you by National Laser Institute. Are you interested in a career that can train you to be a Med Spa technician? Want to become a certified Laser Hair Removal Specialist, Laser Tattoo Removal Specialist, Botox Injections or many more exciting Medical Spa courses? Enroll in the National Laser Institute and find yourself on the fast track to success.

imageBackground
Breast ptosis is an inevitable consequence of gravity and time. Every breast tends to become ptotic in different shapes and degrees. Many surgical techniques were described to solve this problematic issue. The aim of this article is to describe a mastopexy technique used for grades 1 to 2 ptosis, “tuck-in” mastopexy technique.
Methods
Keyhole pattern was used for skin markings. All the planned skin excision areas were de-epithelialized. Breast mound was elevated as a 1-piece flap with extensive subglandular dissection. Elevated breast flap was reshaped and repositioned. Skin incisions were sutured in 2 layers.
Results
Seventeen patients were operated on with this technique; average follow-up time was 10.1 months. No major complications were seen. The results were pleasing for both the patients and the surgeon.
Conclusions
The “tuck-in” mastopexy technique uses breast mound as 1-piece flap, which has great vascularity from medial, superior, and lateral pedicles. Large areas of de-epithelialization facilitate reshaping and repositioning. It permits simultaneous or secondary breast augmentation with silicone gel implants. This easy-to-do technique has low complication rates and a short learning period.

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Surgical Refinement Following Free Gracilis Transfer for Smile Reanimation

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imageImportance
Gracilis free muscle transfer is widely regarded as the gold standard functional smile reanimation in long-standing facial palsy. Although most patients achieve meaningful oral commissure movement, a subset has suboptimal aesthetic outcomes due to midfacial bulk or oral commissure malposition. Safe refinements that do not compromise excursion would be a welcome addition to the surgical armamentarium for this population.
Objectives
The goal of this study was to describe surgical approaches to the 3 most common postoperative sequelae that detract from the final result after gracilis facial reanimation and to examine how these surgical refinements affect aesthetic outcome, smile excursion, and quality of life.
Design
This was a retrospective case series.
Setting
Tertiary care center (Massachusetts Eye and Ear Infirmary Facial Nerve Center).
Participants
Of 260 gracilis transfers performed since 2003, meaningful excursion (>3 mm) but poor aesthetic outcome requiring additional surgery was noted in 21 patients and was related either to excess muscle bulk (9), resting inferior malposition of the oral commissure (9), or resting superior/lateral malposition of the oral commissure (3).
Intervention
Specific surgical interventions to address each of these negative sequelae were developed and refined, to preserve muscle functionality but eliminate the unsightly feature.
Main Outcome
Aesthetic status, determined by midfacial symmetry; quantitative smile excursion; and quality of life (using the FaCE instrument) were measured before and after revision.
Results
Patients who underwent gracilis refinement directed at either muscle debulking, or gracilis tightening or loosening experienced significantly improved aesthetics/midfacial symmetry and improved quality of life with no significant decrease in smile excursion.
Conclusions
Improved aesthetics and quality of life can be achieved through targeted revision of the gracilis free tissue transfer, without significant loss of smile excursion.

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Perioperative Glucocorticoid Treatment of Soft Tissue Reconstruction in Patients on Long-term Steroid Therapy: The Experience of 6 Cases Using Reversed Posterior Interosseous Flap for Hand Neoplasm Surgery

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imageIntroduction
Long-term steroid therapy is associated with increased postoperative morbidity. Whether to use a stress dose of glucocorticoids (GCs) in surgical patients remains controversial. In the present study, we reported our experience in perioperative GC treatment of 6 patients on long-term steroid therapy for autoimmune diseases undergoing hand reconstruction using reversed interosseous flap.
Methods
The reversed interosseous flap reconstructions were performed after local extended resection of hand neoplasms. The patients were all diagnosed with autoimmune diseases and were undergoing long-term steroid therapy. Stress dose of GCs was not given in any case, and all the patients either remained on their baseline maintenance dose or decreased the dose until the morning of the operation day. Hypotension, water-electrolyte imbalance, hypoglycemia, and other symptoms of adrenal insufficiency were carefully assessed. Appearances of flap complications were recorded.
Results
None of the patients developed hypotension or other symptomatic adrenal insufficiency. Flap infection, venous congestion, or complete or partial loss of flap was not observed in any patient. Effusion underneath the flap was developed in only 1 case and was solved by proper drainage.
Conclusions
It is safe, reliable, and versatile to use reversed interosseous flap to repair hand defects in patients on long-term steroid therapy. A stress dose of GCs might not be necessary in this procedure and other equally moderate soft tissue reconstructive surgeries.

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Direct-to-Implant as a Frontline Option for Immediate Breast Reconstruction: A Comparative Study With 2-Stage Reconstruction

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Skin Care news and information found at www.SpaTreatmentTraining.com brought to you by National Laser Institute. Are you interested in a career that can train you to be a Med Spa technician? Want to become a certified Laser Hair Removal Specialist, Laser Tattoo Removal Specialist, Botox Injections or many more exciting Medical Spa courses? Enroll in the National Laser Institute and find yourself on the fast track to success.

imageBackground
Immediate single-stage direct-to-implant breast reconstruction requires caution owing to the possibility of skin necrosis and implant failure. Nevertheless, this method has been performed widely for breast reconstruction. This study aimed to analyze the safety of single-stage implant reconstruction by comparing it with 2-stage reconstruction (TSR).
Methods
Immediate single-stage reconstructions (SSRs) and TSRs with a tissue expander, performed from January 2011 to December 2016, were retrospectively reviewed. Acellular dermal matrix was used in both groups to maintain similar pocket conditions. Risk factors were not considered in patient selection.
Results
We enrolled 290 patients including 8 who received bilateral breast reconstruction. A total of 298 breasts were operated, including 233 SSR cases (78%) and 65 TSR cases (22%). The surgical success (ie, the implant was maintained without explantation) rate was higher in SSR (97%) than in TSR (90.2%) (P = 0.03). Two-stage reconstruction had a significantly higher rate of hematoma (12.3% vs 3.4%, P = 0.005), seroma (41.5% vs 20.6%, P = 0.001), and implant failure (9.8% vs 3.0%, P = 0.03). However, the rate of skin necrosis was lower in TSR (7.7% vs 10.3%) with a trend toward significance (P = 0.053). The implant salvage rate was higher in SSR (61.1%) than in TSR (12.5%) even after revision operation (P = 0.013).
Conclusions
Single-stage reconstruction yielded a lower complication rate than TSR. Moreover, the high salvage rate of SSR causes less concern about implant failure despite the possibility of revision operation. Therefore, SSR may be considered a frontline method for breast reconstruction without any patient selection interference.

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Resident Attrition in Plastic Surgery: A National Survey of Plastic Surgery Program Directors

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imageBackground
Attrition in plastic surgery is poorly characterized in the literature with previous data indicating that independent residents may have a higher rate of voluntary attrition with integrated residents having a higher rate of involuntary attrition. The aim of this study is to identify risk factors, note differences between pathways, and provide insight into resident attrition from plastic surgery residencies.
Methods
An institutional review board–approved anonymous, multiple-choice and short answer, online survey regarding resident attrition was sent to all plastic surgery program directors (PDs) in the United States focusing from 2003 to 2013. Outcomes measured included demographics of the program and attritional resident, timing and reasons for attrition, and possibility of preventing attrition.
Results
Thirty-three (35%) of 95 PDs responded. Average attrition rates were calculated at 2.15% for independent and 0.85% for integrated programs. Risk factors for attrition included being single, divorced, male, and having no dependents. One hundred percent of independent residents left by year 2, and 86% of integrated residents left by year 4. Lifestyle and loss of interest were most sited reasons for attrition. Most independent residents returned to their original field of training, whereas integrated residents were more likely to transfer to another integrated program. Only 17% of PDs believed attrition could have been prevented.
Conclusions
Approximately 3.0% of all plastic surgery residents underwent attrition. Being single, male, divorced, or having no dependents increases the risk of attrition in plastic surgery residencies. This is the first study to demonstrate potential risks factors for plastic surgery residents undergoing attrition.

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