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Background: As patient survival with head and neck cancer has improved, treatment goals have had to evolve to focus on improving quality of life. Traditionally, patients who have undergone mandibulectomy are left with an insensate chin and lower lip secondary to resection of the inferior alveolar nerve (IAN). The purpose of this study was to critically evaluate the authors' initial experience using processed nerve allografts (PNA) for IAN reconstruction following oncologic mandibulectomy and reconstruction with free fibula osteocutaneous flaps and to assess their patients' sensory outcomes., Methods: The authors performed a retrospective review of the first 32 patients who underwent immediate IAN reconstruction with PNA at the time of oncologic mandibulectomy and mandible reconstruction with free fibula osteocutaneous flaps at The University of Texas M. D. Anderson Cancer Center over a 1-year period. Semmes-Weinstein filament sensory testing was conducted at multiple surgical follow-up appointments to evaluate the quality of sensory recovery., Results: Thirteen of the 32 patients underwent postoperative Semmes-Weinstein filament testing. All 13 patients demonstrated partial return of sensation. At a mean follow-up of 8.33 months, the average level of sensation was 60.93% that of the unaffected side of the lower lip., Conclusions: Patients were consistently afforded improvement in lower lip sensation using PNA-based IAN grafting as an adjunct to free fibula-based mandible reconstruction. The procedure adds no additional surgical morbidity and has shown consistent positive results., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs., Methods: The PubMed database was used to identify articles that reported on the use of ADM in breast surgery in four leading plastic surgery journals from January of 2014 to December of 2019. Financial COIs for authors were determined using the open payments database., Results: Fifty-five articles were included. Twenty-four articles (43.6%) supported use of ADM, 12 (21.8%) did not promote ADM use, and 19 (34.5%) were neutral. Fifty-one studies (92.7%) had either a first or senior author with a COI, and authors with a COI more commonly reported positive outcomes ( P = 0.02). Studies with positive outcomes featured first authors who received significantly larger financial payments ($95,955 versus $15,642; P = 0.029) compared with studies with negative or neutral outcomes. Receiver operating characteristic curve demonstrated that studies with first authors receiving over $376.28 were more likely to report positive results. Eight senior authors and three first authors received greater than $500 from ADM producers yet did not report any financial disclosure., Conclusions: Financial COI is associated with higher likelihood of studies reporting benefit of using ADM in breast surgery. There remains inconsistent reporting of COIs, and better oversight is needed to ensure unbiased publication on the use of ADM in breast surgery., Competing Interests: No study has assessed the impact of financial conflicts of interests (COIs) on the reporting of breast reconstruction outcomes with acellular dermal matrix (ADM) in peer-reviewed publications. The authors hypothesized that there is (1) an association between financial COIs and likelihood of studies reporting benefits in using ADM, and (2) inconsistent reporting of financial COIs., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Open tibia fractures are commonly stratified by the Gustilo classification, an orthopedic grading system that does not incorporate the presence of arterial injury when limb perfusion is intact. In the authors' experience, however, the presence of arterial injury appears to negatively impact microsurgical outcomes., Methods: In a retrospective review of 806 lower extremity reconstructions between 1979 and 2016, 361 soft-tissue flaps performed for Gustilo type IIIB/C coverage met inclusion criteria. Patient demographics, flap characteristics, and outcomes were analyzed., Results: Most patients suffered type IIIB [n = 332 (91.9 percent)] injuries; 29 (8.0 percent) had type IIIC injuries. Preoperative angiography [n = 243 (67.3 percent)] demonstrated arterial injury in 126 (51.8 percent); 27 arterial injuries were identified intraoperatively; and the overall incidence was 153 of 361 (42.4 percent). Complications occurred in 143 flaps (39.6 percent) and included 37 partial losses (10.2 percent) and 31 total losses (8.6 percent). Injured recipient arteries [n = 62 (17.2 percent)] had more complications (p = 0.004); specifically, increased take-backs (p = 0.009). Decreasing vessel runoff increased the risk of complications (p = 0.025), take-backs (p = 0.007), and total flap failures (p = 0.024) accordingly. Specifically, among grade IIIB injuries, controlling for age, sex, time since injury, and vein number, single-vessel runoff was associated with higher rates of complications (relative risk, 3.07; p = 0.012), take-backs (relative risk, 3.43; p = 0.013), and total flap failures (relative risk, 4.80; p = 0.010) compared with three-vessel runoff., Conclusions: Arterial injury was common among Gustilo type IIIB patients and correlated with increased reconstructive complications. Nonischemic arterial injury appears to negatively impact reconstructive outcomes and should be accounted for when considering free tissue transfer for lower extremity salvage. The authors propose a 3-2-1 modification of the Gustilo type IIIB classification to incorporate degree of arterial injury, as it appears to add prognostic value and certainly influences the reconstructive plan., Clinical Question/level of Evidence: Risk, IV.

In select patients with advanced disease resulting in large composite tissue defects, consideration is often given to multiple flap reconstruction. The authors propose an alternative option. Using virtual surgical planning the authors demonstrate how modest sacrifice in projection translates into a substantial decrease in the volume and surface area of soft tissue needed, in turn maximizing soft tissue coverage with a single fibula free flap. The authors used 3-dimensional virtual surgery to simulate angle-to-angle reconstructions using free fibula flaps. The reference 3-segment reconstruction was done using symphyseal projection to the plane perpendicular to the anterior nasal spine, a customary landmark. Additional simulations were then performed using recessed projections 0.5 mm, 1 cm, 1.5 cm, and 2 cm posterior to anterior nasal spine plane. Program analytics were used to calculate the surface area and volume of the floor of mouth. With projection recessed by 1 cm, surface area decreased 22% to 14 cm. With projection recessed by 2 cm, surface area decreased 44% to 10 cm. With a 3-segment construct converted to a 2-segment construct, surface area decreased 22% to 14 cm. This demonstrates for the first time an official analysis of an intraoperative modification that sacrifices little and gains a lot. Ultimately, 1 compound flap can be used in extensive reconstructions with increased confidence that it will not be overly stressed.

Background: The profunda artery perforator flap was first introduced for breast reconstruction in 2010. In this article, the authors analyze the results of all profunda artery perforator flaps performed by their group to date., Methods: A retrospective review was completed of consecutive profunda artery perforator flaps performed by the senior author (R.J.A.) from 2010 to 2014. Patient demographics, indications, operative techniques, flap specifics, complications, and number of operations were recorded., Results: Ninety-six patients have undergone 164 profunda artery perforator flap operations for breast reconstruction since 2010. Reconstructions were performed following breast cancer management (59.5 percent), following prophylactic mastectomy for cancer risk reduction (35.7 percent), and for congenital breast deformity (4.8 percent). The average age of the patients was 48 years (range, 24 to 64 years) and their average body mass index was 22.5 kg/m. Average flap weight was 367.4 g and average pedicle length was found to be 10.2 cm. The success rate of the profunda artery perforator flap was greater than 99 percent, with a 3 percent take-back rate and only one flap loss recorded. Complications included hematoma (1.9 percent), seroma (6 percent), fat necrosis (7 percent), and donor-site infection (1.9 percent)., Conclusions: The profunda artery perforator flap is an excellent option for breast reconstruction. Advantages include a reliable blood supply, long pedicle, thick donor tissue, and a favorable donor site. Currently, the profunda artery perforator flap is second only to the deep inferior epigastric artery perforator among flaps used by the authors for breast reconstruction., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Inferior turbinate hypertrophy is often encountered by plastic surgeons who perform rhinoplasty. Many treatment options are available to treat the inferior turbinate. The objective of this study was to systematically review outcomes of available techniques and provide guidance to surgical turbinate management., Methods: A MEDLINE search was performed for means of treating inferior turbinate hypertrophy. Studies selected focused on treatment of the inferior turbinate in isolation and excluding patients with refractory allergic rhinitis, vasomotor rhinitis, or hypertrophic rhinitis., Results: Fifty-eight articles were identified, collectively including the following surgical treatments of inferior turbinate hypertrophy: total turbinectomy, partial turbinectomy, submucosal resection, laser surgery, cryotherapy, electrocautery, radiofrequency ablation, and turbinate outfracture. Outcomes and complications were collected from all studies. Procedures such as turbinectomy (partial/total) and submucosal resection showed crusting and epistaxis at comparatively higher rates, whereas more conservative treatments such as cryotherapy and submucous diathermy failed to provide long-term results. Submucosal resection and radiofrequency ablation were shown to decrease nasal resistance and preserve mucosal function. No literature exists to support the belief that turbinate outfracture alone is an effective treatment for turbinate hypertrophy., Conclusions: Treatment of inferior turbinate hypertrophy is best accomplished with modalities that provide long-lasting results, preservation of turbinate function, and low complication rates. Submucosal resection and radiofrequency ablation appear to best fulfill these criteria. Turbinate outfracture should only be considered in combination with tissue-reduction procedures.

Introduction: The relationship between nonsyndromic craniosynostosis and neurodevelopment remains controversial. Beyond standardized testing, little data exist about parental perceptions of their child's development., Methods: Parents of children who underwent cranial vault remodeling for nonsyndromic craniosynostosis from 2011 to 2015 were asked to complete an anonymous survey., Results: Twenty-two parents (31%) completed the survey. Patients included 52.4% males and 47.6% females with a mean age at surgery of 9.2 months and mean follow-up time of 19.8 months. Craniosynostosis types were primarily metopic (45%) and coronal (35%).The mean score for overall satisfaction with head shape with a maximum score of 10 was 9.2 (range 5-10). When answering whether their child is different for the better other than appearance with a 5 rating as "strongly agree," the mean score was 3.8 (range 1-5). When asked whether their child's motor, speech and behavior, or attention were different following surgery, the majority responded "No" (74%, 83%, and 67%, respectively).All parents would have their child undergo surgery again or recommend surgery to another family. There were no statistically significant differences when stratifying by age at surgery or length of follow-up. When stratifying by sex, parents of males gave higher ratings for whether their children were better other than appearance compared with females, 4.8 versus 3.1 (P = 0.031)., Discussion: Parents rated their child's neurodevelopment as largely age-appropriate following cranial vault remodeling. These findings are concordant with the majority of formal, standardized testing for this age group. Assessing parental perceptions once children enter school age may reveal increased developmental delays.