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Patient demand for nonsurgical and minimally invasive cosmetic treatments has increased in recent years, resulting in a growing market that is particularly vulnerable to specialty creep. Despite this growing demand, nonsurgical cosmetic training for plastic surgery residents is often inconsistent and challenging. To ensure the continued safe and effective delivery of nonsurgical cosmetic care by board-certified plastic surgeons, it is critical to implement standardized training models for plastic surgery residents. In this Special Topic article, the authors describe their experience with a resident-run clinic training model that incorporates graduated autonomy, volunteer patient recruitment, and grant-based industry support that has been successfully implemented at their institution for the past 6 years. The article provides a framework for a resident educational model and addresses common obstacles in resident cosmetic training. The authors also provide recommendations for patient recruitment, optimizing clinic workflow, and the management of patient complications.

Parry Romberg disease (hemifacial atrophy) and linear scleroderma (coup de sabre) are progressive, usually unilateral facial atrophies of unknown cause. The gold standard treatment for these patients has been microsurgical reconstruction following the "burning out" of the facial atrophy and stable contour for 2 years.The authors report their experience treating patients with hemifacial atrophy and linear scleroderma with free tissue transfers between 1989 and 2016. A modified parascapular flap based on the circumflex scapular artery was most commonly used.A total of 177 patients were included. The most common complication was hematoma, occurring in 12 patients (7 percent). Follow-up ranged from 1 to 26 years. All patients subjectively experienced improved facial symmetry and aesthetics. No disease process has recurred to date, even in cases of severe, progressive disease.In the authors' experience, patients treated early in their disease course have immediate and sustained correction of their deformity, with slowing or in most cases cessation of the disease process following free tissue transfer. The authors now advocate for immediate reconstruction for active disease, especially in young children.Therapeutic, IV.

Mammalian skin impacts metabolic efficiency system-wide, controlling the rate of heat loss and consequent heat production. Here we compare the unique fat depots associated with mouse and human skin, to determine whether they have corresponding function and regulation. For human, we assay a skin-associated fat (SAF) body-wide depot to distinguish it from the subcutaneous fat pads characteristic of abdomen and upper limbs. We show that the thickness of SAF is not related to general adiposity; it is much thicker (1.6-fold) in women than men, and highly subject-specific. We used molecular and cellular assays of β-adrenergic induced lipolysis and found that dermal white adipose tissue (dWAT) in mice is resistant to lipolysis; in contrast, the body-wide human SAF depot becomes lipolytic, generating heat in response to β-adrenergic stimulation. In mice challenged to make more heat to maintain body temperature (either environmentally or genetically), there is a compensatory increase in thickness of dWAT: A corresponding β-adrenergic stimulation of human skin adipose (in vivo or in explant) depletes adipocyte lipid content. We summarize the regulation of skin-associated adipocytes by age, sex, and adiposity, for both species. We conclude that the body-wide dWAT depot of mice shows unique regulation that enables it to be deployed for heat preservation; combined with the actively lipolytic subcutaneous mammary fat pads they enable thermal defense. The adipose tissue that covers human subjects produces heat directly, providing an alternative to the brown adipose tissues.KEY POINTS SUMMARYSeveral distinct strategies produce and conserve heat to maintain body temperature of mammals, each associated with unique physiologies, with consequence for wellness and disease susceptibilityHighly regulated properties of skin offset the total requirement for heat productionWe hypothesize that the adipose component of skin is primarily responsible for modulating heat flux; here we evaluate the relative regulation of adipose depots in mouse and human, to test their recruitment to heat production and conservationWe found that insulating mouse dermal white adipose tissue accumulates in response to environmentally- and genetically-induced cool stress; this layer is one of two adipose depots closely apposed to mouse skin, where the subcutaneous mammary gland fat pads are actively recruited to heat productionIn contrast, the body-wide adipose depot associated with human skin produces heat directly, potentially creating an alternative to the centrally regulated brown adipose tissue

Background Few studies have examined the impact of abdominoplasty on chronic back pain. Objectives The aim of this study was to test our hypothesis that patients undergoing abdominoplasty with anterior abdominal wall plication will show significant improvements in back pain and physical function compared with those without plication. Methods We utilized Current Procedural Terminology (CPT) codes to identify patients who underwent abdominoplasty with the senior author over a 10-year period. The Oswestry Disability Index (ODI) and the RAND 36-Item Short-Form Health Survey (SF-36) were administered. All patients indicating preoperative back pain were reviewed. Results Of 338 patients, 143 surveys (42.3%) were returned; 51 patients (35.7%; n = 28 aesthetic, n = 23 massive weight loss) reported preoperative back pain on the ODI. Paired t tests compared overall and strata-specific changes in ODI and SF-36 pre- and postsurgery. Multivariable linear regression models were fitted to model relations between scores and plication, adjusting for presurgery scores and patient variables. There were significant improvements in overall patient cohort in ODI (–15.14), SF-36 physical function (19.92), and pain (17.42) (P Conclusions Abdominoplasty with and without anterior abdominal wall plication significantly improves ODI and SF-36 scores relating to physical function and pain, in both aesthetic and massive weight loss patients. Outcomes did not differ based on plication status. All patients with preoperative back pain showed improvement regardless of operation performed, suggesting that abdominoplasty with or without abdominal wall plication improves chronic back pain in this patient population. Level of Evidence: 4

Hemifacial atrophy (Parry-Romberg syndrome) is an enigmatic craniofacial disorder characterized by progressive facial atrophy. Early age at onset is associated with significant skeletal involvement and jaw abnormalities. Standard reconstructive dogma dictates that the disease should "burn out," with at least 2 years of no disease progression, before pursuing reconstructive intervention. The purpose of this article is to present the senior author's (J.W.S.) experience treating preadolescent children with free soft-tissue transfer for reconstruction of progressing hemifacial atrophy, and to review surgical techniques in this patient population.Pediatric free tissue transfer cases performed by the senior author were reviewed. Free tissue transfer using a circumflex scapular adipofasciocutaneous flap was performed to treat deformities arising from hemifacial atrophy.Thirty-six patients aged 3 to 6 years underwent free tissue transfer in the presence of progressing, active disease. Follow-up ranged from 7 months to 25 years. There were no cases of flap loss. In all patients, the disease process seemed to be altered, with no symptoms recurring to date.The authors believe that early microsurgical correction of hemifacial atrophy in children as young as 3 years is reliable and effective. The authors theorize that the interposition of vascularized, healthy tissue may alter or even halt the progression of disease, and may also prevent the skeletal hypoplasia classically seen in older patients. Further study incorporating autologous fat grafting as a control procedure may provide additional insight into this challenging disease process.Therapeutic, IV.

BACKGROUND Parry-Romberg syndrome is an enigmatic craniofacial disorder characterized by progressive facial atrophy. The pathogenesis and molecular mechanisms governing Parry-Romberg syndrome have never before been described. The purpose of the current study was twofold: (1) to begin to elucidate the pathophysiology of this disease using next-generation RNA sequencing and (2) to evaluate the effect of surgical treatment on gene expression. METHODS Patients with Parry-Romberg syndrome underwent microvascular free tissue transfer to the face to address contour deformity in both active and burned out disease. Tissue samples were collected for analysis at the time of initial microvascular free tissue transfer, and 6 months later at a scheduled revision operation. Patients presenting for rhytidectomy had tissue samples taken as control tissue. Samples from patients with disease were compared to control samples. RESULTS Twenty-two subjects were evaluated (six control and 16 Parry-Romberg syndrome patients). All patients with Parry-Romberg syndrome underwent microvascular free tissue transfer to the face. Thirteen patients underwent scheduled 6-month revision surgery. Disease samples were distinct from healthy controls, and postoperative patient samples were more similar to healthy control samples. Parry-Romberg syndrome patients had a unique proinflammatory gene expression profile, including up-regulation of IL24, ADAMTS4, and GFCSF3. Postoperatively, more than 3400 genes were changed (p < 0.005), and of the 460 genes dysregulated in disease, 118 were changed in a corrective fashion by microvascular free tissue transfer. CONCLUSIONS The authors describe for the first time molecular signatures in Parry-Romberg syndrome. Molecular signatures in skin became more similar to those in healthy controls and were associated with clinical improvement after microvascular free tissue transfer in Parry-Romberg syndrome.

Free tissue transfer to improve bulk and contour in facial deformities has been proven useful, yet refinements that turn an acceptable result into an excellent result are essential to reconstruction. The authors reviewed their experience and described these refinements.The charts of 371 free tissue transfer cases (1989 to 2010) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap or superficial inferior epigastric was performed to treat deformities arising from hemifacial atrophy (n = 126), hemifacial microsomia (n = 89), radiation therapy (n = 40), bilateral malformations including lupus and polymyositis (n = 50), other congenital anomalies (n = 25), facial palsy (n = 17), and burns and trauma (n = 24).Revision surgery planning began at initial flap operation where the flap was stretched maximally and interdigitated with recipient tissue. More tissue was required in the malar region. Revision refinement was indicated in all cases (after 6 months). Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by tissue rearrangement by means of advancement, rotation, transposition, and/or turnover flaps of subcutaneous tissues from the previous free flap. The jawline frequently required more debulking. Periorbital reconstruction was combined with lower lid support with or without canthal repositioning. Conventional face-lift techniques with the flap as superficial musculoaponeurotic system augmented the result. Autologous fat injection to the alar rim, medial canthus, upper eyelid, and lip was a useful adjunct. Severe lip deficiencies were addressed with local flaps.The keys to improving results were continual critical reassessment, open-mindedness to new approaches, and maintaining high expectations.Therapeutic, V.

Extracellular functions of the endoplasmic reticulum chaperone protein calreticulin (CRT) are emerging. Here we show novel roles for exogenous CRT in both cutaneous wound healing and diverse processes associated with repair. Compared with platelet-derived growth factor-BB-treated controls, topical application of CRT to porcine excisional wounds enhanced the rate of wound re-epithelialization. In both normal and steroid-impaired pigs, CRT increased granulation tissue formation. Immunohistochemical analyses of the wounds 5 and 10 days after injury revealed marked up-regulation of transforming growth factor-beta3 (a key regulator of wound healing), a threefold increase in macrophage influx, and an increase in the cellular proliferation of basal keratinocytes of the new epidermis and of cells of the neodermis. In vitro studies confirmed that CRT induced a greater than twofold increase in the cellular proliferation of primary human keratinocytes, fibroblasts, and microvascular endothelial cells (with 100 pg/ml, 100 ng/ml, and 1.0 pg/ml, respectively). Moreover, using a scratch plate assay, CRT maximally induced the cellular migration of keratinocytes and fibroblasts (with 10 pg/ml and 1 ng/ml, respectively). In addition, CRT induced concentration-dependent migration of keratinocytes, fibroblasts macrophages, and monocytes in chamber assays. These in vitro bioactivities provide mechanistic support for the positive biological effects of CRT observed on both the epidermis and dermis of wounds in vivo, underscoring a significant role for CRT in the repair of cutaneous wounds.

Background: Free tissue transfer for adult mandibular reconstruction is a well-established technique; however, there are few reports of pediatric microvascular lower jaw reconstruction. Methods: This retrospective study was undertaken to review the range of indications, choices, safety, and efficacy of pediatric free tissue transfer to the lower jaw. All patients underwent a parascapular, scapular, or fibula free tissue transfer. Flap choice was based on preoperative clinical examination, radiographic findings, need for linear or multiplanar mandibular reconstruction, need for dental restoration, severity of soft-tissue deficit, and peroneal artery anatomy. Results: Over a 10-year period (1989 to 1999), we performed eightfree tissue transfers to reconstruct the mandibles of seven children, aged 6 to 17 years. Indications included radiation-induced hypoplasia (n = 1), postsurgical resection of fibrous dysplasia (n = 1), hemifacial microsomia (n = 3), Robin sequence with severe micrognathia (n = 1), and osteomyelitis (n = 1). The authors transferred four parascapular osseocutaneous, two scapular osseocutaneous, one fibular osseocutaneous, and one fibular osseous flap to reconstruct five ramus, four condyle, and two subtotal mandibular defects. All bony defects were successfully bridged and all osseous flaps successfully integrated. Postoperatively, mandibular symmetry and Angle class I occlusion were restored in all patients throughout the 10.5-year follow-up period (range, 9 to 14 years). Two patients received osseointegrated dental implants. Our only complication was the partial loss of a skin paddle. Conclusion: Microvascular reconstruction of the pediatric mandible, in selected patients, is a safe, reliable procedure that provides the bone stock and soft tissue necessary to restore normal maxillomandibular growth and dental rehabilitation.

Background: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. Methods: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. Results: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). Conclusions: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

Hypertrophic scarring is characterized by disordered collagen fibrils. In order to determine whether this is, in part, a result of changes in the population of proteoglycans that are thought to be involved in regulation of collagen fibril formation, we have compared PGs from post-burn normal and hypertrophic scar tissue, as well as from human dermis and epidermis. Efforts to separate the two major iduronic acid-containing proteoglycans, decorin [PG(IdoA)-II] and biglycan [PG(IdoA)-I], for quantitation were not successful. The different N-terminal sequences of these two iduronic acid-containing proteoglycans PG(IdoA-I and -II were utilized to estimate the relative amounts in the above PG(IdoA) preparations. Normal scar, dermis and epidermis were all found to contain primarily decorin with low (< 10%) levels of biglycan relative to decorin. In contrast, iduronic acid-containing proteoglycans from hypertrophic scar were found to be approximately 30% biglycan [PG(IdoA)-I]. This may be a proximal cause of altered collagen fibrils, or may result in alterations in the sequestration of growth factors, which then results in changes in collagen that effect the appearance of the scar. 1966 Elsevier Science Ltd.

Restoring soft-tissue contour in patients with facial asymmetry is a difficult problem for plastic surgeons. We report our experience with 57 consecutive patients who underwent 60 microvascular free flaps for the correction of facial asymmetry between July of 1989 and June of 1994. Etiologies of facial asymmetry included hemifacial microsomia, hemifacial atrophy, postradiation sequelae, burns and trauma, and selected congenital anomalies. Thirty-eight patients were reconstructed with a customized parascapular flap incorporating extensions of dorsal thoracic fascia. Other donor sites utilized were as follows: six superficial inferior epigastric flaps, three myocutaneous flaps, seven muscle flaps, and six fasciocutaneous flaps with bone. To correct facial asymmetry, the recipient site was dissected through a limited preauricular incision whenever feasible, and the superficial temporal artery and vein were used as recipient vessels. A monitoring skin paddle was rarely used. There were no flap losses in this series. Six patients experienced a postoperative hematoma, three of which were drained at the bedside. Limited skin slough occurred in three patients. No donor-site complications other than hypertrophic scarring were encountered. Flap revisions were performed in 22 of the 57 patients to maximize aesthetic results. Based on our experience, we feel that the operative approach presented here allows excellent and stable correction of facial asymmetry due to a variety of etiologies. Furthermore, this technique is applicable to other congenital craniofacial deformities such as Treacher-Collins syndrome and orbital-facial clefts.

Recent developments in surgery and basic science research offer aesthetic surgeons the prospect of scarless repair. Studies in fetal wound healing provide both cellular and molecular models of optimal tissue healing without scar formation. Furthermore, craniofacial surgeons may one day operate on cleft lip, cleft palate, and other congenital malformations in utero. Cytokine research has begun to unravel possibilities for modulating the wound-healing inflammatory response in hopes of limiting scar formation. This article presents research on these developments and comments on their possible applications to aesthetic surgery.

Factors responsible for breast capsule contracture remain elusive. Using an in vitro model of wound contraction, the fibroblast-populated collagen lattice (FPCL), breast capsule fibroblasts and control dermal fibroblasts from ten patients were analyzed. Comparison was made to determine (1) if the activity of dermal fibroblasts on a collagen lattice correlated with the activity of breast capsule fibroblasts or if capsular fibroblasts are unique, and (2) if the degree of fibroblast-driven collagen contraction correlated with clinical severity of breast capsule contracture. If so, a preoperative predictor of breast capsule contracture would be available. Dermal fibroblasts and breast capsule fibroblasts were cultured and mixed with media and collagen to form a matrix, and then the degree of lattice contraction was measured. A correlation between breast capsule fibroblasts and control dermal fibroblasts with respect to collagen matrix contraction was confirmed. Collagen lattice contraction coordinated by fibroblasts derived from breast capsules did not correlate with clinical severity of capsular contracture. These results indicate that the degree of breast capsule contracture can not be predicted by fibroblast activity alone. An interaction between inflammatory cells, extracellular matrix, and fibroblasts is hypothesized. Further work is needed to delineate the mechanisms responsible for breast capsule contracture.

Nonunion and avascular necrosis after scaphoid fractures continue to be problem sequelae because of unrecognized injuries, inadequate immobilization techniques, or insufficient treatment time. Screw fixation and inlay bone grafting techniques remain the options of choice, with successful union reported in approximately 90% of patients. However, prolonged immobilization with plaster up to 4 to 6 months is required with conventional techniques. With the use of standard latex injection techniques with vascular filling of vessels to less than 0.1 mm diameter in ten fresh cadaver dissections, we discovered a consistent vascularized bone graft source from the distal dorsoradial radius. We have used this vascularized bone graft source with good results in eleven patients with long-standing nonunion of the scaphoid. It is technically easy and seemingly offers the advantages of a decreased period of immobilization and a higher union rate.

Since their first review of microsurgical correction of facial contour deformities in 19 patients with craniofacial malformations, the authors have treated an additional 74 patients (n = 93). The authors review indications, choices, safety, efficacy, complications, and technical refinements. A treatment algorithm is presented.A retrospective chart review of all patients who underwent microvascular reconstruction of the face and all patients with craniofacial dysmorphology was performed. Between 1989 and 2004, a total of 93 patients with the following diagnoses were identified: craniofacial microsomia (n = 73), Treacher Collins syndrome (n = 8), and severe orbitofacial cleft (n = 12). All patients underwent microsurgical facial reconstruction with a superficial inferior epigastric, groin, or circumflex scapular flap. Flap revisions, complications, and non-free flap related surgery were reviewed.The mean age at microvascular reconstruction was 11 years (range, 4 to 27 years). Flap choices included the following: superficial inferior epigastric (n = 4), groin (n = 3), and circumflex scapular (n = 105). Seventy-six patients underwent unilateral and 17 patients underwent bilateral (one of 17 simultaneous) reconstructions. Postoperative complications included partial flap loss (n = 1), reexploration (n = 1), hematoma (n = 5), and cellulitis (n = 5). All patients had subjective improvement in facial contour, symmetry, skin tone, and color. Most patients underwent additional non-free flap procedures including mandibular distraction and ear reconstruction.Microsurgical flaps have markedly improved the authors' ability to restore craniofacial contour in patients with craniofacial malformations. In selected patients, the authors choose primary midface augmentation with free vascularized tissue to restore form and function. Microsurgical flaps in patients with craniofacial malformations are safe, effective, and reliable.

Calreticulin (CRT), an intracellular chaperone protein crucial for the proper folding and transport of proteins through the endoplasmic reticulum, has more recent acclaim as a critical regulator of extracellular functions, particularly in mediating cellular migration and as a requirement for phagocytosis of apoptotic cells. Consistent with these functions, we show that the topical application of CRT has profound effects on the process of wound healing by causing a dose-dependent increase in epithelial migration and granulation tissue formation in both murine and porcine normal and impaired animal models of skin injury. These effects of CRT are substantiated, in vitro, as we show that CRT strongly induces cell migration/wound closure of human keratinocytes and fibroblasts, using a wound/scratch plate assay, and stimulates cellular proliferation of human keratinocytes, fibroblasts, and vascular endothelial cells, providing mechanistic insight into how CRT functions in repair. Similarly, in both animal models, the histology of the wounds show marked proliferation of basal keratinocytes and dermal fibroblasts, dense cellularity of the dermis with notably increased numbers of macrophages and well-organized collagen fibril deposition. Thus, CRT profoundly affects the wound healing process by recruiting cells essential for repair into the wound, stimulating cell growth, and increasing extracellular matrix production.

Introduction: Treacher Collins syndrome is an autosomal dominant mandibulofacial dysostosis with characteristic hard- and soft-tissue facial abnormalities. These include ocular malformations, ear malformations, and hypoplasia of the facial skeleton, especially of the malar bones and mandible. Traditionally, surgical correction of the facial abnormalities has focused on skeletal reconstruction to restore facial form and symmetry. In this report, we describe the use of customized parascapular free flaps, after standard reconstructive surgeries, for the correction of defects of facial contour in Treacher Collins patients. In most cases, bony reconstruction of the zygoma or periorbita is not required. Methods: From June 1995 to December 2003, 8 patients with Treacher Collins syndrome underwent microsurgical correction of facial contour using 16 free flaps. In all patients, staged parascapular free flaps were used for reconstruction. The microvascular technique involved a 2-team approach with simultaneous ipsilateral parascapular flap harvest and facial pocket dissection. The flaps were contoured, revascularized (14 superficial temporal vessels, 2 facial vessels), and inset. No vein grafts were used. The patients were followed for a minimum of 1 year, and postoperative evaluation included medical photography, visual assessment, and evaluation by the patient and family. Results: Seven patients had previous facial skeleton correction using craniofacial techniques. The age at operation ranged from 4-19 years. Sixteen parascapular free flaps were used in the 8 patients. Postoperative complications were limited to 1 hematoma. There were no partial or total flap losses. All of the patients had improved facial contour and symmetry. Overlying skin tone and color similarly improved. Conclusion: After traditional skeletal reconstruction for the complex craniofacial defects of Treacher Collins syndrome, deficiencies in facial contour and symmetry usually persist. Customized soft-tissue free flaps can be employed to differentially resurface these defects and achieve optimal esthetic results in these challenging patients.

The vascular supply of the Le Fort I osteotomy segment was studied by utilizing standard latex injection techniques. Anatomic dissections in 10 fresh cadavers demonstrated interruption of the descending palatine arteries with preservation of the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal artery within the attached posterior palatal soft-tissue pedicle in all specimens following Le Fort I maxillary osteotomy. These ascending arterial branches entered the soft palate at a position approximately 1 cm posterior to the pterygomaxillary junction, which was disrupted during the Le Fort I maxillary osteotomy. Separate ink injections of total maxillary osteotomy segments confirmed vascular perfusion of the ipsilateral hemimaxillary segment by the ascending palatine artery. Thus vascular supply of the mobilized Le Fort I maxillary segment is by means of the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal artery in addition to the rich mucosal alveolar anastomotic network overlying the maxilla.

Parascapular free flaps traditionally have been designed obliquely across the back, corresponding to the descending branch of the circumflex scapular artery. The donor site of this workhorse flap has the drawback of a widened and frequently hypertrophic scar. In searching for aesthetic improvements in the donor site, we have progressively rotated the axis of this flap in an anterior direction. The end result of this modification is the flap we report here: the inframammary extended circumflex scapular flap. This flap has a longitudinal axis of rotation lying curvilinearly from the inframammary fold to the circumflex scapular artery within the triangular anatomic space. We have used this flap in 20 patients over the past 2 years. The vast majority of these cases were deepithelialized flaps with customized extensions of dorsal thoracic fascia to correct facial asymmetry. We feel that the inframammary extended circumflex scapular artery flap donor-site scar is well hidden within the inframammary fold, and that the unavoidable widening and hypertrophy of parascapular and scapular flap donor-site scars were minimized compared with traditional flap designs.

The correction of facial asymmetry in complex craniofacial malformations presents a challenging problem for reconstructive surgeons. Deficiencies of both the facial skeleton and the overlying soft tissue must be addressed to achieve the optimal reconstructive result. We present our experience with a minimum of 1-year follow-up over a 5-year period with 19 patients who initially underwent standard facial skeletal reconstruction and subsequently required microsurgical soft-tissue reconstructions for final correction of facial contour. From July of 1989 to June of 1994, 19 patients with craniofacial malformations underwent microsurgical correction of facial contour using 21 free flaps. The underlying malformations included 15 hemifacial microsomias, 2 orbitofacial clefts, 1 congenital temporomandibular joint ankylosis with micrognathia, and 1 Tessier no. 30 (lower midline mandibular) cleft. Sixteen patients had previous facial skeletal correction using craniofacial techniques. Age at operation ranged from 6 to 27 years. Twenty-one microvascular flaps were used on the 19 patients: 19 deepithelialized parascapular flaps, 1 superficial inferior epigastric flap, and 1 fibula with soleus muscle and large skin paddle for a severe Tessier no. 30 facial cleft with severe micrognathia. Of the 15 patients with hemifacial microsomia, 10 were treated with parascapular fasciocutaneous flaps, 3 with parascapular flaps with bone, 1 with a parascapular flap with teres major muscle for additional bulk, and 1 with a superficial inferior epigastric flap. Complications were two limited hematomas drained at the bedside and a partial skin paddle slough of the fibula flap. Correction of facial contour in complex craniofacial malformations is possible using microsurgical techniques. These free flaps "camouflage" the underlying skeletal deformity that persists despite traditional skeletal reconstruction while restoring symmetrical facial contour. We recommend the marriage of both skeletal and microsurgical soft-tissue reconstructions to achieve the optimal aesthetic result for craniofacial contouring in these challenging patients.

Bilateral facial contour deformities are difficult reconstructive problems to correct. This paper summarizes our experience with five adult patients who were operated on for the correction of bilateral contour deformities. The etiologies of the contour deformities were one case of systemic lupus erythematosus, three cases of hemangioma/lymphangiomas, and one case of systemic lipodystrophy. Patient ages at the time of surgical correction ranged from 19 to 65 years. In two patients, staged microvascular free-tissue transfers were performed. In three patients, a single free flap was used for reconstruction. Seven microvascular free flaps were used to reconstruct facial contour : three superficial inferior epigastric flaps and four inframammary extended circumflex scapular flaps. In three patients, recipient sites were dissected by means of a limited preauricular incision, and the superficial temporal artery and vein were utilized as recipient vessels. The two remaining patients underwent free-tissue transfer to branches of the external carotid system. There were no flap losses in this series. Follow-up ranged from 1 to 4 years. A stable restoration of facial contour was achieved in all five patients. Microsurgical correction of soft-tissue contour problems is possible in bilateral deformities, and superior results are easier to achieve than in unilateral facial contour deformities. Either single or staged reconstructions can restore facial contour depending on the distribution of soft-tissue requirements.

A new technique for microvascular four-stitch sleeve anastomosis of arteries is described. Modifications from previously described techniques include absence of suture material within the arterial lumen, and a decreased proximal to distal artery overlap. In 40 rat arterial anastomoses, 100% patency without evidence of stenosis or early aneurysm formation was seen up to 6 weeks postoperatively by in vivo observation, arteriography and Doppler flow study. This new anastomosis was also successful in repairing two clinical cases of complete radial artery transection as evident from physical examination and doppler flow study. We believe that this new four-stitch sleeve anastomosis is faster and easier to perform and has patency and flow characteristics similar to those of the conventional end-to-end anastomosis.

Romberg's disease is a progressive hemifacial atrophy of unknown etiology. Microsurgical reconstruction, focusing on the correction of facial asymmetry and restoration of contour, has become the gold standard. We report our experience with 15 patients involving 16 free-tissue transfers with a minimum of 1 year of follow-up who were treated from July of 1989 to January of 1993. All patients were classified as having severe atrophy. There were 7 males and 8 females in the series. Distribution of disease was a coup de sabre type or segmental pattern in 6 patients, whereas 9 patients had a hemifacial distribution. Fourteen patients had unilateral disease (7 right and 7 left), and 1 patient had bilateral atrophy. The average age of onset of disease was 11.9 years. The average duration of atrophy was 6.7 years. No patient was operated on with a quiescent interval of less than 2 years. Average age at operation was 28.7 years, with a range from 6 to 46 years. Follow-up ranged from 1 to 4.5 years. Two patients had facial hematomas as the only complication. No flaps were lost. Flap revisions consisting of minor contour corrections were performed in 10 patients. Limited recurrence of facial atrophy was seen in a single patient 2 years postoperatively. All patients rated their improvement as excellent. The deepithelialized extended parascapular flap with large fascial extensions of dorsal thoracic fascia is our procedure of choice. This fascia can be folded into variable thicknesses to correct subtle contour defects of the upper lip, medial canthus, eyelids, and ear that have reportedly been difficult to reconstruct. These extensions can be placed easily across the midline to interdigitate with normal tissues at the boundary of the facial deformity. As such, the transition from augmented areas of the face to uninvolved areas is natural in contour.

Proteoglycans (PGs) were extracted from human hypertrophic and normal scar tissues from two different stages of maturation after burn injury, under dissociative conditions (4 M guanidinium chloride containing proteinase inhibitors). The extracts were fractionated by ion-exchange chromatography, followed by ethanol precipitation, to give PG-containing iduronic acid (PG IdoA ). The size of the PG IdoA decreased with the maturation of scars. Glycosaminoglycan (GAG) chains from PG IdoA were released by alkaline borohydride treatment, and their M r values were evaluated by polyacrylamide gel electrophoresis. The M r values for PG IdoA protein cores of the hypertrophic scars (5 + years and 2–5 years) and normal scar (5 + years and 2–5 years) were 22.6, 25, 19 and 21 KDa, respectively. The iduronic acid content of PG IdoA from both types of scar increased in their maturation phase. The M r , values of PG IdoA decreased with maturation. PG IdoA carried the sulfate group mainly attached at C-4 of the 2-amino-2-deoxy- d -galactose residue. The NH 2 -terminal amino acid sequences of all the PG IdoA were similar to those of normal human skin or bone PG II (decorin) (i.e., Asp-Glu-Ala-B-Gly-Ile-Gly-Pro-Glu-Val-Pro-Asp-Asp-Arg).

This study reviews 21 microvascular free flaps to the diabetic foot in 19 patients over a 65-month period. All flaps were either to the plantar surface of the foot or to cover exposed Achilles tendon. Twenty of the flaps survived. The operations required a long, costly hospitalization with frequent recipient- and donor-site complications. All patients eventually ambulated on their flaps. Five patients came to proximal amputation from 6 to 37 months after surgery. Only one amputation was for flap breakdown.

A case of successful microvascular replantation of a traumatically amputated ear is presented. The postoperative course was complicated by venous thrombosis requiring the use of medicinal leeches and systemic heparinization for salvage. This is the tenth successful microvascular ear replantation reported in the literature. © 1993 Wiley-Liss Inc.

Hyaluronan has long been associated with the remodelling extracellular matrix. Such remodelling occurs in development, growth and wound healing. This role has been thought to be related to the physical structure and chemical composition of the pure glycosaminoglycan chain. We question this proposition and present evidence which suggests that proteins associated with hyaluronan may be more critical determinants of tissue remodelling.

Hyaluronan (HA) extracted from tissues has been demonstrated to have an enhancing effect on the process of wound healing; the question arises whether this effect is due to the HA or to associated collagen and other proteins. In this study, HA has been extracted from human skin and scar tissue under dissociative conditions and isolated by DEAE-cellulose chromatography followed by CsCl gradient and Sepharose CL-6B chromatography. This highly purified HA was found to contain between 4 and 28 % protein, with collagen constituting 5 % of the total protein. A functional association between HA and a collagen protein complex is proposed.