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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.

Background Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. Objectives The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. Methods The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. Results Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. Conclusions Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being. Level of Evidence: 4

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.

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.

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.

Reconstruction of challenging surgical problems has undergone a dramatic evolution over the past quarter of a century. Microsurgical correction of facial contour deformities is a prime example of how far microsurgical reconstruction has evolved. This article discusses the current surgical techniques.

The correction of facial asymmetry in complex craniofacial deformities presents a challenging problem to reconstructive surgeons. Deficiencies of both the facial skeleton and the overlying soft tissue must be addressed to achieve the optimum reconstructive result. Soft tissue contour problems due to any cause can be corrected with microsurgical techniques. The transfer of customized free flaps based on the circumflex scapular vascular pedicle, consisting of dorsal thoracic fascia with variable contributions of overlying fat, can restore facial harmony. Both facial and donor site aesthetics are optimized.

To properly evaluate the potential benefits of in utero repair for cleft lip and palate, an animal model of cleft lip and palate formation is needed that simulates human cleft morphology. We have developed a fetal lamb model in which incisional or excisional unilateral cleft lips were created early in gestation and later repaired. Through a maternal celiotomy and hysterotomy, six excisional and six incisional clefts were created in early first trimester fetal lambs. Clefts were created by a novel space helmet technique and made completely through the lip and the alveolus. Two weeks later, the wound edges were freshened and repaired in all but one lamb in each group. In the early third trimester, the fetuses were harvested and studied. We found that the incisional clefts healed spontaneously with replacement of the native reticular collagen pattern and with regeneration of the skin appendages. However, the excisional clefts did not autorepair and, when repaired surgically, healed without a collagen scar but showed no regeneration of the skin appendages. This preliminary study is the first successful large animal model where cleft lips and palates were created, allowed to develop with the cleft, and later repaired in utero. Prior to repair, the edges of the excisional clefts epithelialize. When repaired early in the third trimester, excisional clefts heal without a dermal scar but exhibit incomplete regeneration of the skin appendages.

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.

Microvascular techniques are important in making routine anastomoses quicker and difficult anastomoses easier. The authors have developed three types of sleeve anastomoses for different size vessels: a three-stitch sleeve anastomosis, four-stitch sleeve anastomosis, and sidecut sleeve anastomosis. Arteriography, in vivo observation, pulsed ultrasound Doppler hemodynamic study, histology, and ultrastructural examination with scanning electron microscopy at 2 to 90 days demonstrated that all three groups of sleeve anastomoses do not stenose, do not show hemodynamically significant vasospasm, and are not complicated by aneurysm formation by 90 days. The hemodynamics were comparable to control sutured anastomoses at 2 to 4 hr postoperatively. The sleeve anastomoses left no suture material within the vessel lumen. Reendothelialization was comparable with controls at 14 days, and the long-term patency rates were similar (p > 0.05). The operative times for all three types of sleeve anastomoses were significantly shorter than sutured control anastomoses (p < 0.001). Although limited by available vessel length and diameter, the sleeve anastomosis is a useful technique for the microsurgeon.

To elucidate the role for transforming growth factor-beta isoforms (beta(1), -beta(2), and -beta(3)) in wound repair, we used isoform-specific antibodies to detect the spatial and temporal expression of the latent and mature/active transforming growth factor-beta isoforms by immunohistochemical localization through 21 days after excisional and incisional wounding of ovine skin. Although incisional and excisional wounds showed similar patterns of transforming growth factor-beta immunoreactivity, we found a differential temporal and spatial expression of the latent and mature transforming growth factor-beta isoforms throughout wound repair. Specifically, 1 day after wounding, there was a marked increase in transforming growth factor-beta isoforms in the epithelium adjacent to the wound, epidermal appendages, and the cells and matrix of the granulation tissue. At this time, transforming growth factor-beta(3) isoform was the most abundant. Most notably, the epidermis adjacent to the wound was intensely immunoreactive for all transforming growth factor-beta isoforms 1 day after injury. However, the migrating epithelium, derived from both the hair follicles and the wound margins, was completely devoid of immunoreactive transforming growth factor-beta until reepithelialization was complete. Within the inflammatory exudate, there was a distinct band of leukocytes that was immunoreactive for transforming growth factor-beta(2) and -beta(3) 1 day after injury and 1 day later for transforming growth factor-beta(1). Although transforming growth factor-beta(1) and -beta(2), latent transforming growth factor-beta(2), transforming growth factor-beta(3), and latent transforming growth factor-beta(3) immunostaining was present in the numerous fibroblasts and other dermal cells, latent transforming growth factor-beta(1) was only associated with the extracellular matrix. In general, immunoreactivity remained high until day 7 after wounding and slowly subsided over time. However, by day 21, immunostaining had not returned to normal and the original wound was replete with immunoreactive fibroblasts and a dense, immunostained extracellular matrix. Thus, although the dynamic presence of transforming growth factor-beta isoforms exemplifies its positive role in the wound repair process, its persistence together with its known potent effects on matrix accumulation, supports its role in scar formation.

Using a newly developed Doppler probe, we have found that a standard suture anastomosis in a rat femoral artery is accompanied by significant (30-60%) cross-sectional area stenosis, which dissipates to baseline levels within 24 hours. We hypothesized that spasm, deposition of coagulation products, or the suture technique itself was responsible. Topical vasodilators (papaverine, sodium nitroprusside, lidocaine) and intravenous thromboxane A2 synthetase inhibitor and receptor blocking agent (Ridogrel, 4 mg/ml), anticoagulants heparin and SC4992 (an experimental platelet inhibitor/arginine-glycine-aspartic acid analogue), were administered. No drug had any significant effect on preventing postoperative stenosis. Varied suture bites affected stenosis measurements. Scanning electron microscopy and light microscopy displayed "bunching" of vessel wall in the suture ties. This was confirmed with methyl methacrylate corrosion casts and microangiography. "Sham" anastomoses also produced stenosis, which was relieved when sutures were removed. We conclude that suture anastomosis of small vessels is accompanied by significant cross-sectional stenosis caused by the physical action of tensioned sutures. This effect dissipates over a 24-hour postoperative period. The mechanism behind these changes and the clinical importance of this effect are still under investigation.

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.

Wound contraction is an important component of healing but, in the extreme, may lead to excessive scar formation and pathological wound contracture. Fetal rabbit wounds heal without contraction or scarring, whereas excisional fetal sheep wounds have been shown to contract, but no scarring or pathological wound contracture is noted. We used an in vitro model, the fibroblast-populated collagen lattice, to study the ability of fetal fibroblasts to coordinate contraction of a collagen matrix and the modulating effects of epidermal growth factor and transforming growth factor-beta 1 on this contraction. With increasing gestational age, fibroblasts increased the degree of collagen lattice contraction. Epidermal growth factor inhibited contraction by fetal fibroblasts, whereas transforming growth factor-beta 1 stimulated it. These findings suggest that while intrinsic differences between fetal and adult fibroblasts exist, polypeptide growth factors may operate at the site of tissue repair to alter cell phenotype. Further work is underway to delineate the role of soluble protein factors responsible for the absence of scarring and contracture seen in the fetal wound.

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.

The ability of fetal skin wounds to heal without scar formation is remarkable. The mechanisms that endow the fetus with this unique healing ability remain unknown. We have developed an in vitro explant model using fetal sheep skin to investigate fetal wound healing. This model eliminates the complex systemic mechanisms that modulate in vivo wound healing. We demonstrated that using an enriched medium, midgestation fetal sheep skin explants following wounding reepithelialized within 4 days. By 7 days after wounding the confluent epidermis was thicker, but the dermal wound remained open. This model demonstrates that it is possible to achieve conditions in culture that maintain tissue viability and support reepithelialization. This model may allow us to resolve some of the individual components that participate in the process of scarless fetal skin healing.

Human fetal surgery is being successfully performed today in a small number of highly selected patients for conditions that may lead to irreversible damage to the fetus and threaten the viability of the newborn. Following surgical repair, fetal wounds heal without scarring. This study was initiated to characterize fetal wounds both histologically and biochemically. Gore-Tex tubing was implanted into the subcutaneous tissue of the back of fetal, newborn, and adult New Zealand white rabbits. Light microscopic examination of healed wounds revealed no evidence of scar formation. Electron microscopy demonstrated a striated fibrillar structure suggestive of collagen within the lumen of the Gore-Tex tubing implants. Amino acid analysis (sensitivity 40 pmol) confirmed the presence of hydroxylysine and hydroxyproline within the Gore-Tex wound chambers indicating the presence of collagen in fetal wounds. The small amount of collagen precluded the typing of the collagen using cyanogen bromide peptide analysis. The absence of scarring and the small amounts of detectable collagen suggest a high degree of reorganization of the connective tissues involved in repair. The fetal wound matrix is rich in hyaluronic acid. Topical hyaluronic acid has been associated experimentally with a reduced amount of scarring in postnatal wound healing. Hyaluronic acid extracted from human skin and scar tissue is associated with collagen and other proteins. We propose that a hyaluronic acid-collagen-protein complex may play a role in fetal wound healing.

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.

The postoperative outcome of hand flexor tendon repair can be complicated by adhesions between the repair site and surrounding tissue. To date, the biology of hand flexor tendon wound healing remains controversial--both intrinsic (resident tenocyte) and extrinsic (tendon sheath fibroblast and inflammatory cell) processes may contribute to repair. Transforming growth factor beta-1 is a cytokine that plays multiple roles in wound healing but is also implicated in the pathogenesis of excessive scar formation. This study examines the activation of transforming growth factor beta-1 mRNA in a rabbit zone II flexor tendon wound-healing model. Forty New Zealand White rabbit forepaws underwent complete transection and repair of the middle digit flexor digitorum profundus tendon in zone II. Tendons were harvested at increasing time intervals (1, 3, 7, 14, 28, and 56 days) and analyzed by in situ hybridization and immunohistochemistry to determine the expression patterns of transforming growth factor beta-1. A small number of tenocytes exhibited expression of transforming growth factor beta-1 mRNA at baseline in nonwounded control tendon specimens. The surrounding tendon sheath in these control specimens also revealed low numbers of fibroblasts and inflammatory cells expressing transforming growth factor beta-1 mRNA. In contrast, flexor tendons subjected to transection and repair exhibited increased signal for transforming growth factor beta-1 mRNA in both resident tenocytes and infiltrating fibroblasts and inflammatory cells from the tendon sheath. These data demonstrate that (1) normal unwounded tenocytes and tendon sheath cells are capable of transforming growth factor beta-1 production, (2) this cytokine is activated in the tendon wound environment, as evidenced by mRNA upregulation, and (3) the upregulation of this cytokine in both "intrinsic" tenocytes and "extrinsic" tendon sheath fibroblasts and inflammatory cells supports dual mechanisms for tendon repair. Because transforming growth factor beta-1 is thought to contribute to the pathogenesis of excessive scar formation, the findings presented here suggest that perioperative biochemical modulation of transforming growth factor beta-1 levels may help limit flexor tendon adhesion formation.

Multiple microvascular anastomotic techniques have been described with varying rates of success. This experimental study presents the results of a comparison of three types of venous microanastomotic techniques: the Unilink system, the sleeve technique, and the suture technique. Twenty male Sprague-Dawley rats, 40 femoral veins, were used for this study. In vivo observation and microvasculography demonstrated that patency rates between the Unilink system and suture techniques were comparable (p > 0.05) and were significantly superior to the sleeve anastomosis (p < 0.05). The anastomotic time for the sleeve technique was significantly shorter than for the suture technique (p < 0.001). Compared with suture and sleeve anastomoses, the anastomotic time employing the Unilink system was significantly the shortest (p < 0.001). The Unilink system proved to be the fastest method with the highest patency rate. These results suggest that the use of the Unilink system is superior with regard to anastomotic time and patency rate, when compared to suture and sleeve techniques for venous microanastomosis.

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.

This study assessed the postoperative microvascular hemodynamics in end-to-side arterial anastomoses of varied angles in order to determine whether the angle of the anastomosis affects arterial flow. Thirty male rats were divided into three groups of ten. Carotid to carotid end-to-side anastomoses were performed with anastomotic angles of 45, 90, and 135 degrees. Postoperative flow was assessed using high frequency pulsed Doppler ultrasound (HFPDU) at 30 and 120 min postoperatively. Measurements at 30 min demonstrated significant differences in flow, with the 45 degrees grafted vessels utilizing 56.5% of total carotid flow, and the 90 degrees and 135 degrees anastomoses appropriating 46.5% and 43.2% of flow, respectively (comparing 45 degrees to both 90 degrees, P < 0.05, and 135 degrees, P < 0.002). The change from baseline in 45 degrees and 90 degrees groups dissipated over a 2 hr postoperative period, but flow in the grafted vessels in the 135 degrees group continued well below 50% at 39.9% (comparing to both 45 degrees and 90 degrees, P < 0.001), thereby displaying a significant difference in the postoperative arterial flow of varied angled microanastomoses.

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.