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Purpose: Given no definite consensus on the accepted autograft orientation during peripheral nerve injury repair, we compare outcomes between reverse and normally oriented autografts using an advanced magnetic resonance imaging technique, diffusion tensor imaging., Methods: Thirty-six female Sprague-Dawley rats were divided into 3 groups: sham-left sciatic nerve isolation without injury, reverse autograft-10-mm cut left sciatic nerve segment reoriented 180° and used to coapt the proximal and distal stumps, or normally oriented autograft-10-mm cut nerve segment kept in its normal orientation for coaptation. Animals underwent sciatic functional index and foot fault behavior studies at 72 hours, and then weekly. At 6 weeks, axons proximal, within, and distal to the autograft were evaluated using diffusion tensor imaging and choline acetyltransferase motor staining for immunohistochemistry. Toluidine blue staining of 1-μm sections was used to assess axon count, density, and diameter. Bilateral gastrocnemius/soleus muscle weights were compared to obtain a net wet weight. Comparison of the groups was performed using Mann-Whiney U or Kruskal-Wallis H tests to determine significance., Results: Diffusion tensor imaging findings including fractional anisotropy, radial diffusivity, and axial diffusivity were similar between reverse and normally oriented autografts. Diffusion tensor imaging tractography demonstrated proximodistal nerve regeneration in both autograft groups. Motor axon counts proximal, within, and distal to the autografts were similar. Likewise, axon count, density, and diameter were similar between the autograft groups. Muscle net weight at 6 weeks and behavioral outcomes (sciatic functional index and foot fault) at any tested time point were also similar between reverse and normally oriented autografts., Conclusions: Diffusion tensor imaging may be a useful assessment tool for peripheral nerve regeneration. Reversing nerve autograft polarity did not demonstrate to have an influence on functional or regenerative outcomes.

Purpose: Polyethylene glycol (PEG) has been hypothesized to restore axonal continuity using an in vivo rat sciatic nerve injury model when nerve repair occurs within minutes after nerve injury. We hypothesized that PEG could restore axonal continuity when nerve repair was delayed., Methods: The left sciatic nerves of female Sprague-Dawley rats were transected and repaired in an end-to-end fashion using standard microsurgical techniques at 3 time points (1, 8, and 24 hours) after injury. Polyethylene glycol was delivered to the neurorrhaphy in the experimental group. Post-repair compound action potentials were immediately recorded after repair. Animals underwent behavioral assessments at 3 days and 1 week after surgery using the sciatic functional index test. The animals were sacrificed at 1 week to obtain axon counts., Results: The PEG-treated nerves had improved compound action potential conduction and animals treated with PEG had improved sciatic function index. Compound action potential conduction was restored in PEG-fused rats when nerves were repaired at 1, 8, and 24 hours. In the control groups, no compound action potential conduction was restored when nerves were repaired. Sciatic functional index was superior in PEG-fused rats at 3 and 7 days after surgery compared with control groups at all 3 time points of nerve repair. Distal motor and sensory axon counts were higher in the PEG-treated rats., Conclusions: Polyethylene glycol fusion is a new adjunct for nerve repair that allows rapid restoration of axonal continuity. It effective when delayed nerve repair is performed., Clinical Relevance: Nerve repair with application of PEG is a potential therapy that may have efficacy in a clinical setting. It is an experimental therapy that needs more investigation as well as clinical trials., (Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Ring avulsion injuries can range from soft tissue injury to complete amputation. Grading systems have been developed to guide treatment, but there is controversy with high-grade injuries. Traditionally, advanced ring injuries have been treated with completion amputation, but there is evidence that severe ring injuries can be salvaged. The purpose of this systematic review was to pool the current published data on ring injuries., Methods: A systematic review of the English literature published from 1980 to 2015 in PubMed and MEDLINE databases was conducted to identify patients who underwent treatment for ring avulsion injuries., Results: Twenty studies of ring avulsion injuries met the inclusion criteria. There were a total of 572 patients reported with ring avulsion injuries. The Urbaniak class breakdown was class I (54 patients), class II (204 patients), and class III (314 patients). The average total arc of motion (TAM) for patients with a class I injury was 201.25 (n = 40). The average 2-point discrimination was 5.6 (n = 10). The average TAM for patients with a class II injury undergoing microsurgical revascularization was 187.0 (n = 114), and the average 2-point discrimination was 8.3 (n = 40). The average TAM for patients with a class III injury undergoing microsurgical revascularization was 168.2 (n = 170), and the average 2-point discrimination was 10.5 (n = 97)., Conclusions: Ring avulsion injuries are commonly classified with the Urbaniak class system. Outcomes are superior for class I and II injuries, and there are select class III injuries that can be treated with replantation. Shared decision making with patients is imperative to determine whether replantation is appropriate.

Background: The management of peripheral nerve injuries remains a large challenge for plastic surgeons. With the inability to fuse axonal endings, results after microsurgical nerve repair have been inconsistent. Our current nerve repair strategies rely upon the slow and lengthy process of axonal regeneration (~1 mm/d). Polyethylene glycol (PEG) has been investigated as a potential axonal fusion agent; however, the percentage of axonal fusion has been inconsistent. The purpose of this study was to identify a PEG delivery device to standardize outcomes after attempted axonal fusion with PEG., Materials and Methods: We used a rat sciatic nerve injury model in which we completely transected and repaired the left sciatic nerve to evaluate the efficacy of PEG fusion over a span of 12 weeks. In addition, we evaluated the effectiveness of a delivery device's ability to optimize results after PEG fusion., Results: We found that PEG rapidly (within minutes) restores axonal continuity as assessed by electrophysiology, fluorescent retrograde tracer, and diffusion tensor imaging. Immunohistochemical analysis shows that motor axon counts are significantly increased at 1 week, 4 weeks, and 12 weeks postoperatively in PEG-treated animals. Furthermore, PEG restored behavioral functions up to 50% compared with animals that received the criterion standard epineurial repair (control animals)., Conclusions: The ability of PEG to rapidly restore nerve function after neurotmesis could have vast implications on the clinical management of traumatic injuries to peripheral nerves.

Background: Limited surgical literature currently exists that evaluates postoperative complications after cosmetic surgery in adolescents., Objectives: The purpose of this study was to determine the incidence of major postoperative complications in adolescent patients undergoing cosmetic surgery and compare their complication rates to older patients., Methods: A prospective cohort of patients undergoing cosmetic surgical procedures between 2008 and 2013 was identified from the CosmetAssure database. Demographics, clinical characteristics, surgical procedures, and major complications in adolescent patients (age 10-19 years) and older patients (≥20 years old) were compared. Risk factors analyzed included age, gender, body mass index, smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures., Results: Overall, 3519 adolescents and 124,409 older patients underwent cosmetic surgical procedures. The adolescent cohort contained more men (20.0% vs 6.0%, P < 0.01), lower mean body mass index (22.6 ± 4.1 vs 24.4 ± 4.6, P < 0.01), lower prevalence of diabetes (0.8% vs 1.9%, P <0.01), and fewer smokers (5.9% vs 8.3%, P < 0.01) compared to the older patient cohort. Most commonly adolescent patients underwent breast followed by face and body procedures. Overall adolescent patients demonstrated a lower incidence of major postoperative complications compared to older patients after single (0.6% vs 1.5%, P < 0.01) and combined (1.2% vs 3%, P = 0.03) cosmetic procedures. Adolescent patients had lower complications rates after face, breast, and body procedures compared to the older cohort. The most common postoperative complications in adolescent patients were hematoma (0.34%) and infection (0.28%)., Conclusions: Cosmetic surgical procedures in adolescent patients are safe with a lower rate of major postoperative complications compared to older patients., Level of Evidence: 2., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com)

Purpose: This study aims to compare engineered nerve conduits constructed from porcine-derived urinary bladder matrix (UBM) with the criterion-standard nerve autografts, for segmental loss peripheral nerve repairs., Methods: Forty-eight Sprague-Dawley rats were divided into 2 groups. All underwent a 10-mm sciatic nerve gap injury. This was repaired using either (1) reverse autograft-the 10-mm cut segment was oriented 180 degrees and used to coapt the proximal and distal stumps or (2) UBM conduit-the 10-mm nerve gap was bridged with UBM conduit. Behavior assessments such as sciatic function index and foot fault asymmetry scores were performed weekly. At 3- or 6-week time endpoints, the repaired nerves and bilateral gastrocnemius/soleus muscles were harvested from each animal. Nerves were evaluated using immunohistochemistry for motor and sensory axon staining and with diffusion tensor imaging. The net wet muscle weights were calculated to assess the degree of muscle atrophy., Results: The UBM group demonstrated significantly improved foot fault asymmetry scores at 2 and 4 weeks, whereas there was no difference in sciatic function index. The net muscle weights were similar between both groups. Motor axon counts proximal/inside/distal to the conduit/graft were similar between UBM conduits and reverse autografts, whereas sensory axon counts within and distal to the conduit were significantly higher than those of the autograft at 6 weeks. Sensory axonal regeneration seemed to be adherent to the inner surface of the UBM conduit, whereas it had a scattered appearance in autografts. Diffusion tensor imaging parameters between groups were similar., Conclusions: Urinary bladder matrix conduits prove to be at least similar to nerve autografts for the repair of peripheral nerve injuries with a short gap. The matrix perhaps serves as a scaffold to augment sensory nerve growth., Clinical Relevance: In a clinical setting, UBM may eliminate the donor site morbidity and increased operative time associated with nerve autografting.

Polyethylene glycol (PEG) has been shown to restore axonal continuity after peripheral nerve transection in animal models. We hypothesized that PEG can also restore axonal continuity in the central nervous system. In this current experiment, coronal sectioning of the brains of Sprague-Dawley rats was performed after animal sacrifice. 3Brain high-resolution microelectrode arrays (MEA) were used to measure mean firing rate (MFR) and peak amplitude across the corpus callosum of the ex-vivo brain slices. The corpus callosum was subsequently transected and repeated measurements were performed. The cut ends of the corpus callosum were still apposite at this time. A PEG solution was applied to the injury site and repeated measurements were performed. MEA measurements showed that PEG was capable of restoring electrophysiology signaling after transection of central nerves. Before injury, the average MFRs at the ipsilateral, midline, and contralateral corpus callosum were 0.76, 0.66, and 0.65 spikes/second, respectively, and the average peak amplitudes were 69.79, 58.68, and 49.60 μV, respectively. After injury, the average MFRs were 0.71, 0.14, and 0.25 spikes/second, respectively and peak amplitudes were 52.11, 8.98, and 16.09 μV, respectively. After application of PEG, there were spikes in MFR and peak amplitude at the injury site and contralaterally. The average MFRs were 0.75, 0.55, and 0.47 spikes/second at the ipsilateral, midline, and contralateral corpus callosum, respectively and peak amplitudes were 59.44, 45.33, 40.02 μV, respectively. There were statistically differences in the average MFRs and peak amplitudes between the midline and non-midline corpus callosum groups ( P < 0.01, P < 0.05). These findings suggest that PEG restores axonal conduction between severed central nerves, potentially representing axonal fusion., Competing Interests: Conflicts of interest: None declared.

Background: Venous thromboembolism (VTE) is one of the most feared postoperative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown with current American Society of Plastic Surgeons (ASPS) prophylaxis recommendations partially extrapolated from other surgical specialties., Objectives: This study analyzed the risk factors for VTE in cosmetic surgical procedures., Methods: A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a clinically significant VTE within 30 days of surgery. Risk factors analyzed included age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures., Results: A total of 129,007 patients were identified, of which 116 (0.09%) had a confirmed VTE. Combined procedures had a significantly higher overall rate of VTE compared to solitary procedures (0.20% vs 0.04%, P < .01). On multivariate logistic regression, significant risk factors for VTE (P < .05) included body procedures (RR 13.47), combined procedures (RR 2.4), increasing BMI (RR 1.06), and age (RR 1.02). Gender, smoking, diabetes, and type of surgical facility were not found to be significant risk factors. Face procedures (0.01%) and breast procedures (0.01%) had the lowest VTE rates, followed by combined face/body (0.16%), body procedures (0.21%), and combined body/breast procedures (0.28%)., Conclusions: The incidence of VTE after cosmetic procedures is relatively low. However, the risk increases with combined procedures as well as with particular body areas, most notably trunk and extremities. Equally, significant patient risk factors exist, including BMI and age.

Background: There has been a dramatic rise in office-based surgery. However, due to wide variations in regulatory standards, the safety of office-based aesthetic surgery has been questioned., Objectives: This study compares complication rates of cosmetic surgery performed at office-based surgical suites (OBSS) to ambulatory surgery centers (ASCs) and hospitals., Methods: A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 were identified from the CosmetAssure database (Birmingham, AL). Patients were grouped by type of accredited facility where the surgery was performed: OBSS, ASC, or hospital. The primary outcome was the incidence of major complication(s) requiring emergency room visit, hospital admission, or reoperation within 30 days postoperatively. Potential risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of procedure, and combined procedures were reviewed., Results: Of the 129,007 patients (183,914 procedures) in the dataset, the majority underwent the procedure at ASCs (57.4%), followed by hospitals (26.7%) and OBSS (15.9%). Patients operated in OBSS were less likely to undergo combined procedures (30.3%) compared to ASCs (31.8%) and hospitals (35.3%, P < .01). Complication rates in OBSS, ASCs, and hospitals were 1.3%, 1.9%, and 2.4%, respectively. On multivariate analysis, there was a lower risk of developing a complication in an OBSS compared to an ASC (RR 0.67, 95% CI 0.59-0.77, P < .01) or a hospital (RR 0.59, 95% CI 0.52-0.68, P < .01)., Conclusions: Accredited OBSS appear to be a safe alternative to ASCs and hospitals for cosmetic procedures. Plastic surgeons should continue to triage their patients carefully based on other significant comorbidities that were not measured in this present study. LEVEL OF EVIDENCE 3., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Peripheral nerve injury can have a devastating impact on our military and veteran population. Current strategies for peripheral nerve repair include techniques such as nerve tubes, nerve grafts, tissue matrices, and nerve growth guides to enhance the number of regenerating axons. Even with such advanced techniques, it takes months to regain function. In animal models, polyethylene glycol (PEG) therapy has shown to improve both physiologic and behavioral outcomes after nerve transection by fusion of a portion of the proximal axons to the distal axon stumps. The objective of this study was to show the efficacy of PEG fusion in humans and to retrospectively compare PEG fusion to standard nerve repair., Methods: Patients with traumatic lacerations involving digital nerves were treated with PEG after standard microsurgical neurorrhaphy. Sensory assessment after injury was performed at 1 week, 2 weeks, 1 month, and 2 months using static two-point discrimination and Semmes-Weinstein monofilament testing. The Medical Research Council Classification (MRCC) for Sensory Recovery Scale was used to evaluate the level of injury. The PEG fusion group was compared to patient-matched controls whose data were retrospectively collected., Results: Four PEG fusions were performed on four nerve transections in two patients. Polyethylene glycol therapy improves functional outcomes and speed of nerve recovery in clinical setting assessed by average MRCC score in week 1 (2.8 vs 1.0, p = 0.03). At 4 weeks, MRCC remained superior in the PEG fusion group (3.8 vs 1.3, p = 0.01). At 8 weeks, there was improvement in both groups with the PEG fusion cohort remaining statistically better (4.0 vs 1.7, p = 0.01)., Conclusion: Polyethylene glycol fusion is a novel therapy for peripheral nerve repair with proven effectiveness in animal models. Clinical studies are still in early stages but have had encouraging results. Polyethylene glycol fusion is a potential revolutionary therapy in peripheral nerve repair but needs further investigation., Level of Evidence: Therapeutic study, level IV.

Background: Despite a rise in thighplasties, outcomes and risk factors have not been well described., Objectives: This study investigated the incidence and risk factors of major complications following thighplasty in a large, prospective, multicenter database. It further evaluated the safety of combined procedures., Methods: Patients undergoing thighplasty between 2008 and 2013 were identified within the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 30 days postoperatively. Age, gender, body mass index, smoking, diabetes, type of facility, and combination procedures were evaluated as risk factors., Results: Among the 129,007 patients enrolled in CosmetAssure, 1493 (0.8%) underwent thighplasty. One thousand and eighty-eight (72.9%) thighplasties were combined with other procedures. Ninety-nine (6.6%) developed at least one complication. The most common complications were infection (2.7%), hematoma (2.1%), suspected venous thromboembolism (VTE) (1.1%), fluid overload (0.5%), and confirmed VTE (0.3%). Thighplasties performed in a hospital had higher complications (8.1%) than ambulatory surgical center (6.2%) and office-based surgical suite (3.1%). When thighplasty was performed alone, smoking was an independent risk factor to develop at least one complication (RR = 9.51) and hematoma (RR = 13.48). Compared to thighplasty alone, complication rate did not increase with the addition of concomitant procedures (4.7% vs 7.4%, P = .079)., Conclusion: Infection and hematoma are the most common major complications. In thighplasty alone, smoking is the only independent risk factor for overall complications and hematoma formation. The addition of concomitant cosmetic procedures does not increase complication rates., Level of Evidence: 2 Risk., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Brachioplasty is a popular procedure to correct upper arm ptosis. However, current literature on complications and risk factors is scant and inconclusive., Objectives: Using a large, prospective, multicenter database, we report the incidence of major complications and risk factors in patients undergoing brachioplasty., Methods: Patients who underwent brachioplasty between 2008 and 2013 were identified from the CosmetAssure (Birmingham, AL) database. The primary outcome was the occurrence of major complication(s), defined as complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Risk factors including age, gender, body mass index (BMI), smoking, diabetes, combined procedures, and type of surgical facility were evaluated using univariate and multivariate analysis., Results: Within the 129,007 patients enrolled in CosmetAssure, 2294 (1.8%) underwent brachioplasty. Brachioplasty patients were more likely to be older than 50 years (50.1%), obese (36.3%), diabetic (5.5%), but less likely smokers (5.5%). Major complications occurred in 3.4% brachioplasties with infection (1.7%) and hematoma (1.1%) being most common. Combined procedures, performed in 66.8% cases, had a complication rate of 4.4%, in comparison to 1.3% for brachioplasties performed alone. Combined procedures (RR = 3.58), males (RR = 3.44), and BMI ≥ 30 kg/m(2) (RR = 1.92) were identified as independent risk factors for the occurrence of any complication. Combined procedures (RR = 12.42), and the male gender (RR = 8.89) increased the risk of hematoma formation., Conclusions: Complication rates from brachioplasty are much lower than previously reported. Hematoma and infection are the most common major complications. Combined procedures, male gender, and BMI ≥ 30 kg/m(2) are independent risk factors for complications. LEVEL OF EVIDENCE 2: Risk., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Nearly 70% of US adults are overweight or obese (body mass index, BMI ≥ 25 kg/m(2)), and more such patients are seeking aesthetic surgery. Previous studies have evaluated surgical risk in obese (BMI ≥ 30) or morbidly obese (BMI ≥ 40) patients, with mixed results., Objectives: This study evaluates BMI 25 to 29.9 and BMI ≥ 30 as independent risk factors of major complications following aesthetic surgery in a large, prospective, multi-center database., Methods: A prospective cohort of patients undergoing aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database (Birmingham, AL). BMI was evaluated as a risk factor for major complications, defined as complications requiring an emergency room visit, hospital admission, or reoperation within 30 days of the procedure. Multivariate analysis controlled for variables including age, gender, smoking, diabetes, combined procedures, and type of surgical facility., Results: Of the 127,961 patients, 36.2% had BMI ≥ 25. Overweight patients were more likely to be male (12.5%), diabetic (3.3%), nonsmokers (92.8%), or have multiple procedures (41%). Complication rate steadily increased with BMI: 1.4% (BMI < 18.5); 1.6% (18.5-24.9); 2.3% (25-29.9); 3.1% (30-39.9); 4.2% (≥40). Infection (0.8%), venous thromboembolism (VTE, 0.4%), and pulmonary dysfunction (0.2%) were twice as common among overweight patients. Incidence of hematoma was similar in the two groups (0.9%). Complications following abdominoplasty (3.5%), liposuction (0.9%), lower body lift (8.8%), or combined breast and body procedures (4.2%) were significantly higher in overweight patients. On multivariate analysis, being overweight (BMI 25-29.9) or obese (BMI ≥ 30) were independent predictors of any complication (Relative Risk, RR 1.17 and 1.51), especially infection (RR 1.63 and 2.73), and VTE (RR 1.67 and 2.56)., Conclusions: Overweight (BMI 25-29.9) and obesity (BMI ≥ 30) are both independent risk factors for post-operative infection and VTE in aesthetic surgery. LEVEL OF EVIDENCE 2: Risk., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Diabetes mellitus has been linked with a variety of perioperative adverse events across surgical disciplines. There is a paucity of studies systematically examining risk factors, including diabetes, and complications of aesthetic surgical procedures., Objectives: The purpose of this study was to compare incidence and type of complications between diabetic and non-diabetic patients undergoing various aesthetic surgical procedures, to identify specific procedures where diabetes significantly increases risk of complications, and to study diabetes as an independent risk factor for major complications following aesthetic surgery., Methods: A prospective cohort of 129,007 patients who enrolled into the CosmetAssure insurance program and underwent cosmetic surgical procedures between May 2008 and May 2013 were reviewed. Diabetes was evaluated as risk factor for major complications, requiring hospital admission, emergency room visit, or a reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, smoking, obesity, gender, type of procedures, and surgical facility., Results: Overall, 2506 patients (1.9%) had a major complication. Diabetics had significantly more complications compared to non-diabetics (3.1% vs 1.9%, P < 0.01). In univariate analysis, infectious (1.1% vs 0.5%, P < 0.01) and pulmonary (0.3% vs 0.1%, P < 0.01) complications were significantly higher among diabetics. Notably, diabetics had higher risks of complication in body cases (4.3% vs 2.6%, P < 0.01) and specifically abdominoplasty (6.1% vs 3.0%, P < 0.01). In multivariate analysis, diabetes was found to be an independent risk factor of any complication (relative risk 1.31, P = 0.03) and infection (relative risk 1.70, P < 0.01)., Conclusions: Diabetes is an independent risk factor of major complications, particularly infection, after aesthetic surgical procedures., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Facelift (rhytidectomy) is a prominent technique for facial rejuvenation with 126 713 performed in the United States in 2014. Current literature on facelift complications is inconclusive and derives from retrospective studies., Objectives: This study reports the incidence and risk factors of major complications following facelift in a large, prospective, multi-center database. It compares complications of facelifts done alone or in combination with other cosmetic surgical procedures., Methods: A prospective cohort of patients undergoing facelift between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring emergency room (ER) visit, hospital admission, or reoperation within 30 days of the procedure. Univariate and multivariate analysis evaluated risk factors including age, gender, BMI, smoking, diabetes, combined procedures, and type of surgical facility., Results: Of the 129 007 patients enrolled in CosmetAssure, 11 300 (8.8%) underwent facelifts. Facelift cohort had more males (8.8%), diabetics (2.7%), elderly (mean age 59.2 years) and obese (38.5%) induviduals, but fewer smokers (4.8%). Combined procedures accounted for 57.4% of facelifts. Facelifts had a 1.8% complication rate, similar to the rate of 2% associated to other cosmetic surgeries. Hematoma (1.1%) and infection (0.3%) were most common. Combined procedures had up to 3.7% complication rate compared to 1.5% in facelifts alone. Male gender (relative risk 3.9) and type of facility (relative risk 2.6) were independent predictors of hematoma. Combined procedures (relative risk 3.5) and BMI ≥ 25 (relative risk 2.8) increased infection risk., Conclusions: Rhytidectomy is a very safe procedure in the hands of board-certified plastic surgeons. Hematoma and infection are the most common major complications. Male gender, BMI ≥ 25, and combined procedures are independent risk factors. LEVEL OF EVIDENCE 2: Risk., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Lengthy microvascular procedures carry hypothermia risk, yet limited published data evaluate the overall impact of core temperature on patient and flap morbidity. Although hypothermia may contribute to complications, warming measures are challenged by conflicting reports of intraoperative hypothermia improving anastomotic patency., Methods: A retrospective review included all free flaps performed by plastic surgeons at an academic medical center from December 2005 to December 2010. Intraoperative core temperatures were measured by esophageal probe, and median values recorded over 5-minute intervals yielded a case mean (Tavg), maximum (Tmax), and nadir (Tmin). Outcomes included flap failure, pedicle thrombosis, recipient site infection and complications associated with patient, and flap morbidity. Analysis used Student t test, Fisher exact test, Probit, and logistic regression., Results: Of 156 consecutive free tissue transfers, the median Tavg, Tmax, and Tmin were 36.5°C, 37.1°C, and 35.8°C, respectively. The flap failure rate was 7.7% (12/156) and pedicle thrombosis occurred in 9 (6%) cases. Core temperatures did not associate with overall flap failure or pedicle thrombosis but recipient site infection occurred in 21 (13%) patients who had significantly lower mean core temperatures (Tavg=36.0°C, P<0.01). Lower Tavg and Tmax significantly predicted recipient site infection (P<0.01 and P<0.05, respectively). Cut-point analysis revealed significant increases in recipient site infection risk at Tavg less than 37.0°C (P=0.026) and Tmin less than or equal to 34.5°C (P=0.020)., Conclusions: Intraoperative hypothermia posed significant risk of flap infection with no benefit to anastomotic patency in free tissue transfer.

Background: Hydrophilic polymers have been shown to improve physiologic recovery following repair of transected nerves with microsutures. Our study was designed to combine hydrophilic polymer therapy with nerve tubes (NT) to enhance polymer delivery to the site of nerve injury., Methods: Using a rat sciatic nerve injury model, a single transection injury was repaired in an end-to-end fashion with NT + polyethylene glycol (PEG) to NT alone. Compound action potentials (CAPs) were recorded before nerve transection and after repair. Behavioral testing was performed for 5 weeks., Results: PEG therapy restored CAPS in all, but one, animals, while no CAPS were recorded in animals not receiving PEG. Behavioral nerve function was measured using the standardized functional assessment technique and foot fault asymmetry scores (FF). FF scores were improved for the PEG therapy groups on postoperative days 7, 14, and 21. However, after expected eventual axonal outgrowth, the benefit was less noticeable at days 28 and 35. Immunohistochemistry of the distal axon segments showed an increase number of sensory and motor axons in the NT + PEG group as compared to NT alone., Conclusion: These data suggest that PEG delivery via a conduit may provide a simple, effective way to fuse severed axons and regain early nerve function. For proximal nerve injuries in large animals, recovery of axonal continuity could dramatically improve outcomes, even if fusion only occurs in a small percentage of axons.

Background: Among aesthetic surgery procedures, abdominoplasty is associated with a higher complication rate, but previous studies are limited by small sample sizes or single-institution experience., Methods: A cohort of patients who underwent abdominoplasty between 2008 and 2013 was identified from the CosmetAssure database. Major complications were recorded. Univariate and multivariate analysis was performed evaluating risk factors, including age, smoking, body mass index, sex, diabetes, type of surgical facility, and combined procedures., Results: The authors identified 25,478 abdominoplasties from 183,914 procedures in the database. Of these, 8,975 patients had abdominoplasty alone and 16,503 underwent additional procedures. The number of complications recorded was 1,012 (4.0 percent overall rate versus 1.4 percent in other aesthetic surgery procedures). Of these, 31.5 percent were hematomas, 27.2 percent were infections and 20.2 percent were suspected or confirmed venous thromboembolism. On multivariate analysis, significant risk factors (p < 0.05) included male sex (relative risk, 1.8), age 55 years or older (1.4), body mass index greater than or equal to 30 (1.3), multiple procedures (1.5), and procedure performance in a hospital or surgical center versus office-based surgical suite (1.6). Combined procedures increased the risk of complication (abdominoplasty alone, 3.1 percent; with liposuction, 3.8 percent; breast procedure, 4.3 percent; liposuction and breast procedure, 4.6 percent; body-contouring procedure, 6.8 percent; liposuction and body-contouring procedure, 10.4 percent)., Conclusions: Abdominoplasty is associated with a higher complication rate compared with other aesthetic procedures. Combined procedures can significantly increase complication rates and should be considered carefully in higher risk patients., Clinical Question/level of Evidence: Risk, II.

Wrist, hand, and finger trauma are the most common nonlethal injuries presenting to emergency departments. In Tennessee, lack of available hand care, particularly the need for emergency hand surgery, could be detrimental to patient outcomes. This is a retrospective outcomes study of patients requiring revisional hand surgeries. Patients were identified and stratified by distance to Vanderbilt University Medical Center (VUMC) to determine if patient complications increase with distance from VUMC. As distance of patient county of residence from VUMC increased, per cent of patients without a complication decreased (P < 0.0001). Counties without 24/7 comprehensive hand call also showed a distance difference in complication rates. Per capita income and mean household income showed no effect on complications. Distance from treating facility is correlated with patient outcomes and need for revisional surgery. Limitations in care availability in Tennessee are not specific to hand surgery. If the trend toward poorer outcomes as a result of limited local care availability extends to other specialties, this could have implications regarding health-care realignment. Specifically for patients with complex injuries or conditions that will be referred to centralized flagship hospitals, increases in patient travel may limit positive outcomes.

Diagnosis and management of peripheral nerve injury is complicated by the inability to assess microstructural features of injured nerve fibers via clinical examination and electrophysiology. Diffusion tensor imaging (DTI) has been shown to accurately detect nerve injury and regeneration in crush models of peripheral nerve injury, but no prior studies have been conducted on nerve transection, a surgical emergency that can lead to permanent weakness or paralysis. Acute sciatic nerve injuries were performed microsurgically to produce multiple grades of nerve transection in rats that were harvested 1 hour after surgery. High-resolution diffusion tensor images from ex vivo sciatic nerves were obtained using diffusion-weighted spin-echo acquisitions at 4.7 T. Fractional anisotropy was significantly reduced at the injury sites of transected rats compared with sham rats. Additionally, minor eigenvalues and radial diffusivity were profoundly elevated at all injury sites and were negatively correlated to the degree of injury. Diffusion tensor tractography showed discontinuities at all injury sites and significantly reduced continuous tract counts. These findings demonstrate that high-resolution DTI is a promising tool for acute diagnosis and grading of traumatic peripheral nerve injuries.

Background: The proportion of elderly patients in North America is increasing. This has resulted in an increased number of elderly patients undergoing cosmetic procedures., Objectives: The purpose of this study was to determine the incidence of postoperative complications in elderly patients (age ≥65) undergoing elective aesthetic plastic surgical procedures compared with younger patients., Methods: A total of 183,914 cosmetic surgical procedures were reviewed using the prospectively enrolled cohort of patients in the CosmetAssure database. Comorbidities and postoperative complications in elderly and younger patient groups were recorded and compared. A separate analysis of postoperative complications was performed in the octogenarian subgroup (age ≥80)., Results: A total of 6786 elderly patients who underwent cosmetic procedures were included in the study. Mean ages (±standard deviation) in elderly and younger patients were 69.1 ± 4.1 and 39.2 ± 12.5 years, respectively. The elderly patient population had more men, a higher mean body mass index (BMI), a higher prevalence of diabetes mellitus (DM), and fewer smokers compared with the younger patients. The overall postoperative complication rate was not significantly different between elderly and younger patients. When stratified by type of cosmetic procedure, only abdominoplasty was associated with a higher postoperative complication rate in elderly compared with younger patients. The most common postoperative complications in elderly patients were hematoma and infection. The overall postoperative complication rate in octogenarians was 2.2%, which was not significantly different from the younger population., Conclusions: Cosmetic procedures in elderly patients, including octogenarians, remain safe with an acceptable complication rate compared to younger patients., (© 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Introduction: Resident aesthetic clinics (RACs) have demonstrated good outcomes and acceptable patient satisfaction, but few studies have evaluated their educational, financial, or medicolegal components. We sought to determine RAC best practices., Methods: We surveyed American Council of Academic Plastic Surgeon members (n = 399), focusing on operational details, resident supervision, patient safety, medicolegal history, financial viability, and research opportunities. Of the 96 respondents, 63 reported having a RAC, and 56% of plastic surgery residency program directors responded., Results: RACs averaged 243 patient encounters and 53.9 procedures annually, having been in existence for 19.6 years (mean). Full-time faculty (73%) supervised chief residents (84%) in all aspects of care (65%). Of the 63 RACs, 45 were accredited, 40 had licensed procedural suites, 28 had inclusion/exclusion criteria, and 31 used anesthesiologists. Seventeen had overnight capability, and 17 had a Life Safety Plan. No cases of malignant hyperthermia occurred, but 1 facility death was reported. Sixteen RACs had been involved in a lawsuit, and 33 respondents reported financial viability of the RACs. Net revenue was transferred to both the residents' educational fund (41%) and divisional/departmental overhead (37%). Quality measures included case logs (78%), morbidity/mortality conference (62%), resident surveys (52%), and patient satisfaction scores (46%). Of 63 respondents, 14 have presented or published RAC-specific research; 80 of 96 of those who were surveyed believed RACs enhanced education., Conclusions: RACs are an important component of plastic surgery education. Most clinics are financially viable but carry high malpractice risk and consume significant resources. Best practices, to maximize patient safety and optimize resident education, include use of accredited procedural rooms and direct faculty supervision of all components of care.

Background: Acellular nerve allografts are now standard tools in peripheral nerve repair because of decreased donor site morbidity and operative time savings. Preparation of nerve allografts involves several steps of decellularization and modification of extracellular matrix to remove chondroitin sulfate proteoglycans (CSPGs), which have been shown to inhibit neurite outgrowth through a poorly understood mechanism involving RhoA and extracellular matrix-integrin interactions. Chondroitinase ABC (ChABC) is an enzyme that degrades CSPG molecules and has been shown to promote neurite outgrowth after injury of the central and peripheral nervous systems. Variable results after ChABC treatment make it difficult to predict the effects of this drug in human nerve allografts, especially in the presence of native extracellular signaling molecules. Several studies have shown cross-talk between neurotrophic factor and CSPG signaling pathways, but their interaction remains poorly understood. In this study, we examined the adjuvant effects of nerve growth factor (NGF) and glial cell line-derived neurotrophic factor (GDNF) on neurite outgrowth postinjury in CSPG-reduced substrates and acellular nerve allografts., Materials and Methods: E12 chicken DRG explants were cultured in medium containing ChABC, ChABC + NGF, ChABC + GDNF, or control media. Explants were imaged at 3 d and neurite outgrowths measured. The rat sciatic nerve injury model involved a 1-cm sciatic nerve gap that was microsurgically repaired with ChABC-pretreated acellular nerve allografts. Before implantation, nerve allografts were incubated in NGF, GDNF, or sterile water. Nerve histology was evaluated at 5 d and 8 wk postinjury., Results: The addition of GDNF in vitro produced significant increase in sensory neurite length at 3 d compared with ChABC alone (P < 0.01), whereas NGF was not significantly different from control. In vivo adjuvant NGF produced increases in total myelinated axon count (P < 0.005) and motor axon count (P < 0.01), whereas significantly reducing IB4+ nociceptor axon count (P < 0.01). There were no significant differences produced by in vivo adjuvant GDNF., Conclusions: This study provides initial evidence that CSPG-reduced nerve grafts may disinhibit the prosurvival effects of NGF in vivo, promoting motor axon outgrowth and reducing regeneration of specific nociceptive neurons. Our results support further investigation of adjuvant NGF therapy in CSPG-reduced acellular nerve grafts., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Merkel cell carcinoma (MCC) is a rare and aggressive cutaneous malignancy. Adjuvant radiation increases survival in advanced stages, but efficacy in stage I disease is unknown. A retrospective review included all patients treated for stage I MCC during a 15-year period at Vanderbilt University Medical Center. Among 42 patients, 26 (62%) had a negative sentinel lymph node biopsy (stage IA) and 16 (38%) had clinically negative lymph nodes (stage IB) at the time of resection. Analysis using Cox regression revealed that higher stage and absence of adjuvant radiation are associated with increased disease recurrence (hazard ratio, 6.29; P=0.003 and hazard ratio, 4.69; P=0.013, respectively). Controlling for stage, radiation therapy significantly increased disease-free survival among patients with stage IB disease (P=0.0026) in a log-rank test comparing Kaplan-Meier curves. These findings support adjuvant radiation therapy in stage IB MCC patients with clinically negative lymph nodes who do not undergo sentinel lymph node biopsy.

Background: The authors' earlier retrospective report of surgical complications after abdominal contouring surgery provided evidence that post-bariatric surgery patients are at increased risk of developing wound complications compared with a normal population. This prospective pilot study was designed as a comparative analysis of both surgical and wound healing characteristics between massive weight loss and normal patients who present for abdominal contouring surgery., Methods: Excisional wounds were created and polytetrafluoroethylene tubing was inserted during the preoperative period for later harvesting in patients undergoing abdominal contouring following Roux-en-Y gastric bypass for weight loss (n = 16) or abdominoplasty (n = 17). Wound fluids were sequentially collected from drains and subjected to matrix metalloproteinase (MMP) analysis. Standard postsurgical complications were documented., Results: Surgical complications were more common in weight loss patients (47 percent) than in control patients (25 percent). MMP analyses showed that MMP-9 levels remained significantly elevated at postoperative day 4 in patients who subsequently experienced complications in either the weight loss group (p = 0.02) or the control group (p = 0.03). Other parameters showed no significant differences between massive weight loss patients and controls., Conclusions: Although many markers were examined, the ratio of MMP-9 to albumin was the only predictor of postsurgical complications in any group. This lends further support to growing evidence that MMP-9 may be a useful biomarker of postsurgical complications. This pilot work showed no causal factors that explain the higher rates of postsurgical complications in the post-bariatric surgery patient population., Clinical Question/level of Evidence: Risk, II.

Background: Activation of the P2X7 receptor on peripheral neurons causes the formation of pannexin pores, which allows the influx of calcium across the cell membrane. Polyethylene glycol (PEG) and methylene blue have previously been shown to delay Wallerian degeneration if applied during microsuture repair of the severed nerve. Our hypothesis is that by modulating calcium influx via the P2X7 receptor pathway, we could improve PEG-based axonal repair. The P2X7 receptor can be stimulated or inhibited using bz adenosine triphosphate (bzATP) or brilliant blue (FCF), respectively., Methods: A single incision rat sciatic nerve injury model was used. The defect was repaired using a previously described PEG methylene blue fusion protocol. Experimental animals were treated with 100 μL of 100 μM FCF solution (n = 8) or 100 μL of a 30 μM bzATP solution (n = 6). Control animals received no FCF, bzATP, or PEG. Compound action potentials were recorded prior to transection (baseline), immediately after repair, and 21 d postoperatively. Animals underwent behavioral testing 3, 7, 14, and 21 d postoperatively. After sacrifice, nerves were fixed, sectioned, and immunostained to allow for counting of total axons., Results: Rats treated with FCF showed an improvement compared with control at all time points (n = 8) (P = 0.047, 0.044, 0.014, and 0.0059, respectively). A statistical difference was also shown between FCF and bzATP at d 7 (P < 0.05), but not shown with d 3, 14, and 21 (P > 0.05)., Conclusions: Blocking the P2X7 receptor improves functional outcomes after PEG-mediated axonal fusion., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Hand trauma is the most frequently treated injury in emergency departments, but presently there is a crisis of insufficient emergency coverage. This study evaluates the discrepancy of emergent and elective hand care trends based on socioeconomic factors in the state of Tennessee., Methods: We identified 119 hospitals in Tennessee that contained operating and emergency room facilities. Of these, 111 hospitals participated in a survey to determine the availability of elective and emergency hand surgery. Wilcoxon rank-sum test or permutation chi-square test and logistic regression were used to analyze reported measures., Results: Our results revealed that hospitals in counties with the lowest per capita income and median household income are less likely to have hand specialists or offer hand call. There are also significantly fewer hospitals that have hand specialists and offer hand call that are located in medically underserved areas. In the state of TN, level 1 trauma facilities are required by the Tennessee Department of Health to have staffed hand specialists and 24/7 hand call. Our study revealed that while 7/8 (87.5 %) level 1 trauma facilities have hand specialists, only 2/8 (25 %) provide 24/7 hand specialist call., Conclusion: Our results strongly suggest the presence of a health care disparity for hand trauma in counties with a low income and in medically underserved areas.

Early free flap coverage in lower extremity trauma is a practice largely supported by research that may be outdated and is frequently impractical due to logistics, resuscitation efforts, and associated injuries. Our objective was to re-evaluate this paradigm to determine whether reconstructive timing impacts outcome in modern clinical practice. We reviewed 60 free flaps for traumatic lower extremity coverage from December 2005 to December 2010 by the plastic surgery service at an academic medical center. All reconstructions were >72-hours from injury, spanning from 3 days to 2.2 years. The overall failure rate was 13.3% (8/60). Statistical analysis yielded no significant associations between reconstructive timing and flap failure or morbidity, although there was a trend toward fewer failures among latest reconstructions (>91 days) compared to within 30 days (P = 0.053). These findings support that delays may be safely utilized to allow patient and wound optimization without negatively impacting outcomes in free tissue transfer., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Approximately 12% of operations for traumatic neuropathy are for patients with segmental nerve loss, and less than 50% of these injuries obtain meaningful functional recovery. Polyethylene glycol (PEG) therapy has been shown to improve functional outcomes after nerve severance, and we hypothesized this therapy could also benefit nerve autografting., Methods: We used a segmental rat sciatic nerve injury model in which we repaired a 0.5-cm defect with an autograft using microsurgery. We treated experimental animals with solutions containing methylene blue (MB) and PEG; control animals did not receive PEG. We recorded compound action potentials (CAPs) before nerve transection, after solution therapy, and at 72 h postoperatively. The animals underwent behavioral testing at 24 and 72 h postoperatively. After we euthanized the animals, we fixed the nerves, sectioned and immunostained them to allow for quantitative morphometric analysis., Results: The introduction of hydrophilic polymers greatly improved morphological and functional recovery of rat sciatic axons at 1-3 d after nerve autografting. Polyethylene glycol therapy restored CAPs in all animals, and CAPs were still present 72 h postoperatively. No CAPS were detectable in control animals. Foot Fault asymmetry scores and sciatic functional index scores were significantly improved for PEG therapy group at all time points (P < 0.05 and P < 0.001; P < 0.001 and P < 0.01). Sensory and motor axon counts were increased distally in nerves treated with PEG compared with control (P = 0.019 and P = 0.003)., Conclusions: Polyethylene glycol therapy improves early physiologic function, behavioral outcomes, and distal axonal density after nerve autografting., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Patients undergoing microvascular reconstruction are often anemic from a combination of iatrogenic hemodilution and acute blood losses. No major clinical study describes the impact of preoperative anemia on free flap morbidity. The plastic surgery service at a high-volume academic center performed 156 free flaps among 147 patients from December 2005 to December 2010. One hundred thirty-two had a preoperative hemoglobin (Hb) or hematocrit (Hct), with mean values of 11.8±2.4 g/dL and 35.2%±7.0%, respectively. The overall failure rate was 9% (12/132), primarily from vascular thrombosis (6/12). Through logistic regression analysis, Hb and Hct were significant predictors of flap failure (P<0.005) and vascular thrombosis (P<0.05). Fisher exact test revealed a significant increase in failure risk at Hct level less than 30% (Hb<10 g/dL) (relative risk, 4.76, P=0.006), and probit analysis demonstrated an exposure-response relationship to decreased Hct level (P<0.005). These findings support that preoperative anemia could significantly impact free flap morbidity.

Unlabelled: The FiberLoop suture has been developed as a double stranded, double-armed suture of FiberWire, but has not been previously studied. This is a comparison study of FiberLoop, FiberWire, and Ethibond., Methods: Six groups of bovine tendons were randomly sorted for testing. They were cut and repaired using FiberWire, FiberLoop, and Ethibond with modified Kessler and modified Krackow repair techniques. A 4-0 core suture was used and tested to failure., Results: Both FiberLoop and FiberWire were significantly stronger than Ethibond regardless of the repair technique used. There was no difference between the nonlocking and locking repair technique in any of the suture groups. However, the nonlocking technique failed by tissue pull through while the locking technique failed by suture breakage., Conclusions: The FiberLoop suture and the FiberWire suture were significantly stronger than the Ethibond suture. Additionally, this study shows that the 4-0 suture is of adequate strength to repair a tendon injury. The double-armed Fiberloop may translate into quicker tendon repairs without sacrificing strength.

Background and Purpose: Improvement in axonal regeneration may lead to the development of longer nerve grafts and improved outcomes for patients with peripheral nerve injury. Although the use of acellular nerve grafts has been well documented (Groves et al, Exp Neurol. 2005;195:278-292; Krekoski et al, J Neurosci. 2001;21:6206-6213; Massey et al, Exp Neurol. 2008;209:426-445; Neubauer et al, Exp Neurol. 2007;207:163-170; Zuo et al, Exp Neurol. 2002;176:221-228), less is known about the ability of neurotrophic factors to enhance axonal regeneration. This study evaluates axonal ingrowth augmentation using acellular, chondroitinase-treated nerve grafts doped with nerve growth factor (NGF)., Methods: Acellular chondroitinase-treated murine nerve grafts were placed in experimental (NGF-treated grafts) and control (carrier-only grafts) rats. Five days after implantation, axonal regeneration was assessed by immunocytochemistry along with digital image analysis., Results: Higher axon count was observed throughout the length of the nerve in the NGF group (P < 0.0001), peaking at 3 mm from proximal repair (P = 0.02). Although the NGF group displayed a higher axon count per slice, the mean diameter of individual NGF axons was smaller (P < 0.0001), potentially consistent with induction of sensory axons (Rich et al, J Neurocytol. 1987;16:261-268; Sofroniew et al, Annu Rev Neurosci. 2001;24:1217-1128; Yip et al, J Neurosci. 1984;4:2986-2992)., Conclusion: The simple technique of doping acellular, chondroitinase-treated nerve grafts with NGF can augment axonal ingrowth and possibly preferentially induce sensory axons.

Wrist, hand, and finger trauma are the most common injuries presenting to emergency departments. Shortage of emergency hand care is an emerging problem, as on-call hand coverage declines. This study evaluates the availability of elective and emergency hand surgery services in Tennessee, with the use of telephone surveys administered to emergency department and operating facility management. One hundred eleven Tennessee hospitals completed the surveys (93% response rate). In all, 77% of hospitals offer elective hand surgery, 58% offer basic emergency hand services, 18% offer occasional hand specialist call coverage and only 7% of hospitals have 24/7 hand specialist call coverage. Hospitals with hand specialists have significantly more payer charges from commercial insurance than hospitals without hand specialists (26.1% vs. 16.1%, P < 0.001). Our results strongly support the need for increased emergency hand coverage. Solutions include creating multihospital coordinated call schedules, increasing incentives for call coverage, and training more hand specialists.

Our prospective clinical trial collected sensory data using a computerized pressure-specified sensory device comparing 4 procedures for reduction mammaplasty. A total of 48 patients were assessed at baseline, 6 weeks (n = 42), 6 months (n = 15), and 1 year (n = 24) postoperatively. The findings of our study showed pressure sensitivity for women <43 years of age improved by pressure-specified sensory device assessment; whereas, outcome data merely indicated return to baseline in pressure sensitivity for women ≥ 43 years of age. Improved sensitivities for moving and static pressures were found in patients receiving vertical or inferior pedicle reduction mammaplasties. Reductions based on superior pedicles exhibited sensory loss as compared with baseline measurements while those receiving free nipple grafts showed negligible change. Moving and static sensation showed differential return after breast reduction irrespective of the specific surgical approach but sensation was uniquely conserved for the nipple. In the total cohort, the type of breast reduction procedure did not produce significant differences in breast sensation.

Bioabsorbable plating systems play an integral role in cranial vault remodeling. After experiencing a case of plate failure requiring emergent reexploration, we investigated the potential causes. We hypothesize that extended submersion in the molding bath during plate preparation might advance the rate of hydrolysis and compromise plate structural integrity. Using an absorbable poly-D/L-lactic acid plating system, we assessed the effect of extended submersion on plate strength and stiffness when loaded in a cantilever fashion and with pure tension. We assessed these differences with the Student t test and linear regression modeling. We also generated a computer model of the plates for finite element analysis. When left in the molding bath for extended periods, the plates changed color and lost strength. After 5 minutes, 30% of maximum plate load capacity was lost in a cantilever beam test (P < 0.001) consistent with use of a 15% thinner plate. Tensile testing revealed the initial elastic modulus of 6.42 +/- 0.13 GPa decreased 16% to 5.41 +/- 0.50 GPa after 5 minutes of submersion (P = 0.027). The changes in plate strength and elastic modulus both worsened with increased submersion times. Finite element analysis of the plates also predicted clinically significant increases in plate deviation under normal loading conditions. Our study demonstrates that extended submersion of absorbable plates during molding results in a significant loss of plate strength and stiffness. Further, our computer model predicts that these changes could result in an unacceptable plate deviation under normal loading conditions. Together, these data caution against overmolding of plates to avoid compromising their structural integrity.

Current guidelines used to predict appropriate resection weight for patients undergoing reduction mammaplasty are typically based on relatively nondescript patient characteristics and are most often inaccurate. The determination of patient measurements that correlate with resection weight could enable appropriate resection weight to be predicted more precisely and on an individualized basis. To better elucidate this, data from 348 patients undergoing bilateral reduction mammaplasty (696 breasts) between October 2001 and March 2009 were reviewed retrospectively. The association between resection weight and sternal notch to nipple distance (SNN), inframammary fold to nipple distance (IMFN), and body mass index (BMI) was assessed. Regression analysis demonstrated a strong correlation between resection weight and SNN distance (r = 0.672, P < 0.001), IMFN distance (r = 0.467, P < 0.001), and BMI (r = 0.510, P < 0.001). The strongest correlation was observed after incorporating all 3 parameters (r = 0.740, P < 0.001). This enabled the calculation of a formula to predict resection weight: Predicted weight = 40.0(SNN) + 24.7(IMFN) + 17.7(BMI) - 1443 In conclusion, resection weight correlates strongly with SNN, IMFN, and BMI in patients undergoing reduction mammaplasty. When considered together, resection weight can be predicted with a strong degree of accuracy.

Abdominal contouring operations are in high demand after massive weight loss. Anecdotally, wound problems seemed to occur frequently in this patient population. Our study was designed to delineate risk factors for wound complications after body contouring. Our retrospective institutional analysis was assembled from 222 patients between 2001 and 2006 who underwent either abdominoplasty (N = 89) or panniculectomy (N = 133). Weight loss surgery (WLS) before body contouring occurred in 63% of our patients. Overall the wound complication rate in these patients was 34%: healing-disturbance 11%, wound infection 12%, hematoma 6%, and seroma 14%. WLS patients had an increase in wound complications overall (41% vs. 22%; P < 0.01) and in all categories of wound complications compared with non-WLS-patients by univariate methods of analysis. In a multivariate regression model, only American Society of Anesthesiologists Physical Status Classification was a significant independent risk factor for wound complications. In conclusion, WLS patients are at increased risk for wound complications and American Society of Anesthesiologists Physical Status Classification is the most predictive of risk.

Background: Optimal surgical outcomes are dependent on an appreciation of comorbid conditions that may handicap results. The purpose of this retrospective analysis was to delineate risk factors for complications after autologous breast reconstruction., Study Design: An institutional database was constructed of patients who underwent autologous breast reconstruction from 1998 to 2005. Variables captured included age, diabetes and smoking status, prereconstruction radiation therapy, concomitant breast resection, preoperative albumin, flap type, and body mass index (BMI; based on World Health Organization classifications: BMI>25, overweight; >30, obese). The primary outcome was noninfectious wound complications (NIWC), a novel classification based on the extent of tissue derangement and need for operative intervention. Secondary outcomes were wound infection, hematoma, hernia, and fat necrosis. Statistical analysis was performed using chi-square tests and multiple logistic regression., Results: The analysis included 200 flaps (transverse rectus abdominis myocutaneous [TRAM]=171; latissimus dorsi=29) in 180 patients. There were 19 infections (9.5%), 3 total flap losses (1.5%), 14 hematomas (7%), and 11 donor-site hernias (6%). The incidences of fat necrosis and any NIWC were 18% and 36%, respectively. Mean followup was 13.1 months (range 1.1 to 51.7 months). Multiple logistic regression demonstrated that obesity (BMI>30) is a statistically significant independent risk factor for any NIWC (hazards ratio=6.58; 95% CI, 2.85 to 15.18; p < 0.01) and for NIWC requiring operative treatment (NIWC>or=3; hazard ratio=6.23; 95% CI 2.15 to 18.05; p < 0.01). Increased BMI predicts NIWC, NIWC requiring operative intervention, and wound infection (p < 0.01)., Conclusions: These data suggest that obesity is a strong predictor of simple and complex NIWC and of wound infection after autologous breast reconstruction. Obese patients should be counseled about their significantly increased risk of experiencing these unwanted outcomes.

Background: Studies of alterations in breast sensibility after augmentation mammaplasty have produced conflicting results. Such discrepancies may be attributed to unsophisticated measuring devices used in earlier studies leading to less accurate measurements and to the comparison of results to different surgical techniques. The primary purpose of our study was to conduct a prospective clinical trial to quantify specific sensory outcomes before and after submuscular breast augmentation., Methods: Preoperative and postoperative questionnaires were used to assess patients' subjective observations on breast sensation. Quantitative data were collected using a very accurate device, the Pressure-Specified Sensory Device, to assess objective breast sensation. Thirty-three micromastia patients underwent quantitative measurements preoperatively (baseline), at 2 to 4 weeks and 6 months postoperatively to assess breast sensitivity., Results: The quantitative data showed similar patterns of sensory change between both the periareolar and the inframammary surgical approach over time. The inferior region was the only region that showed a diminished sensitivity threshold of 9.5 +/- 2.9 gm/mm2 for the inframammary incision, a significantly poorer average than the periareolar incision of 1.7 +/- 0.6 gm/mm2 with p = 0.008 at 6 months. Older patients had significantly higher thresholds of sensitivity compared with younger patients (p < 0.02)., Conclusions: Our study suggests that the periareolar incision may produce less sensory loss in the lower pole of the breast when compared with the inframammary incision. The outcome of this study provides both the surgeon and the patient with concrete information regarding mammary sensation after augmentation mammaplasty and leads to a better informed-consent process.

Liposuction typically has a low incidence of complications and is associated with significant cosmetic benefit. In this case, the patient developed a dermatomal rash with vesicles on an erythematous base consistent with herpes zoster 8 days after liposuction to the back and flanks. To the authors' knowledge, herpes zoster has not been previously reported as a complication of liposuction. Although the precise relationship of herpes zoster infection to the liposuction procedure is difficult to determine, mechanical irritation most likely reactivated the varicella zoster virus in the involved dermatomal distribution. The patient was treated with antiviral and analgesic medications and healed without any further complications.

The development of capsular contracture is the most common complication associated with the insertion of breast implants. The authors studied the role of sodium 2-mercaptoethane sulfonate (mesna) in reduction of capsular formation in a rabbit model. Two 40-cc textured saline implants were placed dorsally into each of the 20 rabbits in the study. At the time of insertion of the implants, 10 ml of a 10% solution of mesna was instilled into one of the pockets and normal saline was instilled into the other. The implants were removed and a capsulectomy was performed at 5 months. The capsules were examined histologically for qualitative differences between the two groups. Quantitative analysis of the thickness of the capsule and the myofibroblast populations was also performed and compared between the two groups. The mean total thickness of the capsule around the implants was 496.8 microm in the mesna-treated group compared with 973.7 microm in the saline-treated group (p < 0.001). Likewise, the thickness of the myofibroblast layer was reduced in the mesna-treated group at 283.2 microm versus 555 microm in the saline-treated group (p < 0.0001). The capsules were also relatively less vascular in the mesna-treated group. Because of its ability to reduce the extent of capsular formation and to diminish development of myofibroblasts in the capsules, mesna would appear to be a useful adjunct in the prevention of capsular contracture formation.

Capsular contracture remains the most common adverse sequela of aesthetic and reconstructive breast surgery when breast implants are used. Capsulectomy may be technically difficult and can result in damage to the neighboring tissues. The aim of this study was to verify the efficacy of sodium 2-mercaptoethane sulfonate (mesna) as a facilitator of periprosthetic dissection when instilled locally at the time of capsulectomy. Two 40-cc textured saline implants were placed dorsally into each of 20 rabbits. After 5 months, capsulectomy was performed after the removal of the implants. Mesna was used to highlight the junction between scar and normal tissue and to help separate the tissues during the capsulectomy in one of the two capsules in each rabbit. Saline was used for the same purpose in the other. The blood loss, duration of operation, and difficulty of dissection as experienced by the surgeon were recorded during the course of the operation. The capsules were also examined histologically for their thickness and graded according to their degree of intactness at the conclusion of the procedure. The histological grading based on the intactness of the removed capsule (p = 0.005), the operating time (p = 0.003), and the subjective evaluation of the difficulty of the procedure (p = 0.003) were significantly better in the mesna group. There was no significant difference in the blood loss between the two groups. Because of its ability as a chemical dissector, mesna may be a useful aid in capsulectomy. Clinical studies to confirm this evidence are required.

Laser scar revision was studied to measure the effects of targeting extracellular matrix protein versus tissue water on scar revision. We compared the free electron laser used at 7.7 microm (the amide III protein absorption band) to the carbon dioxide (CO2) laser and dermabrasion.Nude mice (n = 40) that had rejected skin grafts on their dorsal surface and developed mature scars were used as a model for scar revision. One-half of each scar was revised with either the free electron laser at 7.7 microm (32 to 38 mJ, nonoverlapping pulses delivered with a computerized adjustable pattern generator at 30 Hz, and two to three passes), a 100-microsec CO2 resurfacing laser (500 mJ, 5.0 Hz, and two to five passes), or dermabrasion. The untreated portion of each scar served as an internal control. Evaluation was by measurement of the clinical size of the scar using photography with quantitative computer image analysis to compare the data and histology to evaluate the quality and depth of the scars. The free electron laser at 7.7 microm was significantly better than the CO2 laser and dermabrasion for scar size reduction (p < 0.046 and p < 0.018). The CO2 laser and a highly skilled dermabrader were not statistically significantly different (p < 0.44). The result seen with less skilled dermabraders was significantly worse than all other methods (p < 0.009). The free electron laser at 7.7 microm, which is preferentially absorbed by the proteins of the extracellular matrix, provided better scar reduction than the CO2 resurfacing laser and dermabrasion. Dermabrasion by a skilled operator resulted in improvement similar to the results obtained with the CO2 resurfacing laser, but less skilled operators had significantly poorer results.