The latest medical research on Plastic Surgery

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The Role of the Depressor Nasi Septi Muscle in Nasal Air Flow.

Aesthetic Plastic Surgery

Musculus depressor septi nasi and its tendon, the dermocartilaginous ligament, play an important role in external nasal valve and nasal respiration. If the ligament is cut during septorhinoplasty operations, nasal functions of the nose and facial expressions are affected. Therefore, the aim of this study was to investigate the role of M. depressor septi nasi in nasal respiration at open rhinoplasty operations using rhinomanometry and electromyography.

The study included 29 patients who had only external nasal deformity (nasal hump deformity). All patients underwent open rhinoplasty. The dermocartilaginous ligament of the patients in the study group (DCL + group) was repaired but not in the control group (DCL - group). Rhinomanometry and electromyography were applied to all patients preoperatively and postoperatively.

In the DCL - group, right and left nasal airflow values were significantly lower in post-op (562.92 cm3/s and 548.57 cm3/s), whereas right, left, and total nasal resistances were significantly lower in pre-op (0.28 Pa/cm3/s, 0.22 Pa/cm3/s, and 0.11 Pa/cm3/s). Statistically significant differences were not found between rhinomanometric measurements in pre-op and post-op values of the DCL + group. Post-op right, left and mean values of M. depressor septi nasi amplitude in the DCL + group (2.05 mV, 2.0 mV, 2.02 mV) were significantly higher than those in the DCL - group (1.52 mV, 1.61 mV, 1.57 mV).

Repair of the dermocartilaginous ligament during open rhinoplasty operations enhances nasal respiratory functions by expanding the external nasal valve through M. depressor septi nasi and allows the nose to participate in mimic movements.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Advanced Techniques for the Use of Neurotoxins in Non-Surgical Facial Rejuvenation.

Aesthetic Plastic Surgery

Neurotoxins initially were used to treat hyperfunctional rhytids of the face, but now have been expanded to improve facial shaping, correct facial asymmetry and even improve skin texture and tone.

The clinical approach to non-surgical facial rejuvenation is approached into four anatomical regions: the upper face, midface, lower face and neck.

The key muscles of the upper face include frontalis, orbicularis oculi, corrugator supercilii, procerus, depressor supercilii and temporalis. The muscles in the midface to be discussed include the levator labii superioris, levator labii superioris alaeque nasi, depressor anguli oris, depressor septi nasi and nasalis. Treatment of the lower face focuses on the orbicularis oris, mentalis, depressor anguli oris and masseter muscles. Finally, treatment of the neck region will be reviewed with emphasis on platysmal bands and necklace lines as well as the Nefertiti lift.

Non-surgical facial rejuvenation using neurotoxins should be performed safely and effectively in order to avoid and treat complications.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Quality of Surgery and Outcome in Localized Gastrointestinal Stromal Tumors Treated Within an International Intergroup Randomized Clinical Trial of Adjuvant Imatinib.

JAMA Surgery

The association between quality of surgery and overall survival in patients affected by localized gastrointestinal stromal tumors (GIST) is not completely understood.

To assess the risk of death with and without imatinib according to microscopic margins status (R0/R1) using data from a randomized study on adjuvant imatinib.

This is a post hoc observational study on patients included in the randomized, open-label, phase III trial, performed between December 2004 and October 2008. Median follow-up was 9.1 years (IQR, 8-10 years). The study was performed at 112 hospitals in 12 countries. Inclusion criteria were diagnosis of primary GIST, with intermediate or high risk of relapse; no evidence of residual disease after surgery; older than 18 years; and no prior malignancies or concurrent severe/uncontrolled medical conditions. Data were analyzed between July 17, 2017, and March 1, 2020.

Patients were randomized after surgery to either receive imatinib (400 mg/d) for 2 years or no adjuvant treatment. Randomization was stratified by center, risk category (high vs intermediate), tumor site (gastric vs other), and quality of surgery (R0 vs R1). Tumor rupture was included in the R1 category but also analyzed separately.

Primary end point of this substudy was overall survival (OS), estimated using Kaplan-Meier method and compared between R0/R1 using Cox models adjusted for treatment and stratification factors.

A total of 908 patients were included; 51.4% were men (465) and 48.6% were women (440), and the median age was 59 years (range, 18-89 years). One hundred sixty-two (17.8%) had an R1 resection, and 97 of 162 (59.9%) had tumor rupture. There was a significant difference in OS for patients undergoing an R1 vs R0 resection, overall (hazard ratio [HR], 2.05; 95% CI, 1.45-2.89) and by treatment arm (HR, 2.65; 95% CI, 1.37-3.75 with adjuvant imatinib and HR, 1.86; 95% CI, 1.16-2.99 without adjuvant imatinib). When tumor rupture was excluded, this difference in OS between R1 and R0 resections disappeared (HR, 1.05; 95% CI, 0.54-2.01).

The difference in OS by quality of surgery with or without imatinib was associated with the presence of tumor rupture. When the latter was excluded, the presence of R1 margins was not associated with worse OS.

ClinicalTrials.gov Identifier: NCT00103168.

Association of Personality and Thinking Style With Effective Surgical Coaching.

JAMA Surgery

While interest in surgical coaching programs is rising, there is no objective method for selecting effective surgical coaches.

To identify a quantitative measure to determine who will be an effective surgical coach.

This prospective cohort study included coaches and coachees from 2 statewide peer surgical coaching programs: the Wisconsin Surgical Coaching Program and the Michigan Bariatric Surgical Collaborative coaching program. Data were collected from April 2014 to February 2018, and analysis began August 2018.

The Myers-Briggs Type Indicator was administered to coaches and coachees, and the Life Styles Inventory was administered to surgical coaches before their first coaching session.

Coach performance in the first coaching session and all coaching sessions using the Wisconsin Surgical Coaching Rubric.

Twenty-three surgical coaches and 38 coachees combined for a total of 65 unique pairs and 106 coaching sessions. Overall, 22 of 23 coaches (96%) and 32 of 38 coachees (84%) were men. An increase in a coach's Life Styles Inventory constructive style score correlated with an increase in overall coach performance for the first coaching session (r = 0.70; P = .002). Similarity in the coaching pair's Myers-Briggs Type Indicator judging/perceiving dichotomy was also associated with an increase in overall coach performance for their first coaching session (β = 0.38; P = .02). When all sessions were included in the analysis, these objective measures were no longer associated with coach performance.

Surgeons of all personalities and thinking styles can become an effective coach with appropriate training and experience. Coach training can be tailored to support diverse behavioral styles and preferences to maximize coach effectiveness.

Comparison of Volume Retention and Biocompatibility of Acellular Dermal Matrix/Hyaluronic Acid Filler to Autologous Fat Grafts in a Mouse Model.

Aesthetic Plastic Surgery

Although fat grafting has become a widely used technique in aesthetic and reconstructive surgeries, resorption is still a challenge. Micronized acellular dermal matrix (ADM) has been considered as a stable, biocompatible soft tissue coverage material that can be used as a volume filler. Here, we compared the bioacceptance and sustainability of ADM hyaluronic acid (HA) filler with human fat graft in a mouse model.

Harvested human fat and ADM/HA filler were injected randomly on the dorsal side of mice. Thirty-two mice were analyzed over a 7-week period with respect to volume, weight and microscopic evaluations with hematoxylin and eosin (H&E), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) staining.

The volume and weight were maintained at 80% and 83%, respectively, in the ADM/HA filler group and 56.5% and 49.7%, respectively, in the fat-grafted group by the 7th week. There were no significant microscopic differences in inflammatory changes and granulation via H&E staining. At 1 and 2 weeks, EGF and VEGF immunostaining intensity scores were lower in the ADM/HA filler group. At 7 weeks, there were no significant differences in immunostaining intensity scores between the two groups.

During the 7-week experimental period, the ADM/HA filler showed no foreign body reaction and the proper volume was well maintained. This suggests that the ADM/HA filler can possibly be used in small amounts as an alternative to autologous fat grafts.

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authorshttp://www.springer.com/00266.

The Impact of N-Acetylcysteine on Autologous Fat Graft: First-in-Human Pilot Study.

Aesthetic Plastic Surgery

Our goal was to determine whether N-acetylcysteine (NAC) administered to the tumescent solution can reduce oxidative stress and increase autologous fat graft (AFG) viability.

The study included 15 women with a mean age of 31.8 years (range 23-39 years) who underwent breast asymmetry correction with AFG harvested from both thighs. One thigh was infiltrated with a standard tumescent fluid (control graft) and other with a NAC-enriched tumescent fluid (NAC-treated graft). Each participant had breast MRI imaging before and 6 months after the procedure. Also, adipose tissue samples from each graft were subjected to biochemical analysis, flow cytometric assay and qRT-PCR to determine the markers of oxidative stress, angiogenesis and adipogenesis.

Concentration and activity of superoxide dismutase in the NAC-treated grafts turned out to be significantly higher than in the control grafts, in both fresh (p = 0.041 and p = 0.023, respectively) and frozen samples (p = 0.004 and p = 0.003, respectively). The level of nitric oxide in frozen samples from the control grafts was significantly higher than in the NAC-treated grafts (p = 0.009). iNOS was the only qRT-PCR target showing significant intergroup differences, with higher transcription levels observed in the control grafts (p = 0.027). Breast volumetric analysis demonstrated that the NAC-treated group had a 12.19% lower resorption rate than the control group, although it was found to be statistically insignificant (p = 0.149). No postoperative complications were observed during a 6-month follow-up.

Some results of this study are promising. Further studies on larger groups are needed to determine NAC impact on AFG.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Impact of N-Acetylcysteine on Volumetric Retention of Autologous Fat Graft for Breast Asymmetry Correction.

NCT03197103. URL FOR THE REGISTRY: https://clinicaltrials.gov/ct2/show/NCT03197103?term=acetylcysteine&rank=6.

A Simple Method for Quantitative Assessment of Suction Drains.

Aesthetic Plastic Surgery

Suction drains are widely used in surgical practice, but a consensus is yet to be found around their use in plastic surgery. Nowadays, patients are...

Estimation of Contralateral Perfusion in the DIEP Flap by Scoring the Midline-Crossing Vessels in Computed Tomographic Angiography.

Plastic and Reconstructive Surgery

In deep inferior epigastric perforator flap surgery, the amount of perfusion achievable in the contralateral side over a midline is unclear. Predicting contralateral perfusion preoperatively using computed tomographic angiography will allow efficient breast reconstruction with decreased complications. The authors used computed tomographic angiography to determine whether contralateral perfusion is related to blood vessel status across the midline.

Diagnostic, IV.

Ninety-four patients were analyzed. Mean maximal contralateral perfusion length was as follows: grade 0, 7.50 ± 1.89 cm; grade 1, 7.93 ± 2.01 cm; and grade 2, 10.14 ± 2.29 cm. Grade 2 had a statistically significantly greater contralateral perfusion length than grade 0 (p < 0.001) and grade 1 (p < 0.001). Fat necrosis occurred in 27.3 percent (grade 0), 19.1 percent (grade 1), and 8 percent (grade 2), which was statistically significant (p = 0.035).

A definite vessel connection across the midline (as in grade 2) in preoperative computed tomographic angiography indicates that contralateral perfusion will be sufficiently achieved. This vessel scoring system would be helpful in predicting flap perfusion and planning the surgery.

Suppressive Effect of Leukotriene Antagonists on Capsular Contracture in Patients Who Underwent Breast Surgery with Prosthesis: A Meta-Analysis.

Plastic and Reconstructive Surgery

Capsular contracture is a troublesome and distressing complication in mammaplasty or breast reconstruction involving a prosthesis. Previous studies have indicated that leukotriene antagonists effectively reverse capsular contracture. However, this treatment method lacks comprehensive support from evidence-based medicine and remains considerably controversial. In this study, a meta-analysis was conducted to evaluate the therapeutic and preventive effects of leukotriene antagonists on capsular contracture in patients after breast prosthesis implantation.

A comprehensive literature search was performed in English and Chinese databases. All clinical studies assessing the therapeutic and prophylactic effects of leukotriene antagonists on capsule contracture after breast prosthesis implantation were selected. Risk differences and 95 percent confidence intervals were applied as the final pooled statistics.

A total of five eligible studies were included, involving 1710 breast prosthesis implantations. The final results indicated that leukotriene antagonists markedly inhibited capsular contracture formation, with statistical significance at 32.02 (p < 0.001) (pooled risk difference, 0.84; 95 percent CI, 0.79 to 0.89). In subgroup analysis, subgroups based on different leukotriene antagonists included the montelukast and zafirlukast groups, with significant pooled statistical levels of 19.34 (p < 0.001) and 79.48 (p < 0.001), respectively (montelukast: pooled risk difference, 0.83; 95 percent CI, 0.75 to 0.92; zafirlukast: pooled risk difference, 0.85; 95 percent CI, 0.83 to 0.87), indicating that both montelukast and zafirlukast were effective in inhibiting encapsulation.

This meta-analysis demonstrated that leukotriene antagonists (montelukast and zafirlukast) have significant effects in treating and preventing capsular contracture. These medications should be administered in a reasonable and safe way. Further studies of clinical efficacy, duration, safety, and exact mechanism of leukotriene antagonists for periprosthetic capsular contracture are warranted.

Lumbar Flap versus the Gold Standard: Comparison to the DIEP Flap.

Plastic and Reconstructive Surgery

The lumbar artery perforator flap is an excellent free flap for breast reconstruction whenever the deep inferior epigastric perforator (DIEP) flap is not an option. The main indication is a lack of abdominal bulk, often seen in young BRCA-positive women seeking prophylactic amputation and immediate reconstruction.

Between October of 2010 and July of 2016, a total of 661 free flap breast reconstructions were performed. The authors retrospectively analyzed patient demographics, perioperative parameters, and secondary corrections.

Seventy-six lumbar artery perforator flaps were retained and compared with a cohort of 560 DIEP flaps. The average body mass index for lumbar patients was 23.8 kg/m, with a mean age at operation of 46.3 years. Average body mass index for DIEP patients was 25.2 kg/m, with a mean age at operation of 48.8 years old. Lumbar artery perforator flap weight was 504 g (range, 77 to 1216 g) on average versus 530 g (range, 108 to 1968 g) for the DIEP flaps. The amount of corrective procedures performed was very similar in both cohorts: 13 percent of the lumbar artery perforator and 12 percent of the DIEP patients underwent no procedures, 62 percent in both groups underwent one procedure, and 25 percent versus 27 percent underwent two or more procedures. Lipofilling was performed in 48 percent of lumbar artery perforator flaps compared with 57 percent of the DIEP flaps (p = 0.14). Mean volume injected was 98.0 cc and 125.1 cc for lumbar artery perforator and DIEP flaps, respectively (p = 0.071).

The lumbar flap is a good alternative whenever a DIEP flap is not possible. Bilateral autologous reconstruction is possible even in very thin patients, and secondary corrections are comparable to those for the DIEP.

Oncoplastic Procedures in Preparation for Nipple-Sparing Mastectomy and Autologous Breast Reconstruction: Controlling the Breast Envelope.

Plastic and Reconstructive Surgery

Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, such as breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine whether a staged approach would expand the indications for nipple-areolar complex preservation and permit greater control over nipple-areolar complex position and skin envelope following autologous reconstruction.

Therapeutic, IV.

Sixty-one patients with a mean age of 45.1 years (range, 28 to 62 years) and mean body mass index of 32.6 kg/m (range, 23.4 to 49.0 kg/m) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 to 31 weeks). Clear margins were obtained in all cases of invasive cancer and in situ disease following stage 1. Complications following stage 2 included partial nipple-areolar complex necrosis (n = 5, 8.2 percent), complete nipple-areolar complex necrosis (n = 4, 6.6 percent), nipple-areolar complex malposition (n = 1, 1.6 percent), and mastectomy skin necrosis (n = 4, 6.6 percent). No flap loss was noted in this series.

Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented.

Facial Aging: A 54-Year, Three-Dimensional Population Study.

Plastic and Reconstructive Surgery

There is no accurate visual representation of the aging process, one that visually shows how the shape of the face changes with age in a rigorous and three-dimensional way.

A total of 594 subjects were studied. Two hundred eighty three-dimensional images of male faces and 305 three-dimensional images of female faces were categorized into "young" and "old" groups by sex. The mean age of the younger men was 33.6, and the mean age of the older men was 70.3. The mean age of the younger women was 24, and the mean age of the older women was 74. Landmarks were placed on all images, and in the male groups the distances between these landmarks were analyzed with an independent t test to compare the differences between age groups. These measurements were then used to develop validated three-dimensional averaged models of the different groups. These averages were formed into comparative image transitions and studied.

The comparative image transitions of the average young and old faces in this series show accurate and registered age and shape changes. The faces of men and women age in almost identical ways. The images imply that the aging process is not solely along the surface planes of the face but at right angles to it, that is, many of the changes are in and out, not up and down. Males and females seem to age in quantitatively similar ways.

These images are unique in the facial aging literature. The main points and conclusions of this article are derived from and only visible in the comparative image transitions included in this article as supplemental digital content. The reader is encouraged to study them because the side-by-side still images do not show the changes.