Annals of Plastic Surgery

The Value of Business Training in the Quest for Sustainable Health Care Delivery in Plastic Surgery No abstract available

Rembrandt's Aging Face in Plastic Surgical Perspective Background and Aim When the painter Rembrandt van Rijn (1607–1669) died 350 years ago, he left us some 90 self-portraits showing his aging face. Recognizing aging characteristics of the male face is fundamental to the planning of a surgical procedure and a prerequisite when communicating to the male patient. Rembrandt's recordings through the years might offer an optimal aid to train such recognition, provided that they are truthful. In this article, we present an inventory of age-related changes observed in these self-portraits to assess whether they are truthful. Methods High-quality photographs of 25 self-portraits that are generally accepted as works by Rembrandt were independently assessed in a standardized fashion for the presence of 25 aging characteristics, by 2 plastic surgeons and a physician-portraitist. Results The observed proportion of agreement between assessments reached 0.87 (κ = 0.68, indicating good agreement). We found Rembrandt's self-portraits to reflect his facial aging as a chronologically increasing process. Observed characteristics set in as of 1642, the year that he lost his beloved first wife, Saskia. His face appears to have particularly aged from 1652 to 1659, in which period Rembrandt's second great love Hendrickje was summoned because of her living in sin with Rembrandt, and Rembrandt himself faced financial problems. As of 1660, Rembrandt seems to have been less intended to depict his facial aging characteristics. Conclusions We conclude that Rembrandt truthfully reflected his ongoing age in the self-portraits, up to 1660. These self-portraits therefore may allow for training the art of observation of such characteristics.

Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins Background Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery." Methods We evaluated the records of the medical archives of the Johns Hopkins University. Results We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic. Conclusion This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.

Two-Dimensional Ablation of Apocrine Glands With the Use of Hydrosurgical Treatment of Axillary Osmidrosis: An Analysis of 480 Cases Axillary osmidrosis is a distressing social problem. Topical antiperspirants are only transient solutions. Permanent solutions always need invasive operation. In this study, we evaluated the effectiveness and complications of a minor surgical procedure. From January 2010 to December 2017, 480 patients (376 females and 104 males) whose ages ranged from 8 to 72 years, with an average age of 28 years, were treated for axillary osmidrosis with hydrosurgery (Versajet unit surgical instruments) under local anesthesia on an outpatient basis. Patients were followed for 4 to 80 months with an average of 24 months. The total satisfaction rate was 99.6% (478/480). The patient complication rate was 2.7% (13/480) and the wound complication rate was 1.8% (17/960). There was 2 patient (3 axillae) got recurrent malodor cured with second operation. There were no contracture scars, arm abduction limitation, or any nerve injury in our series. The minor procedure can be an efficient and predictable treatment choice for axillary osmidrosis.

Prospective Evaluation of Health After Breast Reduction Surgery Using the Breast-Q, Short-Form 36, Breast-Related Symptoms Questionnaire, and Modified Breast Evaluation Questionnaire Introduction Breast hypertrophy is a condition associated with physical, psychological, and psychosocial problems. The primary aims of this study were to determine the impact of breast hypertrophy and the effects of breast reduction, performed on the basis of well-described inclusion criteria, on general and breast-related health, using both general and diagnosis-specific validated questionnaires. We used a prospective, longitudinal paired study design. A secondary aim was to analyze the relationship between preoperative breast volume, body mass index, sternal notch-to-nipple distance and the weight of resected tissue on the one hand and improvements in health on the other. Methods Three hundred forty-eight consecutive patients undergoing breast reduction were included and the Short-Form 36 (SF-36), Breast-Related Symptoms Questionnaire (BRSQ), Modified Breast Evaluation Questionnaire (mBEQ) and BREAST-Q were distributed preoperatively and 1 year postoperatively. Results A total of 284 (83%) patients answered the questionnaires either preoperatively or postoperatively, or both, and 159 (46%) patients answered both. The breast hypertrophy patients had significantly lower scores preoperatively than the matched normal population when it came to all dimensions of the SF-36 and mBEQ. The preoperative scores for both the BRSQ and BREAST-Q were low. After breast reduction, there were significant improvements in all dimensions of the BRSQ, mBEQ, and Breast-Q and in several dimensions of the SF-36. Conclusions Breast reduction reduces or removes disease-associated pain. It improves or normalizes perceived health and psychosocial self-esteem in slightly obese women or women of normal weight with preoperative breast volumes around 1000 mL. Women with higher preoperative breast volumes and longer sternal notch-to-nipple distances appear to be more satisfied with the cosmetic result postoperatively.

Early Breast Angiosarcoma Development After Radiotherapy: A Cautionary Tale This is a short clinical report depicting an exceptionally early presentation of radiation-induced angiosarcoma and overview of the literature. This case highlights the need for a high level of clinical suspicion in those patients presenting with unresolving cutaneous skin changes after radiotherapy for breast cancer. Breast-conserving therapy, comprising breast-conserving surgery and adjuvant radiotherapy, has largely replaced mastectomy in the treatment of early-stage breast carcinoma. Breast angiosarcoma is a rare but severe long-term complication associated with postoperative radiotherapy (Int J Radiat Oncol Biol Phys. 2002;52:1231–1237). It often presents as a bluish/purple skin lesion in a breast previously treated for breast cancer. This case explores an unexpectedly early presentation of radiation-induced breast angiosarcoma, which was initially thought to be benign bruising. Management remains challenging and prognosis is poor because of its aggressive local and regional invasion and early metastasis, commonly to the lungs and liver. Early surgical resection with wide margins is the treatment of choice (J Plast Reconstr Aesthet Surg. 2011;64:1036–1042).

Keloid Excision and Adjuvant Treatments: A Network Meta-analysis Background Keloid disease treatment continues to be unsatisfactory with high recurrence rates. We evaluated the literature regarding the effectiveness of keloid excision with various adjuvant treatments following surgery and assessed recurrence rates. Methods We systematically searched databases through November 2016. We performed pairwise meta-analyses and Bayesian network meta-analyses on the number of recurrences. Results Following screening, 14 studies including 996 patients with various types of keloids were eligible for inclusion. Patients were categorized based on the receipt of surgery and the type of adjuvant treatment employed afterward. Paired meta-analysis (6 meta-analyses) showed that "excision + 1 adjuvant drug" led to statistically significantly higher odds of recurrence compared to "excision + radiation" (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.35–7.67). Based on the network meta-analyses, the ORs of keloid recurrence following various treatments compared to no excision were as follows: "excision + pressure, 0.18 (95% CI, 0.01–7.07); excision + 2 adjuvants drugs, 0.47 (95% CI, 0.02–12.82); excision + radiation, 0.39 (95% CI, 0.04–3.31); excision + skin grafting, 0.58 (95% CI, 0.00–76.10); excision + 1 adjuvant drug, 1.76 (95% CI, 0.17–21.35); and excision only, 2.17 (95% CI, 0.23–23.95). Conclusions According to our results, "excision + radiation" had significantly better outcomes than excision alone. "Excision + pressure" had better outcomes than excision + any other treatment modality, and excision + nonradiation adjuvant therapies were also better than "excision only," although these findings did not reach statistical significance.

Long-Term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm Background Full-awake hand surgery (FAHS) has been gaining attention in recent years. However, the extent of full-awake approach for longer and more complicated major surgeries for the hand in trauma cases remains unclear. This study aimed to report the clinical nature of major flexor tendon trauma cases with subsequent repair under FAHS. Methods Retrospective study was performed on 9 male patients with an average age of 32.22 (SD, 9.67) years who experienced surgery for major flexor tendon ruptures under FAHS. Besides involving 3 digits in fingers, hand, or forearm, extensive surgery involved 3 cases with surgical dissection similar to the one needed to repair flexor tendons of 3 digits in zone 2. Results The assessment that was performed at least 3 years after surgery included not only the efficacy of FAHS but also the total active range of motion, opposition function, Medsger severity scale, and Disabilities of Arm, Shoulder, and Hand score. All repairs and explorations were performed under FAHS with 2 subjects who needed conversion to general anesthesia owing to intraoperative visual analog scale score of greater than 4. Average surgery duration under FAHS was 225 (170–309) minutes. Through an average follow-up of 4.1 years, all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion and 8 cases, excellent opposition. Median Disabilities of Arm, Shoulder, and Hand score was 15 (9–28.5). Conclusions Full-awake hand surgery is potential surgical approach for major flexor tendon trauma cases resulting in satisfactory long term functional outcome.

Merkel Cell Carcinoma of the Digit Merkel cell carcinoma (MCC) is a biologically aggressive neuroendocrine tumor of the skin. There are roughly 1500 new cases of MCC diagnosed every year in the United States, with an increased incidence over the past 15 years reaching up to 8%. Epidemiological studies show that the highest MCC incidence is seen in men older than 65 years, with a ratio of 0.23 per 10,000 among whites. Merkel cell carcinoma of the skin most commonly presents as a single, rapidly growing, flesh-colored, painless mass. Because MCC is uncommon, histopathological examination is usually delayed. Because of the high mortality rate associated with this aggressive tumor, a multidisciplinary panel is recommended to ensure high-quality coordinated care. The choice of treatment option depends on disease characteristics, staging at presentation, regional lymph node involvement, comorbidities, and performance status of the patient. We report a case of MCC to alert medical professionals of this potentially fatal tumor, as early diagnosis and treatment may improve morbidity and mortality rates.

Tailored Posterior Pharyngeal Fat Grafting Outcomes in Velopharyngeal Insufficiency Managed According to a Simplified Algorithm Background This study aimed to evaluate the outcomes of posterior pharyngeal fat grafting for the management of velopharyngeal insufficiency using a simplified therapeutic algorithm and a tailored surgical technique. Methods This was a prospective study of consecutive nonsyndromic patients with repaired cleft palate and velopharyngeal insufficiency who were stratified according to a simplified algorithm (minimally scarred palate, transverse orientation of levator veli palatini, and pinhole-to-small velopharyngeal gaps) and who underwent tailored posterior pharyngeal fat grafting. The patients were screened for obstructive sleep apnea before and after surgery. Three blinded evaluators randomly rated perceptual speech (hypernasality, audible nasal emission, and intraoral pressure) and nasoendoscopic (velopharyngeal active gap size) characteristics using audio and video recordings. Successful speech outcome was defined as normal or borderline sufficient velopharyngeal function at 15 months after surgery. Results All included patients (n = 96) presented with a preoperative and postoperative low risk of obstructive sleep apnea. At 15 months after surgery, hypernasality (0.26 ± 0.53), audible nasal emissions (0.29 ± 0.48), intraoral pressure (0.1 ± 0.31), and velopharyngeal closure size (1.86 ± 0.34) were significantly decreased (all, P < 0.05) compared with the corresponding preoperative measurements (hypernasality, 2.17 ± 0.75; audible nasal emissions, 1.89 ± 0.82; intraoral pressure, 0.85 ± 0.35; and velopharyngeal closure size, 0.2 ± 0.49). In total, 84 (87.5%) patients showed successful speech outcomes. Conclusions Tailored posterior pharyngeal fat grafting is an effective and safe surgical strategy for the management of velopharyngeal insufficiency in a selected cohort of patients with repaired cleft palate.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
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2841026182

6948891480

alsfakia@gmail.com