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IMPORTANCE: Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL), a rare peripheral T-cell lymphoma, is increasing in incidence. However, many practitioners who treat patients with breast cancer are not aware of this disease. OBJECTIVES: To assess how BIA-ALCL develops, its risk factors, diagnosis, and subsequent treatment and to disseminate information about this entity to the medical field. EVIDENCE REVIEW: A literature review was performed in an academic medical setting. All review articles, case reports, original research articles, and any other articles relevant to BIA-ALCL were included. Data on BIA-ALCL, such as pathophysiology, patient demographics, presentation, diagnosis, treatment, and outcomes, were extracted. Particular focus was paid to age, time to onset, implant type, initial symptoms, treatment, and survival. The search was conducted in January 2017 for studies published in any year. FINDINGS: After duplicates were excluded, 304 relevant articles were assessed, and 115 were included from the first documented case in August 1997 through January 2017. Thirty review articles, 44 case reports or series, 15 original research articles, and 26 “other” articles (eg, techniques, special topics, letters) were reviewed. A total of 93 cases have been reported in the literature, and with the addition of 2 unreported cases from the Penn State Health Milton S. Hershey Medical Center, 95 patients were included in this systematic review. Almost all documented BIA-ALCL cases have been associated with a textured device. The underlying mechanism is thought to be due to chronic inflammation from indolent infections, leading to malignant transformation of T cells that are anaplastic lymphoma kinase (ALK) negative and CD30 positive. The mean time to presentation is approximately 10 years after implant placement, with 55 of 83 (66%) patients initially seen with an isolated late-onset seroma and 7 of 83 (8%) with an isolated new breast mass. Ultrasonography with fluid aspiration can be used for diagnosis. Treatment must include removal of the implant and surrounding capsule. More advanced disease may require chemotherapy, radiotherapy, and lymph node dissection. CONCLUSIONS AND RELEVANCE: Breast implant–associated anaplastic large cell lymphoma is a rare cancer in patients with breast implants but is increasing in incidence. It is important for all physicians involved in the care of patients with breast implants to be aware of this entity and be able to recognize initial symptoms.

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The Brent technique for microtia repair was first published in 1974 and developed from principles espoused by Tanzer. This process involves careful meticulous planning with creation of preoperative templates. The surgical reconstruction involves 4 stages. Stage 1 is started as early as 6 years of age with harvest of a contralateral costal cartilage and subdermal placement through an anterior auricular incision. Additional stages involved creation and inset of a lobule, elevation of the auricle and creation of a posterior sulcus and grafting of a tragus and deepening of the conchal bowl. Long-term outcomes are successful with this technique with minimal incidence of infection, extrusion, and hematoma. These cartilage constructs grow simultaneously with the patient and the unaffected ear. [ABSTRACT FROM AUTHOR]

Objective To describe the technique and results of structural fat grafting in cleft lip revision, including patient satisfaction and aesthetic outcome.Design Retrospective case seriesSetting Multidisciplinary cleft care center.Patients All patients who underwent structural fat grafting between June 2006 and September 2012 for cleft lip revision, with appropriate photographic follow-up included. Twenty-two cases were reviewed; 18 had sufficient data to be included.Interventions Patients underwent structural fat grafting for cleft lip revision, most commonly injecting fat under deficient philtral columns, the nostril base, and upper lip.Main Outcome Measures Blinded observers rated outcomes using the Asher-McDade nasolabial appearance rating scale. Patients completed questionnaires assessing their satisfaction. A paired Student's t-test was used to test outcomes for significance (alpha = 0.05).Results Patients were an average of 16 years old (range 6-43); average length of follow up was 11.7 months. Overall symmetry and aesthetics were improved based on the nasal form (P= 0.006) and vermillion border (P - 0.04) when rated using the Asher-McDade scale. No complications were recorded. Patients were significantly happier with their appearance after fat grafting (P < 0.001) and were uniformly positive when questioned about the ease of the surgery and rate of recovery.Conclusions Structural fat grafting is a safe and effective way to improve symmetry and enhance facial proportions in patients with cleft lip. Given the high degree of patient satisfaction, few complications, and durable results, fat grafting offers many advantages in cleft lip revision.

Objective To compare facial growth characteristics in patients with cleft palate who have undergone pharyngeal flap with those who had palatal lengthening or pharyngoplasty and to control subjects who have not had surgery for velopharyngeal insufficiency (VPI).Design Matched retrospective cohort study.Setting Multidisciplinary cleft care center.Patients All patients with cleft palate who had undergone pharyngeal flap or pharyngoplasty/palatal lengthening for VPI were included. Patients with craniofacial syndromes or those who had undergone maxillary protraction were excluded. A control group did not undergo surgery for VPI. The three groups were matched based on cleft type and ages at VPI surgery and cephalogram.Main Outcome Measures Thirteen craniofacial measurements were evaluated on postoperative cephalograms using an analysis of variance with a Bonferroni adjustment for significant measures (a = 0.05).Results Seventy-two patients were included; mean ages at VPI surgery and postoperative cephalogram were 5 and 8 years, respectively. Twelve of thirteen craniofacial measures were not significantly different; notably, this included maxillary height and projection. Only gonial angle was found to differ significantly (P= .018) in that pharyngoplasty and pharyngeal flap yielded a smaller angle compared with that in control subjects.Conclusion Facial growth, and in particular maxillary growth, was not altered as expected after pharyngeal flap surgery. Pharyngeal flap appears to be equivalent to pharyngoplasty and palatal lengthening in that no significant effects on early facial growth were detected after surgery for VPI in this cohort of children with cleft palate.

Interest in global burden of disease that can be surgically treated is on the rise, and plastic surgeons, with a wide scope of practice, have the tools that make them integral in providing much of the needed surgical support in the world. Since the 1950s, plastic surgeons have been closely involved in volunteer surgery, and it is through the success and growth of organizations such as Interplast and Operation Smile that we are able to take part in the current paradigm shift to local empowerment and self-sufficiency instead of service delivery alone. This kind of growth started with medical mission work that fostered international partnerships and that remain an important aspect of addressing the unmet surgical burden of disease. Building a mission comprised of an international team of volunteers that travels to a resource-limited environment and provides top-quality surgical care is not without challenges. The aim of this article is to discuss some of these challenges and how they might be overcome.

After studying this article, the participant should be able to: 1. Describe the anatomy and subunits of the mandible. 2. Review the cause and epidemiology of mandible fractures. 3. Discuss the preoperative evaluation and diagnostic imaging. 4. Understand the principles and techniques of mandible fracture reduction and fixation.

The etiology of Dupuytren’s disease is unknown. The causes of the fibroplastic response of nodules, fibrosis of cords, and prominence of pacinian corpuscles are not evident. Histological and immunohistology differences in pacinian corpuscles from the hands of five patients with Dupuytren’s disease compared with 17 Dupuytren’s-free patients are presented. Histological sections of pacinian corpuscle specimens were stained with hematoxylin and eosin and immunostained for nerve growth factor receptor. The length and width of intact pacinian corpuscles were measured, and the number of layers within each corpuscle was counted and recorded. Grossly, the pacinian corpuscles from Dupuytren’s patients were larger and more numerous compared with those from unaffected patients. When measured microscopically, the pacinian corpuscles from Dupuytren’s diseased fascia were significantly larger (2.0 × 1.1 mm) compared with controls (1.5 × 0.78 mm). The pacinian corpuscles from Dupuytren’s-affected patients had significantly more layers (64 ± 14) compared with those from control patients (40 ± 9). Nerve growth factor receptor staining of pacinian corpuscles from patients affected with Dupuytren’s disease showed greater intensity and more area stained compared with unaffected controls. It is suggested that nerve growth factor may be involved in the increased size of pacinian corpuscles in Dupuytren’s-affected fascia. It is proposed that the cellular outgrowth from pacinian corpuscles may generate the cells that develop into Dupuytren’s nodules.

Traditional microsurgery involves the use of bulky and expensive stereo microscopes that have limited portability. Recent advances in video technology have enabled the exploration of alternative visualization methods. The purpose of this study was to evaluate standard laparoscopic equipment for microvascular anastomoses. Eight surgeons completed anastomoses on rat femoral and synthetic vessels using stereo microsurgery and video microsurgery visualization systems. All surgeons had previous experience with stereo microsurgery and none had ever used video microsurgery. Data were collected on overall anastomosis and individual suture times. A sample of completed anastomoses was placed in a video database and evaluated by use of a quality rating scale 8 to 10, excellent 6 to 7, adequate less than 6, poor. All surgeons subjectively evaluated the video microsurgery system. A total of 48 anastomoses were completed. The average total anastomosis time for the stereo microsurgery was 1018.9 ± 463.2 seconds versus 1738.9 ± 460.1 seconds for the video microsurgery. The average individual suture placement time was 114.6 ± 60.6 seconds for the stereo microsurgery versus 211.7 ± 128.4 seconds for the video microsurgery p< 0.05. Twentyfive of the anastomoses underwent quality review. The overall score of the stereo microsurgery group was 8.1 ± 1.7, and the video microsurgery group had an overall score of 7.3 ± 1.6. Survey results revealed that 75 percent of the participants thought that the video microsurgery would be useful for human operations and would improve surgeon comfort, but 87.5 percent would not use the present video microsurgery system over stereo microsurgery in their practice. Although significant differences exist in overall anastomosis and individual suture completion times, no difference was found in the overall quality. Video microsurgery could become a useful tool on the basis of surgeon ergonomics however, optical parameters require further refinement. Plast. Reconstr. Surg.108 864, 2001.

Repair of incision wounds closed by suturing is evaluated by the progressive gain in wound breaking strength. Previously the closure of open wounds in rats ingesting vanadate, an inhibitor of tyrosine phosphate phosphatases, was shown to occur with deposition of more uniformly organized collagen fiber bundles. The hypothesis of this study was that deposition of more uniformly organized collagen fibers would enhance the gain in wound breaking strength of incisional wounds. Six adult rats received vanadatesupplemented saline drinking water for 1 week before placement of two 6cm, parallel, sutureclosed wounds on their backs. Six control rats received identical wounds and were given saline drinking water. The drinking water regimen was continued for 1 week after wounding, and then wound strength was tested with a tensiometer and tissue samples were obtained for histologic evaluation. Wound breaking strength doubled in vanadatetreated rats compared with controls. Brightfield and polarized light microscopy showed that the connective tissue matrix of granulation tissue from control rats was oriented perpendicular to the surface of the skin. In contrast, the connective tissue matrix of granulation tissue from vanadatetreated rats was oriented parallel to the skin surface. The gap in granulation tissue between the edges of the wounds in the vanadatetreated rats was greater than that in controls. Electron microscopy showed that wounds in the vanadatetreated contained uniform collagen fibers that were 20 percent greater in diameter and more evenly spaced than they were in controls. It is proposed that these changes in the organization of collagen fibers within incisional wounds were responsible for the increased wound breaking strength observed in rats ingesting vanadate. Plast. Reconstr. Surg.107 471, 2001.

The efficacy of intraoperative expansion in reducing the tension of wound closure was tested in young pigs. The young piglet as a model for studying human skin was characterized by finding a close similarity between the modulus of elastiticy of young piglet skin and human abdominoplasty and mammaplasty skin (range 12.8 to 23.7 N/mm2for piglet skin, 14.3 to 19 N/mm2for human skin).

The efficacy of presuturing was tested by quantitating the tissue gains for standardized wounds in a white swine piglet 9 to 11kg model. Also measured were the changes in wound closure tension for the wounds. Measurements were carried out at 1, 4, 17, 24, 48, and 72 hours in a total of 20 piglets. Presuturing was carried out on one of the flanks and the opposite flank served as the control. Presuturing achieved a modest tissue gain, amounting to 67 mm at 4 hours and a maximum of 1.4 cm at 48 and 72 hours, for a 4cm defect. The encouraging tissue gain was unfortunately not paralleled by a decrease in the tension required to approximate the wound edges. At 4 hours, the tension to close the wound was 1.2 N only 120 g less than the control wound. This initial small reduction in woundclosing tension was diminished thereafter, and at 72 hours the wounds were stiffer and harder to close than the control. This appeared to be due to tissue edema and was confirmed by an increase in measurable tissue water with increasing time. In this model, presuturing produces a minimal tissue advancement and even less reduction in woundclosing tension. It is concluded, from this work and from previously published work, that undermining will prove generally to be a more useful technique in closing broad defects. Plast. Reconstr. Surg.96 807, 1996.

Global medicine and international rotations are becoming increasingly popular and relevant in training the next generation of Plastic Surgeons. The Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties have started to address the issues that will ensure our residents are protected as well as ensuring that they gain a valuable educational experience. The principles and the process for getting an International Rotation approved by the Plastic Surgery Residency Review Committee are outlined in this article.