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Background: The increasing utilization of laser and light-based technologies in plastic surgery has heightened the need for comprehensive training programs within residency programs, allowing trainees to remain competitive in the cosmetic medicine field., Objectives: This review intends to describe our trainees' experience with lasers in their last 2 years of training while participating in their resident cosmetic clinic., Methods: This retrospective chart review examines laser procedures conducted from 2021 to 2023 within the Resident Cosmetic Clinic at the study institution. Data were gathered from internal records and patient charts, focusing on demographics, procedure types, complication rates, and training structures., Results: This study analyzed 162 resident cosmetic laser, light-based device, and radiofrequency cases between 2021 and 2023. There were 90 patients with an average age of 46.8 years with the majority being females (95.6%). Intense pulsed light was the most frequently used modality used in 46.01% of procedures. The overall complication rate was 6.17%., Conclusions: The findings suggest that resident laser clinics, under proper supervision, provide a safe and effective training ground for future plastic surgeons. This study underscores the need for standardized and comprehensive education to enhance resident knowledge and skills in laser and other energy-based devices., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Soft tissue and cutaneous tension is an important contributor to complicated wound healing and poor scar cosmesis after surgery and its mitigation is a key consideration in aesthetic and reconstructive procedures., Objectives: The study objective was to assess the efficacy of the force modulating tissue bridge (FMTB) ("Brijjit", Brijjit Medical Inc., Atlanta, GA) in reducing mechanical tension on postoperative wounds., Methods: A prospective, single-center, randomized, within-subject clinical trial was conducted to evaluate wound healing and nascent scar formation after 8 weeks of postoperative wound support with the FMTB. Patients received standard of care (SOC) subcuticular closure on the vertical incision of 1 breast and experimental closure with the FMTB on the contralateral incision after Wise-pattern reduction mammaplasty. Three-dimensional wound analysis and rates of T-junction dehiscence were evaluated by clinical assessment at 2, 4, 6, and 8 weeks postsurgery., Results: Thirty-four patients (n = 68 breasts) completed 8 weeks of postoperative FMTB application. There was a reduced rate of T-junction wound dehiscence in FMTB breasts (n = 1) vs SOC breasts (n = 11) (P < .01). The mean vertical incision wound area during the intervention period was significantly decreased in the FMTB breast (1.5 cm2) vs the SOC breast (2.1 cm2) (P < .01) and was significantly lower at 2-, 4-, and 8-week follow-up (P < .01). Only the closure method was significantly associated with variations in Week 8 wound area (P < .01) after linear regression modeling., Conclusions: FMTBs decrease nascent scar dimensions and reduce the occurrence of wound dehiscence. This study provides evidence that the use of continuous mechanomodulation significantly reduces postoperative wound complications after skin closure., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society.)

Summary: In the occipital trigger site for migraine, the greater occipital nerve (GON) is thought to be irritated by surrounding structures, including the semispinalis capitis muscle and occipital artery (OA), producing headaches in the back of the neck. Thus, standard decompression involves removal of surrounding tissue and dissection away from the vessel. The authors noticed a consistent pattern between the GON and OA more distally: the OA approaching laterally and diving under the GON, the OA looping back over the GON and intertwining with the medial branch of the GON, and lastly the OA traveling parallel to the GON. The technique described uses a modified endoscopic approach with a counter incision, endoscopic assistance, and radical artery lysis to address distal sites in addition to the standard release. At the counter incision, distal intertwining between vessel and nerve was released. A high-definition endoscope was used to address dynamic compression points more proximally, including hidden areas where the vessel dives under the GON, as well as to facilitate cautery and removal of the vessel. Without the use of an endoscope and counterincision, it is difficult to achieve complete decompression of the nerve distally without injury to the proximal body of the nerve., (Copyright © 2023 by the American Society of Plastic Surgeons.)

This article accompanying these videos will describe the technique created and innovated by the senior author for gluteal augmentation with autologous fat transfer. While the principles of gluteal fat grafting originated with Pitanguy, Regnault, Gonazalez, and Spina, the nuances vary greatly from surgeon to surgeon. Although there is much controversy regarding gluteal fat grafting, the major principle of avoiding intramuscular injection is the central pillar of safe and effective augmentation today. The senior author fine-tuned his method to optimize patient outcomes over the past 14 years and demonstrated lasting, aesthetic results while maximizing patient safety with his technique. More recently, the senior surgeon has developed the Hybrid Technique, involving manual injection of fat through a syringe and a power-assisted cannula to maximize aesthetic outcomes while adhering to safety principles. This method follows the deep and moderate depth subcutaneous injection principle while respecting the muscular, neurovascular, and ligamentous anatomy of the buttock., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: Methods that aim to accurately measure and predict breast development can be utilized in gender-affirming treatment planning, patient education, and research., Objectives: The authors sought to evaluate whether three-dimensional (3D) stereophotogrammetry accurately measures transfeminine breast volume changes on a masculine frame when simulating anticipated changes in soft tissue after gender-affirming surgical therapy. Then, we describe the innovative application of this imaging modality in a transgender patient to illustrate the potential role of 3D imaging in gender-affirming surgical care., Methods: A 3D VECTRA scanner (Canfield, Fairfield, NJ) was used to measure anthropometric breast measurements. Postoperative changes in breast volume were simulated on a cardiopulmonary resuscitation mannequin using 450 cc MENTOR breast implants (Mentor Worldwide LLC, Irvine, CA). To demonstrate the ability of the VECTRA to accurately simulate transfeminizing augmentation in practice, we describe its use in a 30-year-old transgender female with a 2-year history of gender-affirming hormone therapy, presenting for gender-affirming surgical care., Results: In the mannequin, mean breast volumes were 382 cc on the right (range 375-388 cc), and 360 cc on the left (range 351-366 cc). The average calculated difference in volume between the 2 sides was 22 cc (range 17-31 cc). There were no instances where the left side was calculated to be larger than the right or where the calculated size was smaller than the actual implant size., Conclusions: The VECTRA 3D camera is a reliable and reproducible tool for preoperative assessment, surgical planning, and simulating breast volume changes after gender-affirming surgery., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society.)

Background: The greater occipital nerve is a common compression site for migraine or chronic headache, and variable relationships with the occipital artery have been shown in anatomical studies. Despite surgical decompression, there are still a subset of patients who have an incomplete response. In this article, the authors describe an observed clear and very consistent pattern between the nerve and artery, including both dynamic and static compression points, that must be evaluated for adequate treatment., Methods: Seventy-one patients underwent occipital nerve decompression with high-definition videos and photographs, and the dynamic relationship between the greater occipital nerve and the occipital artery was recorded in a retrospective review., Results: A consistent pattern existed in 92 percent of patients, as follows: (1) hidden proximal dynamic compression of the bottom surface of the nerve as the occipital artery comes laterally to dive under the greater occipital nerve; (2) more apparent dynamic compression on the upper surface of the nerve as the occipital artery loops back on top of the greater occipital nerve; (3) intertwining compression after the bifurcation of the greater occipital nerve as the artery wraps around the medial branch; and (4) parallel travel of the terminal branch of the greater occipital nerve with the occipital artery in close proximity., Conclusions: There is a consistent pattern in the relationship between the greater occipital nerve and the occipital artery after its exit from the trapezius fascia. It is possible that this relationship creates dynamic compression points, including hidden areas, that can only be deactivated by radical excision of the vessel., Competing Interests: Disclosure:The authors have no conflicts of interest or financial disclosures to report., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Patients increasingly use photographs taken with a front-facing smartphone camera-"selfies"-to discuss their goals with a plastic surgeon. The purpose of this study was to quantify changes in size and perception of facial features when taking a selfie compared to the gold standard of clinical photography., Methods: Thirty volunteers took three series of photographs. A 12-inch and 18-inch series were taken with a front-facing smartphone camera, and the 5-foot clinical photography series was taken with a digital single-lens reflex camera. Afterward, subjects filled out the FACE-Q inventory, once when viewing their 12-inch selfies and once when viewing their clinical photographs. Measurements were taken of the nose, lip, chin, and facial width., Results: Nasal length was, on average, 6.4 percent longer in 12-inch selfies compared to clinical photography, and 4.3 percent longer in 18-inch selfies compared to clinical photography. The alar base width did not change significantly in either set of selfies compared to clinical photography. The alar base to facial width ratio represents the size of the nose in relation to the face. This ratio decreased 10.8 percent when comparing 12-inch selfies to clinical photography (p < 0.0001) and decreased 7.8 percent when comparing 18-inch selfies to clinical photography (p < 0.0001)., Conclusions: This study quantifies the change in facial feature size/perception seen in previous camera-to-subject distance studies. With the increasing popularity of front-facing smartphone photographs, these data allow for a more precise conversation between the surgeon and the patient. In addition, the authors' findings provide data for manufacturers to improve the societal impact of smartphone cameras., Clinical Question/level of Evidence: Diagnostic, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: The rapidly increasing modalities and mediums of clinical photography, use of 3-dimensional (3D) and 4-dimensional (4D) patient modeling, and widening implementation of cloud-based storage and artificial intelligence (AI) call for an overview of various methods currently in use as well as future considerations in the field., Objectives: Through a close look at the methods used in aesthetic surgery photography, clinicians will be able to select the modality best suited to their practice and goals., Methods: Review and discussion of current data pertaining to: 2-dimensional (2D) and 3D clinical photography, current photography software, augmented reality reconstruction, AI photography, and cloud-based storage., Results: Important considerations for current image capture include a device with a gridded viewing screen and high megapixel resolution, a tripod with leveling base, studio lighting with dual-sourced light, standardized matte finish background, and consistency in patient orientation. Currently, 3D and 4D photography devices offer advantages such as improved communication to the patient on outcome expectation and better quality of patient service and safety. AI may contribute to post-capture processing and 3D printing of postoperative outcomes. Current smartphones distort patient perceptions about their appearance and should be used cautiously in an aesthetic surgery setting. Cloud-based storage provides flexibility, cost, and ease of service while remaining vulnerable to data breaches., Conclusions: While there are advancements to be made in the physical equipment and preparation for the photograph, the future of clinical photography will be heavily influenced by innovations in software and 3D and 4D modeling of outcomes., (© 2021 The Aesthetic Society.)

The evidence that BCG (bacille Calmette-Guerin) vaccine may increase the ability of the immune system to fight off pathogens other than tuberculosis has been studied in the past. This nonspecific immunity gained our interest, especially after initial reports of less cases in countries with universal BCG vaccination. In hopes of possible protective immunity, all staff of the Emirates International Hospital (United Arab Emirates) were offered a booster BCG vaccine in early March 2020. All the hospital staff were then tested for Covid-19 infection by the end of June 2020. We divided the subjects into two groups: booster vaccinated versus unvaccinated. The rate of Covid-19 infection was compared between the groups. Criteria included all staff who were offered the vaccine. Seventy-one subjects received the booster vaccination. This group had zero cases of positive COVID 19 infection. Two hundred nine subjects did not receive the vaccination, with 18 positive PCR confirmed COVID 19 cases. The infection rate in the unvaccinated group was 8.6% versus zero in the booster vaccinated group (Fisher's exact test p -value = .004). Our findings demonstrated the potential effectiveness of the booster BCG vaccine, specifically the booster in preventing Covid-19 infections in an elevated-risk healthcare population.

Background: Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves., Aim: To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve., Methods: Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed., Results: While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression., Conclusion: Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON., Competing Interests: None

The advent of three-dimensional (3D) printing in the 1980s ushered in a new era of manufacturing. Original 3D printers were large, expensive and difficult to operate, but recent advances in 3D printer technologies have drastically increased the accessibility of these machines such that individual surgical departments can now afford their own 3D printers. As adoption of 3D printing technology has increased within the medical industry so too has the number of 3D printable materials. Selection of the appropriate printer and material for a given application can be a daunting task for any clinician. This review seeks to describe the benefits and drawbacks of different 3D printing technologies and the materials used therein. Commercially available printers using fused deposition modelling or fused filament fabrication technology and relatively inexpensive thermoplastic materials have enabled rapid manufacture of anatomic models and intraoperative tools as well as implant prototyping. Titanium alloys remain the gold-standard material for various implants used in the fixation of craniofacial or extremity fractures, but polymers and ceramics are showing increasing promise for these types of applications. An understanding of these materials and their compatibility with various 3D printers is essential for application of this technology in a healthcare setting.

The COVID-19 pandemic has necessitated a reorganization of healthcare delivery, shedding light on the many unrealized advantages telehealth has to offer. In addition to facilitating social distancing, minimizing the risk of pathogen exposure, and preserving healthcare resources, there are many benefits of utilizing this platform that can extend beyond the current pandemic, which will change the way healthcare is delivered for generations to come. With the rapid expansion of telehealth, we present data from our high-volume academic institution's telehealth efforts, with a more focused analysis of plastic surgery. Although state legislation regarding telehealth varies greatly, we discuss challenges such as legal issues, logistical constraints, privacy concerns, and billing. We also discuss various advantages and the future direction of telehealth not only for plastic surgery but also its general utilization for the future of medicine in the United States., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Migraine surgery is an increasingly popular treatment option for migraine patients. The lesser occipital nerve is a common trigger point for headache abnormalities, but there is a paucity of research regarding the lesser occipital nerve and its intimate association with the spinal accessory nerve., Methods: Six cadaver necks were dissected. The lesser occipital, great auricular, and spinal accessory nerves were identified and systematically measured and recorded. These landmarks included the longitudinal axis (vertical line drawn in the posterior), the horizontal axis (defined as a line between the most anterosuperior points of the external auditory canals) and the earlobe. Mean distances and standard deviations were calculated to delineate the relationship between the spinal accessory, lesser occipital, and great auricular nerves., Results: The point of emergence of the spinal accessory nerve was determined to be 7.17 ± 1.15 cm lateral to the y axis and 7.77 ± 1.10 caudal to the x axis. The lesser occipital nerve emerges 7.5 ± 1.31 cm lateral to the y axis and 8.47 ± 1.11 cm caudal to the x axis. The great auricular nerve emerges 8.33 ± 1.31 cm lateral to the y axis and 9.4 ±1.07 cm caudal to the x axis. The decussation of the spinal accessory and the lesser occipital nerves was found to be 7.70 ± 1.16 cm caudal to the x axis and 7.17 ± 1.15 lateral to the y axis., Conclusion: Understanding the close relationship between the lesser occipital nerve and spinal accessory nerve in the posterior, lateral neck area is crucial for a safer approach to occipital migraine headaches, occipital neuralgia, and new daily persistent headaches and other reconstructive or cosmetic operations.

Background: Migraine headache is associated with high costs, but changes over time of inpatient burden in the United States are unknown. Understanding longitudinal trends is necessary to determine the costs of evolving inpatient treatments that target biological factors in the generation of pain such as vasodilation and aberrant activity of trigeminal neurotransmitters. We report the migraine hospital burden trend in the United States over 15 years., Methods: Data from the Nationwide Inpatient Sample of the Hospitalization Cost and Utilization Project databases were analyzed from 1997 to 2012. Inpatient costs were reported in dollars for the cost to the institution, whereas charges reflect the amount billed. These parameters were trended and the average annual percent change was calculated to illustrate year-to-year changes., Results: Overall discharges for migraine headache reached a low of 30,761 discharges in 1999, and peaked in 2012 with 54,510 discharges. Average length of stay decreased from 3.5 days in 1997 to 2.8 days in 2012. Total inpatient charges increased from $176 million in 1999 to $1.2 billion in 2012. Inpatient costs totaled $322 million in 2012, with an average daily cost of $2,111., Conclusions: Inpatient burden rapidly increased over the analyzed period, with hospital charges increasing from $5,939 per admission and $176 million nationwide in 1997, to $21,576 per admission and $1.2 billion nationwide in 2012. This trend provides context for research examining cost-effectiveness and quality of life benefits for current treatments. The study of these parameters together with better prevention and improved outpatient treatment may help alleviate the inpatient burden of migraine., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Successful penile replantations are rarely reported in the literature and are associated with significant complications. We present a case of a patient who auto-amputated his penis. Delayed microvascular replantation was performed approximately 14 hours following injury. He was treated with a phosphodiesterase inhibitor postoperatively, and adjuvant hyperbaric oxygen (HBO2) therapy was started 58 hours after replantation; 20 treatments at 2.4 atmospheres absolute (ATA), twice daily for eight days, followed by once daily for four days. Perfusion of the replanted penis was serially assessed using fluorescent angiography. With some additional surgical procedures including a split- thickness skin graft to the shaft due to skin necrosis he has made a complete recovery with return of normal urinary and sexual function. This unusual case illustrates the potential benefit of HBO2 therapy in preserving viability of a severed body part. Fluorescent angiography may have potential utility in monitoring efficacy of HBO2., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright© Undersea and Hyperbaric Medical Society.)

Surgical treatment of migraine headaches involves avulsion or decompression of the affected peripheral nerves. One of the sites targeted is site II, the zygomaticotemporal branch of the trigeminal nerve. Although traditionally the procedure involved either an endoscopic or transpalpebral approach to access the nerve, both methods involve general anesthesia in an operating room. The senior authors developed a new technique to directly access the nerve by means of a transverse lateral canthal extension incision that can be performed under local anesthesia in an office setting. A cadaver dissection to assess safety and anatomical variability was performed with visualization and complete avulsion of the zygomaticotemporal branch of the trigeminal nerve in all cases, with no injury to surrounding structures. An office-based procedure for zygomaticotemporal branch of the trigeminal nerve compression can help reduce the risks and costs associated with a general anesthetic and can be used for patients with isolated migraines localized to the zygomaticotemporal branch of the trigeminal nerve or recurrent secondary triggers to that area. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Background: Random pattern skin flaps are applicable for reconstructing any defect in plastic surgery. However, they are difficult to apply because of necrosis. Sumatriptan, a selective 5-hydroxytryptamine 1b/1d agonist, is routinely used to offset acute migraine attacks. Recent studies have suggested that sumatriptan may induce vasodilation at lower concentrations. The authors' aim is to investigate the effect of sumatriptan on skin flap survival and the role of nitric oxide in this phenomenon., Methods: Seventy-two male Sprague-Dawley rats were divided into eight groups. Increasing doses of sumatriptan (0.1, 0.3, and 1 mg/kg) were given intraperitoneally to three different groups after dorsal random pattern skin flaps were performed. To assess the exact role of 5-hydroxytryptamine 1b/1d receptors, GR-127935 was administered solely and with sumatriptan. N-ω-nitro-L-arginine methyl ester (L-NAME, a nonselective nitric oxide synthase inhibitor) was used to evaluate any possible involvement of nitric oxide in this study. All rats were examined 7 days later., Results: The authors' results demonstrated that flap survival was increased by lower doses of sumatriptan compared to a control group for both 0.3 mg/kg (p = 0.03, mean difference = 32, SE = 8) and 0.1 mg/kg (p = 0.02, mean difference = 26, SE = 8). This protective effect was eliminated by coadministration of GR-127935 or N-ω-nitro-L-arginine methyl ester with sumatriptan. Histopathologic studies revealed a significant increase in capillary count and collagen deposition and a decreased amount of edema, inflammation, and degeneration., Conclusions: Sumatriptan in lower concentration increases skin flap survival by means of activation of 5-hydroxytryptamine 1b/1d receptors. This effect is mediated through the nitric oxide synthase pathway.

Inadequate tissue perfusion is a serious complication following reconstructive surgeries. Skin flap necrosis, especially in the head and neck area, may have significant cosmetic consequences. Although clinical exam is the mainstay in evaluating perfusion, it may not always predict ischemic problems. The SPY Elite laser angiographic system, which has been widely used to analyze tissue perfusion in postmastectomy skin flaps, has been shown to be able to evaluate tissue perfusion objectively. We describe a revision rhinoplasty case where hypoperfusion of the nasal tip was seen following placement of structural grafts to the nasal tip, and before the grafts being removed SPY, angiography was used to evaluate if topical nitroglycerin alone could correct hypoperfusion of the nasal tip rather than removal of structural grafts. A SPY angiography was performed to evaluate the hypoperfusion to the nasal tip. Repeat imaging was then performed following treatment with topical nitroglycerin alone. Perfusion of the nasal tip was restored and confirmed by SPY angiography system. The objective findings from the SPY angiography allowed the grafts to remain in place and lead to optimal cosmetic result. Due to the critical information SPY angiography provided in this case, we recommend the use of technology when evaluating reconstructive cases in which the viability of the tissue may be difficult to deduce from clinical exam., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Femoral artery reconstructive operations pose the risk of damage to the lymphatic system and leakage of lymph fluid into the groin. This leakage establishes a stagnant reservoir of protein-rich fluid, further placing the patient at risk for complications, especially a higher infection rate. The use of SPY technology (Stryker Corp/Novadaq Technologies, Kalamazoo, Mich) for lymphatic leaks have been described in previous studies. However, the management of persistent high-output lymphatic leaks addressed secondarily with SPY lymphangiography have yet to be reported. This case report describes a young male who underwent thrombectomy in the left common femoral artery, who presented several days later with a high-output chylous leak. The lymphatic leak was initially managed and failed conventional muscle flaps, and SPY lymphangiography was performed to manage the lymphatic leak during the secondary surgery. The lymphatic vessels were ligated and confirmed with SPY lymphangiography. The management of lymphatic groin complications aided by the use of SPY lymphangiography provided valuable data and allowed for better intraoperative visualization. Utilization of SPY technology allowed the surgeons to properly address all sites of leakage in an otherwise persistent lymphatic leak. Resolution of lymphatic leak was further confirmed with SPY. Lymphatic complications, particularly those in the groin area, are of significant concern to physicians. Any suspected chylous leak should be followed with SPY lymphangiography to ensure proper treatment and resolution. Prophylactic use of SPY technology in high-risk patients during lymphatic surgery of the groin may also be considered., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Skin flap necrosis occurs in 1-3% of facelift procedures. The SPY Elite Fluorescence Imaging System has been widely used in evaluating mastectomy skin flaps for breast reconstruction but has not been described in assessing skin flaps during facelifts. This case report describes the intraoperative use of SPY to assess flap perfusion during a high-risk facelift and static sling for the correction of facial paralysis. The use of intraoperative SPY during this high-risk facelift allowed for the timely assessment of perfusion, successful intervention of nitroglycerin paste to improve blood flow, and prevention of any additional surgical interventions. SPY may have a more widespread role in facelift patients with a higher risk of skin flap necrosis., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The SPY angiography system has several surgical uses. Often, surgeons may experience difficult cases in which the viability and perfusion of tissue is questioned. By using the SPY angiography system intraoperatively, this system may provide additional information allowing the surgeon to make calculated real-time decisions which may lead to improved patient outcomes. This study describes a case of a chronic sternal wound treated with reconstruction using intraoperative SPY angiography. Adequate perfusion of the flap was determined via SPY angiography intraoperatively. The flap was thereafter successfully utilized to cover the chronic wound. The patient was followed postoperatively with progression of wound closure. Sternal wounds often pose a complex problem for patients and physicians. The use of intraoperative SPY angiography provided critical information to the operating team allowing for the successful identification of a viable flap. The use of SPY angiography provided the patient an opportunity to achieve a successful outcome and reduced the risk of skin necrosis or reoperation., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objective: There are very few studies reporting the techniques utilized in penile replantation. Of those in literature, many agree that the use of microvascular technique results in better outcomes. The most common complications are skin necrosis and venous congestion, which are even higher in replants without arterial supply. Methods: This study describes a case of self-inflicted penile amputation treated with microsurgical replantation and managed postoperatively with hyperbaric oxygen therapy and Cialis (tadalafil), and SPY angiography. The penile replant had extensive skin necrosis, which prevented a sufficient clinical evaluation of the replanted penis. Serial SPY angiography was performed to assess tissue viability, following hyperbaric oxygen therapy and Cialis treatment. Results: SPY angiography was critical to the decision making of the operating team in the management of this case of penile replantation. Conclusions: The use of SPY angiography prevented the patient from undergoing revision amputation and allowed for a safe and successful penile replantation.

Cranial nerve disease outside the skull base is a common cause of facial and/or neck pain, which causes significant disability for patients and frustration for clinicians. Neuropathy in this region can be traumatic, idiopathic, or iatrogenic secondary to dental and surgical procedures. MR neurography is a modification of conventional MRI techniques dedicated to evaluation of peripheral nerves and is being increasingly used for imaging of peripheral neuropathies at various sites in the body. MR neurography facilitates assessment of different causes of craniofacial pain and cranial nerves and allows elegant depiction of a multitude of regional neuropathies. This article discusses the anatomy, pathologic conditions, and imaging findings of the commonly implicated but difficult to image infratentorial nerves, such as the peripheral trigeminal nerve and its branches, facial nerve, glossopharyngeal nerve, vagus nerve, hypoglossal nerve, and greater and lesser occipital nerves. © RSNA, 2018.

Background: The number of buttock augmentations with fat transfer is steadily increasing, but a number of fatalities caused as a direct result of gluteal fat grafting have been reported. The technical details relating to cannula size, injection angle or trajectory, and plane of injection are critical for avoiding morbidity and mortality. However, the ligamentous anatomy has not been thoroughly explored, particularly how the ligaments are encountered in the clinical setting of fat transfer by means of cannulas., Methods: The gluteal regions of five fresh cadavers were dissected, for a total of 10 hemidissections. All pertinent cutaneous ligaments in the region were identified. In addition, cannulas were used to simulate typical variations in injection planes., Results: The osseocutaneous and fasciocutaneous ligaments of the buttocks were identified., Conclusions: The authors describe important ligamentous structures consistently found in the region in cadaveric dissections and discuss the implications while safely performing gluteal augmentation. The anatomical features, boundaries, and soft-tissue attachment points may play a role in cannula-directed fat injection misguidance. The ligaments, when not released, can lead to undesired deep injection and therefore fat lobule migration into the venous system. The density, danger zones, and soft-tissue attachments must be clarified further as we continue to offer our patients improved buttock contour with a higher safety profile.

Rhinoplasty is considered one of the most challenging procedures in plastic surgery. The authors introduce a novel concept of translating three-dimensional photographic images into three-dimensionally-printed, patient-specific, life-size models that can be used in preoperative counseling or as an intraoperative reference during rhinoplasty. This article describes the authors' experience with this new application for three-dimensional printing, a technology that is overall garnering more widespread use and has prospective clinical and research applications in aesthetic surgery.

Background: Surgical decompression of peripheral cranial and spinal nerves at several anatomically studied trigger sites has demonstrated significant efficacy in bringing permanent relief to migraine sufferers. In their experience performing frontal nerve decompression on migraine patients, the authors noticed a previously undescribed accessory nerve and vessel in the frontotemporal area, and report its implication in migraine surgery and cosmetic filler injection., Methods: A retrospective review of 113 patients who underwent frontal migraine decompression surgery with the senior author at the University of Texas Southwestern Medical Center from July of 2012 to May of 2016 was performed. For the included 76 patients, measurements of this nerve had been taken intraoperatively using high-definition endoscopic assistance, and topographic measurements were correlated with endoscopic location of the nerve., Results: This frontotemporal nerve (FTN) was present in 55 percent, and the bilateral incidence was 57 percent of those. An accompanying vessel was also present in 81 percent of nerve complexes. Both nerve and vessel varied in size. A large vessel was present in 8 percent of all patients, and a medium vessel was present in 20 percent. Consistently, the nerve exited a foramen in the frontal bone on average 3.4 ± 0.47 cm superior to the lateral canthus., Conclusions: The identification and proper avulsion neurectomy of this newly described sensory FTN may lead to better surgical response rate during migraine surgery. In addition, this nerve should be considered during nerve block and botulinum toxin injections in migraine treatment. The existence of the accompanying vessel could have significant implications in the safety of filler and fat injections to this area.

Background and Purpose: MR imaging of peripheral nerves (MR neurography) allows improved assessment of nerve anatomy and pathology. The objective of this study was to evaluate patients with unilateral occipital neuralgia using MR neurography and to assess the differences in greater occipital nerve signal and size between the symptomatic and asymptomatic sides., Materials and Methods: In this case-control evaluation using MR neurography, bilateral greater occipital nerve caliber, signal intensity, signal-to-noise ratios, and contrast-to-noise ratios were determined by 2 observers., Results: Among 18 subjects with unilateral occipital migraines, the average greater occipital nerve diameter for the symptomatic side was significantly greater at 1.77 ± 0.4 mm than for the asymptomatic side at 1.29 ± 0.25 mm ( P = .001). The difference in nerve signal intensity between the symptomatic and asymptomatic sides was statistically significant at 269.06 ± 170.93 and 222.44 ± 170.46, respectively ( P = .043). The signal-to-noise ratios on the symptomatic side were higher at 15.79 ± 4.59 compared with the asymptomatic nerve at 14.02 ± 5.23 ( P = .009). Contrast-to-noise ratios were significantly higher on the symptomatic side than on the asymptomatic side at 2.57 ± 4.89 and -1.26 ± 5.02, respectively ( P = .004). Intraobserver performance was good to excellent (intraclass coefficient correlation, 0.68-0.93), and interobserver performance was fair to excellent (intraclass coefficient correlation, 0.54-0.81)., Conclusions: MR neurography can be reliably used for the diagnosis of greater occipital nerve neuropathy in patients with unilateral occipital migraines with a good correlation of imaging findings to the clinical presentation., (© 2017 by American Journal of Neuroradiology.)

Throughout history, the technological advancements of conventional clinical photography in plastic surgery have not only refined the methods available to the plastic surgeon, but have invigorated the profession through technology. The technology of the once traditional two-dimensional photograph has since been revolutionized and refashioned to incorporate novel applications, which have since become the standard in clinical photography. Contrary to traditional standardized two-dimensional photographs, three-dimensional photography provides the surgeon with an invaluable volumetric and morphologic analysis by demonstrating true surface dimensions both preoperatively and postoperatively. Clinical photography has served as one of the fundamental objective means by which plastic surgeons review outcomes; however, the newer three-dimensional technology has been primarily used to enhance the preoperative consultation with surgical simulations. The authors intend to familiarize readers with the notion that three-dimensional photography extends well beyond its marketing application during surgical consultation. For the cosmetic surgeon, as the application of three-dimensional photography continues to mature in facial plastic surgery, it will continue to bypass the dated conventional photographic methods plastic surgeons once relied on. This article reviews a paradigm shift and provides a historical review of the fascinating evolution of photography in plastic surgery by highlighting the clinical utility of three-dimensional photography as an adjunct to plastic and reconstructive surgery practices. As three-dimensional photographic technology continues to evolve, its application in facial plastic surgery will provide an opportunity for a new objective standard in plastic surgery.

Flexor tendon rupture is an unusual complication following collagenase injection to relieve contractures. These patients require a close follow-up and in the event of tendon rupture, a decision has to be made whether to repair the tendon or manage the complication conservatively. The authors report the utility of MRI in the prognostication and management of a patient with Dupuytren's contracture, who underwent collagenase injection and subsequently developed flexor digitorum profundus tendon rupture.

Migraine headaches are a debilitating disease that causes significant socioeconomic problems. One of the speculated etiologies of the generation of migraines is peripheral nerve irritation at different trigger points. The use of Onabotulinum toxin A (BOTOX), although initially a novel approach, has now been determined to be a valid treatment for chronic headaches and migraines as described in the Phase III Research Evaluating Migraine Prophylaxis Therapy trials that prompted the approval by the Food and Drug Administration for treatment of chronic migraines. The injection paradigm established by this trial was one of a broad injection pattern across large muscle groups that did not always correspond to the anatomical locations of nerves. The senior author developed the Anatomical Regional Targeted BOTOX injection paradigm as an alternative to the current injection model. This technique targets both the anatomical location of nerves known to have causal effects with migraines and the region where the pain localizes, to provide relief across a wide distribution of the peripheral nerve. This article serves as a guide to the Anatomical Regional Targeted injection technique, which, to our knowledge, is the first comprehensive BOTOX injection paradigm described in the literature for treatment of migraines that targets nerves and nerve areas rather than purely muscle groups. This technique is based on the most up-to-date anatomical and scientific studies and large-volume migraine surgery experience., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid by PRS Global Open at the Discretion of the Editor-in-Chief.

Tissue ischemia can be managed in several different ways based on the cause of the perfusion defect, including topical nitroglycerin or surgical intervention. However, there are times when tissue perfusion is questioned and clinical examination is unable to determine definitively the cause of ischemic tissue and whether it will survive. In this technique article, we describe our comprehensive algorithm for the management of tissue ischemia in mastectomy skin flaps, which can be applied to other plastic surgery procedures by integrating SPY angiography and topical nitroglycerin.

Background: Scar formation after injury or surgery is a major clinical problem. Individually, hyaluronan, or hyaluronic acid (HA), and vitamin C have been shown to reduce scarring by means of different mechanisms. The authors evaluated the efficacy and safety of an HA sponge system containing an active derivative of vitamin C to determine whether the use of this product promotes healing and reduces inflammation and scarring after surgery., Methods: This double-blind, randomized, prospective study was approved by the local institutional review board. Participants who had unilateral or bilateral surgical scars more than 1 month but less than 18 months old were enrolled. Surgical scars were randomly assigned to receive placebo or HA sponge with vitamin C. Three blinded evaluators reviewed photographs of the incision lines and assessed the scars using a visual analog scale. A patient satisfaction survey was also administered. Participants were followed up at 4 weeks, 12 weeks, and 1 year., Results: Twenty-three patients were enrolled in the study. Six patients dropped out of the study, for a total of 17 patients included in final analysis. Mean (range) age of patient was 43.5 (25-67) years. Mean (range) body mass index was 27.4 (18-36.9) kg/m(2). The mean visual analog scale score for scars receiving HA sponge with vitamin C was slightly lower than the scars receiving placebo, but the difference was not statistically significant (t test; P = 0.9). The HA sponge with vitamin C was found to have significant positive findings on a patient satisfaction survey., Conclusions: The HA sponge system with vitamin C is safe to use in any scars older than 4 weeks. It has high patient satisfaction in achieving a better scar after surgery. The micro-roller used to apply the product was easy to use to potentially increase the spread of the medication in older scars.

Background: Scar formation is a major source of dissatisfaction among patients and surgeons. Individually, hyaluronan, or hyaluronic acid (HA), and zinc have been shown to reduce scarring. The authors evaluated the safety and efficacy of an HA sponge with zinc compared with placebo when applied to bilateral breast surgery scars; specifically, they evaluated whether the use of this product modulates inflammation and immediate scarring in treated patients after bilateral breast surgery., Methods: This double-blind, randomized, prospective study was approved by the local institutional review board. Bilateral breast surgery patients with right and left incision lines were randomly assigned to receive HA sponge with zinc or placebo within 2 to 4 days after their procedure. Participants were followed up at 6 weeks, 12 weeks, and 1 year and evaluated at 12 weeks. Three blinded evaluators reviewed photographs of the incision lines and assessed the scars using a visual analog scale, new scale, and a patient satisfaction survey., Results: Nineteen bilateral breast surgery patients were enrolled in the study. Statistical analysis was performed on 14 patients who completed the follow-up. The mean visual analog scale score was lower for the side receiving the HA sponge with zinc (2.6) than for the side receiving placebo (3.0), indicating a better outcome (t test; P = 0.08). The HA sponge with zinc was found to have significant positive findings on a patient satisfaction survey (P = 0.01)., Conclusions: This is a preliminary study that shows zinc hyaluronan was associated with high patient satisfaction in achieving a better scar after bilateral breast surgery, irrespective of skin color. It seems to be safe and effective for early scars.

Background: The nasolabial angle (NLA) is an important aesthetic metric for nasal assessment and correction. Although the literature offers many definitions, none has garnered universal acceptance., Methods: To gauge the consensus level among practitioners, surveys were administered to a convenience sample of rhinoplasty surgeons soliciting practice characteristics, self-assessment of rhinoplasty experience and expertise, and preferred NLA definition. Choices of NLA definition included the angle between: (A) columella and line intersecting subnasale and labrale superius; (B) columella and line tangent to philtrum; (C) nostril long axis and Frankfort perpendicular; and (D) nostril long axis and vertical facial plane., Results: Of the 82 total respondents, mean age was 50 years (range, 30-80years), and mean professional experience was 17 years (range, 0-67 years). Nineteen described themselves as novice rhinoplasty surgeons, 27 as intermediates, and 36 as experts. Mean number of lifetime rhinoplasties performed was 966 (range, 0-10,000). Twenty respondents (24%) agreed with definition A, 27 (33%) with B, 16 (20%) with C, and 13 (16%) with D. Six chose "other," offering their own explanations of NLA. Self-identified novices were more likely to prefer definition D than were experts (P = 0.009)., Conclusions: No majority consensus was reached regarding the definition of NLA. Each method has its benefits and drawbacks, and establishing a single one may be unnecessary and even counterproductive in some cases. Having options available means that surgeons can tailor to each encounter, as long as they adopt a systematic methodology. We submit an algorithm to facilitate this effort.

Surgical decompression of peripheral branches of the trigeminal and occipital nerves has been shown to alleviate migraine symptoms. Site II surgery involves decompression of the zygomaticotemporal branch of the trigeminal nerve by the technique developed by Guyuron. Failure of site II surgery may occur secondary to an inability to recognize a second temporal trigger: site V, the auriculotemporal nerve. A direct approach for site V has been used with no clear description in the literature. Herein, we describe a safe and efficient method for auriculotemporal nerve decompression during the Guyuron endoscopic approach. Close attention to all temporal sites is necessary to avoid potential failure of migraine decompression surgery.

Unlabelled: Surgery remains the gold standard in the treatment of Dupuytren contracture but is technically demanding, carries significant risk of complications, and requires prolonged recovery time. Collagenase injection is an efficacious alternative to surgery; however, contracture release often requires multiple treatments spaced a month apart. We report our experience with a new collagenase treatment protocol aimed to minimize the total treatment time per joint contracture., Methods: We performed a single institution retrospective review of patients with Dupuytren contracture treated with collagenase using our protocol from 2011 to 2013. Patients returned 24 hours after collagenase injection for cord manipulation by a certified hand therapist while under digital block. Treatment success was defined as reduction in contracture to 5 degrees or less. Successfully treated joints were evaluated for recurrence (>10 degrees contracture) at 30-day and 6-month follow-up appointments. Serious adverse events, including skin tears, were recorded., Results: Success was achieved in 36 of 47 treated joints (76.6%) after a single injection. There were 2 recurrences in 32 joints at 30-day follow-up (6.2%) and no recurrences in 17 joints available at 6-month follow-up. Skin tears were the only serious adverse event occurring in 18 of 47 cord ruptures (38.3%). All healed secondarily without complication., Conclusions: Our protocol preserves treatment efficacy while maximizing efficiency. Achieving successful cord rupture with a single injection allows earlier return of function, reduced cost of treatment, and increased convenience for the patient. Patients, particularly those with greater contractures, should be counseled regarding the risk of skin tear during cord manipulation.

The authors describe a case of retained sterile matrix in a 38-year-old Hispanic man with a history of remote trauma and soft-tissue coverage with a groin flap 13 years before presentation. The patient presented with a slowly enlarging, vertically growing dorsal thumb mass with occasional drainage. The patient had minimal functional impairment, and radiographic imaging showed a radiolucent mass projecting dorsally over the distal phalanx. Surgical exploration revealed an approximately 2 × 2 cm keratinized mass attached to a retained nail bed. The keratinized nail plate was removed, along with an ellipse of soft tissue around the draining tract. To the authors' knowledge, this case is the largest reported vertically growing, retained, and cornified nail bed with an unusual size and shape. Physicians should consider the possibility of retained nail plates in patients who present with unusual large growths after trauma or surgery.

The upper lateral cartilages are instrumental in obtaining optimal outcomes in aesthetic and functional rhinoplasty. Knowledgeable manipulation of the upper lateral cartilages can take advantage of the crucial malleable parameters of projection, width, nasal dorsal shape, and tip rotation. A lucid understanding of the anatomical intricacies in this portion of the cartilaginous framework permits the surgeon to use their unique characteristics to consistently achieve the desired results.

There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.

Background: Migraine headaches have not historically been considered a compression neuropathy. Recent studies suggest that some migraines are successfully treated by targeted peripheral nerve decompression. Other compression neuropathies have previously been associated with one another. The goal of this study is to evaluate whether an association exists between migraines and carpal tunnel syndrome (CTS), the most common compression neuropathy., Methods: Data from 25,880 respondents of the cross-sectional 2010 National Health Interview Survey were used to calculate nationally representative prevalence estimates and 95% confidence intervals (95% CIs) of CTS and migraine headaches. Logistic regression was used to calculate adjusted odds ratios (aORs) and 95% CI for the degree of association between migraines and CTS after controlling for known demographic and health-related factors., Results: CTS was associated with older age, female gender, obesity, diabetes, and smoking. CTS was less common in Hispanics and Asians. Migraine was associated with younger age, female gender, obesity, diabetes, and current smoking. Migraine was less common in Asians. Migraine prevalence was 34% in those with CTS compared with 16% in those without CTS (aOR, 2.60; 95% CI, 2.16-3.13). CTS prevalence in patients with migraine headache was 8% compared with 3% in those without migraine headache (aOR, 2.67; 95% CI, 2.22-3.22)., Conclusions: This study is the first to demonstrate an association between CTS and migraine headache. Longitudinal and genetic studies with physician verification of migraine headaches and CTS are needed to further define this association.