Research Spotlight

Perdikis, G., Eaves, F.F., Glassman, G.E., Walker, S., Huang, L.C., Mast, B., Damitz, L., Rubin, J.P., Serletti, J.M., Hansen, J., Potochny, J., Kenkel, J., Taub, P.J., Sobczyk, S., Gilman, R.H., Saint-Cyr, R.H. and Cederna, P. (2020). “Aesthetic Surgery in Plastic Surgery Academia.” Aesthet Surg J Aug 14;sjaa181. [Epub ahead of print.].

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BACKGROUND: Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. OBJECTIVES: The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. METHODS: A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson’s chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. RESULTS: Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery-focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). CONCLUSIONS: The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.

Rodriguez-Unda, N.A., Abraham, J.T. and Saint-Cyr, M. (2020). “Keystone and Perforator Flaps in Reconstruction: Modifications and Updated Applications.” Clin Plast Surg 47(4): 635-648.

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Pedicle perforator flaps and keystone perforator island flaps provide additional tools for the reconstructive surgeon’s armamentarium. Advances in understanding of vascular anatomy, dynamic nature of perforator perfusion, interperforator flow, and “hot spot” principle have led to reconstructive methods that allow for autologous tissue transfer, while limiting donor site morbidity. Further modifications in pedicle perforator flap enabled the propeller flap and freestyle perforator free flap for soft tissue reconstruction. Modifications in keystone perforator island flap increased degrees of freedom the reconstructive surgeon has for soft tissue coverage of large defects, with significant reliability, aesthetically pleasing results, and reduced donor site morbidity.

Mohan, A.T., Suchyta, M., Vyas, K.S., Lachman, N., Mardini, S. and Saint-Cyr, M. (2020). “A Cadaveric Anatomical and Histological Study of Recipient Intercostal Nerve Selection for Sensory Reinnervation in Autologous Breast Reconstruction.” J Reconstr Microsurg Aug 30. [Epub ahead of print.].

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BACKGROUND: Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR. METHODS:  Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared. RESULTS:  A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm(2)) compared with that in the fourth (mean 26,474 ± 38,626 µm(2)), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05). CONCLUSION:  This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

Mohan, A.T. and Saint-Cyr, M. (2020). “Recent Advances in Microsurgery: An Update in the Past 4 Years.” Clin Plast Surg 47(4): 663-677.

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Microsurgery has broad applications in reconstructive surgery. As techniques, diagnostics, and advancing technology rapidly evolve, reconstructive microsurgeons can adapt to address new challenges and push the frontiers to achieve optimal functional and aesthetic reconstruction, and minimize donor site morbidity. This article briefly outlines some of the recent advances and innovations in microsurgery within the last 5 years in perforator flaps, breast, lymphedema surgery, extremity reconstruction, targeted muscle reinnervation, head and neck reconstruction, composite tissue allotransplantation, and robotic surgery.

Mohan, A.T., Zhu, L., Vijayasekaran, A. and Saint-Cyr, M. (2020). “Autologous Breast Reconstruction in Low Body Mass Index Patients: Strategies for Maximizing Skin Envelope and Breast Volume.” Clin Plast Surg 47(4): 611-619.

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Pure autologous breast reconstruction in thin patients creates challenges. This review highlights techniques to optimize the scarce donor tissue available, approaches to reconstruction, and microsurgical techniques. A systematic approach to maximize breast volume and the skin envelope in patients who underwent pure autologous breast reconstruction by a single senior surgeon is presented with a clinical case series. Included in the study were 125 patients (217) with autologous breast reconstructions. Although DIEP flaps were the commonest flap used overall (79%), within in the low body mass index (<22) group, there was a greater use of Latissimus (32%), and thigh-based flaps (>50%).