Bustos, S S

Background: With neck, aging the cervicomental angle becomes obtuse and may be influenced by hyoid bone aging. An understanding of hyoid position changes with aging will further our understanding of its role in neck contour changes. Methods: A 3D volumetric reconstruction of 282 neck computed tomography scans was performed. The cohort was categorized into three groups based on age: 20 years or older and younger than 40 years, 40 years or older and younger than 60 years, and 60 years or older and younger than 80 years. The vertical and horizontal hyoid distances in relation to the mandible were calculated for each patient. Results: A total of 282 patients (153 women, 129 men) were included in the cohort. The age groups were evenly distributed in men and women. Mean hyoid vertical and horizontal distances differed between women and men in all age groups. There was a significant difference in the hyoid vertical distance between 20–39 years old to 40–59 years old in men (P < 0.01), and 20–39 years old to 60–79 years old in both genders (women P = 0.005, men P < 0.01). Hyoid horizontal distance was not affected by age and sex (age and sex: P > 0.05), but rather by body mass index (BMI). Every 5 BMI points corresponded to a forward movement of 2 mm. Conclusions: As individuals age, the hyoid bone descends in both sexes, and an increase in BMI is associated with forward movement. Additional studies are needed to assess the correlation of the hyoid position between upright and supine positions.

Summary: Lymphaticovenous anastomosis (LVA) surgery is an effective surgery for the treatment of lymphedema in the extremities. Indocyanine green lymphography is the reference standard for visualizing lymphatics for LVA surgery, but it has several limitations; most notably, superficial dermal congestion can mask deeper lymphatic vessels. To overcome the limitations, we add contrast-enhanced ultrasound (CEUS) lymphography. We have previously reported that CEUS lymphography can identify lymphatic vessels for LVA surgery that indocyanine green lymphography does not. Here, we describe how we perform CEUS lymphography, including workflow, technique, and documentation. Before informed consent, the patient must be screened for possible adverse reactions to microbubbles. The procedure involves multiple intradermal injections of the microbubble agent at various sites along the extremity. After each injection, imaging for microbubble uptake by lymphatic vessels is performed using an ultrasound scanner with contrast-specific software. We use sulfur hexafluoride lipid-type A microspheres (Lumason/SonoVue; Bracco Suisse SA), but we are investigating the performance of other Food & Drug Administration–approved microbubble agents for CEUS lymphography. Having a systematic approach to marking the skin can mitigate the hindrance of marking over ultrasound coupling gel. Another benefit of CEUS lymphography is the rapid identification of neighboring veins compatible in size and location for anastomosis. We hold regular scheduled multidisciplinary meetings for coordination of care, discussion of outcomes, quality assurance, and ongoing innovation.

Summary: Aging of the face is the result of the interrelation of three-dimensional changes occurring over time among the 5 different layers of the face and its associated structures. Knowledge regarding the causes of these changes and identification of new key anatomic structures have helped elucidate one of the most complex areas of the human body. This has resulted in the introduction of pharmacologic agents to help stop, mitigate, or counteract signs of aging and restore the youthful appearance of the face. The authors performed a systematic search of the literature to review the current highest-level evidence of facial antiaging pharmacologic agents. Pharmacologic and minimally invasive antiaging treatments can target different components of facial aging and continue to evolve. With continuous research efforts, traditional treatments, such as botulinum toxin type A, injectable fillers, and chemical peels, are emerging in newer, more effective formulations, with longer lasting clinical results. However, for soft-tissue descent and facial volume loss, surgery remains the standard treatment. An adequate understanding of the three-dimensional process of facial aging over time (the fourth dimension), facial anatomy, and the pharmacologic properties of antiaging/rejuvenation agents are the sine qua non of facial antiaging treatment. The specific modality should be tailored to patient characteristics, preferences, and goals.

Abstract Background Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair. Methods A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life. Results Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08–0.62), which corresponds to absence or minimal symptoms. Conclusion The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Background Immediate implant-based breast reconstruction (IIBR) is the most commonly used method in breast reconstruction in the United States. However, postoperative surgical site infections (SSIs) can cause devastating reconstructive failure. This study evaluates the use of perioperative versus extended courses of antibiotic prophylaxis after IIBR for the prevention of SSI. Methods This is a single-institution retrospective study of patients who underwent IIBR between June 2018 and April 2020. Detailed demographic and clinical information was collected. Patients were divided into subgroups based on antibiotic prophylaxis regimen: group 1 consisted of patients who received 24 hours of perioperative antibiotics and group 2 consisted of patients who received ≥7 days of antibiotics. Statistical analyses were conducted using SPSSv26.0 with P ≤ 0.05 considered statistically significant. Results A total of 169 patients (285 breasts) who underwent IIBR were included. The mean age was 52.4 ± 10.2 years, and the mean body mass index (BMI) was 26.8 ± 5.7 kg/m2. Twenty-five percent of patients (25.6%) underwent nipple-sparing mastectomy, 69.1% skin-sparing mastectomy, and 5.3% total mastectomy. The implant was placed in the prepectoral, subpectoral, and dual planes in 16.7%, 19.2%, and 64.1% cases, respectively. Acellular dermal matrix was used in 78.7% of cases. A total of 42.0% of patients received 24-hour prophylaxis (group 1), and 58.0% of patients received extended prophylaxis (group 2). Twenty-five infections (14.8%) were identified, of which 9 (5.3%) resulted in reconstructive failure. In bivariate analyses, no significant difference was found between groups in rates of infection (P = 0.273), reconstructive failure (P = 0.653), and seroma (P = 0.125). There was a difference in hematoma rates between groups (P = 0.046). Interestingly, in patients who received only perioperative antibiotics, infection rates were significantly higher in those with BMI ≥ 25 (25.6% vs 7.1%, P = 0.050). There was no difference in overweight patients who received extended antibiotics (16.4% vs 7.0%, P = 0.160). Conclusions Our data demonstrate no statistical difference in infection rates between perioperative and extended antibiotics. This suggests that the efficacies of current prophylaxis regimens are largely similar, with choice of regimen based on surgeon preference and patient-specific considerations. Infection rates in patients who received perioperative prophylaxis and were overweight were significantly higher, suggesting that BMI should be taken into consideration when choosing a prophylaxis regimen.

Background: Early soft-tissue reconstruction of open fractures has been shown to decrease infection rates and improve rates of bony union. The purpose of this study was to compare the rates and time to union of open tibia fractures that underwent soft-tissue coverage. Methods: A retrospective chart review of 118 patients with open tibia fractures requiring soft-tissue reconstruction treated at a single level 1 trauma center was performed. Demographic data as well as flap type were collected. Union status was determined using modified Radiographic Union Scale in Tibia Fractures score greater than 11. Results: Limb salvage was achieved in 90% of patients. The overall rate of nonunion was 33%. Flap type significantly affected time to union, with local fasciocutaneous and keystone flaps having significantly longer time to union [202 days (SD 120.3)] than all other flap groups (P = 0.01). Free flaps had significantly shorter time to union than local flaps [115 days (SD 49.6) versus 149 days (SD 75.4); P = 0.02]. Muscle flaps had significantly shorter time to union than fasciocutaneous flaps [123 days (SD 52.4) versus 165 days (SD 104.1); P = 0.04]. This remained true after controlling for fracture location, patient age, need for second flap, and fixation method (P = 0.037). Patients who underwent an initial soft-tissue reconstruction with a local muscle flap were more likely to require a second flap to achieve wound closure (OR, 3.7; P = 0.008) and needing a second flap significantly increased time to union [162 days (SD 95.9) versus 122 days (SD 51.9); P = 0.03]. Conclusion: Flap type affects time to union but not nonunion rate in open tibia fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: Many insurance companies in the United States rely on the Schnur sliding scale to predict resection weights to determine medical necessity for breast reduction surgery. Accurate methods to predict resection weights are needed to avoid insurance denials. The authors compared the accuracy of formulas such as the Schnur, Appel, Descamps, and Galveston scales in predicting resection weights, and assessed whether they influence insurance coverage decision. Methods: A retrospective review of bilateral reduction mammaplasty procedures from June of 2017 to June of 2019 was performed at the Mayo Clinic, Rochester. Oncoplastic reduction operations were excluded. The accuracy of each formula-based estimate was evaluated with linear regression analysis. Results: One hundred fifty-four patients (308 breasts) were reviewed. The Schnur scale had low correlation with actual resection weight (r 2 = 0.381; b1 = 1.153; p < 0.001). The Appel scale was the most accurate (r 2 = 0.642; b1 = 1.01; p < 0.001), followed by the Descamps (r 2 = 0.572, b1 = 0.934, p < 0.001) and Galveston (r 2 = 0.672; b1 = 0.654; p < 0.001) scales. The Appel, Descamps, and Galveston scales were more accurate for resection weights of 500 g or greater, body mass index greater than 30 kg/m², and patients younger than 50 years. For resection weights of 500 g or greater, the median difference between the estimated and actual resection weight for the Schnur, Appel, Descamps, and Galveston scales was −211.4 ± 272.3, −17.5 ± 272.3, −9.6 ± 229.5, and −99.2 ± 238.5 g, respectively. No scale was accurate for resection weights less than 500 g. Insurance reimbursement was denied in 15.56 percent of patients; of these, 23 percent had resection weights less than 500 g. The Schnur scale overestimated the resection weights in 28.9 percent of patients. Conclusions: The Schnur scale is a poor predictor of breast resection weight. The Appel scale is the most accurate estimator, especially in the young and obese population with larger resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Background: Since its first description in 2012, the Goldilocks procedure has become an option for immediate breast reconstruction, particularly for obese patients who are poor candidates for traditional implant or autologous reconstruction. In this work, the authors performed a longitudinal study of patients who underwent mastectomy with Goldilocks reconstruction to assess the incidence of additional surgical procedures, and to assess surgical outcomes and patient satisfaction. Methods: A retrospective review of patients who underwent mastectomy with the Goldilocks procedure only at Mayo Clinic Rochester between January of 2012 and September of 2019 was performed. Demographics, complications, additional breast procedures performed to attain the final results, and patient-reported outcomes using the BREAST-Q were recorded. Univariate and multivariable analyses were performed to identify statistical associations and risk factors. Results: Sixty-three patients (108 breasts) were included. Mean age was 57.8 years. Mean body mass index was 37.6 kg/m2. Median follow-up time after the mastectomy with the Goldilocks procedure was 15 months. The major complication rate within the first 30 days was 9.3 percent. Forty-four breasts (40.7 percent) underwent additional surgery. Dyslipidemia was significantly associated with an increased risk of additional surgery (adjusted hazard ratio, 2.00; p = 0.045). Scores in the four BREAST-Q domains were not statistically different between patients who had additional procedures and those who did not. Conclusions: Based on the results, the authors recommend a thorough preoperative discussion with patients who are candidates for the Goldilocks procedure to explore all options for reconstruction and their expectations, because it is crucial to reduce the necessity for additional operations in this high-risk population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background: Obesity is a risk factor for complications in breast reconstruction. Thus, implant-based immediate breast reconstruction in obese women may be controversial. The authors analyzed obese patients who underwent skin-sparing mastectomy using Wise-pattern incisions (Goldilocks procedure) and compared outcomes between two groups: Goldilocks with immediate breast reconstruction and Goldilocks only. Methods: A retrospective review was performed of patients with a body mass index of 30 kg/m2 or higher who underwent the Goldilocks procedure at the Mayo Clinic Health System from 2012 to 2019. Data were extracted from electronic medical records. Minor complications (partial-thickness wound dehiscence or flap necrosis, or tissue expander/implant malposition) and major complications (full-thickness wound dehiscence or flap necrosis, capsular contracture, tissue expander/implant explantation, or unplanned reoperation or readmission) were compared between groups. Patient-reported outcomes using BREAST-Q questionnaires were also assessed. Results: One hundred five patients (181 breasts) were included. Mean ± SEM age and body mass index were 57.1 ± 10.4 years and 37.9 ± 5.8 kg/m2 for the Goldilocks-only group and 51.5 ± 1.1 years and 35.5 ± 0.4 kg/m2 for the Goldilocks with immediate breast reconstruction group, respectively. Median follow-up time was 15.1 months (interquartile range, 10.0 to 28.6 months). Overall, 96 breasts underwent the Goldilocks-only procedure and 85 Goldilocks with immediate breast reconstruction. Multivariable analyses revealed a higher rate of minor complications (adjusted hazard ratio, 2.83; 95 percent CI, 1.22 to 7.02) and major complications (adjusted hazard ratio, 2.26; 95 percent CI, 1.25 to 4.24) in the Goldilocks with immediate breast reconstruction group compared with the Goldilocks-only group, at any given time. Patient satisfaction was not statistically different between groups. Conclusions: The Goldilocks procedure is a feasible breast reconstructive option in obese patients; however, when it is performed with immediate breast reconstruction, it is associated with higher rates of complications. For patients with a body mass index of 40 kg/m2 or greater, the authors recommend the Goldilocks-only procedure or delayed reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.