Publications by authors named "Demetrius M Coombs"

31 Publications

Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years.

Cleft Palate Craniofac J 2022 Jul 28:10556656221116007. Epub 2022 Jul 28.

Division of Pediatric Plastic and Reconstructive Surgery, 1079Akron Children's Hospital, Akron, OH, USA.

Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery.

PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery.

Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported.

Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways & protocols. Some studies analyzed multiple approaches.

Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.
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http://dx.doi.org/10.1177/10556656221116007DOI Listing
July 2022

Endoscopic Brow Lift.

Clin Plast Surg 2022 Jul;49(3):357-363

Cleveland Clinic Department of Plastic Surgery, Desk A 60, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

This article discusses the physiology of brow ptosis and compares how depressor muscle alteration combined with wide subperiosteal undermining leads to its correction. A detailed description and a series of videos illustrate the endoscopic technique. Long-term before and after photographs demonstrate the efficacy of the procedure. Pitfalls and flaws in technique leading to less-than-ideal outcomes are described.
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http://dx.doi.org/10.1016/j.cps.2022.02.003DOI Listing
July 2022

Breast Implant-Related Outcomes After Cardiothoracic Surgeries and Electrophysiologic Procedures.

Ann Plast Surg 2022 May 30. Epub 2022 May 30.

From the Department of Plastic Surgery, The Cleveland Clinic.

Background: Outcomes related to preexisting breast implants after cardiothoracic procedures are poorly characterized. This study evaluated complications after minimally invasive cardiac surgery (MICS), median sternotomy (MS), and electrophysiologic procedures (EP) in patients with preexisting breast implants.

Methods: A retrospective review of patients with prior breast implants who underwent MICS, MS, or EP from 1994 to 2019 was performed. Demographic, treatment, and outcome characteristics were recorded. χ2 Test and analysis of variance were used to perform statistical comparisons.

Results: In total, 78 patients (37 MICS, 21 MS, and 20 EP) were identified. Mean breast implant age was 13.3, 11.7, and 10.2 years, respectively (P = 0.235). Intraoperative plastic surgeon involvement was present in 26 (70.3%) MICS cases, compared with 2 (9.5%) MS and 0% EP (P < 0.001). Intraoperative rupture occurred in 5 (13.5%) MICS cases and no MS or EP cases (P < 0.001). Postoperative implant complications occurred in 6 (16.2%) MICS, 8 (38.1%) MS, and 5 (25.0%) EP (P = 0.350) cases, with median time to complication of 5.9, 5.4, and 38.9 months, respectively (P = 0.596). Revision surgery was performed in 5 (13.5%) MICS, 7 (33.3%) MS, and 5 (25.0%) EP (P = 0.246) cases. On multivariate analysis, lack of intraoperative plastic surgeon involvement (P = 0.034) and breast implant age (P = 0.001) were significant predictors of postoperative complications.

Conclusions: Long-term complication rates are highest among patients with breast implants undergoing MS. Plastic surgeon involvement was significantly associated with fewer postoperative complications. Our results support a multidisciplinary approach to managing breast implants during cardiothoracic procedures.
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http://dx.doi.org/10.1097/SAP.0000000000003213DOI Listing
May 2022

Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?

Plast Reconstr Surg 2022 06 5;149(6):1096e-1105e. Epub 2022 Apr 5.

From the Department of Plastic Surgery, Cleveland Clinic Foundation; H/K/B Plastic Surgery (private practice); Couto Plastic Surgery (private practice); Center for Plastic and Reconstructive Surgery (private practice); and Hofstra University/Northwell School of Medicine.

Background: In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members' face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances.

Methods: A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test.

Results: A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication.

Conclusions: The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.
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http://dx.doi.org/10.1097/PRS.0000000000009097DOI Listing
June 2022

Local Infiltration of Tranexamic Acid During Facelift Improves Operating Room Efficiency: A Matched Patient Study.

Aesthet Surg J 2022 Mar 29. Epub 2022 Mar 29.

Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA.

Background: Tranexamic acid (TXA) has rapidly gained popularity in aesthetic surgery. Previous reports have suggested that TXA provides a dry surgical field and significantly reduces operating time during facelift surgery.

Objectives: In this study we build upon these findings by providing a large cohort matched alongside historic controls and more clearly document time saved when performing facelift surgery.

Methods: Retrospective, single-surgeon case-control study from July 2016 to October 2021. All patients underwent facelift surgery alone or in combination with fat transfer and perioral chemical peel. All patients received subcutaneous infiltration of 0.5% lidocaine/1:200:000 epinephrine with or without 1-2mg/mL TXA. Patient demographics, TXA dose, surgical time, minor and major complications were examined.

Results: One-hundred forty-five consecutive patients were identified: 73 in Group 1 (no-TXA) and 72 in Group 2 (TXA). No differences in terms of gender distribution (p=0.75), age (p=0.54), BMI (p=0.18), frequency of secondary rhytidectomy (p=0.08), rate of ancillary lipografting (p=0.44), TXA dose (p=0.238), and minor complication rate (p=0.56) were observed. However, mean surgical time in the no-TXA group was 21 minutes longer than the TXA group (p=0.016). Six patients (8%) in the no-TXA group experienced minor complications versus 8 patients (11%) in the TXA group. No patients experienced major complications.

Conclusions: While prior studies have highlighted the potential benefits of TXA in aesthetic surgery, much of the data remains subjective and non-validated. This report adds to the objective body of evidence supporting TXA in facial aesthetic surgery by documenting time saved in the operating room without additional surgical morbidity.
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http://dx.doi.org/10.1093/asj/sjac067DOI Listing
March 2022

Skeletal and Dental Outcomes after Facial Allotransplantation: The Cleveland Clinic Experience and Systematic Review of the Literature.

Plast Reconstr Surg 2022 04;149(4):945-962

From the Department of Plastic Surgery, Cleveland Clinic.

Background: Most of the literature surrounding face transplantation focuses on technique, immunology, and psychology. Dental and skeletal outcomes remain persistently underreported. This study critically examined the worldwide face transplant experience to evaluate such outcomes.

Methods: A systematic review of all composite allografts containing midface and/or mandible was performed. Dental and skeletal complications were recorded. Formal imaging and photographs available in the literature were analyzed using skeletal measurements, soft-tissue cephalometrics, and the Angle classification. Outcomes of our face transplant patients, including condylar assessment and airway volume measurements, is also presented.

Results: Twenty-five patients received allografts containing midface (n = 7) or mandible (n = 2), whereas 16 contained a double-jaw. All midface-only transplants developed skeletal deformity; 57 percent developed a palatal fistula. Both partial and full arch transplantation patients developed skeletal deformity. Among double-jaw transplants, 69 percent developed palatal fistula or floor-of-mouth dehiscence, 66 percent developed malocclusion, 50 percent developed trismus, and 31 percent required corrective orthognathic surgery. In 40 percent of patients, malocclusion recurred after corrective orthognathic surgery. Forty percent of all patients developed dental cavities or periodontal disease. All of our patients received midface and/or mandible. One patient required corrective orthognathic surgery. Midfacial segments showed clockwise rotation. Airway volumes decreased over time.

Conclusions: Skeletal and dental complications remain extremely common after facial allotransplantation involving either single- or double-jaw composites. Corrective orthognathic surgery and dental extraction is often necessitated. These data will aid face transplant teams during surgical planning and preoperative counseling.

Clinical Question/level Of Evidence: Therapeutic, V.
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http://dx.doi.org/10.1097/PRS.0000000000008949DOI Listing
April 2022

Square-root Palatoplasty: Comparing a Novel Modified-Furlow Double-opposing Z-palatoplasty Technique to Traditional Straight-line Repair.

Plast Reconstr Surg Glob Open 2021 Aug 19;9(8):e3777. Epub 2021 Aug 19.

James A. Lehman Jr. MD Craniofacial Center, Department of Pediatric Plastic and Reconstructive Surgery, Akron Children's Hospital, Akron, Ohio.

The purpose of this study was to introduce a modification of the Furlow double-opposing Z-plasty (DOZ)-the square-root palatoplasty (SRP)-and critically evaluate outcomes compared to children who underwent straight-line repair (SLR).

Methods: A retrospective review was performed of all nonsyndromic children undergoing primary cleft palate closure either by SRP or SLR at our institution between 2009 and 2017. Outcomes of interest included rates/location of oronasal fistula, secondary surgery, speech delay/deficits, resonance, nasal air emission (NAE), articulation errors, and velopharyngeal function. Logistic regression was used to assess for the effect of surgery type on outcomes while controlling for Veau cleft type, age, and gender.

Results: Seventy-eight patients were included; 46 (59%) underwent SRP, and 32 (41%) underwent SLR. The mean follow-up was 4.07 years. When compared to SLR, children who underwent SRP were less likely to have oronasal fistula [odds ratio (OR) 4.8, = 0.0159], speech delay/deficits (OR 7.7, < 0.001), NAE (OR 9.7, < 0.001), articulation errors (OR 10.2, < 0.001), or need for secondary speech surgery (OR 13.2, < 0.0002). Patients who underwent SRP were also more likely to have normal resonance (78.26% versus 43.75%, respectively; = 0.0043) and good VP function (84.78% versus 56.25%, respectively; = 0.0094).

Conclusions: This study describes and evaluates outcomes following a modified-Furlow DOZ technique-the SRP. After adjusting for Veau classification, age, and gender in nonsyndromic children, SRP is associated with significantly less speech delay/deficits, NAE, articulation errors, and need for secondary speech surgery when compared to children who underwent SLR.
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http://dx.doi.org/10.1097/GOX.0000000000003777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8517311PMC
August 2021

Cutaneous Anaplastic Large Cell Lymphoma: A Case Report about Masking Effect of Facial Masks in the COVID-19 Pandemic.

Plast Reconstr Surg Glob Open 2021 Jul 30;9(7):e3783. Epub 2021 Jul 30.

Foglietti Fostyk Plastic Surgery, Beachwood, OH.

The COVID-19 global pandemic commenced widespread usage of face masks. Due to covering of the lower face in public settings, limited social interaction, and patient hesitancy for seeking in-person healthcare, dermatologic conditions of the lower face are prone to delayed diagnosis and management. With society recovering from the pandemic and social distancing restrictions being lifted, an increasing number of patients present with malignant skin conditions at advanced stage. The authors describe a 47-year-old female patient who presented with a 4-month-old facial mass that was initially believed to originate from skin irritation caused by mask-wearing. A biopsy revealed primary cutaneous anaplastic large cell lymphoma (PC-ALCL). This case report outlines the management of the rare PC-ALCL lesion and diagnostic challenges related to facial masks and social distancing.
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http://dx.doi.org/10.1097/GOX.0000000000003783DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8376388PMC
July 2021

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications.

Aesthet Surg J Open Forum 2021 Jan 10;3(1):ojab007. Epub 2021 Feb 10.

Department of Plastic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.
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http://dx.doi.org/10.1093/asjof/ojab007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240741PMC
January 2021

Breast Implant-Associated Anaplastic Large Cell Lymphoma With Invasive Chest Wall Masses.

Ann Plast Surg 2021 10;87(4):409-414

From the Department of Plastic Surgery.

Background: Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) might occur in any patient with a history of textured breast devices, and often presents as a spectrum of disease: from a simple late-onset seroma, to complex advanced locally aggressive disease with chest wall involvement. The combination of medical therapy and surgical implant removal with complete capsulectomy is believed to be curative.

Objectives: In patients with advanced cases, however, and although generalized recommendations exist, no consensus exists regarding the ideal medical and surgical management of those presenting with invasive disease.

Methods: This preliminary report describes 2 distinct presentations of rare invasive chest wall BIA-ALCL, both treated successfully, by using a combined medical and surgical multidisciplinary team approach. Subsequently, we discuss considerations and the current literature surrounding the treatment of advanced BIA-ALCL with chest wall and adjacent structure involvement.

Results: All patients necessitated chest wall resection and composite reconstruction due to tumor involvement of the thorax with residual hypermetabolic activity, despite chemotherapeutic pretreatment with different neoadjuvant medical therapies. All healed well after surgery and experienced resolution of symptoms without signs of relapse on regular follow-up.

Conclusions: In the rare subset of patients presenting with invasive BIA-ALCL, the question persists as to which systemic treatment remains optimal. However, the evidence supports multiple, particularly in combination with surgical extirpation and reconstruction. Here we present 2 proven treatments, both in timing and modalities chosen, as part of the first step to establish a formally accepted treatment paradigm for advanced BIA-ALCL patients with invasive chest wall involvement.
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http://dx.doi.org/10.1097/SAP.0000000000002910DOI Listing
October 2021

Successful Treatment of Life-Threatening COVID-19 Infection in a Face Transplant Recipient.

Ann Plast Surg 2021 07;87(1):105-106

From the Departments of Plastic Surgery.

Abstract: Recent literature suggests that severe COVID-19 is associated with an exaggerated immune response during viral infection, resulting in cytokine storm. Although elevated plasma interleukin 6 (IL-6) has been reported in severe COVID-19 infections, and treatment with anti-IL-6 (tocilizumab) has demonstrated promising outcomes both domestically and abroad, reports remain limited and therapeutic regimens vary considerably. Furthermore, research pertaining to transplant recipients, COVID-19 infection, and anti-IL-6 therapy remains underdeveloped. Herein, we report the successful treatment of the only reported facial vascularized composite allograft (VCA) recipient who contracted severe COVID-19 and the first reported VCA recipient with COVID-19 infection that received anti-IL-6 immunotherapy resulting in an excellent recovery despite his multiple preexisting and COVID-19-related comorbidities-adult respiratory distress syndrome, acute renal failure requiring hemodialysis, and concomitant sepsis due to extensive drug-resistant bacterial pneumonia upon presentation. To date, he has not demonstrated any anti-IL-6 drug-related adverse effects. This preliminary report also suggests that our immunosuppressed VCA patients can indeed demonstrate a robust cytokine response during COVID-19 infection and may also respond favorably to emerging anticytokine immune therapies. We hope that our experience proves helpful to other centers that might encounter critically ill VCA recipients in the ongoing COVID-19 pandemic and in the years to follow.
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http://dx.doi.org/10.1097/SAP.0000000000002790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8224692PMC
July 2021

Acute Superficial Vein Thrombosis of the Upper Extremity: A Case Report.

Plast Reconstr Surg Glob Open 2020 Dec 21;8(12):e3322. Epub 2020 Dec 21.

Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio.

Superficial vein thrombosis has traditionally been considered a disease of the lower extremity. Less frequently it can affect the breast, chest wall, penis, or upper extremity. Cases involving upper extremities are usually associated with intravascular access, and the vast majority remain self-limiting. This case report presents a 63-year-old patient who had acute extensive thrombosis of cephalic and basilic venous systems following resection of a desmoid tumor from the flank. This was likely related to intraoperative positioning and resulted in severe symptoms mimicking deep vein thrombosis and carpal tunnel syndrome. Additionally, diagnostic tools available to the hand surgeon that allow prompt diagnosis, management, and prevention are discussed.
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http://dx.doi.org/10.1097/GOX.0000000000003322DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787343PMC
December 2020

Long-term Effect of Cranioplasty on Overlying Scalp Atrophy.

Plast Reconstr Surg Glob Open 2020 Aug 25;8(8):e3031. Epub 2020 Aug 25.

Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio.

Scalp thinning over a cranioplasty can lead to complex wound problems, such as extrusion and infection. However, the details of this process remain unknown. The aim of this study was to describe long-term soft-tissue changes over various cranioplasty materials and to examine risk factors associated with accelerated scalp thinning.

Methods: A retrospective review of patients treated with isolated cranioplasty between 2003 and 2015 was conducted. To limit confounders, patients with additional scalp reconstruction or who had a radiologic follow-up for less than 1 year were excluded. Computed tomography or magnetic resonance imaging was used to measure scalp thickness in identical locations and on the mirror image side of the scalp at different time points.

Results: One hundred one patients treated with autogenous bone (N = 38), polymethylmethacrylate (N = 33), and titanium mesh (N = 30) were identified. Mean skull defect size was 104.6 ± 43.8 cm. Mean length of follow-up was 5.6 ± 2.6 years. Significant thinning of the scalp occurred over all materials ( < 0.05). This was most notable over the first 2 years after reconstruction. Risk factors included the use of titanium mesh ( < 0.05), use of radiation ( < 0.05), reconstruction in temporal location ( < 0.05), and use of a T-shaped or "question mark" incision ( < 0.05).

Conclusions: Thinning of the native scalp occurred over both autogenous and alloplastic materials. This process was more severe and more progressive when titanium mesh was used. In our group of patients without preexisting soft-tissue problems, native scalp atrophy rarely led to implant exposure. Other risk factors for scalp atrophy included radiation, temporal location, and type of surgical exposure.
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http://dx.doi.org/10.1097/GOX.0000000000003031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489738PMC
August 2020

Prospective Study Assessing the Effect of Local Infiltration of Tranexamic Acid on Facelift Bleeding.

Aesthet Surg J 2021 03;41(4):391-397

Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH.

Background: Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery.

Objectives: The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage.

Methods: This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded.

Results: The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications.

Conclusions: TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

Level Of Evidence: 2:
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http://dx.doi.org/10.1093/asj/sjaa198DOI Listing
March 2021

Advances and current concepts in reconstructive surgery for breast cancer.

Semin Oncol 2020 Aug 24;47(4):217-221. Epub 2020 May 24.

Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, United States of America. Electronic address:

In this article, we report on recent advancements in reconstructive care of the breast cancer patient. New developments in sensate breast reconstruction to help address the problem of numbness after mastectomy have emerged and show promise. Methods to restore lymphatic physiologic flow after axillary lymphadenectomy using supermicrosurgical techniques have begun to show benefit by reducing the short-term incidence of breast cancer related lymphedema (BRCL). Breast implant safety has received significant recent attention and we explore the emergence of BIA-ALCL (Breast Implant Associated Anaplastic Large Cell Lymphoma) and its implications for the breast cancer patient and their multidisciplinary care team.
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http://dx.doi.org/10.1053/j.seminoncol.2020.05.007DOI Listing
August 2020

Liposuction: Concepts, safety, and techniques in body-contouring surgery.

Cleve Clin J Med 2020 06;87(6):367-375

Staff Surgeon, Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic; Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio

Liposuction is the second most commonly performed cosmetic surgery in the United States and the most common surgical procedure in patients between the ages of 35 and 64; practitioners of medicine and surgery will undoubtedly encounter these patients in their practice. This brief review discusses the role of liposuction and fat transfer in aesthetic and reconstructive surgery, as well as key considerations, indications, and safety concerns.
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http://dx.doi.org/10.3949/ccjm.87a.19097DOI Listing
June 2020

Revisiting the "July Effect" in Plastic Surgery: New Data to Support Resident Autonomy.

Ann Plast Surg 2020 01;84(1):95-99

From the Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation.

Background: The "July Effect" represents a topic of considerable interest across residency programs. This study investigated the frequency of postoperative complications following procedures with plastic surgery resident participation (all postgraduate year [PGY] levels) during the first (quarter 3, July-September) and last academic quarters.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to calculate complication rates from 2006 to 2010. Resident involvement was analyzed as a categorical variable consisting of "juniors" (PGY1-PGY3), and "seniors" (PGY4-PGY6). Outcomes from procedures during Q3 were compared with all quarters. Propensity score matching and adjustment enabled logistic regression identifying the effect of resident involvement and admission.

Results: Among all cosmetic and reconstructive procedures (n = 6625), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.069); no significant differences in complication rates were observed between Q3 and all other quarters, though superficial surgical site infection (SSI) approached significance (3.3% of procedures in Q3 vs 2.5% in all other quarters, P = 0.063). Among reconstructive procedures only (n = 5677), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.119); the same held true for cosmetic procedures only (P = 0.275). Surgical site infection, however, was significantly more likely to occur with reconstructive procedures only, in Q3 compared with all other quarters (3.5% of cases vs 2.3%, P = 0.024). When adjusting for PGY status and matching populations, superficial SSI and return to the operating room were not significantly more common in Q3. When adjusting for quarter of admission, however, superficial SSI was significantly more common among the overall and noncosmetic cases with participation by junior residents (P = 0.013 and 0.020, respectively).

Conclusions: This may represent the first fully reproducible, transparent National Surgical Quality Improvement Program study in plastic surgery that demonstrates the absence of a clinically significant "July Effect," and suggests that an appropriate degree of resident autonomy may pose minimal risk during both cosmetic and reconstructive procedures in residency training. Additionally, the findings encourage the development a plastic surgery-specific database to remedy inherent difficulties with larger, more comprehensive surgical databases.
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http://dx.doi.org/10.1097/SAP.0000000000001999DOI Listing
January 2020

Revisiting the "July Effect" in Plastic Surgery: New Data to Support Resident Autonomy.

Ann Plast Surg 2020 01;84(1):95-99

From the Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation.

Background: The "July Effect" represents a topic of considerable interest across residency programs. This study investigated the frequency of postoperative complications following procedures with plastic surgery resident participation (all postgraduate year [PGY] levels) during the first (quarter 3, July-September) and last academic quarters.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to calculate complication rates from 2006 to 2010. Resident involvement was analyzed as a categorical variable consisting of "juniors" (PGY1-PGY3), and "seniors" (PGY4-PGY6). Outcomes from procedures during Q3 were compared with all quarters. Propensity score matching and adjustment enabled logistic regression identifying the effect of resident involvement and admission.

Results: Among all cosmetic and reconstructive procedures (n = 6625), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.069); no significant differences in complication rates were observed between Q3 and all other quarters, though superficial surgical site infection (SSI) approached significance (3.3% of procedures in Q3 vs 2.5% in all other quarters, P = 0.063). Among reconstructive procedures only (n = 5677), mean operative time was not significantly greater in Q3 compared with all other quarters (P = 0.119); the same held true for cosmetic procedures only (P = 0.275). Surgical site infection, however, was significantly more likely to occur with reconstructive procedures only, in Q3 compared with all other quarters (3.5% of cases vs 2.3%, P = 0.024). When adjusting for PGY status and matching populations, superficial SSI and return to the operating room were not significantly more common in Q3. When adjusting for quarter of admission, however, superficial SSI was significantly more common among the overall and noncosmetic cases with participation by junior residents (P = 0.013 and 0.020, respectively).

Conclusions: This may represent the first fully reproducible, transparent National Surgical Quality Improvement Program study in plastic surgery that demonstrates the absence of a clinically significant "July Effect," and suggests that an appropriate degree of resident autonomy may pose minimal risk during both cosmetic and reconstructive procedures in residency training. Additionally, the findings encourage the development a plastic surgery-specific database to remedy inherent difficulties with larger, more comprehensive surgical databases.
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http://dx.doi.org/10.1097/SAP.0000000000001999DOI Listing
January 2020

Soft Tissue Reconstruction for Deep Defects over a Complicated Total Knee Arthroplasty: A Systematic Review.

J Knee Surg 2020 Jul 8;33(7):732-744. Epub 2019 Apr 8.

Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.

Deep soft tissue defects after complicated primary or revision total knee arthroplasty (TKA) can be devastating to the patient and technically challenging. The purpose of this review was to (1) discuss different methods used to provide coverage for deep defects of the knee following TKA, as well as to (2) report on their success rates. A comprehensive literature search was performed. Reports were only included if they (1) were case series, (2) were level III studies or above (including retrospective cohort studies and meta-analyses), (3) were in English, and (4) discussed the outcome of graft or flap coverage of soft tissue defects after total knee arthroplasty. A total of 28 case series and four retrospective comparative studies were retrieved. In 16 studies, 195 out of 241 patients who received gastrocnemius flaps (81%) experienced successful outcomes. In seven studies including 84 patients that underwent fasciocutaneous flap coverage, over 90% of patients experienced successful outcomes. In the four studies examining 144 patients with delayed versus prophylactic soft tissue reconstruction, up to 81% of patients experienced a successful outcome. Various factors must be taken into consideration when assessing full-thickness defects over a TKA and collaboration between plastic and orthopaedic surgeons is required to select the optimal approach.
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http://dx.doi.org/10.1055/s-0039-1684012DOI Listing
July 2020

Breast augmentation surgery: Clinical considerations.

Cleve Clin J Med 2019 02;86(2):111-122

Department of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.

Women receive breast implants for both aesthetic and reconstructive reasons. This brief review discusses the evolution of and complications related to breast implants, as well as key considerations with regard to aesthetic and reconstructive surgery of the breast.
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http://dx.doi.org/10.3949/ccjm.86a.18017DOI Listing
February 2019

In Reply: Nerve Surgeons' Assessment of the Role of Eduard Pernkopf's Atlas of Topographic and Applied Human Anatomy in Surgical Practice.

Neurosurgery 2018 10;83(4):E189

Division of Plastic and Reconstructive Surgery Department of SurgeryWashington University School of Medicine St. Louis, Missouri.

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http://dx.doi.org/10.1093/neuros/nyy329DOI Listing
October 2018

Nerve Surgeons' Assessment of the Role of Eduard Pernkopf's Atlas of Topographic and Applied Human Anatomy in Surgical Practice.

Neurosurgery 2019 02;84(2):491-498

Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri.

Background: Pernkopf's atlas of Anatomy contains anatomical plates with detailed images of the peripheral nerves. Its use is controversial due to the author's association with the "Third Reich" and the potential depiction of victims of the Holocaust. The ethical implications of using this atlas for informing surgical planning have not been assessed.

Objective: To (1) assess the role of Pernkopf's atlas in nerve surgeons' current practice and (2) determine whether a proposal for its ethical handling may provide possible guidance for use in surgery and surgical education.

Methods: Members of American Society for Peripheral Nerve and PASSIO Education (video-based learning platform) were surveyed and 182 responses collected. The survey introduced the historical origin of Pernkopf's atlas, and respondents were asked whether they would use the atlas under specific conditions to serve as a recommendation for its ethical handling. An anatomical plate comparison between Netter's and Pernkopf's atlases was performed to compare anatomical accuracy and surgical utility.

Results: Fifty-nine percent of respondents were aware of Pernkopf's atlas, with 13% currently using it. Aware of the historical facts, 69% were comfortable using the atlas, 15% uncomfortable, and 17% undecided. Additional information on conditions for an ethical approach to the use of the atlas led 76% of those "uncomfortable" and "undecided" to becoming "comfortable" with use.

Conclusion: While the use of Pernkopf's atlas remains controversial, a proposal detailing conditions for an ethical approach in its use provides new guidance in surgical planning and education.
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http://dx.doi.org/10.1093/neuros/nyy159DOI Listing
February 2019

Characterizing Breast Deformities After Massive Weight Loss: Utilizing the Pittsburgh Rating Scale to Examine Factors Affecting Severity Score and Surgical Decision Making in a Retrospective Series.

Ann Plast Surg 2018 Mar;80(3):207-211

Background And Objectives: Massive weight loss (MWL) can result in variable contour deformities of the breasts. The Pittsburgh Rating Scale (PRS) was designed to describe the multitude of deformities after MWL and recommends operations to consider for surgical improvement. We present the first comprehensive description of breast deformities in a large sample of MWL patients, examine factors affecting the severity of deformities, and report the correlation between PRS score and surgical decision making.

Methods: A retrospective review of all MWL patients presenting for breast surgery at our institution's Life After Weight Loss program from 2004 to 2015 was performed. Information including demographics, body mass indices (BMIs), method of weight loss, and type of surgical intervention was collected. Preoperative breast photographs were blinded and scored according to the PRS.

Results: A total of 204 MWL patients were identified; 26% (53) scored 1, 34% (69) scored 2, and 40% (82) scored 3 on the PRS. Greater deformities were seen after weight loss from bariatric surgery versus diet and exercise alone (P = 0.031), in mastopexy versus augmentation/mastopexy (P = 0.001), and in breast reduction versus augmentation/mastopexy patients (P > 0.0001). Patients who underwent reduction mammaplasty had the greatest maximum BMI compared with other procedures (P = 0.016). The PRS scores were positively correlated to maximum BMI (P < 0.001), delta BMI (P < 0.001), and current BMI (P < 0.001).

Conclusions: Massive weight loss patients have variable, and often severe, breast deformities, and the PRS remains a valuable classification tool. Severity scores correlate with BMI, procedure, and weight loss mechanism. Similar scores between mastopexy-only and reduction mammaplasty patients may reflect a composite of personal cosmetic expectations and cost. The PRS scale should also be expanded to include breast reduction as a surgical remedy for PRS grade 3 breast deformities. Understanding breast deformities in this unique population has applications in both preoperative planning and surgical expectations for this unique patient population.
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http://dx.doi.org/10.1097/SAP.0000000000001338DOI Listing
March 2018

Endometrial Cancers Harboring Mutated Fibroblast Growth Factor Receptor 2 Protein Are Successfully Treated With a New Small Tyrosine Kinase Inhibitor in an Orthotopic Mouse Model.

Int J Gynecol Cancer 2018 01;28(1):152-160

Objectives: AL3818 (anlotinib) is a receptor tyrosine kinase inhibitor targeting vascular endothelial growth factor receptors (VEGFR1, VEGFR2/KDR, and VEGFR3), stem cell factor receptor (C-kit), platelet-derived growth factor (PDGFβ), and fibroblast growth factor receptors (FGFR1, FGFR2, and FGFR3). This study evaluates the efficacy of AL3818 studying tumor regression in an orthotopic murine endometrial cancer model.

Methods: We tested the cytotoxicity of AL3818 on a panel of 7 human endometrial cancer cell lines expressing either wild-type or mutant FGFR2 and also assessed the in vivo antitumor efficacy in a murine, orthotopic AN3CA endometrial cancer model. AL3818 was administered daily per os either alone or in combination with carboplatin and paclitaxel, which represent the current standard of adjuvant care for endometrial cancer.

Results: AL3818 significantly reduces AN3CA cell number in vitro, characterized by high expression of a mutated FGFR2 protein. Daily oral administration of AL3818 (5 mg/kg) resulted in a complete response in 55% of animals treated and in a reduced tumor volume, as well as decreased tumor weights of AN3CA tumors by 94% and 96%, respectively, following a 29-day treatment cycle. Whereas carboplatin and paclitaxel failed to alter tumor growth, the combination with AL3818 did not seem to exhibit a superior effect when compared with AL3818 treatment alone.

Conclusions: AL3818 shows superior efficacy for the treatment of endometrial cancer irresponsive to conventional carboplatin and paclitaxel combination and warrants further investigation.
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http://dx.doi.org/10.1097/IGC.0000000000001129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5735020PMC
January 2018

The Challenges of Augmentation Mastopexy in the Massive Weight Loss Patient: Technical Considerations.

Plast Reconstr Surg 2017 May;139(5):1090-1099

Pittsburgh, Pa.

Background: Augmentation mastopexy in the massive weight loss population is challenging because of poor skin elasticity and lack of inframammary support. Despite several large studies of augmentation mastopexy in the literature, few data exist regarding this unique patient population. The authors examine early postoperative ptosis, implant malposition, and strategies to optimize outcomes.

Methods: A retrospective review of massive weight loss patients who underwent augmentation mastopexy from 2003 to 2011 was performed to record age, body mass index, implant characteristics, postoperative ptosis, and implant malposition.

Results: Thirty patients were identified with a mean age of 44.8 ± 8.5 years, mean current body mass index of 26.1 ± 3.9 kg/m, and mean follow-up time of 283.5 days (range, 7 to 1095 days). Preoperatively, patients mostly presented with grade 3 ptosis (63.3 percent). Five patients (16.7 percent) developed postoperative ptosis within the first 3 months after surgery, with no increase after this time. Implant malposition increased significantly with time: 61.9 percent by 12 months (p = 0.006), with a median time for implant malposition of 160 days. Postoperative ptosis was significantly related to age (p = 0.039) and a larger left-side implant (p = 0.022). Implant malposition was significantly related to higher current body mass index (p = 0.047), but not to implant size. Two patients (6.6 percent) underwent revision procedures.

Conclusion: Massive weight loss patients have an increased risk of early postoperative ptosis or implant malposition, reinforcing the need for appropriate preoperative counseling to manage patient expectations.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000003294DOI Listing
May 2017

Medical Students' Assessment of Eduard Pernkopf's Atlas: Topographical Anatomy of Man.

Ann Anat 2017 Jul 3;212:11-16. Epub 2017 Apr 3.

Medical Humanities Program & Department of Medicine, Drexel University College of Medicine, 2900 West Queen Lane, Philadelphia, PA 19129, United States.

Introduction: To date, there has been no study examining the perceptions of first-year medical students regarding Eduard Pernkopf's atlas, particularly during their study of gross anatomy and prior to coursework in medical ethics. We present a discussion of Pernkopf's Atlas: Topographical Anatomy of Man from the perspective of U.S. medical students, and sought to determine whether medical students view Pernkopf's Topographical Anatomy of Man as a resource of greater accuracy, detail, and potential educational utility as compared to Netter's Atlas of Human Anatomy.

Methods: The entire first-year class at Drexel University College of Medicine (265 students) was surveyed at approximately the midpoint of their gross anatomy course and 192 responses were collected (72% response rate).

Results: Of these, 176 (95%) were unaware of the existence of Pernkopf's atlas. Another 71% of students found the Pernkopf atlas more likely complete and accurate, whereas 76% thought the Netter atlas more useful for learning (p<.001). When presented with a hypothetical scenario in which the subjects used in creating Pernkopf's atlas were donated, or unclaimed, but with knowledge that Pernkopf was an active member of the Nazi party, 133 students (72%) retained their original position (p=.001). About 94% desired discussion of Pernkopf within a medical school bioethics course. The relationship between level of self-reported knowledge and whether or not students would advocate removal of the atlas was statistically significant (p=.013).

Conclusion: Discussing ethical violations in medical history, especially the Pernkopf atlas, must attain a secure place in medical school curricula, and more specifically, within a bioethics course.
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http://dx.doi.org/10.1016/j.aanat.2017.02.011DOI Listing
July 2017

The Plastic Surgeon as Employee: A Pilot Survey of the California Society of Plastic Surgeons.

Ann Plast Surg 2017 May;78(5 Suppl 4):S238-S242

From the *Division of Plastic Surgery, University of California, Davis, Sacramento, CA; †Drexel University College of Medicine, Philadelphia, PA; ‡McGeorge School of Law, University of the Pacific; and §Department of Statistics, University of California, Davis, Sacramento, CA.

Introduction: Plastic surgeons endure years of training yet remain poorly equipped to negotiate first employment contracts. Our aims were to evaluate typical plastic surgeon employment contracts and assess contract comprehensiveness. We sought elements that should be included to better preserve varied interests.

Methods: A brief, anonymous, e-mailed survey was sent to California Society of Plastic Surgeons members and responses collected over 2 months. We collected information such as years in practice, geographic area, types of practices and number of surgeons within them, and legal standing of partnerships. We asked whether respondents sought legal assistance and specific elements were elaborated. We asked how content they were with their contracts while allowing commentary.

Results: Our survey generated 113 responses. 50.0% of respondents reported being in practice for at least 20 years; 2.68% had been in practice for up to 5 years. 62.5% reported being in private practice and 27.7% reported being in academia. In-state geographic distribution of respondents accounted for 85.6%, whereas 14.4% reported practicing out-of-state.Practice size was diverse, with 41.4% of respondents having worked in a group practice of 3 or more, 27.9% in partnership, and 23.4% in solo practice. For partnerships, 29.9% had made formal legal arrangements, whereas 20.6% had made informal arrangements. 74.5% of respondents did not seek legal assistance.Malpractice coverage varied from 51.6% with claims-made, to 21.7% with tail, to 33.0% with no coverage at all. 63.9% reported having no group disability policy. 26.4% reported annual income of less than US $100,000; 49.1% reported US $101,000 to US $200,000; 17.9% reported US $201,000 to US $300,000; 6.60% reported greater than US $300,000. Using a 5-point scale, 7.69% of respondents reported being "extremely dissatisfied" with their first employment contracts (score of 1), whereas 24.0% were "perfectly happy" (5).Eighty-two respondents offered advice. Common themes included seeking legal counsel; considering eventual solo practice; planning long-term; seeking mentorship; and cautioning against third party interests.

Conclusions: New plastic surgeons will find themselves employed by institutions. Seeking attorneys familiar with the profession is advisable. Lack of awareness regarding malpractice options and disability coverage are 2 areas of concern. We reveal critical contract elements that surgeons should negotiate to ensure smooth transition to practice.
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http://dx.doi.org/10.1097/SAP.0000000000001050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388558PMC
May 2017

The Vertical Rectus Abdominis Musculocutaneous Flap As a Versatile and Viable Option for Perineal Reconstruction.

Eplasty 2017 16;17:ic2. Epub 2017 Jan 16.

Division of Plastic & Reconstructive Surgery, University of California, Davis, Sacramento, Ca.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5247671PMC
January 2017

Reconstructing Defects of the Lower Lip: An Emphasis on the Estlander Flap.

Eplasty 2016 24;16:ic50. Epub 2016 Dec 24.

Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5193126PMC
December 2016
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