Publications by authors named "Michael J Yaremchuk"

70 Publications

Improving Male Chin and Mandible Eesthetics.

Clin Plast Surg 2022 Apr;49(2):275-283

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 170 Commonwealth Avenue, Boston, MA 02116, USA. Electronic address: https://twitter.com/%20DrYaremchuk.

The size and shape of the chin and mandible are fundamental to sexual dimorphism. Deficiencies in these structures distract from the male facial esthetic. When deficient, these areas of the facial skeleton can be augmented by alloplastic augmentation or skeletal rearrangement. This article discusses these alternatives with emphasis on the design and techniques of alloplastic skeletal augmentation.
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http://dx.doi.org/10.1016/j.cps.2021.12.004DOI Listing
April 2022

Invited Discussion on: Paranasal Augmentation Using Diced Costal Cartilage for Midface Concavity-A Retrospective Study of 68 Patients.

Aesthetic Plast Surg 2022 04 31;46(2):803-804. Epub 2022 Jan 31.

Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, 170 Commonwealth Avenue, #101, Boston, MA, 02116, USA.

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http://dx.doi.org/10.1007/s00266-021-02700-xDOI Listing
April 2022

Role of the Pedicled Mentalis Muscle Flap in Closure of Chin Implants in Genioplasty.

Plast Reconstr Surg Glob Open 2021 Aug 4;9(8):e3728. Epub 2021 Aug 4.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Mass.

With the purpose of obtaining an aesthetically pleasing chin appearance, genioplasty or chin augmentation can be performed through osteotomy or chin implantation, with the latter available in different sizes and materials such as silicone and porous polyethylene. The implants are traditionally placed in a subperiosteal or supraperiosteal plane with different advantages and disadvantages to each. This procedure has evolved through time with many techniques and modifications; and this article is an addition to this ongoing refinement by advocating for closure of the mentalis muscle (a paired chin muscle originating from the incisor fossa to the chin skin) over the implant after securing its position with screws (in the case of porous polyethylene) or creating a snug pocket (in the case of silicone). In this retrospective analysis, 15 patients underwent this procedure with an excellent outcome. A single patient developed numbness in the mandibular nerve territory, while another one developed a fistulating radicular cyst that was unrelated to this technique. In addition to the simple learning curve, the potential advantages of this technique include less chances of fistula formation, implant exposure, infection, extrusion, or malpositioning. Prospective studies with more subjects are required to cement our findings.
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http://dx.doi.org/10.1097/GOX.0000000000003728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8337062PMC
August 2021

Invited Discussion on: "A Reliable Method for Chin Augmentation by Mechanical Micronization of Lipoaspirates".

Aesthetic Plast Surg 2021 08 16;45(4):1518-1519. Epub 2021 Jun 16.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 170 Commonwealth Avenue, Boston, Massachusetts, 02116, USA.

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http://dx.doi.org/10.1007/s00266-021-02263-xDOI Listing
August 2021

Changing Mandible Contour Using Computer Designed/Computer Manufactured Alloplastic Implants.

Aesthet Surg J 2021 09;41(10):NP1265-NP1275

Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Background: The shape of the mandible is the fundamental determinant of the appearance and sexual dimorphism of the lower one-third of the face. Utilization of computer-aided design/computer-aided manufactured (CAD/CAM) alloplastic implants provides unparalleled planning and sophistication in the correction of skeletal deficiencies, irregularities, and asymmetry.

Objectives: This study presented the rationale, indications, techniques, and results of the senior author's (M.J.Y.) 15-year experience employing CAD/CAM alloplastic implants to correct deficiencies and asymmetries of the mandible.

Methods: A retrospective review of a prospectively maintained database was reviewed of all patients who underwent aesthetic augmentation of the mandible employing CAD/CAM alloplastic implants by the senior author.

Results: Over a 15-year period, 123 patients underwent mandibular augmentation utilizing CAD/CAM alloplastic implants. The majority of patients were men (76.4%) with an average age of 31 years (range, 24-63 years). All implants were bilateral. Complications included infection requiring implant removal (2.4%) and patient dissatisfaction resulting in either implant revision (4.1%) or implant removal (2.4%).

Conclusions: As described here, CAD/CAM alloplastic implants are an effective modality to augment aesthetic mandible contour deficiencies.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjab200DOI Listing
September 2021

Invited Discussion on "The Ideal Eyebrow: Lessons Learnt from the Literature".

Aesthetic Plast Surg 2021 04 15;45(2):544-545. Epub 2020 Sep 15.

Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, 170 Commonwealth Avenue, Boston, MA, 02116, USA.

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http://dx.doi.org/10.1007/s00266-020-01945-2DOI Listing
April 2021

Pioneers in Modern Craniofacial Surgery: Assessing the Academic Impact of Drs. Joseph Gruss and Paul Manson.

Plast Reconstr Surg 2020 04;145(4):814e-817e

From the Department of Plastic Surgery, The Johns Hopkins Hospital; the Craniofacial Center, Seattle Children's Hospital; the Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital; and Division of Plastic Surgery, Department of Surgery, University of Oklahoma School of Medicine.

Background: The authors conducted this study to assess the impact that Drs. Joseph Gruss and Paul Manson have had on craniofacial surgery through their individual contributions and through their trainees.

Methods: This was a retrospective analysis of fellows trained by either Dr. Gruss or Dr. Manson. Demographic and bibliometric measures were recorded for each fellow. Demographic factors included years since completion of fellowship training, current practice of craniomaxillofacial surgery, academic practice, and academic leadership roles. Bibliometric measures included number of publications, number of citations, and h-index. To adjust for scholarly activity before fellowship training, only contributions published after fellowship training were included.

Results: Over a 39-year period, a total of 86 surgeons completed fellowship training with either of the two principal surgeons. The mean time since completion of training was 18.7 ± 11.4 years. Seventy-nine percent of surgeons had active practices in craniomaxillofacial surgery; 54 percent had academic practices. The mean number of publications was 26.4 ± 69.3, the mean number of citations was 582 ± 2406, and the average h-index was 6.7 ± 10.6. Among academic surgeons, the average h-index was 10.7 ± 13.1, 89 percent practiced in North America, 89 percent had active practices in craniomaxillofacial surgery, and nearly 50 percent had achieved a leadership role.

Conclusions: Modern craniofacial reconstruction has evolved from principles used in trauma and correction of congenital differences. The extensive impact that Drs. Paul Manson and Joseph Gruss have had on the field, and plastic surgery at large, is evident through their primary contributions and the immense impact their trainees have had on the field.
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http://dx.doi.org/10.1097/PRS.0000000000006647DOI Listing
April 2020

Invited Discussion on: The Relationship Between the Facial Proportion Changes in Hard Tissue and the Satisfaction of Patients After Reduction Malarplasty: A Research Based on Three-Dimensional Cephalometry.

Aesthetic Plast Surg 2020 06 26;44(3):764-765. Epub 2020 Mar 26.

Massachusetts General Hospital, 55 Fruit Street, Wang Building 435, Boston, MA, 02114, USA.

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http://dx.doi.org/10.1007/s00266-020-01690-6DOI Listing
June 2020

Refining Post-Orthognathic Surgery Facial Contour with Computer-Designed/Computer-Manufactured Alloplastic Implants.

Plast Reconstr Surg 2018 09;142(3):747-755

From the Division of Plastic and Reconstructive Surgery and the Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital.

Background: Le Fort I maxillary osteotomies and sagittal split mandibular osteotomies are performed to correct significant dentofacial deformities. The multidimensional skeletal movements, particularly those of large magnitude, may result in contour irregularities and facial imbalances.

Methods: Three-dimensional images were reconstructed from computed tomographic scans in patients unhappy with their appearances after Le Fort I advancement and/or bilateral sagittal split osteotomies. The data from these scans were used to produce alloplastic implants using computer-aided design/computer-aided manufacturing for surgical correction of contour irregularities and imbalances. These implants were surgically placed through intraoral and submental incisions and fixed using titanium screws.

Results: A total of 21 patients underwent implant placement with implants produced using computer-design/computer manufacturing. One patient required removal of implants secondary to infection. All other patients were satisfied with their result.

Conclusion: The use and surgical placement of implants produced by means of computer-aided design/computer-aided manufacturing has been shown to be effective in refining appearance in 21 patients over a 7-year period with minimal morbidity.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000004652DOI Listing
September 2018

Commentary on: Application of a Porous Polyethylene Spreader Graft for Nasal Lengthening in Asian Patients.

Aesthet Surg J 2018 04;38(5):500-501

Massachusetts General Hospital, Boston, MA.

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http://dx.doi.org/10.1093/asj/sjx248DOI Listing
April 2018

Commentary: Reduction Malarplasty that uses Malar Setback Without Resection of Malar Body Strip.

Aesthetic Plast Surg 2017 10 25;41(5):1167. Epub 2017 Apr 25.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.

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http://dx.doi.org/10.1007/s00266-017-0880-5DOI Listing
October 2017

A 64-Year-Old Man With Swollen, Blistered Eyelids.

JAMA Ophthalmol 2017 06;135(6):669-670

Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamaophthalmol.2016.5410DOI Listing
June 2017

Commentary on: Chin Ups and Downs: Avoiding Bad Results in Chin Reoperation.

Aesthet Surg J 2017 03;37(3):264-265

Clinical Professor of Surgery, Harvard Medical School, Boston, MA, USA.

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http://dx.doi.org/10.1093/asj/sjw266DOI Listing
March 2017

Commentary on: Alloplastic Augmentation of the Asian Face: A Review of 215 Patients.

Aesthet Surg J 2016 09 23;36(8):869-71. Epub 2016 Mar 23.

Dr Yaremchuk is a Clinical Professor of Surgery, Harvard Medical School; Chief of Craniofacial Surgery, Massachusetts General Hospital; and Program Director, Harvard Plastic Surgery Training Program, Boston, MA.

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http://dx.doi.org/10.1093/asj/sjw034DOI Listing
September 2016

Pyriform Aperture Augmentation as An Adjunct to Rhinoplasty.

Clin Plast Surg 2016 Jan 17;43(1):187-93. Epub 2015 Oct 17.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, WACC 435, Boston, MA 02114, USA.

Skeletal deficiency in the central midface impacts nasal aesthetics. This lack of lower face projection can be corrected by alloplastic augmentation of the pyriform aperture. Creating convexity in the deficient midface will make the nose seem less prominent. Augmentation of the pyriform aperture is, therefore, often a useful adjunct during the rhinoplasty procedure. Augmenting the skeleton in this area can alter the projection of the nasal base, the nasolabial angle, and the vertical plane of the lip. The implant design and surgical techniques described here are extensions of others' previous efforts to improve paranasal aesthetics.
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http://dx.doi.org/10.1016/j.cps.2015.09.012DOI Listing
January 2016

Lifetime Costs of Prophylactic Mastectomies and Reconstruction versus Surveillance.

Plast Reconstr Surg 2015 Dec;136(6):730e-740e

Boston, Mass. From the Division of Plastic and Reconstructive Surgery and the Avon Comprehensive Breast Evaluation Center, Massachusetts General Hospital.

Background: The past decade has seen an increasing prevalence of prophylactic mastectomy with decreasing ages of patients treated for breast cancer. Data are limited on the fiscal impacts of contralateral prophylactic mastectomy trends, and no study has compared bilateral prophylactic mastectomy with reconstruction to surveillance in high-risk patients.

Methods: Lifetime third-party payer costs over 30 years were estimated with 2013 Medicare reimbursement rates. Costs were estimated for patients choosing contralateral or bilateral prophylactic mastectomy versus surveillance, with immediate reconstructions using a single-stage implant, tissue expander, or perforator-based free flap approach. Published cancer incidence rates predicted the percentage of surveillance patients that would require mastectomies. Sensitivity analyses were conducted that varied cost growth, discount rate, cancer incidence rate, and other variables. Lifetime costs and present values (3 percent discount rate) were estimated.

Results: Lifetime prophylactic mastectomy costs were lower than surveillance costs, $1292 to $1993 lower for contralateral prophylactic mastectomy and $15,668 to $21,342 lower for bilateral prophylactic mastectomy, depending on the reconstruction. Present value estimates were slightly higher for contralateral prophylactic mastectomy over contralateral surveillance but still cost saving for bilateral prophylactic mastectomy compared with bilateral surveillance. Present value estimates are also cost saving for contralateral prophylactic mastectomy when the modeled contralateral breast cancer incidence rate is increased to at least 0.6 percent per year.

Conclusions: These findings are consistent with contralateral and bilateral prophylactic mastectomy being cost saving in many scenarios, regardless of the reconstructive option chosen. They suggest that physicians and patients should continue to receive flexibility in deciding how best to proceed clinically in each case.
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http://dx.doi.org/10.1097/PRS.0000000000001763DOI Listing
December 2015

Occult Histopathology and Its Predictors in Contralateral and Bilateral Prophylactic Mastectomies.

Ann Surg Oncol 2016 Mar 17;23(3):767-75. Epub 2015 Nov 17.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA, USA.

Background: The last decade has seen an increasing prevalence of prophylactic mastectomies with decreasing age of patients treated for breast cancer. Data are limited on the prevalence of histopathologic abnormalities in this population. This study aimed to measure the prevalence of histopathologic findings in contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM) patients and identify predictors of findings.

Methods: Our institution's prophylactic mastectomies from 2004 to 2011 were reviewed. Breast specimens with prior malignancies were excluded. Patient factors and pathology reports were collected. Independent predictive factors were identified with univariate and multivariate logistic analysis.

Results: A total of 524 specimens in 454 patients were identified. Malignancy was found in 7.0% of CPM and 5.7% of BPM specimens. In CPM patients, ipsilateral lobular carcinoma-in situ [odds ratio (OR) 4.0] and mammogram risk group (OR 2.0) were predictive of malignancy. Age group (OR 1.5), ipsilateral lobular carcinoma-in situ (OR 2.3), and prior bilateral salpingo-oophorectomy (OR 0.3) were predictive of moderate- to high-risk histopathology. Only increasing age group was predictive of increased moderate- to high-risk histopathology in BPM patients (OR 2.3). There were no independent predictors of malignancy in BPM. BRCA status was not predictive in either CPM or BPM.

Conclusions: Patients with lobular carcinoma-in situ in the index breast or high-risk mammograms have a higher prevalence of malignancies. Although BRCA patients may benefit from prophylactic mastectomy, the genetic diagnosis does not increase the prevalence of detecting occult pathology. BPM patients can be counseled about relative risk, where occult pathology increases with age.
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http://dx.doi.org/10.1245/s10434-015-4896-2DOI Listing
March 2016

Are Quantitative Measures of Academic Productivity Correlated with Academic Rank in Plastic Surgery? A National Study.

Plast Reconstr Surg 2015 Sep;136(3):613-621

Baltimore, Md.; Cleveland, Ohio; Philadelphia, Pa.; and Boston, Mass. From the Departments of Plastic and Reconstructive Surgery and Neurosurgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine; the Department of Plastic Surgery, Cleveland Clinic; the Department of Surgery, Division of Plastic Surgery, University of Pennsylvania School of Medicine; and the Department of Surgery, Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School.

Background: The purpose of this study was to investigate the correlation between quantitative measures of academic productivity and academic rank among full-time academic plastic surgeons.

Methods: Bibliometric indices were computed for all full-time academic plastic surgeons in the United States. The primary study variable was academic rank. Bibliometric predictors included the Hirsch index, I-10 index, number of publications, number of citations, and highest number of citations for a single publication. Descriptive, bivariate, and correlation analyses were computed. Multiple comparisons testing was used to calculate adjusted associations for subgroups. For all analyses, a value of p < 0.05 was considered significant.

Results: The cohort consisted of 607 plastic surgeons across 91 Accreditation Council for Graduate Medical Education-approved programs. Of them, 4.1 percent were instructors/lecturers, 43.7 percent were assistant professors, 22.1 percent were associate professors, 25.7 percent were professors, and 4.4 percent were endowed professors. Mean values were as follows: Hirsch index, 10.2 ± 9.0; I-10 index, 17.2 ± 10.2; total number of publications, 45.5 ± 69.4; total number of citations, 725.0 ± 1448.8; and highest number of citations for a single work, 117.8 ± 262.4. Correlation analyses revealed strong associations of the Hirsch index, I-10 index, number of publications, and number of citations with academic rank (rs = 0.62 to 0.64; p < 0.001).

Conclusions: Academic rank in plastic surgery is strongly correlated with several quantitative metrics of research productivity. Although academic promotion is the result of success in multiple different areas, bibliometric measures may be useful adjuncts for assessment of research productivity.
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http://dx.doi.org/10.1097/PRS.0000000000001531DOI Listing
September 2015

Commentary on: The Role of Microfat Grafting in Facial Contouring.

Aesthet Surg J 2015 Sep 3;35(7):772-3. Epub 2015 Jul 3.

Dr Yaremchuk is a Clinical Professor of Surgery, Harvard Medical School; Chief of Craniofacial Surgery, Massachusetts General Hospital; and Program Director, Harvard Plastic Surgery Training Program, Boston, Massachusetts.

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http://dx.doi.org/10.1093/asj/sjv084DOI Listing
September 2015

The volar forearm fasciocutaneous extension: a strategy to maximize vascular outflow in post-burn injury hand transplantation.

Plast Reconstr Surg 2014 Oct;134(4):731-735

Boston, Mass. From the Division of Plastic Surgery, the Department of Orthopaedic Surgery, and the Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School.

Summary: Patients with circumferential extremity burns may have a deficiency of cutaneous veins, which presents a challenge for both autologous reconstruction and vascularized composite allotransplantation. The authors present a 44-year-old, left-hand-dominant man with metacarpal level amputation of his left hand secondary to burn injury. Extensive prior débridement and skin grafting resulted in nearly total absence of cutaneous veins in the forearm. The patient underwent unilateral left hand transplantation with an allograft designed to include a volar forearm fasciocutaneous extension supplied by the radial artery and including the basilic vein to permit augmented venous drainage by means of anastomosis at the antecubital fossa. The volar forearm fasciocutaneous extension can increase vessel caliber and possibly improve reliability in the setting of hand transplantation and should be considered following severe burn injury.
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http://dx.doi.org/10.1097/PRS.0000000000000508DOI Listing
October 2014

Adhesion and integration of tissue engineered cartilage to porous polyethylene for composite ear reconstruction.

J Biomed Mater Res B Appl Biomater 2015 Jul 6;103(5):983-91. Epub 2014 Sep 6.

Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts.

The objective of this study was to assess the ability of tissue engineered cartilage to adhere to and integrate with porous polyethylene (PPE) in vivo and to evaluate the biomechanical integrity of the bond formed at the interface. Porcine auricular, articular, and costal chondrocytes were suspended in fibrin gel polymer and placed between discs of PPE to form tri-layer constructs. Controls consisted of fibroblasts suspended in gel or gel alone between the discs. Constructs were implanted into nude mice for 6, 12, and 18 weeks. Upon harvest, specimens were evaluated for neocartilage formation and integration into the PPE, using histological, dimensional (mass, thickness, diameter), and biomechanical (adhesion strength, interfacial stiffness, failure energy and failure strain) analyses. Neotissue was formed in all experimental constructs, consisting mostly of neocartilage integrating with discs of PPE. Control samples contained only fibrous tissue. Biomechanical analyses demonstrated that adhesion strength, interfacial stiffness, and failure energy were all significantly higher in the chondrocyte-seeded samples than in fibroblast-seeded controls, with the exception of costal constructs at 12 weeks, which were not significantly greater than controls. In general, failure strains did not vary between groups. In conclusion, porous polyethylene supported the growth of neocartilage that formed mechanically functional bonds with the PPE.
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http://dx.doi.org/10.1002/jbm.b.33269DOI Listing
July 2015

Aesthetic refinements in the treatment of graves ophthalmopathy.

Plast Reconstr Surg 2014 Sep;134(3):519-526

Cleveland and Cincinnati, Ohio; and Boston, Mass. From the Department of Plastic Surgery, Institute of Dermatology and Plastic Surgery, Cleveland Clinic; the Division of Plastic, Reconstructive & Hand/Burn Surgery, Department of Surgery, University of Cincinnati School of Medicine; and the Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital.

Background: Graves ophthalmopathy is a chronic, multisystem, autoimmune disorder characterized by increased volume of intraorbital fat and hypertrophic extraocular muscles. Proptosis, impaired ocular motility, diplopia, lid retraction, and impaired visual acuity are treated with orbit decompression and fat reduction. The authors present the addition of skeletal augmentation to further improve periorbital aesthetics.

Methods: Through a transconjunctival with lateral canthotomy incision, a balanced orbital decompression was executed, removing medial and lateral walls and medial floor. Intraorbital fat was excised. All patients underwent placement of porous polyethylene infraorbital rim implants and midface soft-tissue elevation, increasing inferior orbital rim projection and improving the globe-cheek relationship. From 2009 to 2012, 13 patients (11 female and two male; 26 eyes) with Graves ophthalmopathy underwent surgery at two institutions. Outcomes were evaluated for improvements of proptosis, diplopia, dry eye symptoms, and cosmetic satisfaction.

Results: Postoperative follow-up ranged from 0.5 to 3 years (median, 1.5 years). The mean improvement on Hertel exophthalmometry was 5.4 mm. Diplopia resolved in three patients (23 percent). No patients had worsening diplopia, and 12 (92 percent) discontinued use of eye lubricants. All patients had cosmetic satisfaction. One patient suffered temporary inferior orbital nerve paresthesia. There were no infections, hematomas, or ocular complications.

Conclusions: Skeletal augmentation is a useful adjunct to orbital decompression and fat excision for treating Graves ophthalmopathy. Balanced orbital decompression with infraorbital rim implants is reliable, effective, and safe, with good, lasting results. Resolution of ocular symptoms is improved, as are the patient's personal well-being and social life, with a high-benefit-to-low-risk.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000000453DOI Listing
September 2014

Reply: quantitative assessment of medial orbit fracture repair using computer-designed anatomical plates.

Plast Reconstr Surg 2013 Jun;131(6):912e-913e

The Johns Hopkins University School of MedicineBaltimore, Md. Department of SurgeryDivision of Plastic and Reconstructive SurgeryMassachusetts General HospitalBoston, Mass.

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http://dx.doi.org/10.1097/PRS.0b013e31828bd2eeDOI Listing
June 2013

The safe zone for placement of chin implants.

Plast Reconstr Surg 2013 Apr;131(4):869-872

Boston, Mass.; Louisville, Ky.; and Loma Linda, Calif. From Massachusetts General Hospital-Harvard Medical School; University of Louisville School of Medicine; and Loma Linda University School of Medicine.

Background: Alloplastic chin augmentation requires the surgeon to predict the location of the mental foramen and the origin of the mentalis muscle to avoid the postoperative sequelae lower lip parasthesia, lower lip incompetence, or chin ptosis. The authors define a safe zone of dissection along the inferior border of the mandible for placement of alloplastic chin implants.

Methods: Fourteen fresh cadaveric hemifaces were dissected with the aid of loupe magnification. Previously described anatomic landmarks were used to identify the origin of the mentalis muscle and the location of the mental foramen along the alveolar ridge of the mandible. Vertical distances were then measured from the mandibular border to the inferior aspect of the mentalis muscle origin and the lower edge of the mental foramen to construct the zone of safe dissection.

Results: The mentalis was identified as a fan-shaped muscle originating from the alveolar process below the incisors roots and inserting into the chin just below the labiomental sulcus. The mental foramen was located most commonly below the roots of the first and second premolars or in the space between the roots. The mentalis origin and the mental foramen were 1.8 ± 0.3 cm and 1.5 ± 0.2 cm cephalad to the inferior edge of the mandible, respectively. These distances define the borders of a safe zone above the mandibular border.

Conclusions: A safe zone of dissection for alloplastic chin augmentation is identified. This study is applicable to implant placement through a submental or an intraoral incision. This safe zone is also useful for reconstructive or orthognathic mandible procedures.
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http://dx.doi.org/10.1097/PRS.0b013e3182818e6cDOI Listing
April 2013

Cost and outcome analysis of breast reconstruction paradigm shift.

Ann Plast Surg 2014 Aug;73(2):141-9

From the *Division of Plastic and Reconstructive Surgery, †Division of Surgical Oncology, Breast Cancer Program, Massachusetts General Hospital, Harvard Medical School; and ‡Center for Regenerative Medicine, Harvard Stem Cell Institute, Boston, MA.

Increased bilateral mastectomy for breast cancer treatment has generated an increased demand for bilateral breast reconstruction. This study examines changing patterns of reconstruction over the last decade to accommodate increased case volume and decreased morbidity associated with reconstruction. A single institution series of 3171 consecutive breast reconstruction cases of more than 10 years was divided into 2 periods, that is, 1999 to 2004 and 2005 to 2010. Bilateral breast reconstruction case volume increased 260% from 1999 to 2004 (n = 237) to 2005 to 2010 (n = 634). Mean patient age at diagnosis decreased by 7 years (P < 0.001). In 2005 to 2010, autologous reconstruction decreased from 60% to 26%, implant-based reconstruction increased from 40% to 74%. There was a noted increase in single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (P < 0.001). Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%) in the later period. A younger patient demographic and increased case volume were accommodated through increased single-staged and prosthesis-based procedures.
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http://dx.doi.org/10.1097/SAP.0b013e318276d979DOI Listing
August 2014

Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy.

Aesthet Surg J 2013 Jan;33(1):19-23

Manhattan Eye, Ear, and Throat Hospital/Lenox Hill Hospital, New York, New York, USA.

Background: An estimated 116 086 facelifts were performed in 2011. Regardless of the technique employed, facial flap elevation carries with it anatomical pitfalls of which any surgeon performing these procedures should be aware. Injury to the great auricular nerve (GAN) is the most common of these injuries, occurring at a rate of 6% to 7%.

Objectives: We report our findings on the location of the GAN on the basis of anatomical landmarks to aid surgeons with planning their surgical approach for safe elevation of rhytidectomy skin flaps in the lateral neck region.

Methods: Sixteen fresh cadaveric heads were dissected under loupe magnification. All specimens were dissected in a 45-degree (facelift) position in which a mid-sternocleidomastoid (SCM) incision was used for exposure. Measurements from the bony mastoid process, bony external auditory canal, external jugular vein, and anterior border of the SCM to the GAN were taken in each cadaver.

Results: The GAN follows a consistent course over the mid-body of the SCM before bifurcating into anterior and posterior branches and terminal arborization. Regardless of the length of the SCM, the GAN at its most superficial location was found to be consistently at a ratio of one-third the distance from either the mastoid process or the external auditory canal to the clavicular origin of the SCM.

Conclusions: Knowledge of the anatomy, course, and location of the GAN along the surface of SCM muscle based on anatomic landmarks and distance ratios can facilitate a safer dissection in the lateral neck during rhytidectomy procedures.
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http://dx.doi.org/10.1177/1090820X12469625DOI Listing
January 2013

Identifying a safe zone for midface augmentation using anatomic landmarks for the infraorbital foramen.

Aesthet Surg J 2013 Jan 7;33(1):13-8. Epub 2012 Dec 7.

Massachusetts General Hospital-Harvard Medical School, Boston, MA 02114-3117, USA.

Background: Midface augmentation is commonly used to improve the appearance of concave faces and to achieve balance in the facial contour. It can also be an adjunct to orthognathic or reconstructive surgery. However, an inherent risk of midface augmentation is injury to the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity, including loss of sensation to the midface, nasal sidewall, upper lip, and lower eyelid.

Objectives: The authors identify a safe zone of dissection in the midface for subperiosteal placement of infraorbital, paranasal, malar, and submalar implants, which avoids injury to the infraorbital nerve.

Methods: Given the popularity of transconjuctival and intraoral access to the midface skeleton, the authors identified relevant bony and dental landmarks from radiographic images and measured distances between the IOF and these landmarks. Forty-four computed tomography scans of adult hemifaces were used to accurately locate the IOF in relation to the anatomic landmarks.

Results: Most often, the IOF's location correlated with the second premolar on a vertical axis. The average distance between the IOF and the infraorbital rim, piriform aperture, tip of the second premolar cusps, and lateral orbital rim was approximately 8.61, 17.43, 41.81, and 25.93 mm (respectively) in men and 8.25, 15.69, 37.33, and 24.21 mm (respectively) in women.

Conclusions: A safe zone of dissection for midface augmentation has been identified, which differs from previous findings. Awareness of this zone may help clinicians locate the IOF and avoid injury to the nerve.
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http://dx.doi.org/10.1177/1090820X12468752DOI Listing
January 2013
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