Differences between Breast Conservation‐Eligible Patients and Unilateral Mastectomy Patients in Choosing Contralateral Prophylactic Mastectomies

There has been an increasing use of bilateral mastectomy (BM) for breast cancer. We sought to examine our trends among breast conservation (BCT) candidates and women recommended for unilateral mastectomy (UM). Our prospective breast cancer database was queried for women with a first‐time, unilateral breast cancer. Patient and histologic factors and surgical treatment, including reconstruction, were evaluated. A detailed chart review was performed among patients from two representative time periods as to the reasons the patient underwent mastectomy. We identified 3,892 women between 2000 and 2012 of whom 60% underwent BCT, 1092 (28%) had UM and 12% underwent BM. BM rose from 4% in 2000 to a high of 19% in 2011, increasing around 2002 for women <40. BCT was less likely with decreasing age (p < 0.0001), lobular histology (p < 0.0001), higher stage (p < 0.0001) and decreasing BMI (p < 0.0001). Among mastectomy patients, contralateral mastectomy was associated with decreasing age (p < 0.0001), Caucasian race (p < 0.0001), and lower stage (p = 0.005). Over time, indications for mastectomy decreased while patients deemed BCT‐eligible opting for UM or BM increased dramatically. Increases in the use of BM are in large part among women who were otherwise BCT‐eligible. Factors associated with BM use are different for BCT‐eligible patients and those recommended for UM. A better understanding of the factors driving individual patient choices is needed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135041/1/tbj12648_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135041/2/tbj12648.pd

Variations of Structural Components: Specific Intercultural Differences in Facial Morphology, Skin Type, and Structures

Analysis of the differences in facial morphology and skin structure and tone among ethnic groups within the realm of plastic surgery is relevant due to the increasing number of ethnic individuals seeking cosmetic surgery. Previous classifications of ideal facial morphologic characteristics have been revised and challenged over the years to accurately reflect the differences in facial structure that are aesthetically pleasing to individuals of differing ethnic groups. The traditional neoclassic canons reflected the European Caucasian facial morphology and cannot be used to classify facial characteristics in ethnic groups due to drastic differences in measurement and proportion. In addition, differences in biophysiologic properties of ethnic skin types influence the progression of aging and the ability of skin to withstand environmental insults. Thickness of the stratum corneum, water content, and melanin composition are important factors that were analyzed in varying ethnic groups. Although it appears that Caucasian Americans are subject to earlier onset of skin wrinkling and sagging than are African Americans due to thinner stratum corneum layers and decreased water content, more research needs to be conducted to be inclusive of other ethnic groups. These data will enable plastic surgeons to treat these groups more effectively while preserving their unique characteristics

Functional integrity of the shoulder joint and pectoralis major following subpectoral implant breast reconstruction

Subpectoral implants for breast reconstruction after mastectomy requires the surgical disinsertion of the sternocostal fiber region of the pectoralis major. This technique is associated with significant shoulder strength and range of motion deficits, but it is unknown how it affects the underlying integrity of the shoulder joint or pectoralis major. The aim of this study was to characterize the long‐term effects of this reconstruction approach on shoulder joint stiffness and pectoralis major material properties. Robot‐assisted measures of shoulder strength and stiffness and ultrasound shear wave elastography images from the pectoralis major were acquired from 14 women an average of 549 days (range: 313–795 days) post reconstruction and 14 healthy, age‐matched controls. Subpectoral implant patients were significantly weaker in shoulder adduction (p < 0.001) and exhibited lower shoulder stiffness when producing submaximal adduction torques (p = 0.004). The underlying material properties of the clavicular fiber region of the pectoralis major were altered in subpectoral implant patients, with significantly reduced shear wave velocities in the clavicular fiber region of the pectoralis major when generating adduction torques (p = 0.023). The clinical significance of these findings are that subpectoral implant patients do not fully recover shoulder strength or stability in the long‐term, despite significant recovery time, and substantial shoulder musculature left intact. The impact of these procedures extends to the remaining, intact volume of the pectoralis major. Optimization of shoulder function should be a key aspect of the post‐reconstruction standard of care. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1610–1619, 2019.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149750/1/jor24257.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149750/2/jor24257_am.pd

Isolated Management of the Aging Neck

The contour of the neck is a very important determinant of facial aesthetics. Precise knowledge of neck anatomy is essential for adequate planning and execution of this procedure. There are three anatomic and surgical planes involved in the management of the aging neck; the superficial plane (subcutaneous fat), the intermediate plane (platysma muscles and the fat between the two muscles), and the deep plane (subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands). These planes need to be thoroughly evaluated in the preoperative assessment and dealt with according to each patient's needs. Even though this article focuses on isolated management of the aging neck, careful evaluation of the neck and its relationship to the lower third of the face is fundamental. If there is significant jowling and descent of the neck-face interface, an isolated neck-lift procedure will not address that problem and will lead to a suboptimal result. In these patients, a face and neck lift is a more appropriate operation

Rhinoplasty: The African American Patient

Over the past three decades, an increasing number of African American patients have undergone rhinoplasty, and many continue to present to surgeons for rhinoplasty evaluation. The reality is that rhinoplasty is no longer an uncommon procedure in the African American population. Most patients desire nasal refinement while preserving their cultural identity. The African American nose has many unique features that have to be appreciated and understood to provide the desired outcome. In this paper, we present an overview of the unique anatomic features of the African American nose, rhinoplasty techniques tailored to this patient population, and complications encountered postoperatively

Functional integrity of the shoulder joint and pectoralis major following subpectoral implant breast reconstruction

Subpectoral implants for breast reconstruction after mastectomy requires the surgical disinsertion of the sternocostal fiber region of the pectoralis major. This technique is associated with significant shoulder strength and range of motion deficits, but it is unknown how it affects the underlying integrity of the shoulder joint or pectoralis major. The aim of this study was to characterize the long‐term effects of this reconstruction approach on shoulder joint stiffness and pectoralis major material properties. Robot‐assisted measures of shoulder strength and stiffness and ultrasound shear wave elastography images from the pectoralis major were acquired from 14 women an average of 549 days (range: 313–795 days) post reconstruction and 14 healthy, age‐matched controls. Subpectoral implant patients were significantly weaker in shoulder adduction (p < 0.001) and exhibited lower shoulder stiffness when producing submaximal adduction torques (p = 0.004). The underlying material properties of the clavicular fiber region of the pectoralis major were altered in subpectoral implant patients, with significantly reduced shear wave velocities in the clavicular fiber region of the pectoralis major when generating adduction torques (p = 0.023). The clinical significance of these findings are that subpectoral implant patients do not fully recover shoulder strength or stability in the long‐term, despite significant recovery time, and substantial shoulder musculature left intact. The impact of these procedures extends to the remaining, intact volume of the pectoralis major. Optimization of shoulder function should be a key aspect of the post‐reconstruction standard of care. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1610–1619, 2019.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149750/1/jor24257.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149750/2/jor24257_am.pd

Complications in body contouring stratified according to weight loss method

BACKGROUND: Body contouring procedures following massive weight loss have become increasingly common and, unfortunately, continue to be associated with a high complication rate. OBJECTIVE: To evaluate how weight loss method affects complications following abdominally based body contouring procedures. METHODS: Patients undergoing abdominally based contouring procedures were retrospectively evaluated over an 11-year period and stratified into two groups based on method of weight loss: diet and exercise; or bariatric surgery. Complications, including seroma, wound dehiscence, skin necrosis, infection, hematoma and venous thromboembolism, were included if they required intervention. An adjusted logistic model was used to examine the effect of weight loss method on aggregate complication rates. RESULTS: A total of 307 patients were included: 77 (25%) lost weight through diet and exercise; and 230 (75%) through bariatric surgery. Results from the logistic model showed no difference in complication rates between weight loss methods (OR 1.01 [95% CI 0.51 to 2.02]). However, there was a strong correlation between body mass index at the time of surgery and complication rates (OR 1.05 [95% CI 1.02 to 1.08]; P<0.01). CONCLUSIONS: The findings reveal no difference in complication rates following abdominal body contouring procedures attributable to method of weight loss. Rather, there was a proportional rise in complication rates in patients with a higher body mass index at the time of surgery. Surgeons and patients should be aware of this trend, and it should be part of any discussion of abdominal body contouring procedures and informing patients of their risk profile