Background: Pediatric lymphedema can result in irreversible, debilitating limb swelling, tissue fibrosis, skin ulcers, infection, and impaired limb function in children at an early age. Manual lymphatic drainage (MLD) is a noninvasive technique, which is a part of intensive decongestive therapy to reroute lymphatic flow to healthy channels used to manage lymphedema. Outcomes of this treatment option in children have not been studied. We evaluated the effect of decongestive therapy involving MLD in pediatric patients with complex lymphatic anomalies by measuring treatment progress and functional outcomes via changes in limb circumference, limb functionality, dexterity, skin quality, and pain. Methods: A single-institution retrospective study on a cohort of 8 pediatric patients with lymphatic anomalies who completed a course of MLD was conducted from 2015 to 2017 to investigate the role MLD plays in their lymphedema reduction. Pain scores were measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable. The functional performance was measured by the Canadian Occupational Performance Measurement questionnaire. Results: Among all patients, there were 4 cases affecting the upper extremities, 4 affecting the lower extremities, and 3 affecting the truncal region. Five of 8 patients demonstrated a reduction in lymphedema with an average girth reduction of 8.2% in the lower extremities, 3.0% in the upper extremities, and 7.4% in the truncal regions. In unilateral cases, the difference in limb circumference between the affected and normal extremity decreased by an average of 25.6%. Four patients completed the Canadian Occupational Performance Measurement questionnaire with an average improvement of 30% in daily task performance. Three patients reported complete resolution of pain. Conclusions: MLD can be used as a reliable noninvasive method for decongestion and analgesia to delay the onset of lymphedema-associated fibrosis and long-term disability in children with complex lymphatic malformations.

Hemifacial microsomia (HFM) is a complex congenital condition with heterogeneous malformations of the facial skeleton that almost always involves mandibular hypoplasia. Here we introduce a unique case in which a patient with HFM had initially successful optimization of facial symmetry using a polyetheretherketone implant for mandibular augmentation. However, multiple factors associated with the intraoperative and postoperative course, including hardware failure and infection, led to diminished mechanical strength of the mandible, ultimately resulting in a mandibular fracture. In this unique case presentation of HFM, we discuss the various factors that contributed to mandibular weakness and increased susceptibility to fracture.

Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.

Plastic surgery is an intricate field that requires cognitive proficiency, advanced technical skill, and sound surgical judgment. One challenge for plastic surgery residents is mastering these surgical skills while also respecting duty hours and providing high-quality patient care. In the face of these demands, resident surgical training must expand to meet the competency-based goals of the residency curriculum. Two potential methods of expansion are through the use of (1) simulation and (2) artificial intelligence as tools for both training and skill evaluation. In 2018, Thomson et al. identified 12 simulators currently implemented in plastic surgery.1 These simulators were divided into four modalities: computer-based (n = 5), synthetic (n = 2), animal (n = 2), and cadaver (n = 3). Combined, these simulators have present-day applications in reconstructive surgery, craniofacial surgery, and microsurgery; they evaluate a range of skills, from identifying anatomy to performing a procedure.1 Although computer-based simulators provide high-resolution and three-dimensional visualizations, they reinforce learning primarily through repetition. Although repetition is important for muscle memory, over time, it undermines active acquisition of new skill sets. Synthetic simulators provide anatomical representation but do not fully resemble actual tissue and require replacement after use. Animal simulators are used to practice sewing anastomoses in microvascular surgery and are great for developing microsurgical technical skills; however, ethical issues often limit the use of animal models in medicine. Cadavers have the highest fidelity and provide the most accurate anatomical accuracy and variation but are expensive and may act as reservoirs for communicable diseases. These simulator modalities have been shown to improve baseline skills, but additional studies are required to assess residents' performance in the operating room. Plana et al. suggest that the lack of scientific evidence for improvement in trainee performance after simulation practice may explain skepticism by faculty members regarding its utility in training. In light of this hypothesis, they conducted a prospective, randomized, blind study and showed statistically significant improvement in trainees' performance of cleft repair surgery using digital simulation versus textbook learning.2 Therefore, scientific studies that provide evidence for the utility and benefits of simulation in surgical training can help promote widespread integration of this novel technology into training programs. Artificial intelligence may have an even larger impact on surgical training if properly implemented. Artificial intelligence encompasses a number of subfields, including machine learning. Machine learning has the ability to analyze big data and learn to recognize patterns, predict outcomes, and increase accuracy with each iteration. In plastic surgery, machine learning already has multiple existing applications in burn, hand, microscopic, craniofacial, and aesthetic surgery.3 In aesthetics, for example, machine learning has been used to assess what people view as "beautiful" and their emotional response to cosmetic procedures.4,5 Knowledge of objective geometric parameters that elicit the best perceived aesthetic and emotional outcomes can drive surgical planning and improve patient counseling. Machine learning may also have powerful applications in enhancing plastic surgery training. When applied to video recordings of trainees, machine learning can assess both skills achieved and underdeveloped and can predict likely postoperative outcomes.3 A tool that identifies the quality of surgical techniques and predicts outcomes could be used to provide teaching points for trainees as they assess their own skills in the operating room. By using historical data, artificial intelligence offers trainees a safe space to learn from mistakes by positive or negative reinforcement of surgical techniques. Plastic surgeons are known for being adaptable and innovative, but simulation and artificial intelligence remain underused in plastic surgery. Although both have different sets of limitations to integration into surgical training, their potential is expansive. Overcoming these limitations will set the stage for the field of plastic surgery to move forward in the modern era of technology and medicine. DISCLOSURE The authors have no financial interests in this article and have received no external support related to this commentary.

The hands are one of the most visible parts of the body, and prominent dorsal veins and extensor tendons are the most readily recognized signs of the aging process. Fat grafting has been demonstrated to be a safe and effective method of hand rejuvenation by restoration of subcutaneous fat. Despite some variability in the technical approach, fat grafting techniques are consistent in their use of low-pressure injection with standard cannula sizes, small aliquots of graft, and a total volume of graft greater than or equal to 15 mL per hand. While distribution of the fat is an area of debate and a topic of active research, published studies have shown high patient satisfaction rates, suggesting that perhaps the restoration of volume alone is paramount. In this article, we will review the applications of fat grafting to the hand, focusing primarily on its role in hand rejuvenation.

Plastic surgery is a rapidly evolving field that requires novel approaches in providing continuous and dynamic educational resources to address the increasing time and skill demands from residents. Online resources in their various forms, such as books, journals, simulators, and applications, are increasingly used by residents, notably over traditional print and in-person counterparts. In this digital era, it is imperative to understand the scope and utility of online resources that have the potential to revolutionize plastic surgery education. In this review article, we first discuss the current model of plastic surgery education and the challenges of meeting its goals and then suggest reasons by which online resources close this gap. We also offer an exposition on the benefits of distinct types of resources and current trends regarding their use. Our goal is to create a framework within which learners and educators are able to organize online resources in plastic surgery.

The temple is an intriguing region of the face with unique anatomic features, such as the temporal hairline, concave contour, and close proximity to vital structures like the frontal branch of the facial nerve. However, cancerous skin lesions can plague this sun-exposed region and, when excised, it can result in large and significant defects. Reconstruction in this area is a formidable challenge for surgeons, as it requires comprehensive knowledge of temple morphology and the use of creative techniques in order to minimize disruption of surrounding functional and aesthetic structures. In this study, we describe our experience with temple reconstruction in patients of varying defect size and depth. Based on these defect characteristics, anatomic and aesthetic principles of the temple, we propose a surgical algorithm for temple reconstruction to aid surgeons in achieving optimal results.

The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well-organized repair minimizes the occurrence of progressive necrosis and severe late-stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

Abstract The nose is the most central and anterior projecting facial feature. Therefore, the presence of a defect is easily noticeable to the untrained eye. Return of the defect to the original form is an achievable end goal of reconstruction, necessitating appropriate reformation of three-dimensional geometry, proper establishment of symmetry, and excellent color and texture match to the adjacent structures. Regarding its physiological importance, disruption of the normal function may cause respiratory obstruction and contribute to patient distress. To achieve successful repair, preoperative preparation must consider the location, the layers involved, and the size of the defect. Prompt and well-organized repair minimizes the occurrence of progressive necrosis and severe late-stage deformity. Here the authors provide a framework to approach various nasal defects and provide a review of the novel ideologies and techniques. The workhorse of nasal repair, the forehead flap, is discussed independently due to the breadth of innovation.

Study ObjectiveTo compare postoperative pain in patients using an abdominal binder with a control group after laparoendoscopic single-site (LESS) surgery.DesignA randomized controlled trial (Canadian Task Force classification level 1).SettingAn academic gynecologic surgeon's practice.PatientsPrivate patients undergoing surgery performed by a fellowship-trained minimally invasive gynecologic surgeon between April 2016 and April 2017.InterventionsNinety total patients were selected for this study, with 60 randomized to receive an abdominal binder after surgery and 30 patients randomized to the control group without a binder.Measurements and Main ResultsUsing a 10-point verbal analog scale, patients recorded pain levels for 3 weeks postoperatively on a variety of measures, including overall and incisional pain. They recorded results on postoperative days 0, 1, 2, 3, 4, 7, 14, and 21. On average, the association between time and the overall pain score did not differ with binder use (p = .37). The overall pain decreases significantly over time (p < .001). After adjusting for time, the overall pain score differed significantly by binder status (p = .04). Those without a binder reported an average pain score that was 1.13 (standard deviation = 0.55) points higher than those with a binder across the first week.ConclusionThe results suggest that abdominal binder use after LESS surgery may be beneficial in reducing postoperative pain in the first week. Results from this study can provide feasibility data for future studies.

Journal of Craniofacial Surgery 28(6):p 1638-1639, September 2017. | DOI: 10.1097/SCS.0000000000003964

Ali, Kausar BA; Perdanasari, Aurelia T. MD; Hollier, Larry H. Jr MD, FACS Author Information

Study Objective: To evaluate the effectiveness of an abdominal binder following single-incision laparoscopic surgery.

Total ear reconstruction has been approached by several techniques involving autologous graft, prosthetic implant, and alloplastic implant options. Recent studies have shown the superiority of porous polyethylene (Medpor, Porex Surgical) reconstruction over autologous reconstruction based on improved aesthetic results, earlier age of intervention, shorter surgery times, fewer number of required procedures, and a simpler postoperative recovery process. A durable and permanent option for total ear reconstruction, like Medpor, can help alleviate the cosmetic concerns that patients with auricular deformities may be burdened with on a daily basis. In this article, the authors discuss the advantages of Medpor-based ear reconstruction and discuss recent advances in the surgical techniques involved, such as harvesting a temporoparietal fascia flap and full-thickness skin graft to adequately cover the Medpor framework and decrease extrusion rates.

Traumatic panfacial fracture repair is one of the most complex and challenging reconstructive procedures to perform. Several principles permeate throughout literature regarding the repair of panfacial injuries in a stepwise fashion. The primary goal of management in most of these approaches is to restore the occlusal relationship at the beginning of sequential repair so that other structures can fall into alignment. Through proper positioning of the occlusion and the mandibular-maxillary unit with the skull base, the spatial relationships and stability of midface buttresses and pillars can then be re-established. Here, the authors outline the sequencing of panfacial fracture repair for the restoration of anatomical relationships and the optimization of functional and structural outcomes.