Taylor J. Ibelli

Background: Treatment management for congenital melanocytic nevi (CMN) on the face (FCMN) is highly variable and requires a thorough assessment of multiple factors. To date, a systematic review of FCMN treatment is lacking. The purpose of the present study was to elucidate the frequency, variety, and outcomes of treatment modalities for FCMN with different levels of complexity. Methods: A comprehensive review of Pubmed, Embase, and Google Scholar databases from 1950 to 2022 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles reporting on FCMN treatment approaches, outcomes, and associated complications were screened and data were extracted according to inclusion criteria. Data were tabulated for thematic analysis of FCMN treatment types, anatomic locations, outcomes, and complications. Results: Of the 561 studies retrieved, 34 met inclusion criteria including 19 surgical treatments, 14 nonsurgical treatments, and one combined surgical and nonsurgical treatment study, totaling 356 patients. The majority of treated FCMN were small-to-medium-sized (56%). Facial CMN treated conservatively were mostly located on the cheek (27%) and/or perinasal region (21%), whereas FCMN treated with surgery were primarily located in the periorbital region (44%) and/or the cheek (17%). Across all treatment cohorts, 22% of patients experienced at least one complication, with 12% of complications experienced by patients treated by surgery. Conclusions: There is a greater need for standardized FCMN nomenclature that encompasses nevi pattern, dimensions, anatomical coverage, and quantitative measurements of treatment outcome. Future studies should focus on identifying anatomic locations of FCMN that are more prone to complications and determine which treatment approach optimizes outcomes.

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor’s letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Background: Despite established indications for orthognathic surgery, insurance coverage is not guaranteed and obtaining coverage is often onerous. There is a paucity of literature regarding insurance coverage within the United States for orthognathic surgery. Methods: The top 50 health insurers in the US, and the top 3 per state, were selected using the National Association of Insurance Commissioners (NAIC) 2020 Market Share Report. Coverage policies were obtained online, or by phone when unavailable. Indications and criteria were compared to the American Association of Oral and Maxillofacial Surgeons (AAOMF) “Criteria for Orthognathic Surgery” recommendations. Results: Of the 65 insurance providers reviewed, 33 offered coverage with clear criteria, 24 offered coverage without listed criteria, and 8 explicitly excluded all orthognathic surgery. The 33 insurers with clear criteria were further reviewed. For malocclusion, 20 insurers used at least 75% of AAOMF measurements, while 4 used stricter criteria. Eleven insurers covered surgery for any congenital disorder; of the remaining, only 13 explicitly covered cleft-associated abnormalities. For the 25 with specified speech anomaly criteria, 21 offered coverage, and 4 excluded coverage. Sleep apnea coverage criteria were inconsistent, and temporomandibular joint disorder (TJMD) coverage was evenly split. No insurer covered orthognathic surgery for esthetic or psychological reasons. Among 66 identified unique criteria, only 6 significantly differed by US Census Region, with coverage for sleep apnea more prevalent in the South District. Conclusions: Access to insurer policies remains difficult. Insurers have inconsistent covered indications, strictness of coverage criteria, and exclusions, which frequently do not match standards of care. The authors present a list of the most commonly used criteria as a resource for insurance submissions, and encourage surgeons to advocate at the insurer and legislative levels for consistent coverage indications and criteria across insurance providers.

The temporomandibular joint (TMJ) is a critical articulation between the mandible and cranium. The unique anatomy allows for a multifaceted motion unlike any other joint in the human body. The bi-convex curvature of the bony prominences facilitates a compound hinging and sliding movement, which are driven by the muscles of mastication and constrained by various ligamentous connections surrounding the joint. Proper alignment and function of these structures are essential to ensure a relationship between the mandibular and maxillary dental arches and fluid motion of the mandible during mastication. While the versatile form and function of the TMJ allow for coordinated jaw movements, pathologic conditions can lead to dysfunction and pain. Therefore, understanding the anatomy and associated pathophysiology of the TMJ is critical for a plastic surgeon who manages craniomaxillofacial trauma and disorders. The present manuscript is the first of a 3-part series with an overview of the TMJ anatomy. Subsequent sections will address the pathology and the treatment of various TMJ disorders.

The temporomandibular joint (TMJ) is a ginglymoarthrodial joint that allows translational or sliding movement in the superior compartment and rotational or hinging movements in the inferior compartment. The articulation of both mandibular condyles with the glenoid fossa of the temporal bone is separated by a cartilaginous articular disk that allows the joint to undergo the functional movements involved in speech and mastication. Any anatomic disequilibrium of the TMJ can produce mechanical dysfunction and orofacial pain. The complexity of the TMJ necessitates a thorough understanding of the anatomy and physiology to diagnose and treat its pathology properly. The authors present the second of a three-part educational series on the TMJ, focusing on the pathophysiology and assessment of joint disorders.

The temporomandibular joint (TMJ) has a complex and unique anatomy. When disarranged, it may produce a constellation of symptoms and dysfunction, leading to morbidity. The causes of TMJ dysfunction are numerous but often present with similar clinical signs and symptoms. In this series, we included a review of normal anatomy and a review of the pathophysiology with assessment of the most common TMJ dysfunctions, including myofascial pain, internal derangements of the articular disk, osteoarthrosis, among others. The authors present the last of a 3-part educational series on the TMJ, addressing treatment strategies for these disorders.

Background Intraoperative observation of Scarpa's fascia (SF) has suggested attenuation in the periumbilical region. This study's purpose was to objectively evaluate SF anatomy in the periumbilical region and assess clinical outcomes of a novel, modified SF closure technique of transverse abdominal wall incisions that only reapproximates SF where it is definitively present. Methods Women were identified who had undergone abdominal magnetic resonance (MR) angiography before their abdominal-based autologous breast reconstruction that used the modified SF closure technique. Statistical analysis of SF presentation on the MR images was performed. Intraoperative measurements from dissected panniculectomy specimens were used to validate MR analysis. Donor site complications were recorded in patients undergoing modified SF closure. Results Sixty-six patients were included in the retrospective MR imaging analysis; this revealed an average attenuation of SF of 4.7 cm (SEM = 0.25 cm), 4.5 cm (SEM = 0.23 cm), 4.6 cm (SEM = 0.23 cm), and 4.2 cm (SEM = 0.22 cm) to the left of, right of, cranial to, and caudal to the umbilicus, respectively. The mean surface area of radiologic SF absence was 56.3 cm² (SEM = 3.57 cm²). There was a significant difference in SF presentation based on patient age (P = 0.013) and body mass index (P = 0.005). Five of the 66 patients (7.6%) experienced abdominal closure site complications. Conclusions This study objectively confirms that there is attenuation of SF in the periumbilical region, describes a novel SF closure technique, and provides evidence to support its adoption when closing transverse abdominal wall incisions.

Background: In breast reconstruction, mastopexy, and breast reduction procedures, surgeons make decisions about the resulting areola size, and this significantly impacts the overall aesthetic result. Despite the importance of these decisions, little is known about the general population's preferences for areola size. The objective of this study was to survey the global population to better understand the public's perceptions of ideal areola dimensions. Methods: A survey was developed with 9 different composite diagrams of a female torso (every combination of 3 breast widths and 3 waist widths). In each composite diagram, 6 different areola sizes were shown (areola-to-breast diameter ranging from 1:12 to 6:12). The survey was distributed via the Amazon Mechanical Turk digital platform, and respondents' demographics (sex, age, race/ethnicity, country, and state if located in the United States) and preferences for the most aesthetically pleasing size in each composite diagram were recorded. Results: Among 2259 participants, with 1283 male (56.8%) and 976 female (43.2%), most participants were between 25 and 34 years old (1012, 44.8%), were from the United States (1669, 73.9%), and identified as White (1430, 63.3%). With 9 breast width and waist width combinations, the respondents were most likely to prefer the 2:12 (32.9%) areola-to-breast ratio (P < 0.0001). The second most commonly preferred ratio was 3:12 (30.6%) (P < 0.0001). Gender subgroup analysis showed that women preferred middle-range ratios, such as 2:12, 3:12, and 4:12 (P < 0.0001). Meanwhile, men were more likely to prefer extreme ratios of 1:12 or 6:12 (P < 0.0001). Across almost all races/ethnicities, 2:12 was significantly the most popular, except among American Indian/Alaskan Native and Middle Eastern where 3:12 was the most preferred (P < 0.0001). Within the top 6 countries (United States, India, Brazil, Italy, Canada, United Kingdom), the United States, India, and Italy preferred 2:12, and Brazil, Canada, and the United Kingdom preferred 3:12 (P < 0.0001). Conclusions: This study provides the first objective data on public impressions of the ideal areola proportions and can serve as a guide for surgical decision making in breast reconstruction and reshaping procedures.