Orbital fractures account for a significant portion of traumatic facial injuries. Although plasti... more Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.
Background Little is written in the plastic surgery literature about thyroid-associated ophthalmo... more Background Little is written in the plastic surgery literature about thyroid-associated ophthalmopathy (TAO), a condition that is separate from Graves-Basedow disease and may not be accompanied by hyperthyroidism. Many patients with this disease frequently seek periocular aesthetic reconstruction prior to medical workup. Methods This study presents a comprehensive review of the literature surrounding TAO in order to better understand the prevalence, diagnosis, pathophysiology, and appropriate management of TAO. Results TAO is frequently under-or misdiagnosed by health-care providers. Patients seeking blepharoplasty or other oculoplastic procedures may have underlying TAO, and the prevalence of TAO in patients who have had a blepharoplasty is approximately 3%. This condition occurs five times more often in women than in men. As a product of the relatively high prevalence of this disease and its underdiagnosis, TAO patients may experience perioperative and late complications due to surgery. Conclusion Blepharoplasties performed on TAO patients must be undertaken with care and insight to avoid cosmetic and functional complications. Keywords Thyroid-associated ophthalmopathy Á Blepharoplasty Á Graves-Basedow disease Á Oculoplastics Á Thyroid eye disease D. J. Gould and F. S. Roth contributed equally to this work.
The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation o... more The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation of patients who have experienced trauma. However, panoramic tomography (PT) continued to be superior in sensitivity to CT in the identification of mandible fractures and has been considered the gold standard for the past 3 decades. In 1989, a faster, higher-resolution spiral or helical CT (HCT) became widely available, and its efficacy in multiplanar evaluation and diagnosis of fractures of the upper two thirds of the face has been well established. The sensitivity of this new-generation HCT in comparison to PT in the detection of mandible fractures has not been determined. The purpose of this study was to compare the sensitivity, physician interpretation error, and interphysician agreement of HCT and PT in the identification of mandible fractures. The number and anatomical location of mandible fractures identified by HCT and PT was not significantly different. However, the number and location of 96% of fractures identified by HCT was agreed on by neuroradiologists compared with only 91% of fractures identified by PT. Furthermore, the interphysician agreement when no fracture was identified was 96% by HCT versus only 81% by PT. In conclusion, HCT has enhanced imaging quality, equivalent sensitivity in identification of fractures, decreased interpretation error, and greater interphysician agreement in the identification of mandible fractures. HCT has surpassed PT as the current gold standard for the radiographic evaluation and diagnosis of mandible fractures.
Orbital fractures account for a significant portion of traumatic facial injuries. Although plasti... more Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.
Obstetrical brachial plexus injuries are reported in the medical literature at a rate of 0.38 to ... more Obstetrical brachial plexus injuries are reported in the medical literature at a rate of 0.38 to 2.6 per thousand live births. Historically, the management of these lesions has been conservative, with observation and physical therapy as the primary modalities of treatment. However, experience has shown that a small majority of these devastating lesions have required more direct and invasive approaches. The experience gathered over a 15-year time span of managing these cervical nerve injuries has afforded the Texas Children's Hospital Brachial Plexus team the opportunity to come to several conclusions regarding the global treatment of these patients. The first is that diagnosis, observation, and therapy are the initial approaches to these injuries and should be initiated immediately. Second, early surgical intervention is essential to maximizing the long-term improvements in select patients by helping to prevent residual growth deformities and underdevelopment of the affected limbs. Third, the development of secondary residual deformities must be addressed with secondary reconstructive procedures to arrest the underdevelopment of affected limbs. These goals of reconstruction have been implemented over a period of 15 years and have been shown to provide marked improvements in the functionality and quality of life in patients affected with these physically disabling lesions.
As techniques for breast reconstruction with autologous abdominal tissue have evolved, free trans... more As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fasciasparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients. (Plast. Reconstr. Surg.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2012
A 29 year old Hispanic woman with a history of breast augmentation and a pregnancy complicated by... more A 29 year old Hispanic woman with a history of breast augmentation and a pregnancy complicated by placental abruption presented to the plastic surgery service for evaluation of a swollen right breast. The patient was examined and several tests were performed to rule out infection, galactocele, and malignancy. The swelling was attributed to fluid adjacent to her implant which was aspirated and found to contain red blood cells and foam cells but no infectious agent or malignant cells. One month after aspiration and continued drainage, the patient returned with recurrent swelling and pain. Repeat imaging showed recurrent fluid collection in the right breast. Excision and capsulectomy were performed and the patient was found to have a double capsule with a seroma. This article presents the first known case of pregnancy-associated late implant seroma formation, as well as a brief review of the literature regarding this rare finding in prosthetic breast augmentation.
The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation o... more The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation of patients who have experienced trauma. However, panoramic tomography (PT) continued to be superior in sensitivity to CT in the identification of mandible fractures and has been considered the gold standard for the past 3 decades. In 1989, a faster, higher-resolution spiral or helical CT (HCT) became widely available, and its efficacy in multiplanar evaluation and diagnosis of fractures of the upper two thirds of the face has been well established. The sensitivity of this new-generation HCT in comparison to PT in the detection of mandible fractures has not been determined. The purpose of this study was to compare the sensitivity, physician interpretation error, and interphysician agreement of HCT and PT in the identification of mandible fractures. The number and anatomical location of mandible fractures identified by HCT and PT was not significantly different. However, the number and location of 96% of fractures identified by HCT was agreed on by neuroradiologists compared with only 91% of fractures identified by PT. Furthermore, the interphysician agreement when no fracture was identified was 96% by HCT versus only 81% by PT. In conclusion, HCT has enhanced imaging quality, equivalent sensitivity in identification of fractures, decreased interpretation error, and greater interphysician agreement in the identification of mandible fractures. HCT has surpassed PT as the current gold standard for the radiographic evaluation and diagnosis of mandible fractures.
Plastic surgeons routinely submit breast capsulectomy surgical specimens for pathologic evaluatio... more Plastic surgeons routinely submit breast capsulectomy surgical specimens for pathologic evaluation. However, clinically significant findings are rarely identified. In an effort to reduce health care costs and the unnecessary use of hospital resources, this study reviews the efficacy of submitting breast capsulectomy specimens for pathologic examination.
A 3-month-old infant was administered high-dose systemic prednisolone for management of a hemangi... more A 3-month-old infant was administered high-dose systemic prednisolone for management of a hemangioma of the nasal sidewall. After 10 weeks of therapy, medical evaluation of weight loss disclosed hypertrophic obstructive cardiomyopathy. After discontinuation of the steroid, the cardiomyopathy resolved.
Background Little is written in the plastic surgery literature about thyroid-associated ophthalmo... more Background Little is written in the plastic surgery literature about thyroid-associated ophthalmopathy (TAO), a condition that is separate from Graves-Basedow disease and may not be accompanied by hyperthyroidism. Many patients with this disease frequently seek periocular aesthetic reconstruction prior to medical workup. Methods This study presents a comprehensive review of the literature surrounding TAO in order to better understand the prevalence, diagnosis, pathophysiology, and appropriate management of TAO. Results TAO is frequently under-or misdiagnosed by health-care providers. Patients seeking blepharoplasty or other oculoplastic procedures may have underlying TAO, and the prevalence of TAO in patients who have had a blepharoplasty is approximately 3%. This condition occurs five times more often in women than in men. As a product of the relatively high prevalence of this disease and its underdiagnosis, TAO patients may experience perioperative and late complications due to surgery. Conclusion Blepharoplasties performed on TAO patients must be undertaken with care and insight to avoid cosmetic and functional complications.
Orbital fractures account for a significant portion of traumatic facial injuries. Although plasti... more Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.
Background Little is written in the plastic surgery literature about thyroid-associated ophthalmo... more Background Little is written in the plastic surgery literature about thyroid-associated ophthalmopathy (TAO), a condition that is separate from Graves-Basedow disease and may not be accompanied by hyperthyroidism. Many patients with this disease frequently seek periocular aesthetic reconstruction prior to medical workup. Methods This study presents a comprehensive review of the literature surrounding TAO in order to better understand the prevalence, diagnosis, pathophysiology, and appropriate management of TAO. Results TAO is frequently under-or misdiagnosed by health-care providers. Patients seeking blepharoplasty or other oculoplastic procedures may have underlying TAO, and the prevalence of TAO in patients who have had a blepharoplasty is approximately 3%. This condition occurs five times more often in women than in men. As a product of the relatively high prevalence of this disease and its underdiagnosis, TAO patients may experience perioperative and late complications due to surgery. Conclusion Blepharoplasties performed on TAO patients must be undertaken with care and insight to avoid cosmetic and functional complications. Keywords Thyroid-associated ophthalmopathy Á Blepharoplasty Á Graves-Basedow disease Á Oculoplastics Á Thyroid eye disease D. J. Gould and F. S. Roth contributed equally to this work.
The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation o... more The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation of patients who have experienced trauma. However, panoramic tomography (PT) continued to be superior in sensitivity to CT in the identification of mandible fractures and has been considered the gold standard for the past 3 decades. In 1989, a faster, higher-resolution spiral or helical CT (HCT) became widely available, and its efficacy in multiplanar evaluation and diagnosis of fractures of the upper two thirds of the face has been well established. The sensitivity of this new-generation HCT in comparison to PT in the detection of mandible fractures has not been determined. The purpose of this study was to compare the sensitivity, physician interpretation error, and interphysician agreement of HCT and PT in the identification of mandible fractures. The number and anatomical location of mandible fractures identified by HCT and PT was not significantly different. However, the number and location of 96% of fractures identified by HCT was agreed on by neuroradiologists compared with only 91% of fractures identified by PT. Furthermore, the interphysician agreement when no fracture was identified was 96% by HCT versus only 81% by PT. In conclusion, HCT has enhanced imaging quality, equivalent sensitivity in identification of fractures, decreased interpretation error, and greater interphysician agreement in the identification of mandible fractures. HCT has surpassed PT as the current gold standard for the radiographic evaluation and diagnosis of mandible fractures.
Orbital fractures account for a significant portion of traumatic facial injuries. Although plasti... more Orbital fractures account for a significant portion of traumatic facial injuries. Although plastic surgery literature is helpful, additional pearls and insights are provided in this article from the experience of an oculoplastic surgeon. The fundamentals remain the same, but the perceptions differ and provide a healthy perspective on a long-standing issue. The most important thing to remember is that the optimal management plan is often variable, and the proper choice regarding which plan to choose rests upon the clinical scenario and the surgeon having an honest perception of his or her level of expertise and comfort level.
Obstetrical brachial plexus injuries are reported in the medical literature at a rate of 0.38 to ... more Obstetrical brachial plexus injuries are reported in the medical literature at a rate of 0.38 to 2.6 per thousand live births. Historically, the management of these lesions has been conservative, with observation and physical therapy as the primary modalities of treatment. However, experience has shown that a small majority of these devastating lesions have required more direct and invasive approaches. The experience gathered over a 15-year time span of managing these cervical nerve injuries has afforded the Texas Children's Hospital Brachial Plexus team the opportunity to come to several conclusions regarding the global treatment of these patients. The first is that diagnosis, observation, and therapy are the initial approaches to these injuries and should be initiated immediately. Second, early surgical intervention is essential to maximizing the long-term improvements in select patients by helping to prevent residual growth deformities and underdevelopment of the affected limbs. Third, the development of secondary residual deformities must be addressed with secondary reconstructive procedures to arrest the underdevelopment of affected limbs. These goals of reconstruction have been implemented over a period of 15 years and have been shown to provide marked improvements in the functionality and quality of life in patients affected with these physically disabling lesions.
As techniques for breast reconstruction with autologous abdominal tissue have evolved, free trans... more As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fasciasparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients. (Plast. Reconstr. Surg.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2012
A 29 year old Hispanic woman with a history of breast augmentation and a pregnancy complicated by... more A 29 year old Hispanic woman with a history of breast augmentation and a pregnancy complicated by placental abruption presented to the plastic surgery service for evaluation of a swollen right breast. The patient was examined and several tests were performed to rule out infection, galactocele, and malignancy. The swelling was attributed to fluid adjacent to her implant which was aspirated and found to contain red blood cells and foam cells but no infectious agent or malignant cells. One month after aspiration and continued drainage, the patient returned with recurrent swelling and pain. Repeat imaging showed recurrent fluid collection in the right breast. Excision and capsulectomy were performed and the patient was found to have a double capsule with a seroma. This article presents the first known case of pregnancy-associated late implant seroma formation, as well as a brief review of the literature regarding this rare finding in prosthetic breast augmentation.
The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation o... more The introduction of computed tomography (CT) in 1972 revolutionized the radiographic evaluation of patients who have experienced trauma. However, panoramic tomography (PT) continued to be superior in sensitivity to CT in the identification of mandible fractures and has been considered the gold standard for the past 3 decades. In 1989, a faster, higher-resolution spiral or helical CT (HCT) became widely available, and its efficacy in multiplanar evaluation and diagnosis of fractures of the upper two thirds of the face has been well established. The sensitivity of this new-generation HCT in comparison to PT in the detection of mandible fractures has not been determined. The purpose of this study was to compare the sensitivity, physician interpretation error, and interphysician agreement of HCT and PT in the identification of mandible fractures. The number and anatomical location of mandible fractures identified by HCT and PT was not significantly different. However, the number and location of 96% of fractures identified by HCT was agreed on by neuroradiologists compared with only 91% of fractures identified by PT. Furthermore, the interphysician agreement when no fracture was identified was 96% by HCT versus only 81% by PT. In conclusion, HCT has enhanced imaging quality, equivalent sensitivity in identification of fractures, decreased interpretation error, and greater interphysician agreement in the identification of mandible fractures. HCT has surpassed PT as the current gold standard for the radiographic evaluation and diagnosis of mandible fractures.
Plastic surgeons routinely submit breast capsulectomy surgical specimens for pathologic evaluatio... more Plastic surgeons routinely submit breast capsulectomy surgical specimens for pathologic evaluation. However, clinically significant findings are rarely identified. In an effort to reduce health care costs and the unnecessary use of hospital resources, this study reviews the efficacy of submitting breast capsulectomy specimens for pathologic examination.
A 3-month-old infant was administered high-dose systemic prednisolone for management of a hemangi... more A 3-month-old infant was administered high-dose systemic prednisolone for management of a hemangioma of the nasal sidewall. After 10 weeks of therapy, medical evaluation of weight loss disclosed hypertrophic obstructive cardiomyopathy. After discontinuation of the steroid, the cardiomyopathy resolved.
Background Little is written in the plastic surgery literature about thyroid-associated ophthalmo... more Background Little is written in the plastic surgery literature about thyroid-associated ophthalmopathy (TAO), a condition that is separate from Graves-Basedow disease and may not be accompanied by hyperthyroidism. Many patients with this disease frequently seek periocular aesthetic reconstruction prior to medical workup. Methods This study presents a comprehensive review of the literature surrounding TAO in order to better understand the prevalence, diagnosis, pathophysiology, and appropriate management of TAO. Results TAO is frequently under-or misdiagnosed by health-care providers. Patients seeking blepharoplasty or other oculoplastic procedures may have underlying TAO, and the prevalence of TAO in patients who have had a blepharoplasty is approximately 3%. This condition occurs five times more often in women than in men. As a product of the relatively high prevalence of this disease and its underdiagnosis, TAO patients may experience perioperative and late complications due to surgery. Conclusion Blepharoplasties performed on TAO patients must be undertaken with care and insight to avoid cosmetic and functional complications.
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Papers by Forrest Roth