Papers by Purushottam Nagarkar
Essentials of Plastic Surgery, Second Edition, 2014
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Plastic and reconstructive surgery, 2016
There have been a variety of techniques describing nasal tip refinement. The cephalic trim has lo... more There have been a variety of techniques describing nasal tip refinement. The cephalic trim has long been accepted as a means for shaping the nasal tip, but it has been misinterpreted by many surgeons. The improper use of a cephalic trim poses potential long-term sequelae. During analysis of the nasal tip, several anatomic findings must be noted to ensure appropriate correction as well as to avoid pitfalls. These findings include the type of boxy tip or bulbous tip, cartilage strength, and the skin quality. The goal of this article is to describe five types of cephalic trim techniques to assist in refining the nasal tip and an algorithm for selection of the appropriate technique based on these anatomic findings.
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Plastic and Reconstructive Surgery, Apr 1, 2010
We read with interest the questions raised in the correspondence by Berry et al. 1 regarding the ... more We read with interest the questions raised in the correspondence by Berry et al. 1 regarding the article by Saint-Cyr et al. 2 on muscle-sparing latissimus dorsi technique for breast reconstruction. We have been using a muscle-sparing latissimus dorsi technique for ...
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Plastic and Reconstructive Surgery, 2015
The profunda artery perforator flap has been emerging as an alternative method of autologous brea... more The profunda artery perforator flap has been emerging as an alternative method of autologous breast reconstruction. This flap uses upper posterior thigh tissue. The profunda artery perforator perforasome is investigated using three-dimensional computed tomographic angiography. Ten cadaveric thighs were dissected centered over the profunda artery perforator. The perforator was injected with contrast medium and the flap was then subjected to computed tomographic scanning using a GE Lightspeed 16-slice scanner. The three-dimensional images were viewed, and measurements were obtained using Aquarius software, including horizontal and vertical extensions of the flap and areas of perfusion. Clinical examples are presented. A profunda artery perforator (occasionally two) was consistently found in the upper medial thigh region, posterior to the gracilis muscle. The area of vascularity shown by the spread of contrast extends inferiorly beyond the usual lower border of the profunda artery perforator flap, which is usually 7 cm wide. In injected cadaveric flaps, the mean horizontal dimension was 16.7 cm and the mean vertical dimension was 16.5 cm. The mean area perfused was 8812 cm. The profunda artery perforator flap is a vascularly sound flap, and is a good option for autologous breast reconstruction. Advantages include a reliable pedicle, no position changes required, and possibly an improved donor-site contour from a thigh lift. It is an excellent alternative to abdominally based free flaps and can also be used in conjunction with other flaps for further volume enhancement.
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Plastic and Reconstructive Surgery
Doubt continues to surround the assassination of President Kennedy to this day. Unfortunately, th... more Doubt continues to surround the assassination of President Kennedy to this day. Unfortunately, the controversy was not diminished by the multiple commissions and panels that were convened to investigate it. This was in large part because these various panels continued to propagate much of the confusion and lack of precision that plagued the initial medical reports, and introduced some new confusion of their own. Much of this controversy was driven by incomplete information, poor documentation and analysis, and the puzzling decision to withhold key medical evidence both from investigators and the public. However, the preponderance of evidence does show that the single-shooter, three-bullet theory is plausible both medically and scientifically.
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Plastic and reconstructive surgery, 2014
In its 1999 report, the Institute of Medicine estimated that medical error leads to between 44,00... more In its 1999 report, the Institute of Medicine estimated that medical error leads to between 44,000 and 98,000 deaths per year. Given that statistic, public reporting of quality and safety metrics is a welcome response that may serve to reduce the rate of adverse events and restore patients' trust in the health care system. To ensure that any public reporting system fulfills its potential, several questions must be addressed: Are we measuring the right metrics? Are the metrics accurate, valid, and is their public reporting effecting change? Based on a review of the literature, it is clear that current metrics suffer from low reliability, low validity, and possibly minimal relevance to the intended consumer. To improve data collection and analysis, both physicians and health care consumers need to be involved in the design and collection of metrics. Until we have a valid, reliable, and actionable data set at our fingertips, it would behoove patients, providers, and institutions to...
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Annals of plastic surgery, 2014
It is well known that the ideal method of creating rank lists for the match is the "true-pre... more It is well known that the ideal method of creating rank lists for the match is the "true-preference" strategy. However, there is anecdotal and survey-based evidence that programs and applicants often deviate from this strategy. We analyzed rank lists of applicants and programs participating in the Plastic Surgery San Francisco Match to investigate whether programs were following an optimal strategy. We obtained deidentified program and applicant rank lists and their match results from SF Match for 4 years (2010-2013). Statistical analysis was carried out with Microsoft Excel. The number of applicants, applications submitted, interviews offered, and match rate were all relatively stable over this 4-year period (range, 117-138 applicants, 36-41 applications, 9.0-10.3 interviews per applicant, and 78%-86% match rate). The "number needed to match" for programs was 4 (range, 1-21). A subset of applicants had poor average ranks on program rank lists but was nevertheles...
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Plastic and Reconstructive Surgery, 2015
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Journal of graduate medical education, 2012
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Plastic and Reconstructive Surgery Global Open, 2014
Soccer is the most popular sport in Brazil and a high incidence of related trauma is reported. Ma... more Soccer is the most popular sport in Brazil and a high incidence of related trauma is reported. Maxillofacial trauma can be quite common, sometimes requiring prolonged hospitalization and invasive procedures. To characterize soccer-related facial fractures needing surgery in 2 major Brazilian Centers. A retrospective review of trauma medical records from the Plastic Surgery Divisions at the Universidade Federal de São Paulo-Escola Paulista de Medicina and the Hospital das Clinicas-Universidade de São Paulo was carried out to identify patients who underwent invasive surgical procedures due to acute soccer-related facial fractures. Data points reviewed included gender, date of injury, type of fracture, date of surgery, and procedure performed. A total of 45 patients (31 from Escola Paulista de Medicina and 14 from Universidade de São Paulo) underwent surgical procedures to address facial fractures between March 2000 and September 2013. Forty-four patients were men, and mean age was 28 years. The fracture patterns seen were nasal bones (16 patients, 35%), orbitozygomatic (16 patients, 35%), mandibular (7 patients, 16%), orbital (6 patients, 13%), frontal (1 patient, 2%), and naso-orbito-ethmoid (1 patient, 2%). Mechanisms of injury included collisions with another player (n = 39) and being struck by the ball (n = 6). Although it is less common than orthopedic injuries, soccer players do sustain maxillofacial trauma. Knowledge of its frequency is important to first responders, nurses, and physicians who have initial contact with patients. Missed diagnosis or delayed treatment can lead to facial deformities and functional problems in the physiological actions of breathing, vision, and chewing.
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Plastic and Reconstructive Surgery, 2013
Doubt continues to surround the assassination of President Kennedy to this day. Unfortunately, th... more Doubt continues to surround the assassination of President Kennedy to this day. Unfortunately, the controversy was not diminished by the multiple commissions and panels that were convened to investigate it. This was in large part because these various panels continued to propagate much of the confusion and lack of precision that plagued the initial medical reports, and introduced some new confusion of their own. Much of this controversy was driven by incomplete information, poor documentation and analysis, and the puzzling decision to withhold key medical evidence both from investigators and the public. However, the preponderance of evidence does show that the single-shooter, three-bullet theory is plausible both medically and scientifically.
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Plastic and Reconstructive Surgery, 2013
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Plastic and Reconstructive Surgery, 2009
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Plastic and Reconstructive Surgery, 2009
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Plastic and Reconstructive Surgery, 2009
Reports suggest that the anterolateral thigh flap can be reliably extended to include adjacent va... more Reports suggest that the anterolateral thigh flap can be reliably extended to include adjacent vascular territories. The vascular basis of this phenomenon is poorly understood. This study examines the three- and four-dimensional arterial and venous anatomy of the extended anterolateral thigh flap and reports the results of a clinical series of extended anterolateral thigh flaps. Fifteen anterior hemithigh specimens harvested from fresh cadavers from the Western population were studied. Four-dimensional computed tomographic angiography was used to investigate the arterial and venous anatomy and pattern of perfusion. Injection of perforators within the lateral femoral circumflex femoral vascular territory, and those of the common femoral and superficial femoral arteries, was performed to investigate the vascular connections within the extended anterolateral thigh flap. Static three-dimensional imaging and latex dissections were also performed to confirm the results. A clinical series of 12 consecutive patients is also reported in which extended anterolateral thigh flaps were used for posttrauma or postoncologic reconstruction. Large-diameter linking vessels at the suprafascial level enabled perfusion of the adjacent common femoral and superficial femoral artery vascular territories. In the clinical series, the flap cutaneous territory ranged from 250 to 630 cm (mean, 365 cm), with all flaps except one perfused by a single perforator. No partial or complete flap losses occurred. This study reports the vascular basis and clinical safety of the extended anterolateral thigh flap, which can be harvested if the linking vessels between adjacent vascular territories in the anterior thigh are preserved. The extended flap is reliably perfused by a single dominant perforator.
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Plastic and Reconstructive Surgery, 2010
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Plastic and Reconstructive Surgery, 2013
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Plastic and Reconstructive Surgery, 2010
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Annals of Plastic Surgery, 2014
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Papers by Purushottam Nagarkar