Sinocutaneous Fistula: A Long-term Complication After Surgical Feminization of the Forehead.

Facial feminization surgery is part of the process of treating patients with gender dysphoria. Forehead contouring, a common part of facial feminization surgery, modifies masculine facial features of the upper third, especially decreasing the thickness of their frontal sinuses and the orbital bossing. Forehead contouring is considered a safe procedure with minor complications and high patient satisfaction. However, rare cases of sinocutaneous fistula have been reported as long-term complications. The diagnosis and therapeutic management of this complication are challenging. Therefore, the authors report a case of frontal sinocutaneous fistula occurring 2 years and 10 months after forehead contouring with its clinical presentation and treatment modalities. Surgeons practicing forehead contouring and patients undergoing this procedure should be aware of the risk of sinocutaneous fistula, a rare but severe complication that requires multidisciplinary medico-surgical care.

Multimodal high-resolution retinal imaging using a camera-based DMD-integrated adaptive optics flood-illumination ophthalmoscope.

We demonstrate the feasibility of a multimodal adaptive optics flood-illumination ophthalmoscope, able to provide both bright-field and dark-field images (such as phase contrast). The multimodality was made possible by integrating a digital micromirror device (DMD) at the illumination path to project a sequence of complementary high-resolution patterns into the retina. Through a versatile post-processing method that digitally selects backscattered or multiply scattered photons, we were able: (1) to achieve up to four-fold contrast increase of bright-field images when imaging the photoreceptor mosaic and nerve fibers; and (2) to visualize translucent retinal features such as capillaries, red blood cells, vessel walls, ganglion cells, and photoreceptor inner segments through phase contrast.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL.

BACKGROUND: Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL. OBJECTIVES: The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance. METHODS: A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement. RESULTS: The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria. CONCLUSIONS: BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

Pathophysiology of nicotine, place of nicotine substitutes and electronic cigarettes in plastic surgery: A review of the literature.

OBJECTIVE: Smokers are more likely to undergo postoperative complications after plastic surgeries. Our main purpose was to update nicotine's effects after plastic surgeries and assess whether nicotine-replacement therapy and vaping are safe enough to be recommended in peri-operatory circumstances. METHODS: We set up a literature review including 40 documents from 1986 to 2020 available on Pubmed. RESULTS: Nicotine has undeniable detrimental effects on patients undergoing plastic surgeries like cutaneous necrosis, skin flap failure and surgical site infection. Nevertheless, this toxicity seems to depend on the plasma concentration of nicotine and thus on the way of administration. While smoking is definitely harmful, nicotine replacement therapies (NRT) like patches and gums do not appear to increase postoperative risks based on available studies. The situation is different with the electronic cigarette since the pharmacokinetic parameters are close to those of the traditional cigarette. Even if powerful studies are lacking because the device is recent, preliminary in vitro studies and case reports suggest non-zero surgical risks for e-cigarette users. CONCLUSION: It seems more appropriate to suggest stopping all nicotine intake before and after plastic surgery. However, if strict cessation is not achievable, it appears preferable to use nicotine replacement therapies rather than e-cigarettes and most of all tobacco.

Thin submental artery perforator flap for upper lip reconstruction: A case report.

Reconstruction of upper lip defects can be challenging even for experienced surgeons. In order to restore both function and morphology, the use of quality soft tissue is essential. To this effect, the most common solution is the use of local flaps, or, in extreme situations, a free flap. However, a thin cutaneous upper lip defect may require a different approach. Perforator flaps are versatile and may allow an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. We present the case of a 41-year-old female with a 1 × 1.5 cm basal cell carcinoma of the right-side upper lip, initially treated with a full thickness skin graft. Due to poor aesthetic and functional result, a thin submental artery perforator (SMAP) flap reconstruction was performed. Flaps' dimensions were 6 cm long and 4 cm wide and it was based on a perforator arising from the submental artery. Dissection was conducted above the platysma muscle, and the SMAP flap was transferred into the defect through a subcutaneous tunnel created below the mandible and posterior to the anterior belly of digastric muscle. The pedicle length of 6.5 cm was adequate for a tension free inset of the flap. Postoperative course was uneventful and the patient was discharged after 2 days. The 4-month follow-up showed a satisfying functional and aesthetic outcome with a concealed donor site scar. This report points out the coverage potential of the thin SMAP flap, which can be successfully used for a harmonious reconstruction in both color and texture of the upper lip.

Facelift With Power-Assisted Dissection: A Preliminary Report.

BACKGROUND: Subcutaneous elevation of the skin has remained a key component in all facelift techniques. OBJECTIVES: The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss. METHODS: The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck. RESULTS: Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema. CONCLUSIONS: The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated.

Three-Dimensional Custom-Made Surgical Guides in Facial Feminization Surgery: Prospective Study on Safety and Accuracy.

BACKGROUND: Facial feminization surgery (FFS) includes several osseous modifications of the forehead, mandible, and chin, procedures that require precision to provide the patient with a satisfactory result. Mispositioned osteotomies can lead to serious complications and poor aesthetic outcomes. Surgical cutting guides are commonly employed in plastic and maxillofacial surgery to improve safety and accuracy. Yet, to our knowledge, there is no report in the literature on the clinical application of cutting guides in FFS. OBJECTIVES: The authors sought to assess the safety and accuracy of custom surgical cutting guides in FFS procedures. METHODS: A prospective follow-up of 45 patients regarding FFS with preoperative virtual planning and 3-dimensional custom-made surgical guides for anterior frontal sinus wall setback, mandibular angle reduction, and/or osseous genioplasty was conducted. Accuracy (superimposing preoperative data on postoperative data by global registration with a 1-mm margin of error), safety (intradural intrusion for the forehead procedures and injury of the infra alveolar nerve for chin and mandibular angles), and patient satisfaction were assessed. RESULTS: A total 133 procedures were documented. There was no cerebrospinal fluid leak on the forehead procedures or any infra alveolar nerve or tooth root injury on both chin and mandibular angle operations (safety, 100%). Accuracy was 90.80% on the forehead (n = 25), 85.72% on the mandibular angles (n = 44), and 96.20% on the chin (n = 26). Overall satisfaction was 94.40%. CONCLUSIONS: Custom-made surgical cutting guides could be a safe and accurate tool for forehead, mandibular angles, and chin procedures for FFS.

Lessons Learned From Twenty-Eight Cases of Burns Following Breast Reconstruction: An Underestimated Complication Requiring Inclusion in Consent Information.

BACKGROUND: There has over recent years been a constant increase in annual breast reconstruction figures. Although reports indicate that burns following breast reconstruction are a rare occurrence, there has nevertheless been a relative increase in cases. The key underlying causes of this type of condition remain unknown. OBJECTIVES: The authors launched a new study on the demographic characteristics of burns in the breast reconstruction population with the inclusion of up-to-date data to assess cases and contributing factors. METHODS: The study was a multicenter retrospective review of patients who underwent any type of breast reconstruction and subsequently sustained burn injuries. RESULTS: Twenty-eight cases of burn injury following breast reconstruction were documented; 6 involved autologous flaps and 22 involved implants. Nine of the 10 implant exposure cases had previous history of radiotherapy, but there was no statistically significant difference between previous radiotherapy history and implant exposure (P = 0.32). Of the 13 cases sustaining full-thickness burns, a large number included implant-based reconstruction (n = 12, 92%), although no statistically significant difference was observed between type of reconstruction and incidence of full-thickness burns (P = 0.17). CONCLUSIONS: Each patient undergoing breast reconstruction should be advised of the potential risks and instructed to avoid significant heat exposure and steer clear of dark-colored bathing suits. At the time of writing, this information has yet to be included in the vast majority of surgery-related informed consent documents.

The Integrase Inhibitors Dolutegravir and Raltegravir Exert Proadipogenic and Profibrotic Effects and Induce Insulin Resistance in Human/Simian Adipose Tissue and Human Adipocytes.

BACKGROUND: Although some integrase strand transfer inhibitors (INSTIs) promote peripheral and central adipose tissue/weight gain in people with human immunodeficiency virus (PHIV), the underlying mechanism has not been identified. Here, we used human and simian models to assess the impact of INSTIs on adipose tissue phenotype and function. METHODS: Adipocyte size and fibrosis were determined in biopsies of subcutaneous and visceral adipose tissue (SCAT and VAT, respectively) from 14 noninfected macaques and 19 PHIV treated or not treated with an INSTI. Fibrosis, adipogenesis, oxidative stress, mitochondrial function, and insulin sensitivity were assessed in human proliferating or adipocyte-differentiated adipose stem cells after long-term exposure to dolutegravir or raltegravir. RESULTS: We observed elevated fibrosis, adipocyte size, and adipogenic marker expression in SCAT and VAT from INSTI-treated noninfected macaques. Adiponectin expression was low in SCAT. Accordingly, SCAT and VAT samples from INSTI-exposed patients displayed higher levels of fibrosis than those from nonexposed patients. In vitro, dolutegravir and, to a lesser extent, raltegravir were associated with greater extracellular matrix production and lipid accumulation in adipose stem cells and/or adipocytes as observed in vivo. Despite the INSTIs' proadipogenic and prolipogenic effects, these drugs promoted oxidative stress, mitochondrial dysfunction, and insulin resistance. CONCLUSIONS: Dolutegravir and raltegravir can directly impact adipocytes and adipose tissue. These INSTIs induced adipogenesis, lipogenesis, oxidative stress, fibrosis, and insulin resistance. The present study is the first to shed light on the fat modifications observed in INSTI-treated PHIV.

Reverse contrast laser Doppler holography for lower frame rate retinal and choroidal blood flow imaging.

Laser Doppler holography (LDH) is an interferometric blood flow imaging technique based on full-field measurements of the Doppler spectrum. LDH has so far been demonstrated in the retina with ultrafast cameras, typically at 75 kHz. We show here that a similar method can be implemented with camera frame rates 10 times slower than before. Due to energy conservation, low and high frequency local power Doppler signals have opposite variations, and a simple contrast inversion of the low frequency power Doppler reveals fast blood flow beyond the camera detection bandwidth for conventional laser Doppler measurements. Relevant blood flow variations and color composite power Doppler images can be obtained with camera frame rates down to a few kHz.

Bipedicled dorsal intercostal artery propeller flaps for reconstruction of extensive cervicothoracic midline defects.

BACKGROUND: Propeller flaps have been reported to cover cervicothoracic midline defects with lower donor site morbidity compared to muscle flaps. When these defects are extensive, we propose a propeller flap technique that we have named dorsal intercostal artery perforator plus (DICAP+) flap based on two perforator pedicles, to secure the large skin paddle. In this article, we present our experience. METHODS: Six propeller DICAP+ flap procedures were performed on five patients, to reconstruct cervicothoracic midline defects. Three of them were caused by tumors and two were secondary to hardware exposure after spinal surgery. Defect sizes ranged from 16 × 5 to 24 × 9 cm. Every propeller flap was harvested on two perforators including one DICAP, and rotated from 80° to 180°. RESULTS: Skin ellipse size ranged from 15 × 7 cm or 82.4 cm2 to 25 × 12 cm or 235.5 cm2 , equal to a mean surface area of 160 cm2 . The donor site was closed by primary suturing in four of the six procedures, by a contralateral propeller DICAP flap in one patient, and was left to heal by secondary intention in another one. All six flaps successfully covered the underlying defects with no evidence of partial or complete necrosis. No other complications were observed at recipient and donor sites. The follow-up period ranged from 9 months to 2 years. CONCLUSIONS: Propeller flaps based on two dorsal perforators including one dorsal intercostal artery perforator, DICAP+, are a reliable means of reconstructing extensive cervicothoracic midline defects.

Primary Breast Augmentation with Autologous Fat Grafting Alone: Evaluation of Patient Satisfaction Using the BREAST-Q.

BACKGROUND: Autologous fat grafting (AFG) for primary aesthetic breast augmentation has grown in popularity over recent years but patient satisfaction has never been objectively evaluated. OBJECTIVES: The aim of the present study was to use the standardized BREAST-Q questionnaire to evaluate satisfaction in patients who had received primary aesthetic breast augmentation with AFG alone. METHODS: All recipients of primary aesthetic breast augmentation by AFG performed between 2013 and 2017 in our plastic surgery department were included. The primary endpoint was assessment of patient satisfaction with the standardized breast augmentation BREAST-Q questionnaire. Three additional questionnaires were used to evaluate patient and surgeon satisfaction. RESULTS: In total, 42 patients (84 breasts) underwent breast augmentation by AFG. Mean patient age was 34 years (range, 23-53 years). The mean volume of reinjected fat was 312.2 mL per breast (range, 130-480 mL). We observed significant improvement in all BREAST-Q postoperative items (excluding physical well-being) with a mean increase of 39 points (95% confidence interval: 28.97, 49.03; P < 0.001) regarding patient satisfaction with breasts. Overall, 82% of patients were satisfied with the result of their liposuction. Minor complications were encountered in 6 of our patients (14%). CONCLUSIONS: Breast augmentation by AFG enhances patient satisfaction as measured by the BREAST-Q. This procedure has a high satisfaction rate and improves quality of life. Breast augmentation by AFG is a valid surgical option for moderate breast augmentation but is not an alternative to implants in large breast augmentation.Level of Evidence: 4.

Intrascrotal injection of botulinum toxin A, a male genital aesthetic demand: Technique and limits.

INTRODUCTION: Scrotal rejuvenation is a real male aesthetic demand. Scrotal injection of botulinum toxin makes the testicles smoother, less dangling and subjectively larger. METHODS: Intrascrotal botulinum toxin injections were performed to a 44-year-old patient for aesthetic purposes. We used the intracremasteric injection protocol. Cremaster muscle injections and dartos muscle injections were performed. RESULTS: The patient was satisfied. No adverse reaction to the intrascrotal botulinum toxin injection was observed. The patient wanted to repeat the procedure in the future. CONCLUSION: At the moment, there is no recommendation about the aesthetic use of intrascrotal injections of botulinum toxin A and the risks are unknown. The purpose of this article is to show the feasibility, context and technical modalities of intrascrotal injection. The risk of infertility is real, but marginal for men who no longer have progeny's desire. LEVEL OF EVIDENCE: Level 3.

Reconstruction of Full-Thickness Lower Lid Defects Using Texier's Procedure: Retrospective Assessment of the Indications.

PURPOSE: Lower lid defects involving more than 75% of the lid's length or affecting the cheek are usually reconstructed with a Mustardé rotational cheek flap. This solution often induces postoperative ectropion. The Texier procedure (an upper lid myocutaneous flap and a chondromucosal alar graft) is usually indicated for 1-step reconstruction of full-thickness defects involving less than 50% of the lower lid. This retrospective study evaluated larger indications for the Texier procedure for full-thickness defects of the lower lid, results of lid defects longer than 50 or even 75%, and the use of a chondromucosal nasal septal graft for lid defects longer than 75%. MATERIALS AND METHODS: All lower lid reconstructions using the Texier procedure over a period of 29 months were retrospectively included. Data on postoperative complications and patient satisfaction were collected. RESULTS: Fifteen patients were included; one third had a defect involving no more than 50% of the lower lid, one third presented with a defect of 50 to 75%, and one third had a defect of at least 75%. In this last group, reconstruction included a septal graft. Mean follow-up was 35 months. Transitory palpebral edema was present in 100% of patients and lasted 8 months on average. No postoperative ectropion or nasal alar retraction of the graft donor site was observed. Mean satisfaction score was 2.86 of 3. CONCLUSIONS: The Texier procedure can be used as first-line treatment to reconstruct most full-thickness defects of the lower lid, including subtotal defects.

Off-axis digital holography with multiplexed volume Bragg gratings.

We report on an optical imaging design based on common-path off-axis digital holography, using a multiplexed volume Bragg grating. In the reported method, a reference optical wave is made by deflection and spatial filtering through a volume Bragg grating. This design has several advantages, including simplicity, stability, and robustness against misalignment.

Paradoxical Adipose Hypertrophy (PAH) After Cryolipolysis.

BACKGROUND: Cryolipolysis is a minimally invasive technique used to decrease local adipose tissue by thermal cooling. Paradoxical adipose hypertrophy (PAH) is a rare complication of cryolipolysis with important aesthetic consequences. OBJECTIVES: The objective of this study was to describe four cases of PAH after a cryolipolysis treatment. METHODS: Between January 2014 and January 2017, all patients who had undergone a cryolipolysis treatment in a single center were reviewed. The device used was a CoolSculpting device and the same operator performed all the cryolipolysis treatments. We retrospectively included all patients who had a suspicion of PAH. RESULTS: In our study, 398 patients underwent a session of cryolipolysis. Four patients presented with a voluminous painless swelling in the treated area, between 2 and 4 months after the cryolipolysis session. One patient was treated with liposuction. Histological analysis of the adipose tissue in this patient revealed a nonspecific panniculitis. The other three patients did not receive any additional treatment, and their symptoms stabilized after several months. CONCLUSIONS: Although cryolipolysis generally yields good results, it can be complicated with PAH, which tends to occur a few months after the cryolipolysis treatment. Patients should be informed of the possibility of developing this complication and encouraged to attend regular follow up for at least 6 months, so that this condition can be readily detected. Surgical treatment should be offered if there is no spontaneous improvement of the symptoms.

One Single Static Measurement Predicts Wave Localization in Complex Structures.

A recent theoretical breakthrough has brought a new tool, called the localization landscape, for predicting the localization regions of vibration modes in complex or disordered systems. Here, we report on the first experiment which measures the localization landscape and demonstrates its predictive power. Holographic measurement of the static deformation under uniform load of a thin plate with complex geometry provides direct access to the landscape function. When put in vibration, this system shows modes precisely confined within the subregions delineated by the landscape function. Also the maxima of this function match the measured eigenfrequencies, while the minima of the valley network gives the frequencies at which modes become extended. This approach fully characterizes the low frequency spectrum of a complex structure from a single static measurement. It paves the way for controlling and engineering eigenmodes in any vibratory system, especially where a structural or microscopic description is not accessible.

Characterization of Breast Implant Surfaces, Shapes, and Biomechanics: A Comparison of High Cohesive Anatomically Shaped Textured Silicone, Breast Implants from Three Different Manufacturers.

UNLABELLED: Several companies offer anatomically shaped breast implants but differences among manufacturers are often misunderstood. The shell texture is a crucial parameter for anatomically shaped implants to prevent rotation and to decrease the risk of capsular contracture, even though concerns have recently been raised concerning the complications associated with textured breast implants. The aim of this study was to characterize differences in terms of texture, cell adhesion, shape, and stiffness between some commonly used anatomically shaped implants from three different manufacturers. METHODS: Five commercially available anatomically shaped breast implants from 3 different manufacturers (Allergan, Mentor, and Sebbin) were used. Scanning electron microscopy, X-ray microtomography, and scanning mechanical microscopy were used to characterize the shell texture. Human fibroblast adhesion onto the shells was evaluated. 3D models of the implants were obtained using CT-scan acquisitions to analyze their shape. Implant stiffness was evaluated using a tractiometer. RESULTS: Major differences were observed in the topography of the textures of the shells, but this was not conveyed by a statistically significant fibroblast adhesion difference. However, fibroblasts adhered better on anatomically shaped textured implants than on smooth implants (p < 0.01). Our work pointed out differences in the Biocell® texture in comparison with older studies. The 3D analysis showed significant shape differences between the anatomically shaped implants of the 3 companies, despite similar dimensions. Implant stiffness was comparable among the 3 brands. CONCLUSIONS: Each texture had its specific topography, and this work is the first description of Sebbin anatomic breast implant texturation. Moreover, major discrepancies were found in the analysis of the Biocell® texture when comparing our results with previous reports. These differences may have clinical implications and are discussed. This study also highlighted major shape differences among breast implants from different manufacturers, which is quite counterintuitive. The clinical impact of these differences however needs further investigation. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Singular-value demodulation of phase-shifted holograms.

We report on phase-shifted holographic interferogram demodulation by singular-value decomposition. Numerical processing of optically acquired interferograms over several modulation periods was performed in two steps: (1) rendering of off-axis complex-valued holograms by Fresnel transformation of the interferograms; and (2) eigenvalue spectrum assessment of the lag-covariance matrix of hologram pixels. Experimental results in low-light recording conditions were compared with demodulation by Fourier analysis, in the presence of random phase drifts.