Abdominal Etching-A Novel Classification Method for Surgical Approach.

BACKGROUND: The abdomen is the aesthetic and physical center of the body. Abdominal etching is used to enhance the appearance of the abdominal musculature. Body contouring and abdominal etching are popular among both men and women, and these procedures have been shown to result in high patient satisfaction and are considered safe. The aim of this study was to describe a novel classification for abdominal etching based on the senior author's technique and experience. METHODS: This single surgeon, nonrandomized, retrospective study was conducted from December 2016 to September 2022. Patients were classified into 4 groups based on their body habitus, abdominal skin pinch test and skin quality, and the surgical plan was tailored accordingly. RESULTS: Sixty-two patients (42 male) with an average age of 36 years underwent abdominal etching during the study period. Subgrouping included 4 (6.45%) in Class 1, 22 (35.5%) in Class 2, 32 (51.6%) in Class 3 and 4 (6.45%) in Class 4. The most common complication was seroma. Concomitant procedures included silicone implants to the pectoral region (male), fat injection to the buttocks, breast reduction and mastopexy and treatment of post-liposuction irregularities. CONCLUSIONS: The abdominal etching technique is safe and reproducible. It has demonstrated long-lasting results and high patient satisfaction. Our classification of patients will enable surgeons to better understand the problem presented and provide aesthetic and efficient results. Use of these guidelines and tailoring treatment options will further improve patient and physician satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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.

Dry Liposculpture of the Calves and Ankles-A Novel Technique for Sculpting the Lower Legs.

BACKGROUND: Liposuction of the calves and ankles was historically described as a "taboo" procedure and linked with higher postoperative pain and unpleasing aesthetic results. OBJECTIVES: This study presents a Novel technique for dry liposculpture of the calves and ankles using a tourniquet, as a safe and less painful procedure, which achieves better aesthetic results. METHODS: This single surgeon, retrospective study included 70 women who underwent surgery based on the technique described. Details regarding the surgical outcomes and pain levels were collected, and patients completed 2 years of follow-up. RESULTS: A mean of 1395 cc fat was aspirated from both legs, combined, and the mean duration of surgery was 98 minutes. No major complications were observed, and postoperative pain levels were low. Pre- and post-surgery pictures were evaluated by 8 certified senior plastic surgeons for aesthetic results. DISCUSSION: The findings suggest that dry liposculpture is suitable for reshaping the calves and ankles. CONCLUSIONS: This technique is safe, with precise and satisfactory aesthetic results, low levels of postoperative pain, and may take less time to perform than wet liposuction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. 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 .

Thermal Signature of Pigmented Lesions as Observed by Digital Infrared Thermal Imaging.

This study examined the thermal signature of pigmented lesions observed by digital infrared thermal imaging as a possible adjunct to physician diagnosis. Thermal images of pigmented lesions were compared to clinical examination by a plastic surgeon interested in skin diseases, dermatoscopy, and histopathology. A total of 35 patients with 55 pigmented skin lesions were considered. We found that all lesions emitting a dark signal on thermal imaging, compared to the nearby skin, were benign, while only one of all benign lesions (1.9%) had a bright "warm" signal. Benign lesions with papule/nodular morphology were dark in 87.5% of patients. All lesions diagnosed as malignant melanoma, both dermatoscopically and histologically, had plaque morphology; yet, only half demonstrated some signals on thermal imaging. Based on these results, we concluded that thermal imaging could be used as an adjunct to diagnosis when examining skin lesions. This study provided an introduction to using thermal imaging for spotting skin lesions.

High-throughput lipidomic profiles sampled with electroporation-based biopsy differentiate healthy skin, cutaneous squamous cell carcinoma, and basal cell carcinoma.

BACKGROUND: The incidence rates of cutaneous squamous cell carcinoma (cSCC) and basal cell carcinoma (BCC) skin cancers are rising, while the current diagnostic process is time-consuming. We describe the development of a novel approach to high-throughput sampling of tissue lipids using electroporation-based biopsy, termed e-biopsy. We report on the ability of the e-biopsy technique to harvest large amounts of lipids from human skin samples. MATERIALS AND METHODS: Here, 168 lipids were reliably identified from 12 patients providing a total of 13 samples. The extracted lipids were profiled with ultra-performance liquid chromatography and tandem mass spectrometry (UPLC-MS-MS) providing cSCC, BCC, and healthy skin lipidomic profiles. RESULTS: Comparative analysis identified 27 differentially expressed lipids (p < 0.05). The general profile trend is low diglycerides in both cSCC and BCC, high phospholipids in BCC, and high lyso-phospholipids in cSCC compared to healthy skin tissue samples. CONCLUSION: The results contribute to the growing body of knowledge that can potentially lead to novel insights into these skin cancers and demonstrate the potential of the e-biopsy technique for the analysis of lipidomic profiles of human skin tissues.

Transmission of Genetic Material and Malignant Cells of Cutaneous Origin via Surgical Sutures.

BACKGROUND: Seeding of skin cancer cells following diagnostic or therapeutic surgical procedures can occur and might cause local recurrences. As current preferred therapy for skin malignancy is surgical excision, seeding of tumour cells by manipulating malignant tissue or suturing can be another factor leading to recurrences. OBJECTIVE: To evaluate whether genetic material and malignant cells adhere to standard suture materials. METHODS: This prospective study included patients who underwent excision of skin lesions. Monofilament and braided sutures were examined. Sutures were passed through the observed tumour or healthy skin margins and were examined for DNA material and cells by cytological analysis, cell culture and characterization, and DNA analysis. RESULTS: Twenty-two patients and 148 sutures were included. DNA quantification showed DNA material on all sutures, with no significant difference between braided and monofilament sutures. Cytological analysis showed that all slides prepared from cell blocks contained normal squamous and atypical cells. Cell culture and characterization showed viable cells adhering to the sutures under direct light microscopy. Cell cultures showed rapid proliferation of epithelial cells from squamous cell carcinoma specimens. CONCLUSION: Suture materials carry DNA material and cells, including malignant cells of cutaneous origin and may seed them at distant sites.

Electroporation-Based Biopsy Treatment Planning with Numerical Models and Tissue Phantoms.

Molecular sampling with vacuum-assisted tissue electroporation is a novel, minimally invasive method for molecular profiling of solid lesions. In this paper, we report on the design of the battery-powered pulsed electric field generator and electrode configuration for an electroporation-based molecular sampling device for skin cancer diagnostics. Using numerical models of skin electroporation corroborated by the potato tissue phantom model, we show that the electroporated tissue volume, which is the maximum volume for biomarker sampling, strongly depends on the electrode's geometry, needle electrode skin penetration depths, and the applied pulsed electric field protocol. In addition, using excised human basal cell carcinoma (BCC) tissues, we show that diffusion of proteins out of human BCC tissues into water strongly depends on the strength of the applied electric field and on the time after the field application. The developed numerical simulations, confirmed by experiments in potato tissue phantoms and excised human cancer lesions, provide essential tools for the development of electroporation-based molecular markers sampling devices for personalized skin cancer diagnostics.

Dermatoscopy as an Aid for Detecting Tumor Borders During Mohs Surgery.

Mohs micrographic surgery (MMS) is a widely used technique for removing cutaneous tumors. Currently, there is no accepted protocol to evaluate and determine lesion borders prior to surgery. Our aim was to evaluate the use of dermatoscopy as an aid for identifying lesion borders prior to MMS. Clinical and dermatoscopic images of skin lesions were evaluated by plastic surgery specialists and students to assess whether they were completely excised, the number of stages required, and characteristics of the lesions. A total of 133 patients and 2128 photographs were included in the study. Overall, specialists were better than students in evaluating lesion borders dermatoscopically (P < 0.001) and clinically (P = 0.015). The use of a dermatoscope increased accurate analysis of both groups for patients who required multiple stages. Dermatoscopy is a powerful tool, complementary to clinical examination and can be used to help delineate lesion borders prior to MMS, especially when evaluating complex skin lesions.

Exploring multisite heterogeneity of human basal cell carcinoma proteome and transcriptome.

Basal cell carcinoma (BCC) is the most common type of skin cancer. Due to multiple, potential underlying molecular tumor aberrations, clinical treatment protocols are not well-defined. This study presents multisite molecular heterogeneity profiles of human BCC based on RNA and proteome profiling. Three areas from lesions excised from 9 patients were analyzed. The focus was gene expression profiles based on proteome and RNA measurements of intra-tumor heterogeneity from the same patient and inter-tumor heterogeneity in nodular, infiltrative, and superficial BCC tumor subtypes from different patients. We observed significant overlap in intra- and inter-tumor variability of proteome and RNA expression profiles, showing significant multisite heterogeneity of protein expression in the BCC tumors. Inter-subtype analysis has also identified unique proteins for each BCC subtype. This profiling leads to a deeper understanding of BCC molecular heterogeneity and potentially contributes to developing new sampling tools for personalized diagnostics therapeutic approaches to BCC.

Treatment of Scleroderma-Related Microstomia Using Hyaluronic Acid: An Interventional Study.

Systemic sclerosis (SSc) or scleroderma is a rare, systemic, autoimmune connective tissue disease. It causes increased collagen synthesis, leading to multi-organ sclerosis, including the skin and joints. Patients' overall health and quality of life are harmed dramatically. Involvement of the face and, especially, the oral opening can limit patients' ability to speak and eat, oral hygiene, and cosmetic appearance. Profhilo® (NAHYCO®) is an over-the-counter product consisting of pure hyaluronic acid. It is used to improve skin quality by increasing collagen production and adipocyte vitality. This interventional study evaluated the results of perioral injections of hyaluronic acid in terms of improved skin quality, elasticity, and increased oral opening. Patients diagnosed with SSc received an injection of one syringe of Profhilo® (2 mL of hyaluronic acid) at each of two clinic visits at one-month intervals. The oral opening was measured between the upper and lower central incisors before and after treatment. Quality of life was assessed using the modified Rodnan Skin Score and Health Assessment Questionnaire-Disability Index. A total of 14 patients received the first treatment, and 11 received the second treatment. The mean oral opening increased from 31.6 mm (range 17-50 mm) prior to therapy to 35.8 mm (range 21-56) 2 months following the second injection. Statistical analysis showed that there was a significant increase in the oral opening as observed one week (36.2 mm, p = 0.011), one month (36.2 mm, p = 0.007), and three months (31.6 mm, p = 0.023) after the second injection, at the 5-month follow-up. Treatment of SSc patients' perioral area with Profhilo® can result in significant improvements in oral opening and quality of life.

Preoperative planning using virtual reality and computed tomography angiogram in deep inferior epigastric perforator flap breast reconstruction.

The gold standard for preoperative planning of deep inferior epigastric perforator (DIEP) flap breast reconstruction uses computed tomography angiography (CTA). Virtual reality (VR) circumnavigates the limitations of CTA by reconstructing a fully immersive and interactive 3D representation of the scan. Scans of 44 patients who underwent DIEP flap breast reconstruction were retrospectively reviewed and compared using CTA and VR imaging modalities. The objective of this research was to compare perforators found using VR to the ones identified using conventional CTA. A correlation was found between the imaging modalities for unilateral (R = 0.96 (CI = 0.92, 0.98)) and bilateral (R = 0.93, (CI = 0.83, 0.97)) DIEP flap surgeries when comparing perforator location related to the umbilicus. Multivariable ordinal logistic regression found that higher intramuscular course length (IMC) is associated with the number of perforators found per side (OR = 1.79 (CI = 1.24, 2.6)), and medial location (OR = 2.85 (CI = 1.38, 5.87)). Larger vessel caliber (VC) is associated with shorter IMC (T2 vs. T3, OR = 3.34 (CI = 1.49, 7.49)), and branching in adipose tissue (AB) is associated with higher VC (T1 vs. T3, OR = 0.02 (CI = 0.007, 0.08); T2 vs. T3, OR = 0.24 (CI = 0.11, 0.55)). Overall, preoperative planning using VR was easy to use, safe, more intuitive, and provided in a time-efficient manner, more information about perforant characteristics. VR can improve the surgeon's decision accuracy, relating to the best perforators for harvesting, in a shorter time period.

The Mastoid Skin Graft: A Fast, Efficient Donor Site for Auricle Reconstruction After Mohs Surgery.

BACKGROUND: Mohs micrographic surgery has been considered the gold standard for treating nonmelanoma skin cancers. Approximately 8% to 10% of skin cancers requiring Mohs surgery occur on the auricle. Skin grafts can be used to achieve optimal functional and cosmetic results. OBJECTIVES: To describe a skin graft technique using the mastoid area as a donor site for auricular reconstruction following Mohs micrographic surgery, to achieve optimal esthetic results in functionally important areas. METHODS: This retrospective study assessed the outcomes of patients who underwent MMS in an out-patient Mohs surgery clinic from 2010 to 2021. All patients had MMS of the auricle with reconstruction using a split thickness skin graft harvested from the mastoid area. RESULTS: A total of 154 patients were included. The average lesion diameter was 13.7 mm (range 5-30 mm), excised in an average of 1.9 rounds of MMS. Skin graft success rate was 96%. Complications included one patient with a hypertrophic scar. The cosmetic appearance of the recipient site was rated as excellent by 87.5% of patients. All patients rated the cosmetic appearance of the donor area as excellent and well-concealed. CONCLUSIONS: Split thickness skin grafts harvested from the mastoid area are a quick and efficient reconstruction method for post-Mohs auricular defects.

Prevalence of Skin Cancer among Beachgoers in Israel.

We assessed the prevalence of suspected skin lesions among beachgoers with dermatoscopy and evaluated their compliance with recommendations. This was conducted as a screening activity at a beach in central Israel. A dermatoscopy specialist evaluated beachgoers and maintained follow-up with them to ascertain compliance with recommendations. In all, 296 participants were screened. Normal examination was observed in 251 (85%), while a malignant finding was suspected in 12 (4%). Compliance with recommendations for excision was moderately low, with 8 of the 14 patients complying with recommendations. Skin malignancy is prevalent in local beachgoing population. Voluntary projects increase awareness in youngsters and deliver accessible screening to the older population. We believe that screening activities must be increased due to high attendance, yet close follow-up must be maintained due to intermediate compliance with medical recommendations.

αvß3 Integrin as a Link between the Development of Fibrosis and Thyroid Hormones in Systemic Sclerosis.

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs. Key players mediating fibrosis are myofibroblasts (MF) that, following transforming growth factor ß (TGFß) exposure, produce a collagen-rich extracellular matrix (ECM) that induces myofibroblast differentiation. Myofibroblasts express αvß3 integrin (a membrane receptor for thyroid hormones) and miRNA-21 that promotes deiodinase-type-3 expression (D3), causing the degradation of triiodothyronine (T3) that attenuates fibrosis. We hypothesized that αvß3 affects the fibrotic processes through its thyroid hormones (THs) binding site. To test this, dermal fibroblasts (DF) were cultured with/without TGFß and removed with a base, leaving only normal/fibrotic ECMs in wells. Then, DF were cultured on the ECMs with/without tetrac (αvß3 ligand, T4 antagonist), and evaluated for pro-fibrotic characteristics, αvß3, miRNA-21, and D3 levels. Blood free-T3 (fT3), miRNA-21 levels, and the modified Rodnan skin score (MRSS) were evaluated in SSc patients. We found that the "fibrotic-ECM" significantly increased the pro-fibrotic characteristics of DF and the levels of miRNA-21, D3, and αvß3, compared to the "normal-ECM." Tetrac significantly inhibited the effects of the "fibrotic-ECM" on the cells. In accordance with tetrac's effect on D3/miRNA-21, a negative correlation was found between the patients' fT3 to miRNA-21 levels, and to the development of pulmonary arterial hypertension (PAH). We conclude that occupying the THs binding site of αvß3 may delay the development of fibrosis.

Transgender and Alagille Syndrome: A Rare Case of a Trans Woman with Alagille Syndrome.

Alagille syndrome is a rare autosomal dominant disorder with variable expression. Liver damage, especially cholestatic, is the most common feature of the syndrome. Transgender patients may suffer from a great distress due to the discrepancy between assigned sex at birth and unaffirmed gender identity. Gender affirmation treatment options for these patients include hormone therapy (HT) to induce secondary sexual characteristics and various surgical procedures. Estrogen-based hormonal treatments have been linked to an increased risk of liver enzyme elevation and disruption of bilirubin metabolism, especially in those with a genetic susceptibility. The case presented here is the first described Alagille syndrome transgender patient to undergo gender affirmation treatment, including (HT) and vulvo-vaginoplasty surgery.

Total Facial Autologous Fat Grafting for Treating Skin Manifestations in Scleroderma.

Systemic sclerosis (SSc) or scleroderma, is a rare, systemic autoimmune connective tissue disease that can cause fibrosis of cutaneous tissue and visceral organs. Facial involvement can have a deleterious effect on patients' function, cosmetic appearance and quality of life. This study describes our experience and results with total facial autologous fat grafting for treating scleroderma. It includes 14 women and 3 men with SSc, at an average age of 51.3 years who underwent 32 autologous fat grafting surgeries between 2017-2022. The surgical technique is further described and demographic and surgical data, including preoperative and postoperative measurements were analyzed. Patients who had multiple surgeries ultimately received grafts with twice the volume of fat than in the first procedure. The oral opening increased an average of 33%. All patients reported improvement in quality of life and were very satisfied with the aesthetic outcomes. The use of autologous fat grafting to treat SSc patients successfully increased oral openings and improved facial manifestations. The procedure is reproducible, safe and leads to improvement in facial manifestations and patients' quality of life. It can be repeated over time to preserve or enhance the results.

Surgical site infection in reconstructive and aesthetic breast surgery: A single center retrospective analysis of the association between healthcare workers and infections.

BACKGROUND: Reconstructive and aesthetic breast surgeries are frequently performed procedures, and the consequences of a postoperative infection are devastating both for the patient and the healthcare (HC) system. Over the years, there has been heightened interest in the physical and mental well-being of physicians and HC workers. Little is known about the relationship between HC workers and surgical site infections (SSI), and whether HC workers are at an increased risk for SSI. The aim of this study was to investigate whether women working in the HC system have an increased risk for SSI following reconstructive and aesthetic breast surgery. MATERIALS AND METHODS: We conducted a retrospective analysis of all patients who underwent aesthetic and reconstructive breast surgery at our institution between the years 2013-2020. Women who were recognized as HC workers were analyzed in a separate group and compared to those who were not. RESULTS: Records of 378 patients were reviewed, of whom 53 (14%) were identified as HC workers. The overall infection rate was 17.4%. HC workers manifested a higher infection rate than the other group (32% vs. 15.1%, p<0.05) and a significantly higher relative risk for SSI (RR 2.12, p<0.01). CONCLUSIONS: Women working in the HC system may have an increased risk of developing postoperative infectious complications following aesthetic and reconstructive breast-related surgery. Further research is needed to corroborate these findings and elucidate the causes.

Diagnostic Accuracy and Cost Savings Associated with Dermoscopy: An Economic Study.

Cutaneous malignancies are the most common overall cancer worldwide. Dermoscopy is widely used among various specialties to evaluate skin lesions and to differentiate benign from malignant lesions. Our objective was to evaluate the diagnostic capability and the economic impact of dermoscopy. The accuracy of diagnoses and economic costs of treating skin lesions were compared between two periods: 2001 to 2007 (prior the use of dermoscopy) and 2009 to 2011 (following implementation of dermoscopy). During the earlier period, 6,549 skin lesions were excised, of which 1,042 (15.9%) were malignant. During the later period, 2,578 lesions were excised, of which 610 (23.7%) were malignant. The potential savings estimated for the Israeli health care system are 6,500,000 USD. The use of dermoscopy increases sensitivity in diagnosing malignant skin lesions, enables diagnoses at an earlier stage, and has the potential for major cost savings for the health care system.

Evolution of the Septal Extension Graft in Endonasal Rhinoplasty: Long-term Efficacy and Reliability.

BACKGROUND: Proper nasal tip projection and rotation have a strong impact on nasal aesthetics. Septal extension graft (SEG) is one of the tools employed to improve tip projection and rotation when performing rhinoplasty. This graft typically overlaps the existing caudal septum in the midline position, lengthening it and facilitating the repositioning of the tip. OBJECTIVES: The authors sought to describe the technical evolution of the SEG in endonasal rhinoplasty and evaluate the reliability and long-term efficacy of the current technique. METHODS: The authors evaluated presurgical and postsurgical photographs of the nasolabial angle and nasal proportions in 60 patients who underwent endonasal rhinoplasty with SEG. RESULTS: The study demonstrated a clear improvement in tip projection and rotation at the 1-year follow-up. The mean preoperative nasolabial angle was 93.75°â€…±â€…9.45° compared with 101.1°â€…±â€…5.3° following surgery. Although both were normally distributed, the range of the postoperative nasolabial angle was narrower than 1-year preoperatively (standard deviation = 5.3° vs 9.45°, respectively). The Crumley ratio, utilized to describe nasal proportions, presented significant changes in nasal proportions: 3.84 preoperatively and 4.04 postoperatively (95% confidence interval = -0.24 to -0.149; P < 0.001). CONCLUSIONS: The utilization of SEG in endonasal rhinoplasty has significantly changed since first described in 2006. The adaptations made to this technique render it more reliable, and our study demonstrates its efficacy in improving tip projection and rotation over the long-term.

Evaluation of Pain After Mohs Micrographic Surgery: A Prospective Study.

BACKGROUND: Mohs micrographic surgery (MMS) is a widely used technique for removal of cutaneous tumors. The procedure is well-tolerated with little surgical or postoperative pain. OBJECTIVE: This study examined pain levels after Mohs surgery throughout the first week of recovery and the relation to patient demographics, lesion characteristics, surgery details, and postoperative analgesia. METHODS: A 2-year prospective observational study included patients who underwent MMS. Patients rated the severity of postoperative pain once daily until removal of sutures and documented analgesics used. Analyses of patient and lesion characteristics along with reconstruction methods were conducted. RESULTS: A total of 2,178 patients were included in the study. Pain levels were strongest on the first postoperative day (POD) and were significantly different between genders on POD 3. Site of skin lesion, method of reconstruction, and number of stages of MMS were significantly related to postoperative pain levels on univariate and multivariate analyses. Postoperative consumption of analgesics differed significantly between men and women and was not correlated to age. CONCLUSION: Mohs surgery is generally nonpainful and is well-tolerated by men and women across all ages. The site of the lesion and method of reconstruction are the major determinants affecting the perception of pain.