The Role of Density in Achieving Volume and Weight Symmetry in Breast Reconstruction.

BACKGROUND: Knowledge of tissue and implant density is crucial in obtaining both volume and weight symmetry in unilateral breast reconstruction. Therefore, the aim of this study was to determine and compare the density of abdominal and breast tissue specimens as well as of 5th generation breast implants. METHODS: Thirty-one breast tissue and 30 abdominal tissue specimens from 61 patients undergoing either mammaplasty or abdominoplasty as well as five different 5th generation breast implants were examined. Density (g/mL) was calculated by applying the water displacement method. RESULTS: The mean specimen density was 0.94 ± 0.02 g/mL for breast tissue and 0.94 ± 0.02 g/mL for abdominal tissue, showing no significant difference (p = 0.230). Breast tissue density significantly (p = 0.04) decreased with age, while abdominal tissue did not. A regression equation to calculate the density of breast tissue corrected for age (breast density [g/mL] = 0.975-0.0007 * age) is provided. Breast tissue density was not related to body mass index, past pregnancy, or a history of breastfeeding. The breast implants had a density ranging from 0.76 to 1.03 g/mL which differed significantly from breast tissue density (-0.19 g/mL [-19.8%] to +0.09 g/mL [+9.58%]; p ≤ 0.001). CONCLUSION: Our results support the suitability of abdominal-based perforator flaps in achieving both volume and weight symmetry in unilateral autologous breast reconstruction. Abdominal flap volume can be derived one-to-one from mastectomy weight. Further, given significant brand-dependent density differences, the potential to impose weight disbalances when performing unilateral implant-based reconstructions of large breasts should be considered.

Sensory Innervation of the Upper Eyelid and Its Implication for Upper Eyelid Surgery.

PURPOSE: Sensory alterations of the upper eyelid skin and eyelashes are frequently encountered after upper eyelid surgery. The objective of this study was to provide information on the exact course and distribution of sensory nerve fibers through the anatomic planes in the upper eyelid. METHODS: Ten formalin-fixed hemifaces were dissected. The nerve branches of the ophthalmic nerve in the upper eyelid were traced in an anterograde fashion. RESULTS: A total of 151 nerve fibers were recorded during dissection. The infratrochlear, supratrochlear, supraorbital, and lacrimal nerve contributed each to both the upper eyelid skin innervation and the upper eyelid rim plexus in different distribution patterns. The mean distance from the eyelid margin at which nerve fibers pierced from preseptal into the orbicularis muscle was 14 ± 1.1 mm for nerve fibers targeting the eyelid dermis and 3.7 ± 1.2 mm for nerve fibers targeting the eyelid rim plexus ( p < 0.001). The mean intraorbicular course of nerve fibers was 3 mm (0-17; standard deviation 4.1). The mean distance from the eyelid margin at which nerve fibers pierced from the orbicularis muscle into the preorbicular plane was 10 ± 1 mm for nerve fibers innervating the eyelid dermis and 1.3 ± 0.8 mm for nerve fibers innervating the eyelid rim plexus ( p < 0.001). The mean distance of the preorbicular course of nerve fibers was 2 mm (0-15; standard deviation 3.6). CONCLUSIONS: Based on the findings, a certain degree of postoperative eyelid skin numbness is inevitable while eyelash innervation may be spared in upper blepharoplasty.

Incidence and Risk Factors of Postoperative Complications After Rhinoplasty: A Multi-Institutional ACS-NSQIP Analysis.

OBJECTIVE: Despite the popularity of rhinoplasty, outcome research has been mainly limited to single-surgeon or single-institution reports. Therefore, we performed a multi-institutional analysis to present a broader portrait of the postoperative outcomes and risk factors for adverse events after rhinoplasty surgery. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2009-2019) to identify patients who underwent rhinoplasty. The postoperative outcomes of interest included 30-day mortality, reoperation, readmission, and surgical and medical complications. We also analyzed risk factors for complication occurrence, including patient comorbidities and preoperative laboratory values. RESULTS: We identified 835 patients, 72% (n=602) of whom underwent a primary, 21% (n=175) a secondary, and 6.7% (n=58) a cleft nasal deformity procedure. The average patient age was 41±17 years, with most patients being female (n=472; 57%) and white (n=643; 77%). Complications rates were generally low, with reoperation (n=19; 2.3%) and superficial incisional infection (n=9; 1.1%) account for the most common general and surgical adverse event, respectively. Multivariable analysis revealed male sex ( P =0.04) and higher ASA scores ( P <0.0001) as risk factors for complications. Low serum albumin ( P =0.04) and hematocrit ( P =0.003) levels were associated with the occurrence of any complication, whereas low serum albumin ( P =0.02) also correlated with the incidence of surgical adverse events. CONCLUSION: Complication rates after rhinoplasty were overall low and seemed to correlate with male sex and ASA scores. We identified preoperative albumin and hematocrit as predictive biomarkers of adverse events. Preoperative nutritional optimization and management of low hematocrit may improve postoperative outcomes.

Thinking like a Lawyer-Human Rights and Their Association with the Plastic Surgeon of Today.

Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). LEVEL OF EVIDENCE V: "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 ."

Outcomes and Risk Factors in Microsurgical Forefoot Reconstruction.

BACKGROUND: Defects at the forefoot frequently require microsurgical reconstruction; however, reconstructive failure can lead to results inferior to primary amputation. The purpose of this study was to identify independent factors affecting surgical outcomes and hospitalization time in these patients. METHODS: All patients that underwent free flap reconstruction of the forefoot between 2008 and 2019 were reviewed retrospectively. Statistical evaluation included binary logistic regression and correlation analysis. RESULTS: A total of 93 free flap procedures were performed in 87 patients. The most common defect etiologies were acute trauma (30 cases; 32.3%), diabetic foot syndrome (20 cases; 21.5%), and infection (17 cases; 18.3%). Muscle flaps were used in 50 cases (53.8%) and fasciocutaneous flaps were used in 43 cases (46.2%). Major complications occurred in 24 cases (25.8%) including 11 total flap losses and 2 partial flap losses. Minor complications occurred in 38 cases (40.9%). Patients aged 60 years or above were at significant higher risk of major complications (p = 0.029). Use of fasciocutaneous flaps (odds ratio [OR]: 14.341; p = 0.005), arterial hypertension (OR: 18.801; p = 0.014), and operative time (min) (OR: 1.010; p = 0.029) were identified as individual risk factors for major complications. Two venous anastomoses significantly reduced the risk of major complications (OR: 0.078; p = 0.022). Multiresistant bacterial wound colonization (OR: 65.152; p < 0.001) and defect size (OR: 1.007; p = 0.045) were identified as independent risk factors for minor complications. The median hospital stay was 28 days (7-85 days). Age significantly correlated with the length of hospital stay (r = 0.405, p < 0.01). CONCLUSION: Our study identified independent risk factors that might help to make individual decisions whether to target microsurgical forefoot reconstruction or primary amputation. Two venous anastomoses should be performed whenever feasible, and muscle free flaps should be preferred in patients at higher risk of major surgical complications.

Perioperative Outcomes and Risk Profile of 4730 Cosmetic Breast Surgery Cases in Academic Institutions: An ACS-NSQIP Analysis.

BACKGROUND: Cosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction. OBJECTIVES: The aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed. RESULTS: In total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and <.0001, respectively). Additionally, multiple procedures (P = .02) and smoking (P = .005) were found to be risk factors for surgical complications. CONCLUSIONS: This study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.

Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects.

BACKGROUND: Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions. METHODS: Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months. RESULTS: Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40-286 cm2; ±67.9 cm2), with a mean size of the MVL free flaps of 266.8 (range, 160-384 cm2; ±69.5 cm2). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients. CONCLUSIONS: The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.

How to Approach Secondary Breast Reduction: International Trends and a Systematic Review of the Literature.

BACKGROUND: Secondary breast reduction is complex and poses significant challenges to surgeons. Complication rates exceed those of primary reduction, commonly caused by impaired vascular supply of the nipple-areolar complex (NAC). Literature on the topic is scare and provides contradicting recommendations, especially with regard to pedicle choice in cases with unknown primary reduction technique. Aim of this study was to investigate international trends and to compare findings with literature. METHODS: A large-scale web-based questionnaire on international trends in mammaplasty (mastopexy and breast reduction) was designed and distributed to over five thousand surgeons in eight geographic regions. The presented manuscript evaluated information regarding pedicle choice in secondary breast reduction and compared data to literature identified in a systematic review. RESULTS: The survey was completed by 1431 participants. Overall, secondary procedures were performed in less than 5% or in 5 to 10% of cases. The preferred pedicle for secondary reductions differed significantly between geographic regions (p<0.001). The majority of respondents reported to use a superior or supero-medial pedicle (34.8% and 32.2%, respectively). Residual analysis revealed a strong association between the use of an inferior pedicle and procedures performed in North America. CONCLUSIONS: Secondary breast reduction is challenging and there remains international disparity with regard to pedicle choice for secondary procedures. Studies investigating outcome when the primary pedicle is unknown are scarce and provide incoherent recommendations. High-quality data is needed to provide evidence-based practice guidelines. LEVEL OF EVIDENCE III: 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.

Impact of Smoking Status in Free Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: A Multicenter Study.

BACKGROUND: Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions. METHODS: In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models. RESULTS: Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p < 0.001) and wound-healing disturbances requiring revision surgery (donor site: 1.5 vs. 4.0; recipient site: 1.3 vs. 3.6%, both p < 0.001) was significantly higher in smokers. Multivariable analysis identified smoking to be an independent risk factor for revision surgery (p = 0.001) and partial flap loss (p < 0.0001). CONCLUSION: Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

The need to collect, aggregate, and analyze global anesthesia and surgery data.

In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.

RéSUMé: À l'époque des objectifs du développement durable, on constate une nouvelle sensibilisation au besoin d'une approche intégrée dans les interventions en soins de santé et un fort engagement en faveur d'une couverture médicale universelle. Pour atteindre l'objectif du renforcement de systèmes entiers de santé, la chirurgie en tant que modalité thérapeutique transversale est indispensable. Pour toute activité de renforcement du système de santé, des données de référence et un suivi longitudinal des progrès sont nécessaires. Avec de meilleures données, il existe des possibilités sans équivalent de cartographier et de comprendre les systèmes, en intégrant des données provenant de multiples sources et secteurs. Néanmoins, il est également nécessaire de prioriser les indicateurs pour éviter une surcharge d'informations et une fatigue dans la collecte des données. Il existe un besoin similaire de définition des indicateurs et de la méthodologie de collecte afin de créer des données standardisées et comparables. Enfin, il est nécessaire d'établir des cheminements de données pour garantir des responsabilités claires entre les institutions nationales et internationales et intégrer les paramètres chirurgicaux dans les mécanismes existants pour une collecte durable des données. Ceci est un appel à la collecte, au regroupement et à l'analyse de données globales en anesthésie et en chirurgie avec un compte rendu des sources de données existantes et une proposition d'avancée.

Microsurgical Reconstruction of the Plantar Foot: Long-Term Functional Outcomes and Quality of Life.

BACKGROUND: When faced with plantar defects, reconstruction of the weight-bearing areas presents unique surgical challenges. Several free flap modalities have been described in this respect, but there remains debate regarding the best-suited flap modality. Aim of this study was to compare free muscle and non-neurotized fasciocutaneous flaps for plantar reconstruction with respect to long-term functional outcomes. METHODS: Overall, 89 patients received 100 free flaps (anterolateral thigh [ALT] n = 46; gracilis n = 54) for plantar reconstruction. The data were screened for patients' demographics, as well as perioperative details. Postoperative complications were accounted for and the two groups compared accordingly. All patients were contacted for a long-term follow-up examination. RESULTS: There were no significant differences between the two groups regarding major (24 vs. 17%; p = 0.366) and minor surgical complications (61 vs. 70%; p = 0.318). However, the ALT group showed a significantly higher need for secondary surgeries (39 vs. 19%; p = 0.022). Sixty-eight patients (76%) returned for long-term follow-up evaluation (mean: 51.2 months, range: 13-71 months). The ALT group showed significantly less pain at the recipient (p = 0.0004) and donor (p = 0.010) sites, and scar assessment revealed significantly better results (p < 0.001). Additionally, the ALT group showed better depth (p = 0.017) and superficial (p = 0.007) sensation and enabled better shoe provision (p = 0.014). CONCLUSION: Both the free ALT and gracilis flaps are well suited for plantar reconstruction, yielding overall similar functional outcomes. However, the ALT flap produces less scarring and pain, while showing better recovery of sensation and enabling better shoe provision. The ALT flap thus presents our preferred option.

Impact of Duration of Perioperative Ischemia on Outcomes of Microsurgical Reconstructions.

BACKGROUND: Free tissue transfers have become routine for a variety of reconstructive purposes. During the time of transfer, some period of ischemia time is unavoidable, causing structural and metabolic changes. This study aimed to evaluate whether length of intraoperative ischemia affects the outcomes of microsurgical reconstructions. METHODS: Within a 7-year period, 638 patients having undergone 690 microvascular free flap reconstructions fulfilled inclusion criteria for this study. The data were retrospectively screened for patients' demographics, intra- and perioperative details, flap survival, surgical complications, and outcomes. The cases were divided into two groups according to the length of intraoperative ischemia time, "< 60" versus "≥ 60 minutes." RESULTS: Both groups were comparable regarding the patient constellation, comorbidities, smoking status, and perioperative characteristics. Operative times were significantly longer in patients which had ischemia times of ≥ 60 minutes (p < 0.05). Also, during our 3-month follow-up period, a significantly higher rate of major and minor surgical complications, including total and partial flap losses, as well as higher revision rates occurred in the ≥ 60 minutes ischemia time group (p < 0.05). CONCLUSION: In this study, prolonged ischemia time during free flap reconstructions was associated with higher rates of revision surgeries and complications rates.

Effect of Preoperative Medical Status on Microsurgical Free Flap Reconstructions: A Matched Cohort Analysis of 969 Cases.

BACKGROUND: Free tissue transfers have become standard for a wide variety of reconstructive purposes. In an era of increasing economic pressure, it is important to precisely define appropriate candidates and indications for a complex surgery to optimize efficiency and patient outcomes. This study evaluates the feasibility to perform microsurgical procedures in a medically compromised patient cohort at a major academic microsurgical center. METHODS: Within 7 years, 897 patients underwent 969 microvascular free flap reconstructions. The data were retrospectively screened for patients' demographics, perioperative details, flap survival, surgical complications, and outcomes. The cases were divided into two groups in "low-risk" (American Society of Anesthesiologists [ASA] I and II) or "high-risk" (ASA III and IV) as per the preoperative medical status classified according to the ASA score of physical status. RESULTS: Despite the significantly high prevalence of hypertension, peripheral artery disease, diabetes, obesity, and smoking status in the "high-risk" group (p < 0.05), there was no significant difference in the rate of surgical or medical complications, in operative times regarding overall as well as different flap entities, flap failures, need for revision surgery, or hospital length of stay between the two patient groups during our 3-months follow-up period (p > 0.05). CONCLUSION: In this study, free flap reconstruction in medically compromised patients was not associated with higher rates of revision surgeries, overall complication rates, or surgery-related costs. Complex microsurgical free flap reconstruction can therefore also be advocated in patients with high preoperative risk constellation.

Impact of Two Attendings on the Outcomes of Microvascular Limb Reconstruction.

BACKGROUND: Free tissue transfers are routinely performed for extremity reconstruction. In an era of increasing economic pressure in many healthcare systems, efficiency needs to be optimized for any kind of operative procedure. This study is examining the possible benefit of a two-attending approach to microsurgical reconstruction of the limbs using antero-lateral thigh- (ALT) or gracilis-muscle flaps at a major academic microsurgical center. METHODS: 309 patients underwent 392 free ALT- (206) or gracilis-muscle (186) flaps for limb defect reconstruction at our institution (2009-2015). All available data was retrospectively screened for patients' demographics, perioperative details, surgical complications, and overall flap survival. The cases were divided into two groups according to the number of operating microsurgeons: one versus two attendings. RESULTS: No significant differences existed between the two groups (341 "one attending" versus 51 "two attendings") regarding preoperative comorbidities. Overall, there was no significant difference between both groups regarding operative times, revision surgery rates, total as well as partial flap loss, and hospital length of stay (p > 0.05) during the 3-month follow-up period. Further, evaluating ALT and gracilis flaps separately also showed no significant differences between both groups (one versus two attendings). CONCLUSION: The addition of a second operating attending does not significantly shorten surgery times, hospital length of stay, need for revision surgery, or complications rates. A two-operation surgeon approach may therefore only provide a marginal benefit in microsurgical limb reconstruction.

Does Cigarette Smoking Harm Microsurgical Free Flap Reconstruction?

BACKGROUND: Free tissue transfers can successfully address a wide range of reconstructive requirements. While the negative influence of cigarette smoking is well documented, its effects in the setting of microsurgical free flap reconstruction remain debated. This study evaluates the impact of cigarette smoking on microsurgical reconstructions. METHODS: Over a 7-year period, 897 patients underwent 969 microvascular free flap reconstructions at a single surgical center. The cases were divided into "smoker" (S) and "nonsmoker" (NS) groups according to their cigarette smoking status. The data were retrospectively screened for patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and overall outcomes. RESULTS: Both groups were comparable regarding comorbidities including hypertension, peripheral artery disease, diabetes, American Society of Anesthesiologists scores, types of performed free flaps, and recipient sites. While patients in the NS group were significantly older and had a higher prevalence of obesity (p < 0.05), there were no significant differences regarding the rate of major or minor complications during our 3-month follow-up period (p > 0.05). CONCLUSION: While minor and major complications were increased regarding virtually all examined parameters, cigarette smoking did not have significant effects on the overall outcomes of microsurgical free flap reconstructions.

Current Trends in Breast Augmentation: An International Analysis.

BACKGROUND: Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care. OBJECTIVES: The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability. METHODS: A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature. RESULTS: There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets. CONCLUSIONS: Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.

Microsurgical reconstruction in patients greater than 80 years old.

BACKGROUND: Demographic change implies that the human population is getting older and the elderly are living longer. Consequently, achieving good functional and aesthetic outcomes in microvascular procedures, especially in very old patients with higher incidence of atherosclerosis and vessel calcifications, constitutes a microsurgical challenge. This study evaluates the feasibility of microsurgical procedures in a very old patient cohort. PATIENTS AND METHODS: Between 2009 and 2015, 754 patients underwent 838 free flap reconstructions. The patients were divided into two groups according to age in "middle-aged" (<80 years old; n = 711) or "very old" (≥80 years old; n = 43). The series was retrospectively analyzed regarding potential influence of medical comorbidities, surgical and medical complications and outcomes. RESULTS: Between the groups, there was a significant difference regarding comorbidities with a higher prevalence of hypertension (P < 0.0001) and peripheral artery disease (P < 0.0001) in the very old group. However, there was no significant difference regarding the rate of surgical or medical complications, flap failure (middle aged group 43/791 flaps (5.44%) versus very old group 4/47 flaps (8.51%); P = 0.328), and revision rate (117/791 flaps (14.79%) versus 6/47 flaps (12.77%); P = 0.834) between the patient groups during our 3-months follow-up period. CONCLUSION: Our findings suggest that despite higher rates of patient comorbidities, successful free tissue transfer can also be achieved in a very old population with acceptable risk for complications.

Extending the Limits of Microsurgical Reconstruction in Patients with Moderate to Very Severe Obesity: Single-Center 6-Year Experiences.

Background Worldwide obesity has more than doubled since 1980. Given this epidemic change, surgical and medical care has become more complex as obesity is a known risk factor for complications. Consequently, one could expect a higher prevalence of medical and surgical complications in an obese patient collective in the setting of free tissue transfer. Goal of this study was to evaluate whether this assumption holds true. Material and Methods Between January 2009 and June 2015, 838 patients underwent free tissue transfers at a single institution. The cases were divided into three groups using the World Health Organization body mass index (BMI) criteria into a nonobese (n = 751), a moderately obese (n = 59), and a severely to very severely obese group (n = 28). The series was retrospectively analyzed and the groups were compared regarding the potential influence of BMI in respect to surgical complications and outcomes. Results Overall, there was no significant difference in morbidity between the groups of patients regarding the rate of surgical complications during our 3-month follow-up period. Conclusion This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of patient obesity on outcomes. Our findings suggest that despite higher rates of patient comorbidities, successful free tissue transfer can be achieved in this population with acceptable risk for complications.

Lip Attractiveness: A Cross-Cultural Analysis.

Background: Perception of beauty is influenced by the individual's geographic, ethnic, cultural, and demographic background. However, objective measurements remain the foundation for aesthetic evaluations. In the quest for to better define "ideal" lip characteristics, this study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception. Objectives: This study will increase surgeons' awareness with respect to different lip size preferences. The provided information might enhance and clarify communication among plastic surgeons and aid to put often quoted "ideal proportions" in context. Methods: An online survey was designed. Modifiable ranges of lip fullness were achieved via digital alteration, enabling participants to interactively change the shape of a single model's lips. The questionnaire was sent to more than 9000 plastic surgeons and laypeople worldwide. Demographic data were collected and analysis of variance was used to elucidate lip shape preferences. Results: A total of 1011 responses (14% response rate) from 35 different countries were gathered. Significant differences regarding lip fullness were identified. Surgeons who practice in Asia or non-Caucasian surgeons prefer larger lips, while those in Europe and Caucasians prefer smaller lips. Lastly, laypersons living in Asia prefer the smallest lips. Conclusions: Country of residence, ethnic background, and profession significantly impact individual lip shape preferences. These findings have implications for patients and surgeons, because differences in aesthetics' preferences can lead to dissatisfaction of patients and surgeons alike. In our increasingly global environment, cultural differences and international variability must be considered when defining new aesthetic techniques, treating patients, and reporting outcomes.

The MEEK technique: 10-year experience at a tertiary burn centre.

Extensive full-thickness burns pose a great challenge to the burn surgeon. Lack of autograft donor sites is an important limiting factor to achieving wound closure. To overcome this problem, various methods of treatment have been suggested in the past, including the MEEK technique. This study was carried out at the Bogenhausen Hospital Burn Unit, Munich, Germany from 2006 to 2015. There were a total of 148 skin grafting operations. The modified MEEK technique was performed on 67 patients. Patients included 34 males and 33 females, with an average age of 39·6 years. The mean percentage body surface burned was 65%, and full-thickness injury occurred in 52%. The mean area graft per procedure was 20%. The viability of the graft as assessed between the 7th and 10th day was generally in the range of 60-90%. The average number of operations required was 2·21. The mean length of stay was 27 days. Infection was documented in five patients, and seven deaths occurred. The mean follow-up was 3·2 years. When faced with large surface area burns and limited donor sites, the MEEK technique is a satisfactory method for coverage.