The Outward Curved Concha, an Unfamiliar Congenital Auricular Deformation: A Novel Protocol for Nonsurgical Management.

ABSTRACT: Anomalies present in about 30% of newborn ears; 15% to 20% of them are permanent. Malformations can be treated solely surgically; however, deformations, when promptly diagnosed, can be treated with nonsurgical methods, such as splinting and molding. The deformity of an outward curved concha is not only an aesthetic issue, but may confer functional problems that impair hearing and hearing aid usage. The goal of this report was to present this unique anomaly and our novel noninvasive treatment protocol for its management. Our cohort comprised 10 newborns treated for outward curved concha during 2018 and 2019. The patients underwent nonsurgical treatment using the EarWell system. In some patients, the management was followed by molding and taping to achieve the best effect. Treatment for all the patients began before age 3 weeks (mean, 2 weeks). Treatment duration was 5.2 weeks, on average. Nine patients did not show any adverse effects. The majority of parents expressed satisfaction with the aesthetic result; 70% were extremely pleased. Early initiation of the treatment-protocol for outward curved concha deformation yielded excellent and timely results in the infants, without the necessity of an invasive procedure.

Ear Deformations in Preterm Newborns: Non-Surgical Treatment.

ABSTRACT: Approximately 30% of newborns have some degree of congenital ear anomalies, the minority will resolve spontaneously. Deformations can be treated non-surgically, when diagnosed early, whereas malformations surgically only. The authors use the EarWell system proven to achieve excellent results in treating deformations. Although prematurity might raise the risk of ear-deformations compared to term infants, in our experience, there is a longer time frame until effective treatment is initiated due to the cartilage malleability.Treatment included splinting with retractors and taping or a custom-made silicone ear-mold if necessary. Patients were examined weekly, and treatment continued until appropriate ear shape was achieved (6-14 weeks).The authors treated 8 preterm infants during 2018 to 2020 with the above method. Average age of application was 9.25 weeks; treatment was initiated in all patients before the age of 12 weeks. 5/8 had a right-side, 2/8 a left-side, and one a bilateral deformation. Average treatment duration was 10 ±â€Š2.9 weeks. Assessment of satisfaction was made by parents via phone questionnaires; most were pleased with the overall result, while 62% were extremely satisfied.The authors observed higher compliance and longer-lasting malleability of the cartilage in preterm compared to term-infants. They also had fewer complications than in the term group, maybe due to their older (actual age), and more resistant and durable skin compared to a term-infant of the same age. The authors recommend initiating treatment in preterm infants later than accepted practice as results were excellent, and despite the longer treatment duration, this is a better treatment option than surgery.

Suturectomies Assisted by Cranial Orthosis Remodeling for the Treatment of Craniosynostosis Can Be Performed Without an Endoscope.

BACKGROUND: Minimally-invasive endoscopic strip-craniectomy (or suturectomy) for the repair of craniosynostosis combined with postoperative cranial orthotic molding has been widely adopted in the past 2 decades, proving itself as a safe and effective procedure. Over time the authors transitioned from performing an endoscopic strip-craniectomy, to performing the same surgery without the endoscope. The authors here describe our technique and compare its results to those published in the literature for endoscopic suturectomies. METHODS: A retrospective chart review was performed for patients with nonsyndromic craniosynostosis who underwent minimally-invasive nonendoscopic suturectomy between 2019 and 2020 at our institution. RESULTS: Thirteen patients (11 males; 2 females) were operated including 5 Metopic, 5 Sagittal, 2 coronal, and 1 lambdoid craniosynostosis. The average age at surgery was 4.35 months. The average length of surgery was 71 minutes. Averaged intraoperative estimated blood loss was 31.54 mL. Eleven patients received a blood transfusion (most before performing the skin incision) with a mean amount of 94.62 mL of blood transfused during surgery. The mean hemoglobin at discharge was 10.38 mg/dL. There was only 1 intraoperative mild complication. The mean intrahospital length of stay was 1.77 days with no postoperative complications noted. All patients initiated remodeling orthotic treatment following surgery. Long-term follow-up scans were available for 8 patients (5 metopic, 2 sagittal, and 1 lambdoid) with an average follow-up of 9 months. In all cases, there was a significant improvement in the skull width at the synostosis location as well as in the skull proportions and symmetry. The above outcomes are similar to those published in the literature for endoscope-assisted strip-craniectomies. CONCLUSIONS: Suturectomies assisted with cranial orthosis remodeling for the treatment of all types of nonsyndromic craniosynostosis can be performed without an endoscope while maintaining minimal-invasiveness, good surgical results, and low complication rates.

Is Time a Factor in Quality of Life Improvement Following Breast Reduction?

BACKGROUND: Macromastia (breast hypertrophy) has a significant influence on patients' quality of life (QoL), and surgical treatment therefore offers clear medical benefits.Rapid improvements in musculoskeletal complaints are being reported long before final aesthetic results are traditionally evaluated. OBJECTIVES: The aim of this study was to use the RAND Health Status Survey, in modified validated Short Form 36 (SF-36), to analyze patient QoL after breast reduction, and examine whether QoL changes as a function of postoperative time. METHODS: This cross-sectional study included 50 consecutive selected female patients who underwent breast reduction surgery by the same technique performed by a single surgeon between January 2016 and December 2019. Changes in QoL were reported based on a modified SF-36 survey, with scores standardized according to the mean of the general population. Time intervals between the operations and surveys were recorded. RESULTS: The patients were divided into 3 categories according to time since their operation (<3 months, 3-12 months, and >12 months), and assessed pre- and postoperatively. The mean [standard deviation] weight of breast tissue removed was 479.97 [159.38] g per breast. Mean follow-up time was 15.02 [14.3] months. All patients were satisfied with the shape of their new breasts and none reported to have suffered major complications postoperatively. For all 3 groups, patients' scores in the SF-36 survey post- compared with preoperation indicated improvement unrelated to time elapsed since operation. CONCLUSIONS: Breast reduction improves symptoms and well-being, unrelated to amount of tissue removed or to time elapsed postsurgery. This improvement is rapid and may lead to better coverage from medical insurance providers.

Quality of Patient-Reported Outcome Studies Utilizing the BREAST-Q: A Systematic Review.

BACKGROUND: Patient-reported outcome (PRO) studies are essential in the assessment of surgical procedures in plastic surgery. One accepted and validated questionnaire is the BREAST-Q. OBJECTIVES: The aim of this study was to assess the quality of PRO studies in plastic surgery utilizing the BREAST-Q questionnaire. METHODS: This study involved 2 steps: (1) a systematic review of 23 key criteria assessing the quality of survey research in studies utilizing the BREAST-Q that were published between 2015 and 2018; (2) a review of current guidance for survey research in journals related to plastic surgery and breast surgery which were included in the systematic review. RESULTS: Seventy-nine studies were included in the systematic review. Many key criteria were poorly reported: 51.9% of the studies did not provide a defined response rate and almost 90% did not provide a method for analysis of nonresponse error; 67.1% lacked a description of the sample's representativeness of the population of interest, and 82.3% did not present a sample size calculation. The methods used to analyze data were not described in 11.4% of the papers; in 27.8% the data analysis presented could not allow replication of the results. Of the 16 journals in the fields of plastic surgery and breast surgery for which the "instructions to authors" were reviewed, 15 (93.7%) did not provide any guidance for survey reporting. CONCLUSIONS: The majority of key criteria are underreported by authors publishing their survey research in peer-reviewed journals in the fields of plastic and breast surgery. There is an urgent need to construct well-developed reporting guidelines for survey research in plastic surgery, and particularly in breast surgery.

[BREAST PLASTIC SURGERY - CHALLENGES AND INNOVATIONS BREAST SURGERY EDITORIAL].

INTRODUCTION: The breast as an organ has much more importance than its physiological role and is considered a symbol of fertility and femininity for thousands of years. The history of plastic surgery operations of the breast developed parallel to the oncological breast surgery started for the late 19th century. In a number of issues of IMAJ and "Harefuah", some of the challenges and complexities are presented and discussed: breast implants associated lymphoma, mycobacterial infections, and galactorrhea. There are challenges in breast reconstruction post-chemotherapy, using autologous fat with a negative pressure to enhance vascularity and fat take. Modification of the surgical technique is presented to prevent the use of acellular dermal matrix in immediate direct to implant breast reconstruction. The Israeli innovation of creating a lighter implant manipulating the silicone is also described and the experience of one center in transgender breast reductions.

One-Step Triple-Layer Reconstruction of an Exposed Calvarium in a Patient With Radiated Tinea Capitis.

Full-thickness large scalp defects with underlying exposed calvarium pose a significant reconstructive challenge. Traditional reconstructive techniques are usually not an option in patients with irradiated scalp with thin skin and reduced laxity.Dermal substitutes-based reconstruction techniques have been described in recent years. A common approach is the staged methodology, with the initial application of skin substitute followed by a split-thickness skin graft few weeks later; however, this method involves a prolonged period of local wound management prior to skin grafting and is often associated with complications that interfere with wound healing.This report describes a single-stage triple-layer technique for the reconstruction of a large scalp defect with exposed bone in a patient with a history of radiation treatment, using 3 turnover pericranial flaps in conjunction with a Matriderm dermal substitute and split-thickness skin graft. This immediate multilayered reconstruction provides a long-lasting structural and aesthetic outcome, with minimal donor site morbidity and reduced complications.

[SCARPA FASCIA AND ABDOMINAL WALL DEEP ADIPOSE COMPARTMENT PRESERVATION IN ABDOMINOPLASTY - CURRENT CLINICAL AND ANATOMICAL REVIEW].

INTRODUCTION: During the last two decades, in parallel to the increased prevalence of bariatric procedures, there has been a marked increase in the prevalence of abdominoplasty surgery in the United States, and in accordance an increase in the scientific and clinical research related to all aspects of this technique. The most common complication of abdominoplasty is the formation of post-operative seroma. Various theories have been raised regarding the pathophysiology of seroma formation, and numerous methods for seroma prevention have been employed and tested. In the early 90's, a new theory argued that post-operative seroma formation is secondary to damage caused to the abdominal wall's lymphatic drainage during flap undermining. In light of this theory, a new surgical technique was suggested to execute the flap undermining in a more superficial plane. This enabled the preservation of the scarpa fascia and the deep adipose compartment, which preserved the integrity of the abdominal wall lymphatic collectors. This method was successful in reducing the rate of postoperative seroma formation. Recent studies have shed new light on the anatomy of the abdominal lymphatic collectors, pathophysiology of seroma formation and methods of its prevention. This new data undermines the foundations of the scarpa fascia preservation theory, and the surgical technique that was derived from it. A new theory that tries to settle the contradiction between the clinical success of the technique in reducing seromas and the new findings regarding abdominal wall's lymphatic collectors anatomy, is the presence of a 'sticky interface' between the deep adipose compartment and the flap.

A Multicenter Controlled Study to Evaluate Multiple Treatments With Nonthermal Focused Ultrasound for Noninvasive Fat Reduction.

BACKGROUND: Demand for nonsurgical esthetic body procedures has led to the development of noninvasive techniques for reducing localized subcutaneous adipose tissue. OBJECTIVE: This study assessed multiple treatments with nonthermal focused ultrasound for noninvasive abdominal treatment of excess fat deposits. MATERIALS AND METHODS: Subjects were randomly assigned to Group 1 for a 4-week control phase before undergoing 3 abdominal fat reduction treatments, at 2-week intervals, or to Group 2 for immediate treatment. Weight, abdominal circumference, tolerability to treatment, subject satisfaction, and adverse events were recorded. RESULTS: Weight remained stable in the 126 participants. Mean reduction in midline circumference was 2.5 ± 2.1 cm in the Group 1 and 3.5 ± 2.7 cm in the Group 2 at Week 22. The effect of multiple treatments was cumulative with a steady decrease in abdominal circumferences during the study. Erythema was observed in 28% of treatments but was mild and transient in nature. Subjects tolerated the treatments well and were satisfied with treatment outcome. CONCLUSION: The study demonstrated the efficacy and safety of multiple nonthermal focused ultrasound treatments of excess abdominal fat deposits. Although the remodeling effect is minor compared with traditional surgical procedures, successive focused ultrasound treatments significantly reduced treatment area circumference, while avoiding invasive techniques and their associated disadvantages.

[PARTIAL BREAST RECONSTRUCTION BY MODIFIED BREAST REDUCTION TECHNIQUES].

INTRODUCTION: Partial resections of the breast are more than 50% of breast oncological surgery. The resulting defect can be substantial and cause meaningful deformity that leads to reduced body image satisfaction of the patients, affecting their ability to cope with the cancer. Parallel to the development of breast oncology techniques, an evolution of breast reconstruction techniques occurred. During the last decade, by using techniques from cosmetic breast surgery (such as breast reductions, augmentations and mastopexies), we can reconstruct extensive partial defects of the breasts at the immediate and delayed setting and achieve symmetrical aesthetic results. Of the 350 oncological breast surgeries a year performed in our center, 70% undergo partial breast resection and only 10% of those surgeries exhibit a defect necessitating reconstruction. The recovery and post-operative complications, especially in the immediate setting, are significantly reduced in comparison to total breast reconstruction. Our experience shows that by using plastic surgery techniques in those operations, we can overcome the deformity created by large partial resection of the breast and improve the mental recovery from breast cancer.

Single probe light reflectance spectroscopy and parameter spectrum feature extraction in experimental skin cancer detection and classification.

Skin cancer, an anomalous development of skin cells in the epidermis, is among the most common types of cancer worldwide. Because of its clinical importance and to improve early diagnosis and patient management, there is an urgent need to develop noninvasive, accurate medical diagnostic tools. To this aim, light reflectance spectroscopy over the visible and near-infrared spectral range (400-1000 nm) based on a single-fiber six-around-one optical probe was applied to extract nine features used for diagnostics. These features include skewness, entropy, energy, kurtosis, scattering amplitude, and others, and are spread over each of four different spectral signatures, namely, light reflectance, absorbance, scattering profile approximation, and absorption/scattering ratio. Our preliminary studies focused on 11 adult patients with diagnoses of malignant melanoma (n = 4), basal cell carcinoma (n = 5), and squamous cell carcinoma (n = 2) in a variety of locations on the body. Measurements were taken first in vivo before surgery, at the site of the lesion and from healthy skin of the same patient, and ex vivo after surgical excision, where the lesion was rinsed in saline solution and measurements of the reflected light from the "inside" facing plane of the tissue were taken in the same manner. Overall, experimental results demonstrate that by examining a variety of wavebands, features, and statistical metrics, we can detect and distinguish cancer from normal tissue and different cancer subtypes. Nevertheless, discrepancies in results between in vivo and ex vivo tissue were observed and explanations for these discrepancies are discussed.

Revitalizing Hands: A Comprehensive Review of Anatomy and Treatment Options for Hand Rejuvenation.

Dorsal hand rejuvenation is gaining popularity as a solitary procedure and adjunct to face and neck rejuvenation treatments. As the hands age, the skin loses elasticity and becomes more translucent, the veins, joints, and tendons appear more prominent, and the bones become more noticeable. These changes are due to intrinsic and extrinsic factors. Current treatment methods include the injection of dermal fillers and autologous fat grafting. Anatomic studies to ensure the successful implementation of rejuvenation procedures identified three separate fascial layers in the dorsum, from superficial to deep. More recent re-evaluations revealed a less distinct, inseparable, sponge-like fascial layer. All authors agree that the superficial dermal layer is probably the optimal location for the injection of volumizing materials because it is free of anatomical structures. Many methods for harvesting, preparing, and injecting fat grafts to the dorsum of the hand have been described in the past three decades. Both filler and fat-graft procedures are performed on an ambulatory basis under local anesthesia. Good results with low postoperative and long-term complication rates and high patient satisfaction have been reported.

Temporal hollowing causes, classifications, and treatment options: A systematic review.

BACKGROUND: Recent developments in surgical techniques and grading schemas to treat temporal hollowing necessitate critically assessing their efficacy. This systematic review presents the currently available protocols for temporal hollowing, aimed toward improving the clinical approach, for the benefit of the surgeon and patient. METHODS: A search was conducted in PubMed, EMBASE, and Google Scholar in September 2021 using the keywords "temporal hollowing" and "temporal augmentation." Inclusion criteria were English-written articles published in peer-reviewed journals that reported an outcome relating to the cause, classification, or procedure used to prevent or correct hollowing in humans. RESULTS: Of the 413, 966 publications retrieved, 24 met the study inclusion criteria. Twenty-one publications discussed the etiology of temporal hollowing, 12 discussed a classification or grading system for temporal hollowing, and 19 discussed a procedure to prevent or correct temporal hollowing. The most commonly reported etiology for temporal hollowing was iatrogenic (63%). For classifying temporal hollowing severity, visual analogue scales (25%) were most commonly used. Mesh (26%) and autologous fat grafts (26%) were the most popular procedures used to prevent or correct temporal hollowing. DISCUSSION: We presented the spectrum of temporal hollowing grading schemas and treatment modalities currently published in the field. The use, by a majority of publications, of a grading system based on the subjective judgment of the examiner (either alone or adjunct to imaging results) suggests the need for a more standardized measurement tool. Future studies should investigate a universally applicable temporal hollowing classification system and its impact on treatment outcomes.

Israeli Innovations in the Field of Plastic Surgery.

Numerous innovations within the field of plastic surgery have been developed in Israel over the last few decades. Many of these therapeutic devices and techniques have been established globally with demonstrable efficacy and respectable safety profiles. This article offers an overview of recent Israeli cutting-edge medical therapeutic solutions contributing to the global practice of plastic surgery.

Medical Students' Knowledge of Plastic Surgery as a Reflection of the Public Perception.

Plastic surgery is a broad field that requires a mixed skillset. Therefore, it is important that students be exposed to all its various subspecialties to make informed career decisions and to properly refer patients in different clinical situations. A nationwide survey was conducted of Israeli medical students to investigate their knowledge and perceptions regarding the field of plastic surgery and its subspecialties, and the impact of a clinical rotation in plastic surgery on these factors. A total of 300 subjects responded. Approximately, 61% of the cohort was female and 70% were enrolled in a 6-year program. About one-third stated that their field of interest was surgical rather than medical. Significant variability was noted in the accuracy of responses to questions about different procedures encompassed in the scope of plastic surgery. Although 90% of the students were aware of some common plastic surgery procedures that are also often thought to be well known to the public, only 50% were able to correctly identify lesser-known surgeries performed by plastic surgeons. Knowledge about plastic surgery was unrelated to an interest in the field. We recommend adjusting preclinical instruction and clinical rotations in plastic surgery to better prepare students to select a specialty best suited to their future goals, as well as to improve their ability to refer patients to other specialists as necessary.

Reconstructive Microsurgery in the COVID-19 Environment.

The COVID-19 pandemic has presented unique challenges to the plastic surgery field. Substantial changes have been incorporated in hospital and practice protocols in all branches of medicine. Organic medical teams were placed on scheduled shifts to prevent cross-infection, and some working teams were discontinued. Remote technology consultations and deliberations were instituted in hospitals and community medical services to maintain the flow of information on patient status. Several mitigation strategies were implemented during these times throughout medical facilities. We present those implemented in our facility to ensure adequate labor, resources, and facilities along with proper protocols for patient selection and management according to predetermined risk assessment criteria with the hope to assist the healthcare staff to minimize mortality risks.

Research Productivity among Plastic Surgeons in the State of Israel: h-index and M-quotient Assessment.

The h-index has been proven in the US and Canada to be a solid tool to assess the quality and impact of individual scientific work in the field of plastic surgery. M-quotient is an additional metric that mitigates the h-index's inherent bias toward more seasoned researchers. The objective of this study was evaluating the relationship between h-index and M-quotient and research productivity among plastic surgeons in the state of Israel. METHODS: A list of all Israeli board-certified plastic surgeons registered in the Israeli Society of Plastic and Aesthetic Surgery was obtained from the organization's website. Relevant demographic and academic factors of each surgeon were retrieved. The Scopus database was queried to determine each surgeon's h-index and M-quotient, among other bibliometric parameters. RESULTS: Our study included 173 plastic surgeons, 90% of whom were men. In total, 49.7% were working in academically affiliated hospitals; 14.4% of the surgeons had an academic rank. The mean h-index was 6.13; mean M-quotient was 0.27. Statistical analysis demonstrated a positive correlation between total number of publications (P < 0.0001), total number of citations (P < 0.0001), the surgeon's seniority (P < 0.0001), academic rank (P = 0.007), appointed as past/present plastic surgery department director (P < 0.0001), and working in an academic affiliated hospital (P < 0.025). The same parameters were found to have a positive correlation with M-quotient. CONCLUSIONS: The h-index is an effective measure to compare plastic surgeons' research productivity in Israel. M-quotient is an ancillary tool for the assessment of research productivity among plastic surgeons, with the advent of neutralizing the surgeon's seniority.

Burns in the Military Setting-Analyzing 12,799 Routine and Combat Cases.

Burns are a major trauma source in civilian and military settings, with a huge impact on patient's well-being, health system, and operation status of the force in the military setting. The purpose of our study was to summarize characteristics of all burn cases seen by the Israel Defense Forces primary care physicians during the years 2008 to 2016. This can help understand what causes most burns, in what units, at which stages and settings and consequently will allow commanders to make decisions regarding safety rules, protective equipment and uniforms, medical education for soldiers, etc. Data were collected from the military database system. All burn-related visits were analyzed using a designated big data computerized algorithm that used keywords and phrases to retrieve data from the database. 12,799 burn injuries were found presented in 65,536 burn-related visits which were analyzed according to the demographics, burn mechanism, and military unit. It was observed that most of the burns (70.7%) occurred during routine noncombat setting and there was a gradual decrease in burn injuries during the investigated period, from 17.6% of the cases in 2008 to 2.3% in 2016. Most of the burns occurred in the Air Force (19.4%), and the leading etiology was chemical (35%). The average TBSA was 7.5%. Since most of the burns occurred in a routine setting and were occupational-related, investment in education and improving fire protection has proven itself, leading to the decrease in burn prevalence, we recommend that more emphasis should be given on proper handling of chemicals.

Epidemiology of Burn Wounds Arriving to a Level 1 Trauma Center in Israel.

Burn injuries have grave consequences for patients and impose a heavy economic burden on healthcare services. Studies on the epidemiology of burn injury in Israel are sparse and outdated, and improved understanding of current trends can help experts plan prevention campaigns and design effective treatment paradigms. This study sought to assess the background, clinical, and treatment characteristics of adult patients admitted with burn injury to a level 1 trauma center in Israel in 2005 to 2017. Data were retrospectively retrieved from the hard copy and electronic files as follows: patient sex and age; burn type, degree, and etiology; percentage total BSA (%TBSA) affected; and type of treatment and length of hospital stay (LOS). The cohort included 734 patients of mean age 41.79 years and a male-to-female ratio of 1.8:1. Thermal factors, particularly hot liquids, were the most common cause; second-degree burns were the most common. Mean %TBSA was 5.39%; mean LOS was 11.81 days; and mean LOS/%TBSA was 4.65. Advanced dressings alone yielded satisfactory outcome in 74.2% of patients. The relatively younger patient age and male predominance of our cohort were in line with published findings. The LOS was similar to previous studies in Israel but lower than in Europe. The LOS/%TBSA was higher than in the literature, with a decrease over time suggesting an increased effectiveness of treatment. There appears to be a decline in the rate of surgery for burn injury and increased expertise in the use of advanced dressings. National prevention campaigns should focus on scalds rather than flame-induced burns.