Augmentation-Mastopexy: Analysis of 95 Consecutive Patients and Critical Appraisal of the Procedure.

Single-stage mastopexy-augmentation has been demonstrated to be a safe procedure. However, revisions may still be necessary. We evaluate 95 consecutive patients undergoing mastopexy-augmentation and introduce a new surgical technique for the procedure: the modified dual plane technique. In this retrospective study, 95 patients (mean age 34 ± 11 years) underwent mastopexy-augmentation between 2009 and 2019. The procedures were classified as subglandular, dual plane, or modified dual plane technique. The outcome measures included major and minor complications. A total of 19 patients underwent a subglandular procedure, 32 patients a dual plane procedure, and 44 patients a modified dual plane procedure. We observed a high overall complication rate in the subglandular group (n = 12, 63%), dual plane group (n = 15, 47%), and modified dual plane group (n = 10, 23%). Complications leading to implant loss/change occurred in seven patients in the subglandular group (37%), six patients in the dual plane group (19%), and no patient in the modified dual plane group. While we observed a high complication rate in patients undergoing mastopexy-augmentations, the modified dual plane technique was associated with a lower complication rate.

A Systematic Analysis of the Nasal Septum in Crooked Noses and Suggested Treatment Algorithm According to Preservation Rhinoplasty (PR) Principles.

BACKGROUND: A deviated nose is a common problem among patients for both cosmetic and functional reasons. The correction remains a major challenge for the rhinoplasty surgeon. Unrecognized nasal septal deviations stand as the primary reason for failed rhinoplasty outcomes. There is a paucity of data in the literature about septoplasty classifications and technical details in preservation rhinoplasty (PR) for various crooked noses. MATERIALS AND METHODS: The aim of this article is to provide a comprehensive overview of the various septum deviations according to the nasal axis. Moreover, a treatment algorithm is suggested with technical details based on PR principles. RESULTS: The directions and curvature of the cartilaginous deviation of crooked nose such as C-shaped, reverse C-shaped, straight axis deviations (I-shaped), and S-shaped are described. According to the deviation, a septoplasty classification (Type 1-Type 4) is suggested. CONCLUSIONS: On the basis of septal deviation, different PR techniques are proposed to achieve the desired straight nasal dorsum with an optimal functional outcome. Compared to the classical L-strut concept, the quadrangular cartilage remains preserved in the swinging door technique. The cartilage might be further used in the future for grafting in the hybrid structural/preservation technique if needed, ultimately saving rib cartilage and/or conchal cartilage. Finally, surgery time is reduced, and patient's morbidity remains minimal. 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 .

Multistage Reconstruction of Large Arm Defect Using Keystone Type I Flap and Temporary Synthetic Skin Substitute.

Large arm defects remain a challenge to the reconstructive surgeon, as local and regional flaps are limited regarding size and free flaps have disadvantages such as poor color match, technical complexity, prolonged operative time, and the risk of total flap loss. Keystone flaps are fascia-based flaps and combine perforator-based vascularity with relative simplicity of nonmicrosurgical techniques and do not distort local anatomy in cases of malignant excision with wide defects. This article highlights the approach of a multistaged procedure to reconstruct a large arm defect using a keystone type I flap and a temporary synthetic skin substitute for closure in a patient referred to our department for wide resection of a large melanoma in situ on the posterior aspect of the left arm. The defect, measuring 14 cm × 8 cm, was initially reconstructed with a keystone type I flap. Part of the wound was temporarily covered with EpiGARD (Biovision GmbH, Ilmenau, Germany) to avoid excessive wound tension. One week later, the wound was partially narrowed, and a smaller EpiGARD was placed in office under local anesthesia. The multistaged approach was completed with direct closure 1 week later after removal of the smaller EpiGARD. No complications occurred and the result was satisfactory with a pleasing cosmetic result after an 8-month follow-up. In conclusion, the keystone flap allows reconstruction of large arm defects. Temporary synthetic skin substitute coverage can serve as a good addition for those cases where tension on the margins is observed at the price of a small in-office procedure.

The Double-pedicle Tip Anchor Flap (DPTA-Flap) Preservation Technique for Autologous Breast Augmentation Circumvertical Mastopexy.

The ultimate breast mastopexy technique allows a reliable and consistent transposition of the nipple-areolar complex (NAC) with preservation of nipple viability, sensation, and lactation potential. Ideally, good upper pole fullness with a durable result is achieved. However, as the inferior pole parenchyma often gravitates downward, the long-term result remains unsatisfactory. Anchoring remains a key procedure in autoaugmentation mammoplasty as the flap needs to be stable against gravity. We hereby describe a further refinement of a chest wall-based flap for the support of the upper pole, namely a double-pedicle tip anchor flap (DPTA-flap). By using this technique, good upper pole fullness is achieved, sensation is preserved, and lactation remains likely. Level of Evidence: V.

Rintala Flap and Posterior Perichondrial Cutaneous Graft: A Combined Approach for Nasal Tip Reconstruction.

Nasal tip reconstruction requires a meticulous approach due to the complexity of the nasal anatomy and its aesthetic importance. Many procedures have been described to restore this aesthetic unit, including the paramedian forehead flap, which is one of the workhorse flaps. However, despite excellent final outcomes, this procedure may be refused by patients, due to its temporary conspicuous appearance possibly associated with serious psychological implications, and the need of multiple interventions. We aimed to present an approach combining the Rintala flap and the posterior perichondrial cutaneous graft as a valuable alternative to treat large nasal tip defects.

Quality of Life (QoL) and Outcome After Preservation Rhinoplasty (PR) Using the Rhinoplasty Outcome Evaluation (ROE) Questionnaire-A Prospective Observational Single-Centre Study.

BACKGROUND: Rhinoplasty is a challenging procedure, and the ultimate goal is not only to restore the function and youthful appearance, but also to improve the quality of life (QoL). Little is known about the QoL after preservation rhinoplasty (PR). The aim of this study was to assess patient satisfaction after PR by using a validated questionnaire. PATIENTS AND METHODS: Patients undergoing primary PR were included in this prospective cohort single-centre (private) study. Overall, 58 patients (41 female and 17 male patients, mean age 32 ± 9.7 years) were operated on between 2017 and 2021. Patient assessment regarding their outcome was evaluated before surgery and at final follow-up using a validated questionnaire (Rhinoplasty Outcomes Evaluation Questionnaire = ROE). Subgroup analyses were performed between the ROE questions and radiological analysis by using the cone-beam computed tomography (CT) before surgery and at final follow-up. RESULTS: After a mean follow-up of 19.7 ± 7.9 months (range = 1-50 months), a high overall patient satisfaction was observed (37.9 ± 9.2 vs. 81.25 ± 14.17, p < 0.0001). Subgroup analysis showed the highest improvement in nose appearance, breathing, and self-confidence after surgery. The improvement of subjective breathing (1.471 ± 0.90 vs. 3.1 ± 0.88; p<0.0001) goes in line with an overall improved internal nasal valve (INV) angle (19.88° ± 3.3° vs. 22.04° ± 4.1°, p = 0.0231). CONCLUSIONS: Our study showed a high patient satisfaction after PR as evaluated by the ROE, which goes in line with aesthetics and function. 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 .

Facial reanimation with interposition nerve graft or masseter nerve transfer: a comparative retrospective study.

Both interposition nerve grafts and masseter nerve transfers have been successfully used for facial reanimation after irreversible injuries to the cranial portion of the facial nerve. However, no comparative study of these two procedures has yet been reported. In this two-site, two-arm, retrospective case review study, 32 patients were included. Of these, 17 patients (eight men and nine women, mean age 42.1 years) underwent interposition nerve graft after tumor extirpation or trauma between 2003 and 2006 in the Ear Institute, School of Medicine, Shanghai Jiao Tong University, China, and 15 patients (six men and nine women, mean age 40.6 years) underwent masseter-to-facial nerve transfer after tumor extirpation or trauma between November 2010 and February 2016 in Shanghai Ninth People's Hospital, China. More patients achieved House-Brackmann III recovery after masseter nerve repair than interposition nerve graft repair (15/15 vs. 12/17). The mean oral commissure excursion ratio was also higher in patients who underwent masseter nerve transfer than in patients subjected to an interposition nerve graft. These findings suggest that masseter nerve transfer results in strong oral commissure excursion, avoiding obvious synkinesis, while an interposition nerve graft provides better resting symmetry. This study was approved by the Institutional Ethics Committee, Shanghai Ninth People's Hospital, China (approval No. SH9H-2019-T332-1) on December 12, 2019.

A multivariate analysis after preservation rhinoplasty (PR) - a prospective study.

BACKGROUND: Preservation rhinoplasty (PR) is considered to be an innovative approach with high patient satisfaction. However, little is known about its functional outcomes and radiological analyses. PATIENTS AND METHODS: In this prospective clinical study, 30 patients (20 female and 10 male patients, mean age 30.7 ±9.8 years) were operated on between 2017 and 2021. Radiological assessment was evaluated by cone beam computed tomography before surgery and at final follow-up. Patient assessment regarding their outcome was assessed at final follow-up using a validated questionnaire (rhinoplasty outcomes evaluation questionnaire = ROE). RESULTS: After a mean follow-up of 8.4 ± 5 months (range = 1 - 18 months), radiological analyses denoted an overall improved internal nasal valve (INV) angle after surgery (preoperative = 20.77° ± 3.2° vs. postoperative = 21.82° ± 5.7°, p = 0.18). Those results are in accordance with an overall high patient satisfaction for both function and aesthetics (ROE score 18.4 ± 4.3). CONCLUSION: Our study showed a preserved and widened INV angle after PR, along with high patient satisfaction. LEVEL OF EVIDENCE: III.

The Butterfly Technique: A Retrospective Study for Labia Minora Reduction Using an Integrated Approach.

In recent years, the demand for genital plastic procedures has increased. Of those, the reduction of the labia minora has become very popular. Several techniques are described, with all its advantages and disadvantages. The aim of this study is to introduce a novel approach combining de-epithelialization with wedge resection. METHODS: In this retrospective study, we included patients seen between September 2011 and April 2014 with hypertrophic labia minora. The surgical technique consisted in an integrated approach of de-epithelialization and wedge excision. Patients were examined for early and late postoperative complications. Furthermore, patient satisfaction was evaluated at the final follow-up. RESULTS: A total of 17 labioplasties (Franco type II-IV) in 10 patients with a mean age of 29 ± 12 years (range 20-62 y) were performed. Three patients experienced wound-healing problems, requiring surgical revision. After a median follow-up of 39 ± 6 months (range 28-48 mo), a high overall patient satisfaction has been achieved (8.6 ± 1.1). No dyspareunia, hypertrophic scarring, or micturition problems have been reported. CONCLUSIONS: By using our integrated approach, hereby called the "butterfly technique," the neurovascular supply remains preserved, and an efficient volume reduction can be achieved with a concealed scar. Nevertheless, suture techniques and suture materials have to be tested to reduce the incidence of wound dehiscence rate.

[Management of symptomatic breast hypertrophy and reduction mammaplasty]. / Prise en charge de l'hypertrophie mammaire symptomatique et réduction mammaire.

Breast hypertrophy (macromastia) can cause various symptoms correlated with excessive breast volume and is usually associated with breast ptosis. Symptomatic macromastia can constitute a heavy burden on patient's global health. While conservative therapy does not allow for long term relief, breast reduction mammaplasty is an effective and safe treatment. Multiple techniques have been described, but all rely on common principles. Measures can be taken to lower surgical complications rates and implemented by primary care physicians in collaboration with the plastic surgery approach.

L'hypertrophie mammaire symptomatique se définit comme un ou plusieurs symptômes en lien avec un volume mammaire augmenté, en général associé à une ptose mammaire. Elle peut avoir un impact majeur sur la santé globale des patientes. Alors que les traitements conservateurs ne permettent pas de soulager les patientes à long terme, la réduction mammaire chirurgicale est un traitement efficace et sûr. De nombreuses techniques ont été décrites, mais reposent sur des principes communs. Certaines mesures permettent une diminution des risques de complications chirurgicales et peuvent être entreprises conjointement à la prise en charge en chirurgie plastique.

Sensory assessment of meshed skin grafts over free gracilis muscle flaps without nerve coaptation for lower extremity reconstruction.

BACKGROUND: Little is known about the sensate recovery of skin grafts over free non-neurotized muscle flaps. The aim of this study was to evaluate the sensitivity of free gracilis muscle flaps and meshed skin grafts without nerve coaptation. METHODS: Thirteen consecutive patients with a median age of 55 years (range, 21-70 years) who underwent lower extremity reconstruction between September 2014 and October 2016 were included. Complications, flap contour, skin perception, and sensate recovery were assessed. RESULTS: All flaps survived completely. In one patient, wound dehiscence and infection occurred 1 month after surgery. After a median follow-up of 14 months (range, 10-51 months), a satisfactory contour and skin perception were achieved. The Semmes-Weinstein (SW) monofilament test (154.8±22 g) and static two-point discrimination (2-PD) (12.6±0.7 mm) showed intermediate recovery compared to the surrounding site (41% and 76%, respectively). There was an intermediate correlation between flap size and sensate recovery (2-PD: r=0.27, P=0.36; SW test: r=0.45, P=0.12). Vibration sensation recovered to 60%, whereas thermal sensation remained poor (19% at 5°C and 25% at 25°C). CONCLUSIONS: Finer sensation could be partially restored. However, thermal sensation remained poor.

Arteriovenous Loops Enable Free Tissue Transfer With Otherwise Inadequate Local Donor and Recipient Vessels.

BACKGROUND/AIM: Free flap reconstruction with damaged or diseased vessels is a challenging problem. We describe our case series using an arteriovenous loop or bypass surgery with free flaps for complex defect reconstructions at the lower extremity and the pelvic region. PATIENTS AND METHODS: In this single-center retrospective cohort study 11 consecutive patients (mean age=73 years, range=53-88 years) were operated on, between June 2016 and August 2018. Patients were reconstructed with free gracilis flaps (n=8), free latissimus dorsi flap (n=1) and chimeric scapular flap (n=1), respectively. RESULTS: The mean loop length was 30 cm (range=12-40 cm). The loop/bypass revision rate was 27% (3/11), and the overall flap loss rate was 20% (2/10). After a mean follow-up time of 17 months (range=12-24 months), the limb salvage rate was 75% (6/8). CONCLUSION: We successfully reconstructed complex defects with poor recipient vessels using arteriovenous loops or bypass surgery and free flaps.

Functional and Radiological Assessment After Preservation Rhinoplasty - A Clinical Study.

BACKGROUND/AIM: We hypothesized that improved functional outcome after preservation rhinoplasty can be validated by radiological analyses. PATIENTS AND METHODS: In this retrospective study, five patients were included. Radiological assessment was evaluated by cone-beam computed tomography. Patient satisfaction regarding nasal function was evaluated by a Likert scale from 0 to 10 (0=poor result; 10=very satisfied). RESULTS: After a mean follow-up of 5±1 months (range=4-6 months), significantly improved function was noted by all patients, with a mean Likert scale of 9.2±0.45 (preoperative score=2.8±0.8, p=0.0079). These results are in line with the radiological results, showing an improved internal nasal valve angle (preoperative=26.2°±1.8° vs. postoperative=32.3°±1.2°, p=0.02). CONCLUSION: Our study showed that besides nasal appearance, nasal function can also be dramatically improved after preservation rhinoplasty.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Clostridial Infection After Open Fractures of the Lower Extremity - Report of Two Cases and Discussion of Pathomechanism and Treatment.

BACKGROUND: Management of post-traumatic open fractures resulting from severe injuries of the lower extremity continues to challenge orthopedic and reconstructive surgeons. Moreover, post-traumatic osteoarticular infections due to Clostridium species are rare, with few reports in the literature. We describe possible pathomechanisms and propose treatment options for cases of delayed diagnosis of osteoarticular infections with Clostridium spp. CASE REPORTS: Two patients sustained severe osteoarticular infection due to Clostridium spp. after open epi- and metaphyseal fractures of the lower extremity. In combination with radical debridement, ankle arthrodesis and long-term antibiotic treatment, satisfactory results were achieved after a follow-up of 18 months and 24 years. CONCLUSION: Clostridium species are difficult to identify, treatment is usually delayed and most patients have unfavourable outcomes.

Suture techniques and cartilage grafts in nasal tip surgery: An algorithm in primary and secondary rhinoplasty.

OBJECTIVE: In most primary and secondary rhinoplasties, the adjustment of the nasal tip in terms of position, projection, and configuration is mandatory. Usually, this is one of the most challenging parts of the operation. The aim of this study was to present a step-by-step algorithm that evaluates popular techniques for a predictable outcome. PATIENTS AND METHODS: A single-surgeon retrospective review of primary and secondary rhinoplasty patients was undertaken for nasal tip refinement. An overview of popular and clinically relevant suture techniques and cartilage grafts is provided, in particular, concerning the position, projection, and rotation. On the basis of clinical examples, we will present different indications, the latest operative treatment options, and long-term results. RESULTS: Between 2013 and 2018, we devised an algorithm based on 322 patients. Ninety patients (28%) were admitted for primary rhinoplasties and 232 patients for secondary rhinoplasties (72%). Our patients reported overall high satisfaction rates, and no further revisions were required. CONCLUSIONS: Preoperative analyses and the knowledge of different suture techniques and cartilage grafts for nasal tip surgery are crucial factors for a successful postoperative outcome.

Early Postoperative Application of Botulinum Toxin Type A Prevents Hypertrophic Scarring after Epicanthoplasty: A Split-Face, Double-Blind, Randomized Trial.

BACKGROUND: Postoperative hypertrophic scarring of the medial canthal area is a common phenomenon and deterrent for patients considering epicanthoplasty. Botulinum toxin type A has been reported for hypertrophic scar and keloid treatment. However, there is a lack of high-level evidence regarding the effects of botulinum toxin type A in the medial canthal area. METHODS: In this split-face, double-blind, randomized trial, 43 consecutive consenting patients undergoing Park Z-epicanthoplasty were randomized to receive 5 U of botulinum toxin type A or the same volume of saline injections at days 6 to 7 postoperatively. Scars were assessed independently using the Vancouver Scar Scale, the visual analogue scale, and patient satisfaction rating at the 1-, 3-, and 6-month follow-ups. RESULTS: Overall, 30 patients completed this trial. The botulinum toxin type A-treated side achieved significantly improved Vancouver Scar Scale scores. The most obvious improvements were observed at the 3-month follow-up visit. Among the four subscores of the Vancouver Scar Scale, the most significantly improved subscores were the height and pliability. The visual analogue scale scores also decreased significantly on the botulinum toxin type A-treated side at all three follow-up visits. Approximately 86.7 percent of the patients were satisfied with the scar and epicanthoplasty outcomes. No severe complications were reported. CONCLUSIONS: Early postoperative botulinum toxin type A injection in the medial canthal region efficiently reduces hypertrophic scarring and improves the outcome of epicanthoplasty. Therefore, botulinum toxin type A injection can be used as a routine method to prevent hypertrophic scarring and improve the outcome of epicanthoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Outcome of Beveled versus Vertical IncisionTechnique after Reconstructive or Aesthetic Facial Surgery.

BACKGROUND: We suggest that the degree of scar improvement with a beveled incision technique with an angle of about 20 degrees to the skin can be translated for various reconstructions on the face and can be verified by a validated clinical assessment scale and histology. METHODS: A total of 5 patients (2 men and 3 women) with a mean age of 68 years (range 54-84 years) undergoing elective surgeries on the face for tumor excision or cosmetic procedures were included. The beveled incision technique was compared with the conventional vertical incision (control group). Outcome measures were major and minor complications, pain and scar quality using the Patient and Observer Scar Assessment Scale, and histomorphologic scar assessment. RESULTS: After a mean follow-up of 7.6 months (range 6-13 months), all patients healed uneventfully without pain, hypertrophic scars, or infection. We found a better overall Patient and Observer Scar Assessment Scale score in the beveled incision technique group (15 ± 3.4) compared with the conventional vertical incision group (18.4 ± 7.8, P = 0.7). Histomorphologic analyses showed after 6 months less scar zone, less inflammatory reaction, fewer macrophages, less foreign body reaction, and more hair follicles in the beveled incision technique group compared with the vertical incision group. CONCLUSION: We showed that the beveled incision technique using a 20-degree angle in elective surgeries on the face yields a cosmetic pleasant result for both the patient and the surgeon, which also goes in line with our histomorphologic analyses.