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 .

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 .

[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.

Modified Lower Blepharoplasty with Fat Repositioning via Transconjunctival Approach to Correct Tear Trough Deformity.

BACKGROUND: Over the years, many techniques have been described to correct tear trough deformity (TTD). Fat-repositioning lower blepharoplasty via a transconjunctival approach is increasingly applied due to its satisfactory rejuvenating effect. However, those methods have disadvantages such as a complicated surgical approach, residual scar, and long recovery time. OBJECTIVES: We modified the surgical technique of fat-repositioning transconjunctival lower blepharoplasty with an effective but easy internal fixation method via a supraperiosteal approach. METHODS: From January 2014 to December 2017, 110 patients underwent bilateral modified lower blepharoplasty with fat-repositioning. Preoperatively, the grade of TTD was evaluated according to Barton's grading system. Postoperative results and complications were assessed during the follow-up period. RESULTS: TTD was ameliorated in 97.73% of the cases; the remaining 2.27% cases with no improvement underwent revision and achieved Grade 0 on Barton's grading system thereafter. All patients were satisfied with the final outcome. Few postoperative complications were observed, none of which led to a permanent condition. Three cases of local depression and one case of local bulge were treated with surgical refinements. One case of postoperative hemorrhage was healed by electrocautery. CONCLUSIONS: Our modified method of transconjunctival lower blepharoplasty with fat repositioning is safe and effective to improve TTD without severe orbital skin laxity. 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 .

Treatment of Early-stage Extracranial Arteriovenous Malformations with Intralesional Interstitial Bleomycin Injection: A Pilot Study.

Purpose To assess the efficacy and safety of intralesional interstitial bleomycin injection in the treatment of early-stage (Schobinger stage I or II) extracranial arteriovenous malformations (AVMs). Materials and Methods This prospective study involved 34 patients with early-stage AVMs, as defined by the Schobinger staging system. The patients received intralesional interstitial bleomycin injected at a maximum dose of 15 000 IU or 1000 IU per kilogram of body weight for children who weighed less than 15 kg per procedure for a total of 6 months (once every month). Therapeutic outcome was evaluated by the degree of devascularization at angiography and the clinical outcome 3 months after the last treatment. Further follow-up was evaluated based on further clinical outcome. Adverse events were recorded according to the Society of Interventional Radiology classification. Results Of the 34 patients with early-stage AVM, 32 (mean age, 20.5 years; 24 female [75%]) completed the study. The results showed that 27 (84.4%, 95% confidence interval [CI]: 71.1, 97.7) patients were responsive to bleomycin injection, including nine (28.1%) with a complete response. Four (12.5%) patients showed no response, and one (3.1%) patient experienced worsening 3 months after the last treatment. During further follow-up (mean follow-up time, 20.7 months; range, 5-28 months), the outcome remained stable in 31 (96.9%) of the 32 patients. A major complication, anaphylactic shock, was observed in one (3.1%, 95% CI: 0, 9.5) patient. Common minor complications included hyperpigmentation, nausea, pruritus, and bullae. Conclusion Intralesional interstitial bleomycin injection is a feasible approach for early-stage AVMs and yields safe and effective outcomes. © RSNA, 2017.

Regeneration of nerve crush injury using adipose-derived stem cells: A multimodal comparison.

INTRODUCTION: To restore full function following nerve crush injuries is critical but challenging. In an attempt to develop a viable therapy, we evaluated the effect of rat adipose-derived stem cells (rASC) in 2 different settings of a sciatic crush injury model. METHODS: In the first group, after 14 days of nerve crush injury, rASCs were injected distal to the lesion under ultrasound guidance. In the other group, alleviation of compression through clip removal (CR) was combined with epineural injection of rASCs. Gait analyses, MRI, gastrocnemius muscle weight ratio (MWR), and histomorphometry were performed for outcome analysis. RESULTS: CR combined with rASC injection resulted in less muscle atrophy, as evidenced by MWR. These findings are further supported by better functional and anatomical outcomes. DISCUSSION: Animals treated with CR and epineural stem cell injection showed enhanced anatomical and functional recovery. Muscle Nerve 58: 566-572, 2018.

Surgical Management of Large Periorbital Cutaneous Defects: Aesthetic Considerations and Technique Refinements.

PURPOSE: The aim of this study was to repair large periorbital cutaneous defects by an innovative technique called PEPSI (periorbital elevation and positioning with secret incisions) technique with functional and aesthetic outcomes. METHODS: In this retrospective study, unilateral periorbital cutaneous defects in 15 patients were repaired by the PEPSI technique. The ages of patients ranged from 3 to 46 years (average, 19 years). The outcome evaluations included scars (Vancouver Scar Scale and visual analog scale score), function and aesthetic appearance of eyelids, and patient satisfaction. The repair size was measured by the maximum advancement distance of skin flap during operation. RESULTS: All patients achieved an effective repair with a mean follow-up of 18.3 months. Except one with a small (approximately 0.3 cm) necrosis, all patients healed with no complication. The mean Vancouver Scar Scale and visual analog scale scores were 2.1 ± 1.7 and 8.5 ± 1.2, respectively. Ideal cosmetic and functional outcomes were achieved in 14 patients (93.3%). All patients achieved complete satisfaction except 1 patient with partial satisfaction. The mean maximum advancement distance of skin flap was 20.2 mm (range, 8-50 mm). CONCLUSIONS: This study demonstrated that the PEPSI technique is an effective method to repair large periorbital cutaneous defects with acceptable functional and aesthetic outcomes.

Treatment of Head and Neck Arteriovenous Malformations Involving the Facial Nerve: A Tailored Algorithm.

BACKGROUND: Head and neck arteriovenous malformations (AVMs) involving branches of the facial nerve often cause tremendous cosmetic, functional, and psychological problems that are challenging to treat. We proposed an algorithm to obtain the optimal treatment and esthetic outcome. METHODS: Medical records of 24 patients were reviewed between 2002 and 2015. The lesions were classified into 4 types: type 1, involving no more than 2 facial nerve branches, with a maximal diameter of lesion of 5 cm or less (n = 7); type 2, involving no less than 2 facial nerve branches, with a maximal diameter of lesion of greater than 5 cm (type 2a, facial nerve preservation, n = 8; type 2b, facial reanimation, n = 5); and type 3, involving the mastoid segments or the trunk of the facial nerve (n = 4). Treatment efficacy was assessed and facial function was evaluated using the regional House-Brackmann Facial Nerve Grading System. RESULTS: Cure was achieved in 11 (45.8%) patients, and improvement was achieved in 12 (50.0%) patients, with a follow-up of 36.3 ± 32.9 months (range, 12-144 months). There was no significant difference of the regional House-Brackmann Facial Nerve Grading System score before and after treatment (type 1, unchanged; type 2a, P = 0.356; type 2b, P = 0.423; type 3, unchanged). Treatment outcomes were not significantly related to the type of nerve involvement (P = 1.000) and the facial reanimation procedure (P = 1.000). CONCLUSIONS: Surgical excision or ethanol embolization alone is efficient for type 1 AVMs. The optimal approach for type 2a AVMs was surgery, followed by well-vascularized tissue transfer. In type 2b AVMs, the satisfied treatment results are achieved by lesion excision and immediate facial reanimation. A 2-stage strategy may result in contented treatment outcome in type 3 AVMs.

Extending the limits of the anterior tibial artery as the recipient vessel for around the knee and proximal lower extremity defect reconstruction using the free anterolateral thigh and gracilis flap.

PURPOSE: The aim is to describe a technique with orthograde dissection of the anterior tibial artery (ATA) used as the recipient vessel for the end-to-end (ETE) anastomosis in defect reconstruction around the knee and for proximal/middle third leg defects with free anterolateral thigh (ALT) and gracilis flaps. PATIENTS AND METHODS: Between March 2009 and May 2014, 22 patients undergoing lower extremity reconstruction were evaluated. Of those, 4 patients were included. The locations of injury were 3 defects around the knee and 1 defect at the proximal and middle third of the lower leg (mean defect size 18 x 8.5 cm and a range of 17-20 x 5-10 cm). There were 2 cases after trauma and 2 cases with infection. Two free gracilis and 2 free ALT flaps were performed of equal size to the defects. The mean flap pedicle length was 11 cm (range of 7-16 cm) and the mean length of the mobilized recipient vessels was 10.5 cm (range of 6-14 cm). RESULTS: One flap loss (ALT) occurred, requiring a salvage procedure with a latissimus dorsi flap, whereas wound dehiscence at the donor site and a hematoma below the ALT flap was observed in 2 cases, requiring small revision. After a mean follow-up of 52 months (range of 38-87 months), there was stable soft tissue coverage in all patients. CONCLUSION: By orthograde dissection of the ATA, an adequate vessel length and size may be achieved, improving arc of rotation to successfully cover more distant defects.

A Penetrating Facial Wound With Burn Injury.

A patient presented with a complex penetrating facial wound by high temperature steel. The hot steel penetrated right temple, ethmoid bone, and maxillary sinus, and then exited from his left cheek. He kept his right eye but lost his sight. For functional and esthetic considerations, treatments were provided in a staged procedure. First, the debridement was performed under the endoscope. The dead bone was removed, broken teeth were extracted, and necrotic tissue was cleaned. The exposed wounds were cleaned, and dressing was changed daily until the exudation was widely reduced. Then, a 50-mL expander was placed in the left cheek, and an 80-mL expander was put in the scalp just before the defect in the temple area. Five months later, expander inflation was accomplished. Expanders were taken out and expanded flaps were transposed to cover the defect. At the same time, an anterolateral thigh flap was harvested to repair the inner lining of the cheek and the gingiva. Thereafter, several operations were performed to revise the wound scar and the remaining deformity. Both defects in the temple and left cheek were restored with a satisfactory functional and aesthetic outcome. The temporal area was repaired with haired expanded scalp, whereas the face was repaired with an expanded facial flap with similar texture and color. The oral commissure regained balance and integrity. The defect of the gingiva was repaired. A severe penetrating wound in the cranium and face can be nicely repaired using tissue expander and microvascular reconstruction.

Application of Tissue Expansion with Perforator Flaps for Reconstruction of Challenging Skin Lesions.

BACKGROUND: One set of perforators can supply its own perforasome as well as the adjacent perforasome. The process of tissue expansion can mimic the effect of surgical delay to include more perforasomes into the perforator flap. By combining the perforasome theory with the technique of tissue expansion, large and various expanded perforator flaps can be achieved. METHODS: From July 2007 to July 2014, we performed eight different types of expanded perforator flaps in a total of 83 cases: 41 supraclavicular artery perforator flaps, 11 superficial cervical artery perforator flaps, 15 lateral thoracic perforator flaps, 6 internal mammary artery perforator flaps, 6 thoracoabdominal perforator flaps, 2 facial artery perforator flaps, 1 posterior interosseous perforator flap, and 1 ulnar collateral artery perforator flap. During the follow-up period, the survival rate, color, texture, and retraction of the flaps were assessed. RESULTS: The dimensions of the flaps ranged from 8 × 6 to 25 × 25 cm. Minor flap necrosis occurred in 20.5% of the cases, and severe flap necrosis developed in 2.4% of the cases. The donor sites were closed primarily in all but three cases. During the follow-up period (average, 13 months; range, 8-18 months), no flap contracture was observed with a good color and texture match. CONCLUSION: By combining the concept of perforasome with the technique of tissue expansion, flaps with large dimensions and reliable blood supply can be achieved, allowing a more flexible design to reconstruct various and challenging skin lesions.

Application of Indocyanine Green in Flap Surgery: A Systematic Review.

BACKGROUND: The vascularization of the distal portions of transferred tissue represents the most critical factor in the success of reconstructive surgery. In recent years, indocyanine green (ICG) fluorescence imaging techniques have been applied during surgery to evaluate flap perfusion. However, this investigation has found that there is little consensus regarding the standard dose of ICG as well as the pre-operative requirements of ICG allergy testing. The aim of this study is to summarize the applications of ICG to tissue transfers and safe dosing practices and to provide insight to the possible adverse effects of ICG on flap surgery with the goal of helping clinicians apply ICG safely and efficiently to tissue transfer procedures. METHODS: A literature search was performed using, Wiley InterScience, and Springer with the key words, 'Flap,' 'indocyanine green,' 'surgery,' and related mesh words for all publications between 2005 and 2015. Title and abstract screening was performed using predefined in- and exclusion criteria. RESULTS: Seventy-three articles were included. These were classified as "application of ICG in flap surgery" and "the security of applying ICG in flap surgery". CONCLUSIONS: ICG fluorescence imaging preoperatively facilitates the detection of perforators in tissue flaps with thickness <20 mm, aids in the evaluation of flap microcirculation and perfusion, and allows surgeons to select dominant cutaneous nerves while evaluating the quality of vascular anastomoses and locating thromboses. The literature also concluded that potential allergic reactions to ICG should be taken into consideration.

The Modified Z-Epicanthoplasty-A Stepwise and Individualized Design.

PURPOSE: To describe a medial epicanthoplasty technique using a stepwise, customized design and to review the outcome in Asian patients after the treatment of medial epicanthal fold. DESIGN: Retrospective, noncomparative and interventional case series with the introduction of a new surgical technique. PARTICIPANTS: Forty-eight consecutive Asian patients with primary medial epicanthal fold. METHODS: Patient charts were reviewed from patients (mean age, 24.6 ± 3.8 years; range, 19-40 years) with a stepwise z-epicanthoplasty. The intercanthal distance (ICD), interpupillary distance (IPD), and scar visibility were evaluated at regular intervals (preoperative, immediate postoperative, 3 months, 6 months, and 1 year after the operation). The ratio of the ICD to IPD (ICD ratio) was calculated, and the visibility of the surgical scar assessed. MAIN OUTCOME MEASURES: Postoperative improvement in ICD ratio and scar quality. RESULTS: The preoperative median ICD ratio was 0.60 (range, 0.57-0.66) and decreased to 0.57 (range, 0.52-0.60) postoperatively. The median ICD ratio reduction was 5.6% (range, 2.6-14.1%; P < 0.001, Wilcoxon signed-rank test). Forty patients (83.3%) had no visible scarring or scarring only visible under close inspection. Eight patients (16.7%) experienced a more apparent scar, but none of them developed a severe scar requiring revision. CONCLUSIONS: The modified z-epicanthoplasty using a stepwise design is a customized and effective technique for the treatment of the epicanthal fold. This method has a short learning curve, is widely applicable to various types of epicanthal fold, and has a high satisfaction rate with a stable long-term result.

Stepwise, Multi-Incisional, and Single-Stage Approach to Reshape Facial Contour After Large Cutaneous Lesion Resection.

BACKGROUND: Removal of large facial benign cutaneous lesions remains challenging. Serial or complete excisions together with local flaps or expander-based reconstructions are required. However, those techniques are time-consuming and may contribute to poor cosmetic and functional outcomes. OBJECTIVE: The authors describe the resection and reconstruction of large facial benign cutaneous lesions by using Stepwise, Multi-Incisional, and Single-Stage (SMISS) approach. METHODS: The authors performed a retrospective review from all patients with large facial benign cutaneous lesions who underwent "SMISS" approach for reconstruction between September 2013 and December 2014. RESULTS: The authors treated 47 patients (32 female and 15 male; mean age 23.5 years, range 9-50 years). Follow-up was for 12 months or longer. The mean length of major axis was 43.91 mm, minor axis 32.10 mm, and scar 66.91 mm. Good to excellent outcomes were achieved in all patients with a mean Vancouver scar scale score of 3.46 ±â€Š0.39 (Cronbach α = 0.890) and mean visual analog scale score of 8.02 ±â€Š0.69 (Cronbach α = 0.946). LIMITATIONS: This was a nonrandomized, unblinded clinical case series with a limited sample size. CONCLUSION: For the excision and reconstruction of large facial benign cutaneous lesions, "SMISS" technique can be considered as a suitable option, leading to excellent results and a high patient satisfaction.

Microsurgical Replantation of Total Avulsed Scalp: Extending the Limits.

BACKGROUND: Avulsion of the scalp is a rare but severe trauma and challenging to the reconstructive surgeon. It poses not only physical concussion but also significant persisting psychological distress to the patients. METHODS: Medical records from 5 patients who suffered scalp avulsion were reviewed retrospectively. The following data and methods were assessed: age, number of vessels repaired, method of replantation, vein grafts required, blood transfusion, ischemia time, total operating time, and percentage of scalp survival. RESULTS: In 4 patients, the replantation was performed at the anatomic site. Two arteries and 2 veins were anastomosed in 2 patients; a single artery and a single vein were anastomosed in 2 patients. The middle temporal vein was chosen for anastomosis as a recipient vessel in 2 patients. In the fifth patient with simultaneous cervical fracture that makes primarily replantation technically not possible, the scalp was implanted ectopically in the forearm for the purpose of secondary replantation at the anatomic site. After a mean follow-up of 22.6 months (range 13-29 months), 4 of 5 patients exhibited successful survival of the replanted scalp. CONCLUSIONS: The success of scalp replantation is determined by a comprehensive management of the trauma and well-trained microsurgical technique. The middle temporal vein can be used as a reliable alternative recipient vessel for microvascular anastomosis when replanting the avulsed scalp. In patients in whom primary replantation is not possible, temporary ectopic implantation of the avulsed scalp and anatomic replantation at a second stage is considerable.

Modified S-Flap for Nipple Reconstruction.

BACKGROUND: Nipple reconstruction is an important last step in the process of autologous or implant-based breast reconstruction. A multitude of techniques have been described, among others the S-flap. To prevent nipple retraction after surgery, we modified the originally described method by Cronin. METHODS: By adding an S-shaped incision line, the flap can be transposed with less tension and sutured on top of the new nipple along a curved line. Furthermore, two small triangular flaps were inserted at the base for reinforcement and reduced linear contraction. Assessment was completed by measuring nipple diameter and projection with a caliper. RESULTS: A total of 16 patients underwent the technique, of whom 11 could be followed after 3 and 6 months. Overall patient satisfaction with the aesthetic result was high, and we observed no infection or necrosis. Nipples were stable in size and shape at 6 months. Although reduction of 68% in projection and 31% in diameter was observed, the nipples remained pleasantly similar to the contralateral non-operated side. CONCLUSIONS: The modified S-flap is a simple and reliable technique for moderate-sized nipple reconstruction. By providing more tissue at the base, size and projection remain stable and durable. Moreover, by a modified linear incision line at the base, tension and subsequent scar contraction is minimal. 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 .

Evaluation of the Neo-umbilicus Cutaneous Sensitivity Following Abdominoplasty.

BACKGROUND: Abdominal cutaneous sensitivity loss after abdominoplasty is an undesirable outcome. However, little is known in the literature about sensitivity changes of the neo-umbilicus after abdominoplasty. The aim of this study was to evaluate post-abdominoplasty cutaneous sensitivity of the neo-umbilicus using clinical, quantitative, and reproducible methods. METHODS: Patients who underwent abdominoplasty were included, whereas the control group consisted of healthy volunteers with similar demographic characteristics but who did not undergo abdominoplasty. The umbilicus was divided into five zones, and superficial tactile sensitivity and spatial orientation were assessed subjectively (score 1-4) and objectively (Semmes-Weinstein monofilament examination). RESULTS: Twenty patients (45 ± 12 years) operated on consecutively between April 2012 and May 2016 and 14 healthy volunteers in the control group (39 ± 9 years) could be included. Although there were statistically significant differences (p = 0.0005) in the average cutaneous pressure thresholds between the control group (0.4 g/mm2, range 0.07-2 g/mm2) and the study group (0.4 g/mm2, range 0.07-4 g/mm2), patient satisfaction after a mean follow-up of 33 ± 16 months (range 10-62 months) was acceptable (mean satisfaction score 1.8 ± 0.7). Furthermore, spatial perceptions were precise in all patients and similar to the control group. CONCLUSION: Our long-term results indicate that spontaneous reinnervation of the neo-umbilicus after abdominoplasty together with accurate spatial orientation can occur. 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 .

Gluteal Augmentation Techniques: A Comprehensive Literature Review.

Background: Many studies of gluteal augmentation techniques have been published in recent decades, including case reports, retrospective and prospective case series, and multicenter survey reviews. However, to date, there has been no study of the overall complications or satisfaction rates associated with the broad spectrum of techniques. Objectives: The authors performed a comprehensive literature review to determine outcomes and complications of gluteoplasty techniques, including patient satisfaction. Methods: A search on PubMed/Medline was performed for clinical studies involving gluteal augmentation techniques. A priori criteria were used to review the resulting articles. Results: Fifty-two studies, published from 1969 through 2015, were included - representing 7834 treated patients. Five gluteal augmentation techniques were identified from these studies: gluteal augmentation with implants (n = 4781), autologous fat grafting (n = 2609), local flaps (n = 369), hyaluronic acid gel injection (n = 69), and local tissue rearrangement (n = 6). The overall complication rates of the most commonly utilized techniques were: 30.5% for gluteal augmentation with implants, 10.5% for autologous fat grafting, and 22% for local flaps. Patients' satisfaction was reported as consistently high for all the five techniques. Conclusions: Implant-based gluteal augmentation is associated with high patients' satisfaction despite a high complication rate, while autologous fat grafting is associated with the lowest complication rate yet including serious major complications such as fat embolism. Local flaps and local tissue rearrangements are the ideal procedures in case of massive weight loss patients. A paucity of data is available for hyaluronic acid gel injections, which appear to be effective but temporary and expensive.

Nipple Reconstruction After Autologous or Expander Breast Reconstruction: A Multimodal and 3-Dimensional Analysis.

BACKGROUND: Little is known about the influence of the underlying tissue as donor for nipple-areola complex (NAC) reconstruction. Also, there is a complete lack of knowledge about the fate of nipple volume. OBJECTIVES: The goal of this retrospective, single-institution study was to analyze a case series after nipple reconstruction using a multimodal evaluation including 3-dimensional (3D) laser scanner analyses. METHODS: Unilateral mastectomy patients after either expander-based or autologous breast reconstruction using the skate flap were included. NAC caliper measurement of nipple and areola size was performed. 3D laser scanner analysis (Minolta Vivid 900) was used to calculate nipple volume, measurement of nipple, and areolar projection and diameter. Sensitivity was evaluated using the Semmes Weinstein test and patient satisfaction by a visual analog scale (VAS 1-10). RESULTS: A total of 10 patients were included in the expander group and 12 patients were included in the flap group. After a median follow-up period of 32 months in the expander group and 34 months in the flap group, non-contact 3D laser surface scanning revealed a difference in projection of 55 to 60% compared to the contralateral side. The contraction in all 3 dimensions led to a dramatic difference in nipple volume with 12 ± 8% (flap reconstructions) and 12 ± 7% (expander reconstructions). Sensitivity of the areola showed better values after expander-based reconstruction. Despite the significant discrepancy in nipple volume and projection as well as areolar diameter, overall patient satisfaction was acceptable (VAS 4.1 ± 3.5). CONCLUSIONS: Volume assessment revealed a massive asymmetry to the intact nipple but not between expander and flap reconstructions. Although asymmetry of the areola and nipple remains, patient satisfaction is acceptable. LEVEL OF EVIDENCE 4.

Adipose-Derived Stromal Cells from Lipomas: Isolation, Characterisation and Review of the Literature.

OBJECTIVE: The aim of this study was to characterize adipose-derived stromal cells (ADSCs) from patients diagnosed with multiple symmetric lipomatosis (MSL) in order to obtain potentially new insights into the pathophysiology, pathogenesis and treatment of this disease. METHODS: Cells from the stromal vascular fraction were analysed by the colony-forming efficiency assay and flow cytometry using standard markers. Moreover, the power of adipogenic plasticity was evaluated. Finally, a literature review was performed from 1982 to 2015 using the US National Institutes of Health's PubMed database. RESULTS: Three European-descent patients diagnosed with either MSL type I or II could be identified for analysis. The resulting mean colony-forming efficiency assay was 14.3 ± 5%. Flow-cytometric analysis of the ADSCs revealed high levels of CD34 (70 ± 9%), CD45 (37 ± 13%) and CD73 (55.8 ± 14%), whereas low levels of CD31 (16.8 ± 14%) and CD105 (5.8 ± 0.7%) were detected. Furthermore, ADSCs showed a strong adipogenic potential, which is in line with the literature review. The stem cell pool in lipoma shows several alterations in biological activities, such as proliferation, apoptosis and stemness. CONCLUSIONS: ADSCs from lipoma may be interesting in the application of regenerative medicine. We discuss possible molecular treatment options to regulate their activities at the source of the MSL.