Negative Pressure Wound Therapy in Free Muscle Flaps-Risk or Benefit?

BACKGROUND: Application of negative pressure wound therapy (NPWT) on free flaps not only reduces edema but also increases the pressure from outside. The impact of these opposite effects on flap perfusion remains elusive. This study evaluates the NPWT system's influence on macro- and microcirculation of free flaps and edema reduction to better assess the clinical value of this therapy in microsurgical reconstructions. METHODS: In this open-label, prospective cohort study, a total of 26 patients with free gracilis muscle flaps for distal lower extremity reconstruction were included. Flaps were covered with an NPWT (13 patients) or a conventional, fatty gauze dressing (13 patients) for 5 postoperative days (PODs). Changes in flap perfusion were analyzed by laser Doppler flowmetry, remission spectroscopy, and an implanted Doppler probe. Flap volume as a surrogate parameter for flap edema was evaluated by three-dimensional (3D) scans. RESULTS: No flap showed clinical evidence of circulatory disturbances. The groups showed significant differences in the dynamic of macrocirculatory blood flow velocity with an increase in the NPWT group and a decelerated flow in the control group from PODs 0 to 3 and PODs 3 to 5. No significant differences in microcirculation parameters were observed. 3D scans for estimation of edema development demonstrated significant differences in volume dynamics between the groups. Flap volume of the controls increased, while the volume in the NPWT group decreased during the first 5 PODs. The volume of NPWT-treated flaps decreased even further after NPWT removal from PODs 5 to 14 and significantly more than the flap volume in the control group. CONCLUSION: NPWT is a safe form of dressing for free muscle flaps that enhances blood flow and results in a sustainable edema reduction. The use of NPWT dressings for free flaps should therefore be considered not only as a pure wound covering but also as a supportive therapy for free tissue transfer.

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.

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.

Impact of Intraoperative Hypothermia on Microsurgical Free Flap Reconstructions.

BACKGROUND: Patients requiring microsurgical defect reconstruction are highly susceptible to intraoperative hypothermia, given oftentimes long operative times and exposure of large skin surface areas. While the impact of hypothermia has been extensively studied across various surgical fields, its role in the setting of microsurgical free flap reconstruction remains elusive. This study evaluates the effects of hypothermia on outcomes of free flap reconstructions. METHODS: Within 7 years, 602 patients underwent 668 microvascular free flap reconstructions. The cases were divided into two groups regarding the minimal core body temperature during free flap surgery: hypothermia (HT; < 36.0°C) versus normothermia (NT; ≥36.0°C). The data were retrospectively screened for patients' demographics, perioperative details, flap survival, surgical complications, and outcomes. RESULTS: Our data revealed no significant difference with regard to the rate of major and minor surgical complications, or the rate of revision surgery between both groups (p > 0.05). However, patients in the HT group showed significantly higher rates of total flap loss (6.6% [HT] vs. 3.0% [NT], p < 0.05) and arterial thrombosis (4.6% [HT] vs. 1.9% [NT], p < 0.05). This translated into a significantly longer hospitalization of patients with reduced core body temperature (HT: mean 16.8 days vs. NT: mean 15.1 days; p < 0.05). CONCLUSION: Hypothermia increases the risk for arterial thrombosis and total flap loss. While free flap transfer is feasible also in hypothermic patients, surgeons' awareness of core body temperature should increase. Taken together, we suggest that the mean intraoperative minimum temperature should range between 36 and 36.5°C during free flap surgery as a pragmatic guideline.

Experimental Studies of Latissimus Dorsi Detrusor Myoplasty for Bladder Acontractility: A Systematic Review.

Current therapies that allow patients with bladder acontractility to void are limited. The standard therapy is clean intermittent catheterization. Latissimus dorsi detrusor myoplasty (LDDM) has been shown to provide functional contraction and allow patients with bladder acontractility to void voluntarily. Our goal was to summarize experimental studies of LDDM. We hypothesized that experimental studies would show that latissimus dorsi muscle (LDM) flaps for detrusor myoplasty have superior outcomes when compared with other types of flaps. On January 17, 2020, we conducted a systematic review of the PubMed/MEDLINE, Cochrane Clinical Answers, Cochrane Central Register of Controlled Trials, and EMBASE databases, without time frame limitations, to identify articles on the use of LDDM. We excluded studies that investigated other treatments. Of 54 articles identified by the search, three fulfilled the eligibility criteria. A total of 24 dogs underwent procedures and were evaluated with a maximum follow-up of 9 months. Three types of procedures were performed: LDM in situ reconfiguration, LDM myoplasty, and augmentation cystoplasty after supratrigonal cystectomy. Electrical stimulation, cystography, urodynamic and hydrodynamic measurements, and microscopic examinations were performed. Innervated LDM flaps transferred to the bladder were able to contract and promote voiding in response to electrical stimulation. Experimental studies have shown the feasibility of LDDM in canine models. Although no comparison groups were included, innervated LDM flap transferred to the bladder showed promising results regarding contraction capable of voiding.

Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions.

BACKGROUND: Whether to perform an end-to-end (ETE) versus end-to-side (ETS) arterial anastomosis is an integral part of preoperative planning and intraoperative decision making in free flap-based reconstructions. This study evaluated the impact of microsurgical anastomotic technique on outcomes of lower extremity reconstructions, with a focus on patients with peripheral arterial disease (PAD). METHODS: Over a 6-year period, 425 patients underwent 437 microvascular lower extremity free flap reconstructions with fasciocutaneous anterolateral thigh- or gracilis muscle flaps at a single surgical center. The cases were divided into an ETE (n = 297 patients) versus ETS (n = 128 patients) group according to the anastomotic technique. A retrospective analysis of patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and the potential impact of PAD on outcomes was performed. Patient groups were comparable regarding comorbidities, American Society of Anesthesiologists scores, types of performed free flaps and recipient sites. RESULTS: We found no significant differences between the ETE versus ETS groups regarding the rate of major or minor complications (p > 0.05). Specifically, in patients suffering from PAD (n = 64) the type of arterial anastomosis had no effect on the outcome. CONCLUSION: Overall, no significant differences in outcomes were observed when comparing the types of performed arterial anastomosis. This observation also held true for the subgroup of patients with PAD. Given that an ETS anastomosis did not increase the risk to encounter complications while preserving distal perfusion, we believe that this technique is the method of choice, especially in patients with impaired vascular status.

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.

The spreaded gracilis flap revisited: Comparing outcomes in lower limb reconstruction.

BACKGROUND: In lower limb reconstruction, the free gracilis muscle flap is usually chosen for coverage of small- to medium-sized defects. Aim of this study was a re-appraisal regarding the reconstructive indications of the gracilis muscle flap with a focus on postoperative complications in order to evaluate if it can also be routinely used to reconstruct large-size lower limb defects. METHODS: A total of 204 patients underwent free gracilis muscle transfers for lower limb reconstruction at our institution. Cases were divided according to the size of the defect into two groups (<150 cm2 versus ≥150 cm2 ). The small- to medium defect size group included 150 patients and the large defect size group included 54 patients. In the large defect size group, the muscle was enlarged as needed by careful dissection of the epimysium and all connective tissue surrounding the intrinsic vessels under loupe magnification to protect the muscle perfusion. Surgical complications were accounted for and the two groups compared accordingly. RESULTS: Overall, there were no significant differences between the two groups of patients regarding the rate of major (15.72% versus 10.91%; P = .506) and minor surgical complications (6.92% versus 3.64%; P = .522). The total percentage of flap losses in the small to medium defect size group was 5.03%. There were no total flap losses in the large defect size group (P = .117). CONCLUSION: The use of the spreaded gracilis flap provides a valuable option for the microsurgeon, especially also to reconstruct large size lower limb defects.

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.

Microsurgical Forehead Reconstruction.

Reconstruction of the forehead remains challenging. Especially in cases of large or even complete forehead defects, local flaps and skin grafting may not be an option, necessitating free flap coverage. The aim of this retrospective case series was to develop an algorithmic surgical approach as well as to evaluate surgical and aesthetic outcomes of microvascular-based forehead reconstructions, using gracilis muscle or anterolateral thigh flaps in 15 cases. The mean size of the defects was 84.6 (range: 25-160, ±44.1) cm, all with significant area of bone exposure. The free flap reconstructions included 7 gracilis muscle flaps, covered with 1.2-mm-thick unmeshed split-thickness skin grafts, and 8 anterolateral thigh flaps with a mean size of the free flaps of 160 (range: 56-300, ±78.6) cm. In all patients, wound healing at the donor site was uneventful. Minor complications occurred in 3 patients and required small revision procedures. This case series demonstrates that microsurgical reconstruction of multiple entities of forehead defects poses a reliable method, especially in large and complex defects. In our opinion, given low risks for major complications and superior aesthetic results, the gracilis muscle flap covered with unmeshed split-thickness skin graft is ideally suited to reconstruct the forehead and should be one of first choices.

Less Is More? Impact of Single Venous Anastomosis on the Intrinsic Transit Time of Free Flaps.

Background The number of venous anastomoses advisable for a free flap continues to be controversial. Intrinsic transit time (ITT) is the time it takes dye during indocyanine green (ICG) microangiography to travel from the arterial to the venous anastomosis. ITT provides information on blood flow velocity and can predict postoperative circulatory complications. This study investigated the effect of the number of venous anastomoses on ITT. Methods The study enrolled 126 patients who had undergone microsurgical reconstruction and intraoperative ICG microangiography. Selection was limited to free gracilis and anterolateral thigh flaps as flaps with a single venous system. The retrospective assessment included reconstruction characteristics of the flaps, clinical outcome, ITT, and the number of venous anastomoses. Results The two groups were homogenous in terms of reconstruction characteristics. The single-venous anastomosis group (n = 75) had a reduced ITT (23.6 ± 11.7 vs. 43.8 ± 23.7 seconds; p < 0.001) compared with the double-anastomosis group (n = 51). A shorter ITT resulted in a significant reduction in the risk of reexploration for anastomotic thrombosis (OR 0.96; p = 0.024). Despite this, a higher reexploration rate tended to occur in the single-venous anastomosis group (9.3 vs. 7.8%; p = 1.0). Conclusion The results highlight the effect of shortening the ITT (thromboprotective blood flow acceleration) by using only one venous anastomosis. However, if the ITT is already at a low enough level with two veins, restriction to one vein does not appear to result in a reduced reexploration rate. For these flaps, the advantages of double-venous anastomosis prevail in terms of a backup drainage.

Perfusion Controlled Mobilization after Lower Extremity Free Flaps-Pushing the Limits of Time and Intensity.

Background The current standard to gradually adapt the fragile perfusion in lower extremity free flaps to an upright posture is the dangling maneuver. This type of flap training neither fits the orthostatic target load of an upright posture, nor does it assist in mobilizing the patients effectively. In this study, we quantitatively analyzed training effects of an early and full mobilization on flap perfusion. Methods A total of 15 patients with gracilis flaps for distal lower extremity reconstruction were included. Flap training was performed daily by mobilizing the patients on a tilt table into a fully upright posture for 5 minutes between the third and fifth postop days (PODs). Changes in micro- and macrocirculation were analyzed by laser Doppler flowmetry, remission spectroscopy, and an implanted Doppler probe. Results All flaps healed without complications. Yet, in three patients, the increased orthostatic load required an adjustment of the training duration due to a critical blood flow. The others showed an increasing compensation in the microcirculation. When tilting the patients, blood flow and oxygen saturation dropped significantly less on POD5 than on POD3. Furthermore, a significant increase of the blood flow was noted after an initial decrease during the mobilization on all days. An increasing compensation in the macrocirculation could not be determined. Conclusion Full mobilization of patients with lower extremity free flaps can be performed safely under perfusion monitoring, already starting on POD3. Additionally, monitoring allows a consideration of the individual orthostatic competence and therefore, exploitation of the maximum mobilization potential.

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.