The utility of the internal bra for breast support, reconstruction, and in revision breast surgery has been recognized and various materials have been introduced for this application. As clinical experience has grown and new products have been developed, the roles of these materials are becoming better defined. This paper reviews the use of the internal bra concept to date.

Aim: To examine the impact of underweight body mass index (BMI) values on breast reconstruction outcomes.

Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed for all patients who underwent breast reconstruction between 2006 and 2011. Patients were first stratified by breast reconstruction modality into prosthetic or autologous cohorts, and second by BMI values into underweight (BMI < 18.5), normal to overweight (reference, BMI 18.5-29.99), moderate obesity (BMI 30-34.99), severe obesity (BMI 35-39.99), and morbid obesity cohorts. Multivariate logistic regression models were used to determine independent predictors of complications.

Results: With regard to prosthetic breast reconstruction patients, obese patients demonstrated increased rates of surgical complications, while underweight patients did not have any differences on multivariable analysis. With respect to autologous reconstruction, risk-adjusted multivariate regression models showed a dose dependent response between obesity and risk for surgical complications and reoperation, but not for underweight patients.

Conclusion: On multivariable analysis of over 4,600 patients, there were no significant differences in the rates of adverse events between underweight patients (BMI < 18.5) and their reference-weight counterparts, in spite of a significant increase in surgical and medical complication rates in underweight patients on univariate analysis.

Aim: Breast augmentation has traditionally been performed in either the subglandular or submuscular plane. Dual plane augmentation has been described before and captures the advantages of both of these techniques but reduces the trade-offs. The biplane muscle splitting technique adopts the similar advantages seen with the dual plane method without the need for extensive costal muscle fibre release at the infra-mammary fold.

Methods: Thirty-five patients underwent bilateral breast augmentation using the biplanar technique from November 2007 to December 2008. All operations were performed by the senior author and followed up prospectively.

Results: Follow up ranged from 9 months to 21 months. All of the patients achieved precise and reliable implant placement with no revisions or patient dissatisfaction. There have been no cases of implant misplacement/migration; synmastia, dynamic breast deformity, capsular contracture or infections. A single case of unilateral haematoma occurred early in the series.

Conclusion: Our operative cases and early follow-up supports the use of this novel biplanar technique for breast augmentation. It optimizes the advantages of subglandular and submuscular breast augmentation with simpler dissection and less complications than other submuscular techniques. It can be used in a wide variety of breast types with predictable results.

Aim: Simultaneous or single stage mastopexy with augmentation is challenging, unique and commonly performed by a plastic surgeon. In this procedure pocket for implant placement, marking for envelope reduction and type of implants used can affect the outcome of the procedure. Muscle splitting pocket for mastopexy is a plane described by the author for implant placement with a short term follow up. The use and outcome of the technique is presented with a larger series and a long term follows up to evaluate the efficacy of the procedure.

Methods: Retrospective data was collected. Augmentation was performed using muscle splitting technique and periareolar, vertical scar and wise pattern were used for skin reduction and mastopexy. A single surgeon performed all procedures.

Results: In total 108 patients mastopexy with augmentation in muscle splitting technique. The mean age of the patient was 32.2 years (range: 18-67 years) with an average follow up of 4.5 years (range: 3 months to 10 years). All patients had round textured cohesive gel silicone implants with a mean size of 308 cc (range: 200-555 cc). Wound infection was seen in 4 (3.7%), wound breakdown in 7 (6.5%) patients. Drains were used in 25 (23.1%). All patients were treated as day cases and revision surgery was performed in 12 (11.1%). There was no hematoma, deep venous thrombosis (DVT) or nipple areolar complex in the series.

Conclusion: Simultaneous augmentation mastopexy in muscle splitting pocket can be performed with good aesthetic results along with an acceptable revision rate.

Aim: Simultaneous augmentation mastopexy is a challenging operation for esthetic plastic surgeons. Complication and revision rates following augmentation mammoplasty or mastopexy are less commonly seen when these two procedures are performed separately. However, when the two procedures are combined, the complication rate is reported exponentially higher when compared with its individual component carried out separately. The current retrospective chart review is a comparative analysis of the two procedures performed by a single surgeon.

Methods: Retrospective data were collected using patient’s charts. All patients who had augmentation mammoplasty (Group A) or simultaneous augmentation with mastopexy (Group B) in muscle splitting biplane using round cohesive gel textured silicone implants by a single surgeon were included.

Results: A total of 1,406 patients had consecutive augmentation mammoplasty or simultaneous augmentation mastopexy. Augmentation mammoplasty (Group A) included 1,298 and simultaneous augmentation with mastopexy (Group B) had 108 patients, respectively. The mean age of the patients in Group A and B was 29.6 years and 32.2 years, respectively (P = 0.006). The mean size of the implants in Group A and B was 340 mL and 308 mL (P = 0.001), respectively. Wound infection in Group A and B was seen in 0.6% and 3.7%, respectively. Wound breakdown was seen in 1.1% in Group A as compared to 6.5% in Group B (P = 0.001). Revision surgeries were performed in 1.4% and 11.1% of Group A and B, respectively (P = 0.001).

Conclusion: There was a statistically and clinically significant higher rate of complications and revision rate noted in simultaneous augmentation with mastopexy (Group B) as compared to augmentation mammoplasty alone (Group A). However, the rise in complications rate is sum of the complications of the two individual components performed and not exponential.

Aim: Autoinflation of the breast following mammoplasty using breast implants can be divided into early and late. Early autoinflation of the breast is commonly due to haematoma. Late autoinflation of the breast is an uncommon complication and its true incidence is not known due to the paucity of its reporting.

Methods: A retrospective review was performed of the available charts for 2,772 consecutive bilateral primary, secondary augmentation mammoplasties and mastopexy with augmentation mammoplasties by the author between April 1999 and February 2015. Each breast was taken as a single unit for a total of 5,544 breasts.

Results: There were 2,334 patients in primary augmentation mammoplasty, 258 in secondary augmentation mammoplasty and 180 in simultaneous mastopexy with augmentation mammoplasty. There were three autoinflation of breasts due to late seromas identified in the series. All patients presented at least six months following augmentation mammoplasty and all had textured implants place in muscle splitting submuscular pocket. There was no late seroma noted in secondary augmentation mammoplasty or simultaneous mastopexy with augmentation mammoplasty. All patients were treated conservatively without a recurrence.

Conclusion: Late autoinflation of the breast due to seroma is an uncommon clinical complication and can be treated conservatively in the first instance.

Aim: The differentiation of hair follicle stem cells (HFSCs) into hair follicle cells has potential clinical applications for cutaneous burns. However, the mechanisms regulating the differentiation of HFSCs into hair follicular papilla or epidermal cells are currently not clear. This study investigated the role of the Wnt/β-catenin pathway and its crosstalk with other signaling components during this differentiation process.

Methods: Lithium chloride (LiCl, 10 mmol/L) and keratinocyte growth factor (KGF, 10 µg/L) were used to induce HFSC differentiation, validated by immunofluorescence analysis. The mRNA expression of β-catenin, adenomatous polyposis coli, glycogen synthase kinase-3β (GSK-3β), axin, and lymphoid enhancer factor-1 after 3, 5, 7, and 9 days were measured to evaluate the role of the Wnt/β-catenin pathway.

Results: During LiCl-induced HFSC differentiation into hair follicle cells, the Wnt/β-catenin signaling pathway was activated and the expression of GSK-3β, a vital component of the degradation compound, was inhibited. This led to increased cytoplasmic β-catenin expression, nuclear translocation, and subsequent target gene transcription. By contrast, KGF induced the differentiation of HFSCs into epidermal cells and did not affect the expression of β-catenin. This data indicates that LiCl and KGF distinctly regulate the differentiation of HFSCs into hair follicle and epidermal cells, respectively. Furthermore, the Wnt/β-catenin signaling pathway is predominantly involved in hair follicle differentiation.

Conclusion: these results demonstrate that LiCl can be used to differentiate HFSCs into hair follicle cells in vitro, which has important therapeutic applications for treating patients with cutaneous damage.

Aim: Reconstruction of the anterior skull base offers an especially complex challenge as the impermeable separation of the dural space and the upper aerodigestive tract must be maintained. We propose the use of the radial forearm free flaps (RFFF) as a superb method of re-establishing integrity in anterior skull base defects.

Methods: Literature review and retrospective analysis of 4 single-institution cases of anterior skull base defects reconstructed with a RFFF. Data were collected on successful and unsuccessful defect repairs, complication rates, and length of hospitalization.

Results: The indications for surgery were pneumocephalus, recurrent brain abscesses, recurrent frontal sinus mucoceles, and cerebrospinal fluid leak. Of the 4 cases, 1 was complicated by a small dehiscence of the craniotomy site, 1 developed infection, and 2 required further surgery.

Conclusion: The use of RFFF is an excellent option for reconstruction of defects in the anterior skull base, especially those complicated by radiation, prior surgery, or infections. Patients with skull base defects are inherently at high risk for post-surgical complications. The RFFF transfers healthy, viable, well-vascularized tissue to prevent further infections and provides a reliable barrier between the dural and sinonasal spaces. This can reduce the need for repeat neurosurgical operations and hospitalizations.

Aim: Anterolateral thigh (ALT) flap is widely used in reconstruction of various defects. Preoperative imaging facilitates perforator mapping, overcoming intraoperative uncertainty. The purpose of this study was to investigate the utility of multi-detector row computed tomography angiography (MDCTA) and a handheld Doppler in locating ALT perforators.

Methods: Twenty patients were randomized into two groups. Group 1 patients received MDCTA and Doppler studies whereas Group 2 received only a Doppler study. The number, location, course, and source of all cutaneous and sizable perforators were compared with intraoperative findings. Surgeons’ stress levels during flap harvest and flap harvest time were compared.

Results: MDCTA findings correlated well with intraoperative findings for perforator type and segmental distribution with 100% concordance. Doppler alone had a 52% rate of concordance. The sensitivity and specificity for MDCTA in demonstrating the presence of perforators were 85.71% and 97.22%, respectively; whereas for Doppler alone the sensitivity and specificity were 80% and 87.91%, respectively. In demonstrating perforator source, MDCTA showed a sensitivity of 100% and specificity of 91.66%, with 100% accuracy. Sensitivity and specificity for sizable perforators were 90% each, with 88.88% accuracy. Doppler studies were unable to provide this information. Comparison of surgeon stress levels showed no differences between the two groups, although the time for flap harvest was significantly shorter in Group 1.

Conclusion: MDCTA compared to Doppler is more sensitive, specific, and accurate with respect to location, course, and source of perforators.

Aim: Snakebite injuries of the extremities are common in tropical India among those involved in farming and outdoor activities. These injuries often complicated by cellulitis, gangrene, regional lymphadenopathy, compartment syndrome, bleeding abnormalities, septicemia, hypotension, and disseminated intravascular coagulation, resulting in significant morbidity and mortality. The purpose of the study is to share our experience of hyperbaric oxygen (HBO) therapy in the management of snakebite injuries.

Methods: All patients who were treated for snakebite injuries in our department between October 2012 and October 2013 were included in the study.

Results: Out of a total 395 patients, 174 patients treated with anti-snake venom with a mortality of 17 posttreatment. Forty-four out of the 174 patients was in the pediatric age group. Out of the patients referred to our department, 23 presented with cellulitis, 7 with compartment syndrome and 17 for the management of soft tissue cover over the extremities. Of the 47 patients, 30 involved the lower extremity and rest involved the upper extremity. All patients were subjected to HBO therapy as an adjunct. Six patients required flap cover: cross finger flap (n = 2), anterolateral thigh free tissue transfer (n = 1), lateral supramalleolar flap (n = 1), groin flap (n = 1), and dorsal metacarpal artery flap (n = 1). There was no need for fasciotomy among the patients who suffered impending compartment syndrome.

Conclusion: HBO therapy may reduce the incidence of fasciotomy and increase the effectiveness of plastic surgical modalities if administered early and may be used as a useful adjunct in the management of snake envenomation injury.

Aim: Penoscrotal defects may be caused by a variety of events. Reconstruction of the penoscrotal region is required not only for aesthetic appearance but also for functional and psychological reasons. Numerous techniques have been described for penoscrotal reconstruction reflecting the challenge and complexity of the region involved. This suggests that no single method is satisfactory for all types and degrees of tissue defects. This prospective study was conducted in a tertiary care hospital in India, over a period of 5 years.

Methods: Eighteen patients with penoscrotal defects of varying etiology were included in the study and underwent different surgical techniques. Age of the patients ranged from 20 to 60 years. The etiology of penoscrotal defect was Fournier’s gangrene in 12 cases, trauma in 4 cases, and burn in 2 cases. The patients with Fournier’s gangrene were initially treated by debridement, drainage, and antibiotics. The penoscrotal defects were treated with local flap advancement with skin grafting (n = 7), pedicled anterolateral thigh flap (n = 4), gracilis muscle flap with split skin grafting (n = 4), and medial thigh flap (n = 3).

Results: There was complete healing in 16 patients with minor complications in the form of partial skin graft loss (n = 1) and wound dehiscence (n = 1). Results were highly satisfactory in 6 patients, satisfactory in 8 patients, and not satisfactory in 4 patients. Scarring at the donor site was limited and acceptable.

Conclusion: The vast arsenal of options for penoscrotal defect coverage ranges from skin grafting to flaps, and every case needs a customized approach with regard to its feasibility, outcome, and complication rate. Flaps should be the preferred choice over the skin grafts because of the superior functional and aesthetic results and better compliance.

The ever-increasing interest in retaining a youthful physical appearance has facilitated the development of various minimally invasive dermatological techniques. The use of intradermal fillers can be incorporated into dermatological practices with minimal overhead costs. This strategy addresses facial volume loss and dynamic lines, which are the main features of facial aging. Moreover, intradermal fillers provide an array of flexible treatment options for a balanced and holistic result to dermatological practitioners. This paper reviews the different intradermal fillers categorized by biodegradable and non-permanent fillers including collagen based materials, hyaluronic acid and autologous fat, semi-permanent fillers including poly methyl methacrylate, poly-L-lactic acid and calcium hydroxyapatite microspheres, and permanent fillers including silicone. A discussion is provided of the commercial products made of these materials and their clinical efficacy in the treatment of facial aging.

With the development of autologous stem cells transplantation, the application of autologous fibroblast graft has been an important therapy in defect repair. In the past decade, amounts of studies have reported favorable treatment effect and safety about the therapy. The material has the ability to produce human collagen in vivo. This article details recent scientific work of the cases, effect, injection technique, complications and safety of autologous fibroblast injection treatment.

Posttraumatic orbital reconstruction has been a challenging mission for decades in craniomaxillofacial surgery. Complications like enophthalmos, diplopia and gaze obstacles emerge when orbital trauma occurs, affecting people’s daily life as well as their appearance. Advances in technology and research gained through years of experience has provided us with a greater understanding of the changes following trauma, as well as providing us with a variety of filling materials that we can choose from to handle the deformities. However, the best type of material for repair of orbital deformities remains controversial. This paper reviewed approximately 60 articles discussing materials used in orbital reconstruction or soft tissue defect filling in the past years, with the aim of giving a comprehensive overview of the advantages and disadvantages of materials used in this field so as to help surgeons to make a better choice.

Facial rejuvenation has changed over the last decade, evolving from the rhytidectomy to an approach that focuses on revolumization, due to a more complete understanding of the changes to bone and soft tissue that occur with the aging face. Soft tissue augmentation using various injectable filler agents has gained popularity due to their nonsurgical, non-invasive procedures, instant cosmetic outcomes and limited recovery time. The skin filler market is booming and the variety of available skin fillers is increasing, providing the plastic surgeons many choices. Nonpermenant, biodegradable, resorbable agents may induce little complications, but they will normally disappear soon after injection. Semipermenant, biodegradable, biostimulary, nonresorbable fillers may induce a bit more complications, but they will normally disappear spontaneously in a few months. Permanent, nonresorbable fillers usually give rise to severe complications or reactions which may not disappear spontaneous. They may appear several years after the injection, and treatment is often insufficient. Unfortunately, the ideal filler with lasting effect but without any complication has not been discovered yet. In this review, we give an update on currently available skin filler agents, and what is new in recent 5 years.

There are some surgeries after which a temporary cover for raw wounds is required to ensure healing. Some of those circumstances are loss of tissue due to burns, trauma, amputation, chronic ulcer, leprosy, and skin graft sites. Although the body initiates regeneration mechanisms, however the time taken for complete healing of wounds is unpredictable. Also, there is a tendency for long standing wounds to undergo infection and scarring. Oral mucosa is no exception to scarring and infection of wounds and there has always been a search for new materials that can be used for coverage of oral defects. Xenogenous collagen is one such grafting material. Over the years collagen implant solutions for a number of clinical applications include general surgery, burn surgery, neurosurgery, plastic and reconstructive surgery, oral surgery, and peripheral nerve and tendon surgery. This paper aims to focus on collagen as an effective option of wound closure in plastic and reconstructive surgery of the head and neck, especially after loss of soft tissue following resection of oral malignancies.

Aim: Blood lipid profiles changed following nonfocused ultrasound treatments for body contouring. The present study elucidates clinical effects of these devices on adipose tissue.

Methods: Ultrasound treatments for 5 males and 5 females in a supine position, ages 37-67 years, were applied at 20 KHz and 3.0 W/cm² in modulated emission. Whole abdomen was treated by an ultrasound handpiece for 30 min followed by a 6-min lymphatic drainage. Waist circumferences at the level of the umbilicus and body weight were measured before and immediately after treatment. Blood lipid profiles including total cholesterol, low-density lipoprotein, high-density lipoprotein, triglyceride (TG), nonesterified fatty acid (NEFA) and lipoprotein-a were measured at baseline, every 10 min during treatment, and 15, 30, 45, 60, 75, and 90 min after treatment completion.

Results: NEFA showed statistically higher values after 10 min following treatment initiation. Subsequent values remained high despite some fluctuation, reaching a maximum at 90 min. In contrast, TG gradually decreased in concentration until the last measurement, especially for the first 30 min, with statistically significant reduction. Changes in other lipid profiles and lipoprotein-a were not significant.

Conclusion: Changes in NEFA concentration were significant following ultrasound treatment, and suggest that metabolism of TGs stored within the adipocytes occurred immediately after treatment initiation.

Aim: Self-esteem is one’s attitude towards oneself. It is one of the most important psychological aspects of rhinoplasty, a common aesthetic operation. Prior studies have indicated an improvement in patients’ self-esteem after this operation. The aim of current study was to preoperatively compare self-esteem in patients seeking aesthetic rhinoplasty with that of functional rhinoplasty patients.

Methods: A total of 42 patients completed the validated Rosenberg Self-Esteem Scale preoperatively (21 aesthetic surgery patients and 21 functional surgery patients). Those with both aesthetic and functional purposes were categorized regarding their primary objective. The t-test for independent groups was used for analysis of the data, and Cohen’s d was calculated as a measure of effect size.

Results: The mean level of self-esteem in the aesthetic surgery group was significantly lower than that of the functional surgery group (P < 0.05). Age, gender, socio-economic status, and educational backgrounds were analyzed and comparative analysis of each showed no significant difference between the two groups. The value of effect size measure was very high (d = 1.04).

Conclusion: The findings of the present study showed that aesthetic rhinoplasty patients had lower self-esteem in comparison with functional rhinoplasty patients.

Aim: Reconstruction of orofacial soft tissue defect is often challenging and this is more difficult in resource challenged environment. This retrospective study highlights our experience with the use of forehead flap to overcome some of the challenges of orofacial reconstruction in a resource depleted environment.

Methods: A 23-year retrospective analysis of all patients who had orofacial defect reconstruction using forehead flap in our department was undertaken. Information was sourced from patient’s case notes and operating theatre records. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 16 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel 2007 (Microsoft, Redmond, WA, USA).

Results: A total of 43 patients were managed within the period reviewed and consisted of 31 (72.1%) males and 12 (27.9%) females. Trauma 24 (55.8%) accounted for most defect and the lip was the commonest site of defect. Complete forehead flap was used in 31 (72.1%) of cases and when timing of defect repair is considered, delayed reconstruction was the preferred method. Postoperative complications was observed in 8 (18.6%) patients and consisted of failed flap in 2 (25.0%) patients, tumor recurrence in reconstructed site in 2 (25.0%) patients and tumor occurrence in forehead flap donor site in 1 (12.5%) patient.

Conclusion: The forehead flap remains a reliable option in orofacial soft tissue defect reconstruction. It is easy to raise and can provide coverage for wide defects as far as the paramandibular and submandibular regions. Moreover, it does not require patient repositioning.

Aim: The aim of this study was to evaluate the efficacy of autologus blood injection in the management of recurrent temporomandibular joint (TMJ) dislocation.

Methods: A total of 11 patients, 4 males, 7 females, mean age of 58.6 years and suffering from recurrent dislocation of TMJ, were included in the study. In all the patients the procedure included anesthesia- local or sedation, arthrocentesis which was followed by autologous blood injection in the upper joint cavity. The peri-articular tissues were also infiltrated with autologous blood. Post procedure advice included restricted mouth activity and liquid diet for a month.

Results: The results indicate that success rate of treatment of recurrent dislocation of TMJ is 72.8% which can be considered as impressive. The recurrence was noticed in 27.2% cases after one year follow up.

Conclusion: Autologus blood injection is an effective, simple, non-invasive, and safe procedure for treatment of recurrent dislocation of TMJ and can be performed on outpatient basis.

Angioleiomyoma of the hand is a rare differential diagnosis of painful soft tissue nodule in the extremity. It arises from smooth muscle of the blood vessels and the most common symptom is pain. Imaging with magnetic resonance imaging shows characteristic features like a hypodense peripheral capsule with linear or branching internal hyperdensities on T2-weighted images, and post-contrast diffuse homogenous enhancement with a vessel leading up to the lesion. Histopathological examination shows well circumscribed fascicles of mature smooth muscle cells surrounding vascular lumina, lined by normal appearing endothelium without elastic lamina present. These cells stain positive for smooth muscle actin, desmin, vimentin, type IV collagen and S100, but stain negative for HMB-45 and ER. Angioleiomyoma is amenable for surgical resection. We report a case of painful subcutaneous nodule of hand, with radiological and histopathological findings suggestive of angioleiomyoma. We outline the clinical, radiological and histopathological features of this rare diagnosis for painful nodule of extremity.

Aim: The causative role of human papillomavirus (HPV) has been established into the aetiology of oral squamous cell carcinoma (OSCC). Some authors believe that HPV can determinate the prognosis and module treatment response from this kind of malignancies.

Methods: Articles published in the last 10 years, focusing on the role of HPV in the development, molecular biology, prognosis and treatment of OSCC were reviewed.

Results: Thirty-nine articles from 252 were selected, highlighting 4 meta-analysis, 3 prospective and 2 retrospective studies. According to its role in the development of cervical cancer, HPV is classified into a high risk for malignant lesions subtype and a low-grade malignant lesions subtype. Epidemiology and prevalence of HPV varies according to the published data: large studies tend to have lower rates of HPV (< 50%) than smaller ones (0-100%). Interestingly, HPV+ patients are usually diagnosed at a younger age, mainly those with oropharyngeal tumours. There is a predilection for the oropharynx and Waldeyer ring tumours. Regarding prognosis, OSCC HPV+ patients tend to have better outcome and treatment response.

Conclusion: HPV divides OSCC in two types of tumours with different prognostic and therapeutic implications, with increased survival, better treatment response rates and lower risk of death and recurrences.

Aim: The purpose of this study was to conduct a systematic review of the published literature to assess the state of the art of this procedure. Sentinel node biopsy (SNB) in oral squamous cell cancer (OSCC) is a novel and proven useful technique alternative to the neck dissection (ND) in the management of OSCC.

Methods: The authors searched PubMed for literature in English published for the last five years, addressing this topic. Prospective studies articles were selected with at least thirty patients studied.

Results: Of 235 studies found, 14 studies met the exclusion and inclusion criteria for this review. The studies selected focused on the role of the SNB in the OSCC, advantages compared to ND and its limitations, testing different solutions and innovations that could implement the conventional procedure. Meta-analysis studies and review articles were also selected in order to perform the introduction and support the discussion. Based upon these findings authors have tried to establish the state of the art of the SNB and authors have highlighted recent advances that improve the sentinel lymphatic node biopsy technique in the future.

Conclusion: SNB is an excellent staging method in OSCC and an interesting alternative to ND. The authors show the most appropriate procedures recommended in the bibliography revised in a trend to depict the actual state of the art.

Aim: One of the most important factors associated with recurrence rate and overall survival is the status of surgical margin of resection free of disease. However, sometimes, the margins measured intra-operatively at the time of surgery differ of those measured by the pathologist in the histopathologic analysis. Faced with this dilemma, a literature review of the best available evidence was conducted in an attempt to determine how the phenomenon of tissue shrinkage may influence on the surgical margin of resection in patients undergoing oral and oropharyngeal squamous cell carcinoma (SCC).

Methods: An electronic and manual search was conducted by one reviewer. A combination of controlled Medical Subjects Headings and keywords were used as search strategy. Inclusion and exclusion criteria were established.

Results: Finally, after an exhaustive selection process, four articles fulfilled the inclusion criteria and were analyzed. All articles reported a decrease of surgical margin after resection. The tumor site and tumor stage seem to influence in degree of margin shrinkage.

Conclusion: Tissue shrinkage on surgical margins of resection in oral SCC is a tangible phenomenon. There is a significant discrepancy between margins measured intraoperatively previous to resection and margins measured by pathologist after histologic processing. The highest percentage of retraction occurs at the time of resection. Margin shrinkage based on tumor site and tumor stage should be considered by any oncologic surgeon to ensure adequate margins of resection cleared of tumor.

Radiotherapy plays a critical role in the treatment of oral cavity squamous cell carcinoma as monotherapy in early stage cancer or combined with surgery and/or chemotherapy in advances ones. Recent developments in the imaging of cancer and radiation technology have allowed developing more precise delivery of treatment with recent data demonstrating improvement in survival and lessening of adverse toxics effects of radiation. This review will focus in the recent advances and current state-of-the-art in radiation oncology both external beam radiotherapy and brachytherapy. As complexity of cancer treatments increases a close coordination between head-neck surgeons and radiation oncologist is needed due to a significant proportion of patients will be treated with combined modality therapy.

Aim: The indication of neck dissection in oral squamous cell carcinoma (OSCC) is a problem of risk-benefit evaluation between probability of neck metastases, the problem of complications associated with neck dissection and the prognostic influence of delayed diagnosis of metastasis during follow-up. There is no consensus on the elective treatment of the neck in early oral cancer patients with a clinically N0 (cN0) neck.

Methods: The author performed a search of PubMed articles with the words "elective neck dissection vs. observation", "node negative neck" and "early stage oral squamous cell carcinoma". The author selected those articles that studied the early OSCC (T1-T2), and elective neck treatment was compared with clinical observation.

Results: Many studies have compared the outcome of elective neck dissection (END) to observation of the neck in early OSCC. The results of them are described. The biologic aggressiveness of oral cavity squamous cell carcinoma, particularly in the early stages, is reflected in its ability to metastasize to regional lymph node chains. Many pretreatment imaging techniques to diminish the incidence of occult metastases haven been studied, and comparative studies have shown ultrasound guided fine needle aspiration cytology (USgFNAC) to be the most accurate.

Conclusion: A few non-randomized studies have shown no advantages of END when strict USgFNAC follow-up was employed. Thus, if routine strict follow-up using USgFNAC by a well-trained ultrasonographer cannot be assured, END is the safest strategy.

Aim: Surgical treatment of clinically negative neck in maxillary squamous cell carcinoma (SCC) of the upper jaw is controversial. The purpose of this systematic review was to define the incidence of cervical metastasis and to assess if elective neck dissection is justified when the neck is not primarily affected.

Methods: An electronic literature search was conducted in several databases, including MEDLINE, EMBASE, and Cochrane Central databases, for articles written in English.

Results: Twenty-eight articles were included in the review. The overall cervical metastases rate was 33% and the total initial cervical metastases rate was 16%. Interestingly, the author found that 71% of patients with cervical metastases from maxillary SCC carcinoma were T3/T4 stage.

Conclusion: This review shows the need for a change in the management of the N0 neck in SCC arising in the maxillary alveolus and hard palate. Elective neck dissection should be performed in patients with T3/T4 tumours with clinic or radiographic negative necks (N0c).

Oral cavity squamous cell carcinoma (OSCC) has a high incidence of cervical micrometastases and sometimes metastasizes bilaterally because of the rich lymphatics in the submucosal plexus, which freely communicate across the midline. The presence of contralateral pathologic lymph nodes has been reported previously as a critical factor influencing the survival of patients. There are a few reports in the literature with regard to the rates of contralateral neck disease and the factors that may be involved in the risk with them. An elective ipsilateral neck treatment is generally recommended for initial treatment in all OSCC. However, no consensus exists whether or not to perform an elective contralateral neck dissection or radiation. In this study, a systematic review has been performed in order to evaluate the predictive value of clinical-histopathologic factors potentially related to contralateral occult lymph node metastasis in squamous cell carcinomas of the oral cavity to form a rational basis for elective contralateral neck management.

Aim: To select and analyze the most representative papers published in the literature concerning oral squamous cell carcinoma (OSCC), specifically dealing with salvage surgery following primary treatment by surgery with or without by postoperative radiotherapy, specifically focusing in the oral cavity and oropharynx locations.

Methods: A bibliography search on MEDLINE and EMBASE databases for studies published from March 2000 to March 2016 was conducted. The authors only included studies published in the English language and those dealing with “squamous cell carcinoma of the oral cavity and/or oropharynx”. The following technical bibliographic exclusion criteria were applied: (1) case reports; (2) technical report; (3) animal or in vitro studies; (4) review articles; (5) uncontrolled clinical studies; and (6) publications in which the same data were published by the same group of researchers. The abstracts of yielded results were reviewed and the full text of those with apparent relevance was obtained.

Results: A total amount of 188 studies were found using the above reported searching parameters. Thirteen original papers were finally selected according to the inclusion and exclusion criteria. From 1,692 analyzed patients, overall recurrence rate was 26% (range: 15-41.7%), with a mean 47.3%, 35.1% and 10.9% local, regional and loco-regional recurrence, respectively. Mean 5-year overall survival rate was 40.2% (range: 37.5-42.9%).

Conclusion: Salvage surgery is the best option for the treatment of recurrent OSCC, either local, regional or loco-regional, with the highest rates in terms of survival and with an acceptable morbidity.

Aim: Traditional donor site closure from radial forearm free flap (RFFF) has been associated with esthetic and functional morbidity. To avoid complications, such as color mismatch and secondary donor site morbidity, a new technique named ‘‘Iberic graft’’ for covering the RFFF donor site was described previously by our team.

Methods: A study of patients who underwent reconstruction of head and neck defects using a RFFF was conducted to assess postoperative complications of the RFFF donor site and also to evaluate the morbidity in terms of aesthetics and function following the use of the “Iberic graft”. The donor site was covered by the use of a combined local triangular full-thickness skin graft. Color match, quality of the scar, presence of necrosis, dehiscence of the suture or tendon exposure were recorded and analyzed.

Results: One hundred and twenty-five consecutive patients undergoing RFFF harvesting were included. RFFF donor site defects ranged from 15 cm² to 70 cm²; 9 patients (7%) had small dehiscences of the forearm skin graft, whereas 2 cases (1.6%) presented tendon exposure. Otherwise, partial skin graft loss occurred in a few patients. In all cases, these sites healed secondarily by conservative management, with no final impairment of function. Assessment of the forearm donor site at 1 to 3 months after the primary surgical procedure showed complete defect coverage, good color match, and no scarring along the graft line.

Conclusion: The “Iberic graft” is a reliable method for closing most of RFFF donor site defects as it provides excellent color match and pliability, while obviates the need for a second surgical site.

Head and neck squamous cell carcinoma (HNSCC) is one of the most common cancers in the world with a close relation with some risk factor like, tobacco, alcohol consumption and more recently, with human papilloma virus infection. A review of the literature about actual prognosis and quality of life in HNSCC has been done analysing the results of surgical treatment and their impact on the quality of life of patients. Despite the elevated incidence of HNSCC, the survival rate has increased considerably over the last years thanks to the development of new surgical techniques, such as, microvascular reconstruction or transoral robotic surgery and the most accurate adjuvant radiochemotherapy. Even in bad prognosis cases, there are many options to take into account not only with curative expectation, even, keeping in mind the preservation of the quality of life of patients. Due to the improvement of the prognosis, the interest of surgeons has been focused on preserve the aesthetics, functional and psychosocial aspect of patients without a worsening of the main objective which is the curative result. Although prognosis of HNSCC has improved, further studies are necessary to understand the behaviour in every case and determine how the impact on the quality of life can be a useful tool to individualize the therapies.

Face transplant (FT) has evolved enormously in the last 10 years since the successful completion of the first facial transplant. This procedure has become a new reconstructive option for complex facial deformities to restore the anatomy of patients with severely disfigured faces. The authors review the literature and discuss the main surgical, immunological, and ethical aspects as well as the results described in patients undergoing FT. To date there have been more than thirty FT worldwide. The main indication was post-traumatic deformity. In all cases a standard immunosuppression was performed with three drugs, although acute rejection episodes were observed, that could be controlled with conventional immunosuppressive regimen. Overall, functional and aesthetic results have been excellent at short-term and high satisfaction rate exceeded initial expectations, although long-term data are still scarce. Major complications were opportunistic infections. Five deaths that occurred have reopened the ethical debate about the potential complications and concerns of providing informed consent to recipients. Continuous progresses in microsurgical techniques and preoperative planning have promoted the evolution from partial to full FT. All these are on the basis of accurate and careful selection of well-motivated candidates. The next challenge will be getting new immunosuppressive treatment strategies. Although clinical experience has demonstrated the FT viability, it is still considered an experimental procedure in which we have much to learn to define its true role in the current reconstructive surgery and resolve major technical, medical and ethical problems involved.

Pathologies comprising more than half the length of the trachea are a challenge to the reconstructive surgeon. Innovative tracheal transplantation techniques aim to offer the patient a curative solution with a sustained improvement in quality of life. This review summarizes the authors’ experience with the rabbit as a versatile model for research regarding tracheal transplantation. Because of the segmental blood supply of the trachea, it is not feasible to transplant the organ together with a well-defined vascular pedicle. As such, the key element of successful tracheal transplantation is the creation of a new blood supply. This vascularized construct is created by prelaminating the rabbit trachea heterotopically, within the lateral thoracic fascia. After prelamination, the construct and its vascular pedicle are transferred to the orthotopic position in the neck. This model has become gold standard because of the advantages of working with rabbits, the anatomy of the rabbit trachea, and the reliability of the lateral thoracic artery flap. In this paper, the key elements of surgery in the rabbit are discussed, as well as the tracheal anastomosis and the harvest of the lateral thoracic artery flap. Practical tips and tricks are presented. The data described in this review represent the fundaments of ongoing translational research in the center over the past twenty years.

Aim: Effects of rhinoplasty were already studied from many points of view: otherwise poor is scientific production focused on changes of voice after rhinoplasty. This preliminary study analyzed objectively and subjectively these potential effects on 19 patients who underwent exclusively closed rhinoplasty.

Methods: This preliminary evaluation was conducted from September 2012 to May 2013 and 19 patients have undergone primary rhinoplasty with exclusively closed approach (7 males, 12 females). All patients were evaluated before and 6 months after surgery. Each of them answered to a questionnaire (Voice Handicap Index Score) and the voice was recorded for spectrographic analysis: this system allowed to perform the measurement of the intensity and frequency of vowels (“A” and “E”) and nasal consonants (“N” and “M”) before and after surgery. Data were analysed with the Mann-Whitney test.

Results: Sixteen patients showed statistically significant differences after surgery. It was detected in 69% of cases an increased frequency of emission of the consonant sounds (P = 0.046), while in 74% of cases the same phenomenon was noticed for vowel sounds (P = 0.048).

Conclusion: Many patients who undergo rhinoplasty think that the intervention only leads to anatomical changes and improvement of respiratory function. The surgeon should instead accurately inform patients about the potential effects on the voice. This preliminary study reveals the significant effects of closed rhinoplasty on the human voice.

Aim: The aim of this study is to evaluate the efficacy of the protocol of nanofat and platelet-rich plasma (PRP) infiltration and fractional CO₂ laser resurfacing for face atrophic scars by acne and to analyse patient’s satisfaction with the original questionnaire.

Methods: From March 2014 to June 2015, 30 patients with acne scarsonthe cheeks were selected for this pilot study. Patients were evaluated pre- and postoperatively by a physical examination, photographs and ultrasound scan with a 22 MHz probe to measure subcutaneous tissue thickness. All patients were treated by infiltration of nanofat and PRP. The production of PRP was achieved by RegenLab THT tube^® method.

Results: Preoperative thickness of subcutaneous tissue of patients from group A was 0.532 mm, whilst preoperative thickness of subcutaneous tissue of patients from group B was 0.737 mm. Postoperative thickness of subcutaneous tissue was 1.201 mm in group A and 1.367 mm in group B. The improvement of thickness of subcutaneous tissue was 0.668 mm in group A and 0.630 mm in group B. The authors applied a t-test on unpaired data, comparing the difference in thickness obtained with the treatment both in group A and in group B, with a P = 0.7289 (not significant). All patients in both groups had a treatment benefit.

Conclusion: Combined approach with nanofat, PRP and CO₂ laser seems to be effective to improve trophic scars, however, infiltration alone proved to significantly increase skin and subcutaneous tissue thickness. QoL-Q confirmed the impact of acne scars on the face in social life and relationships.

Amyloidosis is an uncommon disorder characterized by extracellular deposition of abnormal proteins. Breast involvement has rarely been reported and can clinically be misdiagnosed as breast cancer. A 60-year-old woman presented with a 3-mm diameter mass in the right breast close to a silicon implant positioned 20 years before. A core biopsy, performed to rule out breast cancer, showed amyloid deposit. Further exams confirmed a systemic amyloid light chain amyloidosis. After few months the mass increased causing breast volume and shape distortion. Since breast cancer may be the cause of amyloid deposits or be hidden by it, the patient underwent a bilateral skin sparing mastectomy and expander and fat grafting breast reconstruction. The resection specimens showed amyloid deposits only, no evidence of cancer. At 2 years follow-up, no breast amyloidosis recurrence was shown. Breast amyloidosis is rare but can occur in a plastic surgeon’s practice. It is mandatory to rule out a comitant breast cancer or systemic amyloidosis.

There are a myriad of suture techniques available to close incisions of the brow and forehead, each with their own advantages and disadvantages. The ideal suture technique would provide excellent cosmetic results, offer expedient wound closure, optimize skin eversion and wound edge apposition, and provide excellent cosmetic results. The authors describe a new suture technique, the Running-X suture, a running horizontal mattress suture that has successfully been used by the senior author for many years to re-approximate surgical wounds of the brow and forehead in an expeditious and aesthetic manner.

Aim: Negative pressure wound therapy (NPWT) has been studied extensively in adult patients, but less is known about pediatric patients. This study assesses the efficacy and safety of vacuum-assisted closure^® usage in pediatric oncology patients.

Methods: Retrospective data on all patients treated with NPWT at a single pediatric oncology hospital were collected between April 2005 and September 2013. Details on pre-treatment factors, treatment course, and post-treatment events were collected. No control group was available for comparison.

Results: Sixty-six patients were identified, with a total of 74 wounds. Median age at the time of NPWT application was 13 years (range, 10 months-23 years). Median duration of treatment was 21 days (range, 3-236 days). NPWT therapy was started with continuous high negative pressures (125 mmHg) in most patients. Sixty-nine percent of patients had their wounds healed without intervention, and 20% of patients required surgical closure. NPWT was discontinued temporarily secondary to skin maceration or cellulitis in 12% of patients. NPWT was used in a number of non-standard clinical situations, including primarily-closed incisional wound NPWT and bridging NPWT through adjuvant chemotherapy.

Conclusion: In pediatric oncology patients, NPWT is safe, effective, and well-tolerated. Although this study is retrospective in nature, and there was no control group for comparison, these data are important for clinicians to guide therapy as device monitoring agencies and payors increasingly require outcomes data for the approval of therapeutic decisions.

Alloderm was the first acellular dermal matrix used and remains a popular choice among plastic surgeons. However, while the overall surgical outcome of breast reconstruction using alloderm has been a success, the economic burden on the health care system makes it a subject of frequent re-evaluations in cost-effectiveness. Prompted by the high price of $3,700 USD for a 6 cm × 16 cm area, our group proposes the meshing of AlloDerm to decrease the total amount needed for breast reconstruction, while achieving comparable surgical outcomes as using unmeshed alloderm.

Aim: Reduction mammaplasty is a commonly performed procedure for the treatment of symptomatic macromastia and is increasingly desired by the obese population. With the increasing prevalence obesity in the population, it is imperative to understand its effect on postoperative outcomes. The purpose of this study is to evaluate obesity as an independent risk factor for postoperative complications in breast reduction surgery using 1:1 patient matching through propensity scores between obese patients and non-obese controls.

Methods: Between 2005 and 2013, the National Surgical Quality Improvement Program dataset identified a total of 6,016 patients as having undergone primary reduction mammaplasty with 30-day postoperative follow-up. Patients were divided into obese [body mass index (BMI) of 30 or more] vs. not obese (BMI below 30). Patients were initially analyzed using standard multivariable analysis. Using propensity scores obtained from a logistic regression model, patients were subsequently matched 1:1 according to preoperative and operative variables to truly isolate the effect of obesity on surgical outcomes. Outcomes were compared between the matched cohorts using McNemar’s test and the Wilcoxon signed rank test.

Results: In unmatched multivariable analysis, rates of overall complications (7.2% vs. 5.3%, P = 0.0024), wound complications (5.5% vs. 3.6%, P = 0.0004), superficial surgical site infection (4.1% vs. 2.8%, P = 0.0050), and wound dehiscence (0.3% vs. 1.1%, P = 0.0005) were found to be statistically different between obese vs. non-obese, respectively. However, when comparing 1:1 matched obese and non-obese patients, only wound complications (4.6% vs. 3.1%, P = 0.0334) were significantly increased in the obese cohort.

Conclusion: Using the most robust statistical tools available, obesity was determined to affect wound complications after breast reduction without increased detriment on other major complications when compared to the non-obese. Obesity should be a considered with other preoperative comorbidities, rather than an independent contraindication to surgery. Breast reduction appears to be safe in the obese patient who is otherwise healthy.

Aim: Scrotal soft tissue loss is a part of the challenging conditions for plastic surgeon. The non-availability of adequate nearby healthy soft tissue and its probability of frequent contamination by excretory substances make the issue of reconstruction complicated. The authors present their experience with penoscrotal soft tissue loss with hyperbaric oxygen therapy as an adjunct.

Methods: This retrospective study was undertaken in the department of plastic surgery, over a period of 2 years. Nine patients with scrotal or penile injury and infection were enrolled in the study. Age of the patients ranged 20-60 years. Five patients had traumatic loss of scrotal skin and 4 resulted following necrotizing soft tissue infection. All patients underwent hyperbaric oxygen therapy before and following surgery.

Results: Healing was complete in all patients with minor complications as partial skin graft loss in 2 patients. Five patients (55.5%) had sustained the soft tissue loss due to trauma. The cause of necrotizing fasciitis was found in 4 patients (44.4%). The mean length of hospital stay was 42.5 days.

Conclusion: Management of soft tissue loss of penoscrotal region requires an organized approach and the utilization of newer modalities for early recovery of these injuries is of primary need. Operating surgeons should know the various reconstructive pathways and use of adjunct measures like hyperbaric therapy for early recovery.

In this paper, the authors presented a case report of a 39-year-old man taken to the Emergency Unit with a 25-year-old giant neurofibromatosis. Moreover, the treatment applied for this case and the physiopathology of the neurofibromatosis disease are also discussed.

Aim: The advent of 3D photoimaging and mammometrics has allowed for quantitative, volumetric breast analyses. This study uses 3D photoimaging and mammometrics to compare the postoperative morphometric outcomes of the modified Robertson technique to the more traditional Wise pattern inferior pedicle technique.

Methods: Inferior pedicle reduction mammoplasty was performed using either a Wise pattern or modified Robertson skin incision. 3D photography and analysis were done at 1-3 months and 6-12 months postoperatively.

Results: There were 14 breasts in the modified Robertson group (ROB) and 24 breasts in the Wise pattern group (WISE). There were no significant differences in demographic data or amount of tissue resected. At 6-12 months, the modified Robertson cohort demonstrated increased superior pole fullness (62.9% ROB vs. 58.3% WISE, P = 0.05). The Wise cohort, however, maintained greater maximum breast projection (5.52 cm ROB vs. 6.54 cm WISE, P = 0.01) and increased medial pole fullness (29.6% ROB vs. 46.9% WISE, P < 0.01). There was no difference in tissue shifting from the superior pole to the inferior pole over time (+3.36 superior pole % ROB vs. +1.42 superior pole % WISE, P = 0.28). Areola surface area increased equally in both cohorts (+3.08 cm² ROB vs. +2.59 cm² WISE, P = 0.77); however, the final size of the areola was greater in the modified Robertson cohort (26.9 cm² ROB vs. 21.6 cm² WISE, P < 0.01).

Conclusion: Using 3D mammometrics, we found increased superior pole fullness in the modified Robertson group while the Wise pattern group demonstrated greater medial pole fullness and maximum breast projection.

Aim: The authors observed the nostril floor in a gross cadaver specimen histologically and innovated a medially based de-epithelialized flap for nasal base narrowing and nostril sill augmentation.

Methods: In cadaver, fully thick section was taken from the nostril sill at the midpoint of the columella base and ala base, and stained with Masson-Trichrome. In eight patients, circumferential incision along the nostril sill and alar base freed the alar base from the upper lip. At the columellar base, fresh epithelium was shaved on the medial side of the incision line. The widened scar on the upper lip was excised. The de-epithelialized tip of the columellar base was pulled under the medial tip of the alar base flap and sutured tightly. Four anthropometric distances were measured preoperatively and postoperatively.

Results: Histologically the nostril sill was composed of thickened dermis. Just below the dermis, the depressor septi nasi muscle ran obliquely, augmenting the nostril sill. The nostril floor width, alar distance, and alar curvature distance decreased on the cleft side after the operation.

Conclusion: A medially based de-epithelialized flap narrows the alar base and augments the nostril sill simultaneously, since the de-epithelialized part of the excess skin augments the depressed nostril sill.

Aim: The primary author previously described his technique for periareolar closure in mastopexy using a pinwheel interlocking purse string with absorbable barbed suture and now reports the results of a retrospective photometric analysis comparing this technique with the same closure using Gortex® suture. This study is designed to compare the degree of areolar widening and safety profile of using absorbable barbed sutures for periareolar closure versus permanent smooth suture.

Methods: A retrospective chart review was conducted of all patients whose periareolar closures were performed using an interlocking purse-string technique over a 10-year period. Only patients undergoing circumvertical mastopexy were included. All had photometric evaluation and follow-up performed within 6-24 months.

Results: In total, 20 patients (40 areolas), which were closed with absorbable barbed suture, were analyzed photometrically. In this suture group, areola size increased a mean of 4.9% from baseline, and no complications (0%) were observed. This compared favorably with previously reported complication rates using permanent sutures and with a series of cases presented herein in which permanent smooth suture was used for purse string closure. The degree to which absorbable barbed suture controls areolar spread was shown to be significantly better than those where permanent smooth purse string techniques were employed.

Conclusion: Circumvertical mastopexy closures using absorbable barbed suture was shown to be safe and effective and compared favorably to older techniques using permanent smooth suture for similar closures. This paper lends support to the safety of using absorbable barbed suture in circumareolar closures to limit areolar spread.

Palatal cysts are always confusing by defining their exact nomenclature or conclusive diagnosis. One of these presentations is globulomaxillary cyst which requires to be categorized under appropriate head for the management point of view. Though this entity appears to be of odontogenic in origin but because of its anatomical relation and histo-pathological background this is placed in non odontogenic group. Though the mechanism of its formation remains the same but this cyst cannot be mixed up with nasopalatine cyst as per their location. Globulomaxillary cyst appears as inverted pear shaped radiolucency in all radiological procedures. This remains asymptomatic for a long time and rarely gets infected. We present a 29-year-old male who reported with one year history of asymptomatic right side hard palate swelling. He was subsequently diagnosed as globulomaxillary cyst with the help of radiological modalities like computerized tomography and magnetic resonance imaging. This article will highlight mainly the clinical and radiological features of these cysts with particular reference to globulomaxillary cyst which is our presenting case.

Rhinoplasty and septal reconstruction often require the use of cartilage grafts. Complete nasal septal reconstruction may be required in very specific situations like difficult secondary septoplasty or severely deformed post traumatic noses. Usually in these cases the septal cartilage or bone is insufficient for septal reconstruction. The authors hereby describe a new technique of complete septal reconstruction by using the 7th rib (costal) cartilage combined with author’s ingenious technique to prevent warping.

Aim: Limb salvage is the treatment of choice for lower extremity bone sarcomas in children. To date, peers have not described algorithms for soft tissue reconstruction of these defects. This paper is to report a large single center series of lower extremity salvage after sarcoma treatment, with algorithm.

Methods: The authors performed a retrospective review of patients undergoing resection of lower extremity bone sarcomas at a single center over 12 years.

Results: In total, 65 children (29 girls, 36 boys) with a mean age of 13 years (range 2.9-23.3 years) underwent resection of a lower leg sarcoma with limb-salvage. Tumors types included 50 osteosarcomas, and 15 Ewing sarcoma family of tumors. The types of reconstruction utilized included: 34 primary closures, 22 gastrocnemius and soleus flaps, 3 bipedicled flaps, 2 sural artery flaps, 1 pedicled anterolateral thigh flap, 3 pedicled posterior thigh flaps for subsequent above-knee amputations. No free flap based reconstructions were performed. An algorithm for reconstruction of leg defects in the setting of limb-salvage surgery is presented. Successful limb salvage rate was 95.4%. Limb salvage failed in 3 patients and they required amputation. Finally, 56 patients were able to ambulate without assistance at last follow-up.

Conclusion: The authors present an algorithm for the reconstruction soft tissue after resection of lower extremity bone sarcomas. The use of these techniques helps to decrease complications and maximize function in children with these tumors.

Aim: To evaluate the age-related effects on the adipogenic differentiation and proliferation potentials of human orbital adipose-derived stem cells (OASCs).

Methods: Orbital adipose samples were harvested from the central fat compartment in the lower eyelids of 10 young and middle-aged patients during routine blepharoplasty surgery. After assessment of the morphological changes of adipocytes with aging, OASCs were isolated from the fat samples and expanded in vitro. Differences in the stem cell colony number (fibroblast colony-forming unit), growth rate and phenotype characterization (flow cytometry analysis) were evaluated. The ability of OASCs to differentiate into adipocytes was determined by oil red O staining and the mRNA expression level of peroxisome proliferator-activated receptor γ.

Results: Fat cell size showed a decreasing trend with advancing age. Although no difference was found in the expression of cell surface markers, the colony number and proliferative rate of OASCs from middle-aged donors were significantly lower than those from the young donors. The adipogenic differentiation capacity of middle-aged OASCs was also reduced. These differences were statistically significant (P < 0.001).

Conclusion: The data showed that the progenitor cell number, proliferation capacity and adipogenic potential of OASCs decreased with aging, suggesting that using OASCs from elderly patients for therapeutic purposes might be restricted.

Aim: Topical rapamycin for angiofibromas has been reported to be a new promising treatment. This study aims to report the outcome in clinical practice.

Methods: A retrospective clinical follow-up on twenty-three patients who had been prescribed an oral solution of 0.1% rapamycin, to be applied on facial lesions once a day.

Results: Seventeen of 23 patients continued the treatment. Papules and nodules were improved in 8 patients (47%) and erythema in 12 (70%). Side effects, such as stinging and redness were reported in 35% of patients. Blood samples were taken from 5 patients and no rapamycin could be detected. All patients who paused the treatment relapsed.

Conclusion: Topical rapamycin has a positive effect on angiofibromas with improvement in both erythema and papules even if only applied every second to third day, but continuous treatment is needed.

Morel-Lavallee lesion (MLL) entity represents as a haemolymph mass as a result of closed degloving injury following focal trauma. The swelling can be mistaken as a tumor or simple hematoma formation, and it can be of concern as it gradually increases in size. It is important to diagnose the entity promptly as proper management can avoid skin necrosis and further complications. We present a 20-year-old female nursing student who fell down from a scooter and developed painful massive right thigh swelling over a 3-week course following trauma. She underwent plain radiography which was unremarkable. Ultrasound and magnetic resonance imaging revealed the diagnosis of MLL and she was treated accordingly.

Aim: The author describes a new endoscopic midface lifting technique using solely temporal access and evaluates its advantages and perspectives.

Methods: This is a single-surgeon case study. Through a short temporal incision, dissection is performed along a single plane connecting the superficial surfaces of both the facial and temporal superficial musculoaponeurotic system (SMAS) layers. Subsequent midface dissection divides the malar fat pad into the deeper and superficial parts. A new concept of a combination high malar SMAS lift and internal skin flap anchorage that provides long-term stability is described.

Results: The temporal endoscopic midface (TEM) lift technique resulted in good objective results with high patient satisfaction. The temporal access allowed proper vertical vector correction of the sagging centro-facial structures. The resulting scar was inconspicuous and hidden in the hair bearing skin, and its length was measured between 5-6 cm. A conversion to the conventional long facial scar approach was completely avoided.

Conclusion: The TEM lift is a new and effective procedure for facial rejuvenation, especially the midface and cheek. The results illustrate the importance of internal anchorage of both the midface SMAS and skin flap. These are the keys to long-lasting and pleasing results. The procedure is best suited for younger men and women with little or no neck skin laxity.

Epidermoid cysts, dermoid cysts and teratoid cysts are cystic malformations lined with squamous epithelium. They present as soft nodular lesions with a sessile base. Their prevalence is 7% in head and neck patients and 1.6% within the oral cavity. The authors present a case series of 21 patients with dermoid and epidermoid cysts who underwent surgical removal. One year of follow-up was carried out without evidence of recurrence. The removal of these cysts is of great concern as it can cause serious social stigma, aesthetic and functional impairment, dysphagia and dysphonia.

Aim: Scar prevention and reduction is an area of therapeutic opportunity and unmet medical need. With no current effective scar therapy, patients are often disappointed in their appearance post surgery and re-present to surgeons, only to be turned away. The purpose of this study was to develop and test a device that produces intermittent parallel stretch on new scars and to analyze its potential to reduce scarring.

Methods: Mice were randomized into 5 scar stretch treatment groups: 1 control, 1 sham, and 3 stretch models (0.5×, 1×, or 2× device strength) and treated for 10 days. Scars were scored using the Vancouver Scar Scale. Scar tissue samples were compared by histology and transforming growth factor beta 1 (TGF-β1) expression between control and treatment groups.

Results: Scar scores of 0.5× and 1× groups were significantly lower than the control group (P < 0.05). Scar scores from the 1× treatment group were also significantly lower than the 0.5× group (P < 0.05). Sham, control scar and 2× groups showed more collagen deposition and a thicker dermal scar than the 0.5× and 1× groups. Unstretched scars had fewer fibroblasts with more collagen deposition than the 0.5× and 2× groups. TGF-β1 levels were significantly lower in the 0.5× (342.1 ± 9.2) and 1× (254.1 ± 3.1) groups than in the control group (P < 0.05). TGF-β1 levels in the 1× treatment group were also significantly lower than the 0.5× treatment group (P < 0.05).

Conclusion: Intermittent cutaneous tissue stretch parallel to scars during the proliferative phase of wound healing decreases fibrosis on a macroscopic, microscopic and biochemical level.

Aim: The extended running W-plasty technique using the W-plasty principle is a modification of the conventional technique. The use of this technique was utilized for simultaneous reduction of the protuberant labia minora and the redundant clitoris.

Methods: Twenty-three patients presented to the plastic surgery clinic between 2008 and 2015 with the complaints of protuberant and enlarged labia minora in conjunction with a hypertrophied clitorial hood. The extended running W-plasty was performed in all patients. Surgery was performed under general anesthesia as an outpatient procedure with a range of operative time from 30-45 min. The Likert scale was used to evaluate outcomes.

Results: Patients maintained labial length with decreased scarring. Small hematomas occurred in 2 patients and were treated conservatively. One case of wound dehiscence occurred and was also treated conservatively. Patients returned to normal activity 5-7 days postoperatively. The cosmetic outcome of all patients was very satisfactory.

Conclusion: The running W-plasty technique is ideal for closure of secondary defects following excision of both the redundant labia minora and clitoral hood, while maintaining length and providing tensionless scars. The technique conserves the original tissues while avoiding over- or under- resection of the labia.

Aim: Ear reconstruction is a challenge for plastic and reconstructive surgeons. The ear requires sufficient skin coverage and a three-dimensional (3D) cartilage framework. In this paper, the authors present their 10-year experience in microtia reconstruction using tissue expansion and an autogenous rib cartilage framework.

Methods: Ear reconstruction was performed in 3 operative stages. During the first procedure, a 50-80 mL kidney or cylinder-shaped expander was implanted deep to the subcutaneous fascia of the retroauricular mastoid region. Over a period of 3-5 months, the expander was filled to a final volume of 80-110 mL. In the next operation, the retroauricular fascia was eliminated or reserved following expander removal, and the autogenous costal cartilage framework was placed below the expanded skin flap. At the third and final stage, the earlobe transposition, tragus construction and conchal deepening were performed.

Results: A total of 165 patients (166 ears) were reconstructed using tissue expansion and an autogenous rib cartilage framework. Complications included hematomas in 3 cases, expander exposure in 8 cases, cartilage exposure in 6 cases, infection and cartilage resorption in 2 cases, exposure of steel wire in 4 cases, and aseptic seroma in 2 cases. Follow-up ranging from 3 months to 5 years showed that 159 patients were satisfied with the reconstructed ear including size, location, projection, convolution, skin-colour matching, symmetry with opposite ear.

Conclusion: Expansion of the retroauricular skin and fascia can provide sufficient non-hair-bearing skin and tissue for coverage of a three-dimensional costal cartilage framework. Avoidance and prompt treatment of complications are advised in order to obtain a satisfactory reconstruction of the ear.

Aim: Non-invasive body contouring is a promising modality. However, due to a lack of good evidence-based data, the mechanism by which contouring occurs remains unclear. The purpose of this study was to evaluate the effect of treatment with the Contour I™ ultrasound system (Ultrashape^®, Syneron^®, Israel) on abdominal circumference and to compare 2 power levels for efficacy and safety.

Methods: A prospective, self-controlled double-blind design was used. Thirty-six women, aged 30-45 years, were randomized to receive treatment with the Contour I at high or low acoustic outputs in 3 successive sessions, 1 month apart. Safety was evaluated by adverse events, local skin reaction, and pain. Efficacy was evaluated by the change in abdominal circumference relative to baseline and to the untreated thigh area (internal control). Patients were followed for 28 days after the last treatment session.

Results: At 1 month after the first session, the mean reductions in abdominal circumference measured 1.65 cm (P < 0.001) and 0.87 cm (P < 0.019) in the high and low-power groups, respectively. At 1 month after the last session, the cumulative reductions in circumference were 2.56 cm (P < 0.001) and 1.49 cm (P < 0.012), respectively. There was no change in the internal-control circumference throughout treatment. There were no treatment-induced severe adverse events.

Conclusion: Multiple successive treatments of the abdominal area with the Contour I lead to a significant progressive reduction in circumference. The magnitude of the reduction is directly correlated to the acoustic power output which suggests that the technology itself is the main cause for the contouring effect.

Aim: Negative pressure wound therapy (NPWT) in diabetic foot ulcers (DFU) has been discussed in several studies, but without a focus on peripheral arterial disease (PAD), which is a common comorbidity. This study aims to investigate the feasibility of NPWT in the treatment of DFU with PAD in regards to limb salvage and the clinical course.

Methods: The authors retrospectively collected patients with DFU and PAD diagnosed with either Doppler ultrasound or angiography as the PAD study group. Patients with DFU but no PAD were enrolled as the non-PAD comparison group. NPWT was applied to both PAD and non-PAD subjects.

Results: There were 10 patients in the PAD group and 3 patients in the non-PAD group. In the PAD group, there was a 70% limb salvage rate with 14.70 (± 10.33) treatment days. The non-PAD comparison group had a higher limb salvage rate (100% vs. 70%, respectively), but a longer treatment time (30.00 vs. 14.70 days, P < 0.05, respectively) when compared to the PAD group. The 3 patients in the PAD group who failed limb salvage all had issues related to uncontrolled infection.

Conclusion: NPWT is a feasible adjuvant therapy for DFU in patients with PAD, with a 70% limb salvage rate. Prolonged treatment time was due to the initial severity of the subjects with multiple comorbidities. The main reason for limb loss was intractable infection.

Aim: This study aims to characterize the effects of elastic facelifts using the elasticum suspension technique on the cervical angle and anthropometric distances.

Methods: Forty-six patients underwent surgery. Two 4-5 mm incisions a few centimetres apart were made at sideburn. Through blunt dissection, the deep temporal fascia was approached. An elastic thread (Elasticum^®) was anchored to this fascia. A 1.0 cm incision was made just in front of the earlobe. The elastic thread was anchored to the tympanoparotid fascia. Jano needle was passed under the skin surface, as determined by the depth mark of the needle along the cervicomandibular angle, and the elastic threads were looped around the contralateral tympanoparotid fascia. Standard lateral photographs were taken and evaluated.

Results: The elasticum suspension significantly decreased the cervical angle (P < 0.001, -5.5 ± 9.8%). This procedure significantly decreased the distance from the gonion-gnathion to the labiale inferioris (Gn-Li) (P < 0.001, -18.4 ± 25.5%). The ratio of the distance from Gn to the cervical point (Gn-C) to Gn-Li increased significantly (P < 0.001, 62.8 ± 85.8%) and the ratio of the distance from C to the visible thyroid cartilage (C-T) to Gn-C decreased significantly (P = 0.007, -7.1 ± 45.2%).

Conclusion: Elasticum suspension may be a satisfactory minimally invasive method for facelifts, brow lifts, and neck lifts.